Chapter 13
flexibility among users
when preferred substance is unavailable, theye use a diff drug, heroin draught, amphetamines, benzo, and opiods, rise in use of cocaine, 531
the profits
united nations, 411 billion global market for illicit drugs, cultivation 16 bil, after processing value increases to 120 bil, sales on the street 411, over 2/3 of the words supply would have to be confiscated, 88 percent of countries 529
american medical association
vocal critic of steps that eliminated the ability of physicians to prescribe narcotics for addicted person, not prompted by enlightenment, concern was governments interference in physicians professional practice, setting limits after harrison drugs became punitive
Pregnancy and the use of drugs other than alcohol
Teratogens can disrupt fetal development, alc in combination with other drugs is leading cause of preventable birth defects 607 Epidemiology Stats on how it is used, in absolutes white women largest group of preg, take into account education disappear, sig factor is age, highest rate is in young, trimester 607 Opiate-exposed infants Enormous problems Most common probs: abscesses, ulcers, bacterial infections, hepatitis, dirty needles, STDs, living conditions poor, vitamin deficit, anemia, most common obstetrical complication is preterm birth, complications seen in premature, if born fullterm pneumonia or meconium aspiration syndrome, extremely high risk environment predisposes to neonatal probs, in heroin, is due to low birth weight, and prematurity, 50 percent, med complication reflect amount of prenatal care, suffered any obstetrical complication, multiple drug use, increase death, extremely hazardous because it predisposes to things that causes bad things Withdrawal from opiates can occur in premature and term infants, characterized by signs and symptoms of central nervous system hyper., gas, respiratory, vague autonomic symptoms, yawning, sneezing mottling and fever, babies develop tremors, mild and progress, exaggerated moro reflex, Rooting reliex is increased and sucking is common, babies throw up a lot, loose stools, closer to delivery the greater the delay in onset of withdrawal, more severe symptoms, maternal smoking increases severity, 6-8 days, drug therapies may be used, sym. May persist 3-4 months 608 Buprenorphine versus methadone use in pregnancy Medical withdrawal from methadone or bup. Is not necessary or recommended, long time methadone was mainstay of treatment for opioid dependent women, methadone sage for preg women, abstinence syndrome in baby was problem, bup withdrawal is less common and less severe if it does occur, prenatal care is important which can also attend to the appropriate dosage of bup or methadone, third trimester, women need increase in medication bc physiological changes, weight gain, only be subtext which does not contain naloxone, harmful to fetus 610 Cocaine exposed fetus Highly soluable, can easily cross plecenta, fetus limited ability to metabolize cocaine, binge higher level of cocaine in fetus, transfer of cocaine from mother to infant is greater in first and third trimester, most potent effects is constriction of blood vessels, can retard transfer of cocaine, far from being protective device, less passage of everything else, essential nutrients, less ability to exchange waste, effects not clear cut, many other risks, Accompany maternal cocaine use: greater likelihood of maternal health probs, can have impact on neonate, impaired fetal growth, small infant head, premature birth, increased still births, premature labor, animal studies, low in animal seems to require high doses, cocaine not a major source of defects children likely to be normal, problems that are seen may be result of other factors not cocaine, poverty, inadequate care, nutrition, other drugs, and other medical problems 610 Policy and legal issues One basic premises of child rearing models is infant behavior is a part of communication system within environment. Feedback from one partner to another is used to regulate this system, in early work with drug exposed infants not appreciated, believed that drug exposure led to poor developmental outcomes, interventions that provide needed supports can make a difference, the maternal lifestyles study, protective factors are often at work, In respect to social policy variety approaches have been suggested to protect children, instituting systematic education and support, giving hospitals legal power to care for babies until ready for discharge and home is safe, placing children in foster care if parents cant care for them, facilitating adoption, special programs are limited, Special considerations for children who in home, drug abuse treatment necessary, most alarming in terms of outcome are those associated with neglect, child abandonment is common, intoxication from crack is associated with outbursts, urban areas have long waiting lists for treatment, facilities that will accept women with infants are few, individuals dependant on crack more difficulty maintaining abstinence, thus oversight of children is imperative, 611
social costs
180.8 billion (2002), 2011 annual social economics cost is 193 billion, includes health care (11.4), criminal justice, (113.2) loss in productivity, (68.4), supply reduction, only includes illicit drugs, 70 billion for abuse of pharmaceuticals,
Food and drug administration
1906, earliest federal provisions affecting narcotics, over counter containing opiates cannabis, marijuana, cocaine, or chloral hydrate needed label identifying relative percentages 526
harrison act
1914, certain drugs as controlled substances, no longer over the counter, and only given by physicians for medical purposes, view did not prevail for long, closing of small clinics to provide drugs to addicts,
Age
2008 half under 26, in four years dropped too 40 percent, numbers increasing in young people, table 13.2 age groups, teens gave 1 1/2 times higher use and three times higher in 18-25, most dramatic changes are baby boomers, 519
crime and incarceration
2011c more arrests for drug abuse violations than any other offense, 1.53 million arrests, 13 percent of all arrests, half for posession, users and small time dealers have equal sentences to those higher up, bottom have no room for plea bargain, prison population product of emotion not reason, distinction between cocaine as a powder and crack, cocain powder was misdemeanor, felony when crack, 5 year senetence, Fair sentencing act The Anti-drug abuse act, 100-1 ratio between crack and powder, 18 to 1 ratio lowered, african american males 20 percent longer sentences, stop and frisk in new york, minorities stopped more frequently, 85-90 percent of minorities stopped were innocent,523
geographic region
2012 west and northeats have highest rate of illicit drug use, lowest is south, illicit drug use highest in large metropolitan areas declines in tandem with declines in population, lowest was entirely rural communities, among youngest opposite is true, highest use of drugs in rural, differences in geographic regions less marked, 521
definitions of medical terms
538
classification schemas licit versus illicit
541 categorizing illicit and licit provides little insight into med problems, implications for law and societal problems, health implications, questionable, drugs on street may be anything, caveat emptor 542
commandeering public space
80 percent of marijuana in california is grown on public lands, inflicts ecological damage, sequoia national park officers destroyed 100 pot gardens but only enough money to clean up half the sites. eradication efforts are under way, barely make a dent, 2006 record number, state conducted raids, cost 7 mil. only 27 arrests, 530
nicotine
Abuse potential High potential, the nicotine addiction trap a 40 year sentence for 4 cigaretters, trapped into a career of regular smoking, bulk begin smoking as adolescents, another perspective on high rate of dependence among use nicotine can be gleaned by looking at proportion of past year smokers who are also current smokers, 85 percent 547 Pharmacological Action: nicotinic receptors, present in different concentrations, the number and concentration increase with use of tobacco, appear to located both on cell bodies and nerve terminals, release of neurotransmitters:: acetylcholine, norepinephrine, serotonin, endorphin, glutate and and dopamine, rewarding properties. Nicotine leads to the release of growth hormone, prolactin and ACTH, by the pituitary gland, tolerance develops rapidly, first side effects are diminished by the second and absent after several, within a day of smoking tolerance to subjective effects. 547 Absorption and metabolism nicotine is carried by tar droplets which are inhaled and deposited in the air sacs of the lungs, nicotine passes into bloodstream, in 10 to 19 seconds it enters the brain, speed depends on route of administration, smoking is the fastest, nicotine in brain decline rapidly then distributed to tissues in other parts, half-life is two hours, smokers do not space cigs an hour apart, the nicotine persists throughout the night, by liver and lungs but much smaller amount, excretion of kidneys accounts for 20 percent, speeds up the livers metabolism of other meds, meds don't have intended effect, nicotine broke down into several compounds, cotinine, remains in body longer, 16 hours, used as a marker of nicotine use, excreted by kidneys, no clear what its effects are, does impact neurotransmitters in brain and number of enzymes, withdrawal 547 Assessment: smoking cessation, The fagerstrom test for nicotine dependence, those with high scores need assistance in efforts to stop, nicotine patch for high scores, 548
clinical issues
Basic issues that pertain to assessment of alcohol problems are also applicable to other drug use, for anyone being sen with respect to an alcohol problem attention needs to be directed to other drug use as well, a screening test specific to drug use is DAST Screening test: two exceptions: 4 and 5, a score of 6 or above indicates substance use problem, 595 assessment DSM 5 criteria for diagnosis of substance use disorders Significant change in fifth edition, prior to 5th edition abuse and dependence were viewed as wholly separate catagories, these are now replaced by single diagnosis, substance use disorder, varying levels of impairment, mild moderate or severe, 11 criteria associated with any substance use disorder, mild when 2-3, moderate when 4-5, severe when 6 or more, dropped legal problems, and added craving, 596 Criteria for diagnosis of substance use withdrawal Vary, opposite effects associated with use and intox., 597 WITHDRAWAL CRITERIA 598 Amphetamines: cessation or reduction in amphetamine, or a related substance use that has been heavy and prolonged and dysphoric mood and 2 or more physiological changes, same as cocaine, fatigue dreams insomnia increased app., psychomotor retardation, agitation Caffeine: cessation in caffeine use followed within 24 hours by 3 or more: headache, fatigue, dysphoric mood, dpressed, diff. concentrating, flu like, caffeine not included in DSM 5 but a withdrawal is included, Cocaine: two or more of same as amphetamines Hallucinogens: not documented Inhalants: nothing Nicotine: for at least several weeks and cessation, 24 hours by 4 of following: depression, insomnia, irritability, frustration, anger, anxiety, concentrating, restless, heart rate decrease, increase app., Opioids: three or more Phencyclidine: nothing Sedatives hypnotics or anxiolytics:2 DSM 5 criteria: intoxication: 599 Not due to medical condition, not better explained by disorder Amphetamine intoxication, caffeine intoxication, cannabis intox, cocaine, hallucinogen, inhalant intox, opiate intox, phencyclidine intox Sedative same as alc
Hallucinogens and dissociatives 566
Both natural and synthetic preparations, ability to alter reality and produce hallucination like effects, have played role for thousands of years, variety of plants can cause detachment and precipitated visions, largely in social and religious contexts, contain chemicals mescaline and psilocybin, similar to serotonin, LSD most powerful hallucinogen, dissociatives: anesthetics, phencyclidine, (PCP) and ketamine, block pain and induce loss of consciousness, sub anesthetic, thresholds they produce effects similar , refers to an altered sense of self of being outside of oneself, heightened awareness of color and sound, their use as anesthetics was short lived, patients became agitated, delusional, and irrational as the effects wore off, white powder that dissolves easily in water and alcohol, MDMA: ecstasy, designer drug, both a stimulant and psychedelic properties, analog of meth, placed on DEA schedule due to abuse and linked to another drug found to damage serotonin neurons in the brain, women more sensitive, are associated with rave scene, DXM is found in over the counter cough medicines, chemically related to morphine, small doses it is a cough suppressant but in large doses It produces consciousness-altering effects similar in nature to dissociatives. Obtainable and drug of choice for minors Summary: Hallucinogens dissociatives 568
Caffeine
Caffeine Most widely used psychoactive drug in the world, far exceeds alc and nicotine, stimulant but effects are subtle, not able to identify changes, many it is just a beverage, 587 Sources of caffeine Young soft drink, adult coffee, old tea, 588 Patterns of use Changing rapidly because of energy drinks, age groups far from certain, variation in different countries, high chronic consumer, high acute consumer binge drinking, dynapep, microshot, marketed to adolescents, 13 deaths reported, long term effects, the answer is unknown of long term effects, 588 Absorption and metabolism Through water, peak in 30-75 mins, metabolize by liver, 4-5 hours half life, consumed at faster rate than being removed 589 Acute Effects Stimulant by inhibiting GABA receptors slow communication in central nervous system, 100-200 alertness, drowsiness relief, improved thinking, endurance, impairs fine motor coordination 250-700 induce anxiety, jitters, insomnia nervousness, hypertension, levels above 1000 cause heartrate, sleeplessness, tinnitus, cog. Difficulties, fatal over 5000 40 cups Depends on innate sensitivity, tolerance, dose, caffeine does improve performance, few people know how much caffeine they are ingesting, increases focus and attention heightens energy, enhances performance in safety critical issues, Influenced by persons regular level of caffeine consumption, neg effects follow doses higher than usual, anxious jitters headaches, assessing effects is difficult, tests are conducted when people abstain, 589 Chronic effects Dependence is immediate issue, reg use produces tolerance, quite rapidly, within a week increase in usual amount ceases to interfere with sleep, in days of high caffeine increase blood pressure fade Caffeine ranks as poor cousin compared to other stimulants, drug seeking does not produce equal liking or euphoria, not equal in changes of mood, reinforcing properties is similar to nicotine, 590 Withdrawal Mild, headache, drowsiness, decrease in well being, less sociable, flue like, blurred vision, tests show impairment in performance, severity to leel of usual dose and length of use, half report headaches after stopping use, peak of discomfort 24-48 hours, range from 2-3 days, until usual alertness 591 Significance of withdrawal 82 percent use caffeine, importance due to sheer size not effects, far more questions than answers, 591 Medical Import of long term use A concern is nature of medical conditions from long term use, cutting back from caffeine helps with ulcers, heart, cancer, anxiety, no medical conditions recognized as caused by caffeine 592 Caffeine other drug interactions As a stimulant caffeine counts depressant effects of alcohol on alertness and memory, caffeine reduces alc induced sleepiness, other effects are not tempered with caffeine, caffeine does help with dizziness, question raised whether caffeine increases alcohol tolerance, Nicotine: more pleasurable and reinforcing associated with more liking, dopamine, stays in system longer, removal will be slowed, 592 Alcohol-caffeine interactions: Four loko, 11 percent alc content, 4-5 beers, hospital reports, FDA banned addition of caffeine to alc, one thing they both have in common and they increase level of dopamine which is associated with pleasure which explains special high 592 A substance of abuse? What is considered abuse is a social definition, self limited, one third of population Is dependent on caf., withdrawal is not clinically significant, may seek medical attention if have severe withdrawal for anxiety or insomnia, caffeinism, 592 Childrens use of caffeine Most discussed, ADD,mostly in carbonated beverages, use at higher levels related to sleep disturbances less total sleep and increased awakenings and more daytime sleep,impacts newborn, prenatal caffeine exposure, children and variable too I sensitivity, super stim for some, if they consume four times their normal dose the show signs of being less alert, responds slowly, when they stop, no evidence of an effect during the couse of pregnancy or on infant development, effects on children are modest, issue for some children with anxiety or particular sensitivity, as tolerance develops quickly there are signs of withdrawal, danger is in the calories, 593
Cannaboids 572
Cannaboids Imported from Europe, hashish, hash oil, hemp, cloth and rope, recognized as having psychoactive and used as medicine, abuse wasn't an issue, non medical was restricted to artists and bohemians, not sufficient to be passed in Harrison Act, Marijuana tax act regulated marijuana, act was supposed to revenue measure with individuals who dispensed or possessed marijuana , WW2 572 Availability Over tons harvested in mexico and Canada, states where it is produced, exporting states, significant element is economy, twice the THC, 572 Patterns of use Most widely used drug, 43 percent used it, highest number who qualify as having a dependence, twice as common in men, higher in unemployed, 573 Societal perspectives Isn't a big issue, attitudes changed dramatically, some view it benign, possible cognitive impairment, schizophrenia, dependence can occur, long term are less dramatic than heavy long term drinking, criminal sanctions harsh, 573 Clinical issues May be facing some issues like an alcoholic, may not be dependence, question if moderate marijuana is reasonable, can be problematic with other drug use, self exam., follow up, 574 Medical Marijuana Conditions can be alleviated by use of marijuana, requirements to legalize, use be recommended by physician, register with the state, obtain an identification card, regulations, 575 Summary cannabinoids: 576
Club drugs 571
Club drugs: a special case 1000 of people, originated in England, most commonly referred to as club drugs are ecstasy, ketamine GHB and rohypnol, enhance social intimacy, sensory perception and endurance allows users to continue for hours on the dance floor, roh is included in discussions of club drugs the evidence suggests it is uncommon, purchased at the event, not what they are purported to be, common additives in UK are cocaine, amph. And morphine, US meth, PCP, and ecstasy practice is sequential doses of same substance or sequence of bump, bump is problematic because drugs vary in their rates of clearance and metabolism and the effects vary with dose, alcohol also involved, hot conditions, ecstasy increase in bod temp, invite liver kidney and heart probs, dehydrated, water intoxication, GHB is a sedative, can lead to reduced respiration and coma when with alcohol, many club drugs have sedative properties, when consumed with alcohol invite the risk of depressed respiration and coma, number of emergency room visits involving club drugs increased GHB and ecstasy in combination represented tiny percent
summary
Examples, route of administration, pharmacological action, metabolism, length of action desired effects, other acute effects, intoxication/overdose, withdrawal symptoms, interaction with alcohol, medical uses, nicotine, 550
561 GHB
Gamma hydoxybutyrate GHB: A special case Exceedingly limited legitimate use, marketed as Xyrem approved in 2002 for treatment of narcolepsy, not drug diversion by production in illicit clandestine labs, easily synthesized from chemicals, can be injected, capful or teaspoon, clear odorless and tasteless, sedating properties, sexual assault, GHB rapidly absorbed peak levels in 20 to 60 mins, no longer than 3 hours
heroine use
Heroin Use Generational memory, popularity waxes and wanes over time, heroin use associated with those called "the dinosaurs" in their 40s and 50s, in 1990s reserge of heroin use, new generation 13-23, lowering price and great purity, and cocaine suppliers also starting giving heroine, and no generational memory of heroin use and its problems, with increase in purity there was more potential for other routes of administration besides IV, intransally or smoked chaing the dragon, lighting heroin placed on a surface and inhaling the smoke, spread to the suburbs and rural areas, peaked in 1996, 554 Other Opioid Use There are synthetic manufactured opiates, intended to treat pain and were prescribed, the most frequently abused are those most frequently prescribed. Those frequently abused are more available, they are the most potent, oxycotin, hydrocodone, Vicodin, other oxycodone, methadone, morphine, hydromorphone, fentanyl, and buprenorphine, 554
opiates
Historical Notes: recognized over 10,000 years ago as having psychoactive properties, Assyrians, in Iraq, known to the Greeks, one of the mainstays of ancient medicine, pure food and drug act disappearance of laudanum, tea, opium in Britain, history of racism, major factor in disparate prison sentences for cocaine based on whether it is form of crack or powder, war on drugs 551 Opium Derivatives: Any natural occurring drug is less potent and less problematic, distillation is required to produce alcoholic beverages above 14 percent, in early 1800s poppies were refined to create morphine, 10 times more powerful, real breakthrough in 1853 invention of syringe, made it widespread, potential for delivering morphine intravenously, enhanced its effects, first widespread medical use was in the civil war, without appreciation of addictive potential, "soldiers illness" "army disease" synthesis of heroin from morphine in 1898, heroin joined opium and morphine ingredients of various tonics and medications available, heroin noted for its rapid onset of action and short half life, both features contribute to addictive potential, about twice as potent as morphine, average half-life is 3 minutes, its metabolized quite rapidly one product of metabolism is morphine, stays in system much longer, pure food and drug and Harrison the legal supply of opium and major derivatives morphine and heroin disappeared, heroin outlaws in 1924, 1956 possession illegal, the british system, allows prescription of heroin, diamorphine, methadone maintenance, 552
inhalants
Inhalants: Give off vapor or fumes which are inhaled for their psychoactive properties, paints, lighter fluid, paint thinners, aerosols, felt tipped pens, correction fluid, cleaning compounds, gas and glue Hydrocarbons, volatile solvents, nitrites: air fresheners, poppers amyl nitrites, snappers, used to treat angina, nitrates, anesthetics, nitrous oxide, laughing gas 577 Patterns of use Declined, highest rate in in adolescents, 8th graders, easily available can cause permanent brain damage, females more than males 577 Pharmacological actions Molecules are small, lungs, effects similar to CNS depressants, fat soluble, don't effect neurotransmitter, painters syndrome, 578 Summary: inhalants: 578
international comparisons and looking ahead
International comparisons United nations, new psychoactive substances, designer drugs or legal highs, or synthetic, over internet, number rose 251, only 7 percent of highest rate purchase online, 613 Looking ahead Rising prominence of Africa in global substance use, drug trade always sensitive to best route to transport drugs, one effects is to make more available in Africa, ever growing new psychoactive substances, how to move proactively to avoid increases where rates are low, UN office on drugs and crime dominant perspective is control, legal constaints, size of drug industry, how do we wish to allocate out resources, if legal save law enforcement 41.3 bil., tax revenues of 46.7 bil, 613
Anabolic Androgenic Steroids
Male hormones used by athletes, roid rage, most widely known dianabol, 580 Patterns of use: Female use is a quarter of male use, high school seniors, GHB, precursors, 581 Routes of administration: Orally or injected, cycle, 582 Summary: anabolic androgenic steroids 582 Other performance enhancing drugs Alter body not brain, 583 Human Growth Hormone:pituitary gland, increases muscles but not performance 584 Amphetamines and stimulants Resistance to fatigue, 584 Ephedrine and ephedra: Alertness, energy, appetite suppressants, decongestants, banned, ephedrine the ingredient of many cold remedies, Olympic committee and NCAA have banned ephedrine, ban is related to adverse effects, irritability, rapid heartbeat, sleeplessness, stroke, heart attack, 584 Erythropoietin Endurance athletes will be aided by things that increase capacity to handle oxygen, blood doping, the transfusion of blood so there is an increase in hemoglobin, associated with stroke, heart attack and blood clots, 585 Creatine 300 mill market in us, naturally occurring in the liver, pancreas and kidneys, stored in muscles, anaerobic events, widely used by college, high school, and people in fitness regimens, swimmer, cyclist, and weight lifters, sprinters, not regulated by FDA, no problems short term but long term is unknown, 585 Beta Hydroxy beta methylbutyrate Anti catabolic, suppresses breakdown of protein, does prevent muscle change, modest improvement for persons not involved in training, involved in training there is no improvement, no neg side effects, lowering of cholesterol and blood pressure, 586 Adrostenedione (Andro) Over the counter, increasing testosterone, baseball, was it safe, the FDA classified to anabolic steroid, significant medical consequences, MEN: gynecomastia, prostate, acne, reduced sperm, infertility, testicular atrophy, WOMEN: body hair, deep voice, bald, BOTH: pancreatic kidney or liver cancer damage, reduction in HDL good cholesterol, glucose intolerance, blood clots, increased risk of heart attack 586
Drug Use Patterns
NIDA national survey on drug use and health and monitoring the future, consistent decline in illicit substance abuse 50 percent decline between 1979 and 1992, 1995 began to fall again, table 13.1 drug use in 2012 age 12 and older, other notable trend is drop in age of first use in past decade, alc and nicotine americas favorites, 518
major classes Nicotine
Nicotine: Patterns of use: ranks up there with alcohol, most widely used in the united states, major public health concern, decline in nicotine use, now 22 percent of population are smokers used to be 44, different forms of tobacco, 69 people use tobacco products in past month, 9 million people used illicit drug, one person using drug 8 used tobacco, waterpipes for smoking tobacco,perception is waterpipes aka argileh, hookah, narghile, shisha, is less harmful and less addictive, more acceptable ,rise in smokeless tobacco 545 Demographics of nicotine use: men more likely to use tobacco, gender gap disappearing, men quit smoking at higher rate than women, no difference in use patterns in young people, when it comes to age rate of tobacco rises dramatically from 12 to 18, peaks at 23 42 percent smoking, proportion declines, much more gradual than rate of acquisition, mid 60s before rate is equal to 16 year olds Racial differences: native americans highest rate, Education: associated with lower levels of tobacco use Employment: highest in unemployed, lowest among other includes homemakers students and retired and disabled, Geography: west lowest rate, size of community also plays a role, highest is found in rural areas and lowest in metropolitan areas 545 Associated Drug Use:smoking strongly associated with other substance use, best predictors of other drugs is smoking status, those who use tobacco more likely to use sedatives, hallucinogens, stimulants, and opioids. More likely to have used other drugs that are smoked, being used this to this route of administration of drugs smokers have more likelihood of experimenting with other drugs that are smoked, striking among teenagers, under age 18 9 times more likely to use illicit drugs, more likely to use marijuana and inhalants, use of heroin by non smokers is too rare 546
Other psychoactive drugs used worldwide 594
Other psychoactive drugs used worldwide Ayahuasca: amazon region in south America, two plants, religious practices and consumed as tea, difficult to produce Ibogaine: roots native to western Africa, combat fatigue hunger thirst and higher doses in religious rituals, promote abstinence, reduce craving to stims and opiates, no recreational use Kava: south pacific islands figi Hawaii and tonga, relaxation does not interfere with concentration, ingredient in some diet supplements, liver failure, problems found in above ground portion, alt to benzo Khat: shrub (Catha edulis) eastern Africa and yemen, medicinal plant, amohetamine like effects chewed, juice is swallowed and remaining portion kept in mouth, natural amphetamine, used at social gatherings, keep alert and reduce fatigue, cause some gastric problems, Betel nut: india, southeast asia, and pacific, nut, seashells, spices, folded into betel vine, quid, placed in mouth between cheek and gum, sucked, lime, mild stimulant, instant coffee, Salvia Divinorom: mexico, used ritually, mint, psychotropic, mild psychedelic, gained interest as recreational drug, smoking enhances, not federally controlled
problems
Pharmacological effects can lead to acute problem in the absence of dependence tendency is to think that major medical problems occur only after extended use, be decades of heavy drinking before irreversible liver damage or brain damage occurs, not true with other drugs, inhalants can have serious medical consequences with permanent damage in short periods of time 539
basic pharmacological concepts
Route of administration: how a drug is taken, how quickly it reaches the brain, and how fast the effects are felt, has sig. in terms of kinds of problems that accompany drug use, Site of Action: particular neurotransmitters that are affected, distribution in the brian, former, latter, Metabolism: how a drug is broken down and removed, problems that may result, alc. Is metabolized by enzymes, in liver and stomach, cytochrome, diff drugs present they are in competition and removal Is slowed, stepwise process, by products, some are benign, Solubility in fat and water: important in how drugs distributed after ingestion 536
clinical issues
Treatment goals: most central question, troublesome question: in absence of is establishing moderate level of use a goal?" never a goal, exception is marijuana, concern dependence in abuse potential, with cocaine or nicotine risk is considerable, establishing moderate is unlikely, continuing use changes route of administration, increasing risk of dependence, some drugs long term use makes health consequences, other drugs short term effects, clinical efforts to stop using, 602 Harm Reduction:although clinicians goal may be abstinence, that might not be clients goal, programs can be purists and push away those who are not interested in abstinence, alternative: harm reducation, fewer overdoses, bad trips, fewer sex disease, medical emergencies, creating smarter users yields benefits, reduce the risks and harms associated with use, reality is that clients have own goals, best thing is to get them to reconsider options, needle exchange program, informed about injections, in inhalants point out marijuana, word out there that there is bad dope, drug substitution, heroine replaced, 603 Overdose emergency kits Harm reduction in Opiate users, administering naloxone, nasal or injection, limited eval the general response is positive, recently released prisoners, individuals after prison increased risk in overdose, previously not problematic may be lethal 604 Pharmacological treatment Potential to develop drugs with specific properties that may help in treatment, three major approaches to drug therapies 604 Drug Replacement: Substitution of a different drug, prescribing drug of abuse, twofold, one is harm reduction other is promotion of an environment where rehab efforts can gain foothold, nicotine is a prime example, another example is methadone, and buprenorphine which are two pharmacological subs for heroine, many risks of heroine are related to route, contaminents or unintentional overdose, heroine shorter length of action which requires more administration, methadone is safer and does not not provide rush but does stave off withdrawal, buprenorphine is newer drug and sub for heroine, available for office based use, can be taken 3 times a week, adequate dose must be given 604 Anit-craving drugs Nicotine, cocaine, heroine, and alc, wellbutrine and Chantix, psychotropic meds in anxiety and depression reduces craving 605 Blocking agents Chemical walls, adverse reactions if substance is used, naltrexone, opiates, for person who has withdrawn from all opiates the use can serve as if poiates are taken there is not rush or high that motive for use. Bind to receptors like they already took drug 605
nicotine
Treatment: Offered in hospitals and community health departments, 15-25 percent success, people try to quit smoking several times before succeeding, include patient education, group supports, counseling, and nicotine replacement, nicotine gum, patch, nasal sprays, inhalers, the gum and patch are over the counter, inhalers require a prescription, Wellbutrin reduces craving, zyban the two should not be taken simultaneously, can use nicotine replacement and bupropion, med is associated with suicidal ideation, resistance of treating smoking cessation as part of other alc or drug use treatment: relatively higher levels of smoking in staff, misperception that addressing nicotine with other use leads to poorer outcomes, the idea that multiple dependencies should be handled sequentially, and most important inadequate training in smoking techniques, 549
clinical issues
Use of naltrexone Important in several ways people cant get high and it is pointless, 20 hours, daily reminder and safety net, help prevent lapse in relapse, two forms oral and injection, vivitrol lasts for month, Many hesitant to use monthly injectable form due to concerns of pain in case of accident, anesthesiologists can overcome opioid blocking effects, used in first 90-180 days, longer is possible as long as liver is good 606 Naltrexone vs naloxone Both blocking, naloxone in emergency not oral rapid onset, carefully, can cause seizures and heart attacks, disulfiram is blocking agent. Serves as disincentive to drink, will become sick, isn't blocking in pharmacological sense, due to its slowing the breakdown of by product, 606 Looking ahead: Vaccines Barrier for drug abuse, gobble up drug before reach brain, primary prevention effort, nicvax, 607
withdrawal
abstinence syndrome, differ by drug class, symptoms associated with use and opposite for symptoms associated with abstinence, depressant symptom is agitation, shorter the duration of the effects of a drug the more intense the withdrawal, withdrawal will be short, 537
social influences
abuse is a pharmacological concept, social acceptance, opportunity for use, would not be widely abused if little access to it, monitoring the future survey, availability and perceptions and how easy it would be to get a drug above age 30 typically a drop in those who perceive easy access, one notable acception in 50 year olds cocaine is accessible, steroids in one drug that high school students consider more accessible 539
pharmacological effects
another way of classifying drugs is group in terms of primary effects, diagnostic and statistical manual uses this, particular use to working in clinical field, how those who use drugs think about them, slang like uppers or downers, family of drugs, drugs in the same class share important characteristics, used for particular effect, have similar effects on brain symptoms of overdose or toxicity and similar withdrawal syndromes. Also basis for treatment 544
marijuana
asain in east mexican in west, number one cash crop 35.8 bil, corn, 400 mil purchases annually, six-7 joints, no prof. dealer, friend or relative or free, 532
Sedative-Hypnotics Central Nervous System Depressants,
category to which alcohol belongs, many of the drugs in this group have properties similar to those of alcohol, most serious interactions with alcohol occur with drugs in this class because they both have depressant effect, medications in this class are used for detox from alcohol, substituted for the alcohol with doses then tapering off 559 Patterns of use Lease difference in use based on gender, 559
cocaine
coca leaves, andes, bolivia, peru and columbia, centered in colum. 532
DEA schedule
controlled substances act: originated as Harrison act, identifies some drugs as controlled substances and sets forth rules about manufacture use and distribution, FDA houses machinery for determining status of a drug, controlled are limited to those for which there is potential for abuse, if controlled the drug is placed in five categories, depending on potential for abuse dependence and accepted medical use. Schedule I: high level of abuse and dependence no accepted medical use: heroin, LSD, and marijuana Schedule II: similar to schedule 1 evidence of the potential for abuse, there is an accepted medical use, restrictions on manufacture and distribution via production quotas and import and export controls, non refillable and include methadone, morphine, amphetamines, and cocaine Schedule III: moderate risk for physical dependence, high risk for psychological dependence, reasons for medical use, Vicodin, suboxone, and Tylenol no. 3 and 4 Schedule IV: low risk for physical dependence but moderate risk of psychological dependence, accepted intications for medical use, valium, Ativan, Halcion, Darvon Schedule V: low risk for both physical dependence and psychological dependence. Lomotil is an example.543
flexibility in the drug trade
crops can be grown anywhere, afghan and iceland, trader on camel to purchase opium in 1970, all changed when poppy banned in iran, mexico major supplier of marijuana, cocaine from colombia, seeming solution was to tighten the boarder, very shortly afterward the country witnessed rapid increase in cocaine, shifted attention rom marijuana to cocaine 529
heroin
derived from opium popies in afghan, us bulf of it from mexico, heroin dominated west black tar and brown, white powder in east, (columbia) now moving to east markets, decline in colum. 532
club drugs: an exception
do not constitute a pharmacologic class of compounds, fall into multiple drug classes: sedatives/depressants, stimulants, hallucinogens, dissociatives. Common denominator isn't chemistry, it the settings in which they are used, nightclubs, music festivals, dance parties, and raves, the rock concerts, raves commonly in private clubs hence club drugs, discussed later in more detail 544
flexibility in drug production
emerald triangle, golden triangle, marijuana production in california has become business of mexican drug organizations, mexican gangs import workers to plant and tend large marijuana plots, "grows", trees removed, ground cover removed, remove male plants, increases THC and street value, 529
The conundrum: mythical numbers
estimates, re-thinking the war on drugs, mythical numbers, Example: marijuana more than 10,000 MT of dom mari., 20 mil users in us, state department report, 522
rethink prohibition as a drug policy
growing number of historians point out that many of problems and social costs are not pharmacological effects but they result from we have made drug use illegal. one option is to control and regulate now-illicit rugs in the manner of legal drugs combined with vigorous public health efforts, national public health experiment, legal status of marijuana, 19 states have legal marijuana, differs fed gov wanted to step in, includes patient registery, dispensaries, specify conditions, and state recognition of patients from other states, , american society of addiction medicine, (ASAM), the role of physician in medical marijuana, opposes medical marijuana on several grounds, absence of peer reviewed research, not usual FDA scrutiny, smoking is health hazard, potential impact marijuana has on public sentiment, adolescents concern because of schizophrenia, adolescent marjuana use was not affected before and after legalization, at some point the fed gov will take action, economic aspects, 527
new methods of cultivation
hydoponic famrs, 2007 major arrest in los angeles, rented home in nice suburb into hydroponic farm, 530
controlled substance analog
identified by their chemical formulas. Changed drugs slightly so the drugs chemical composition was no longer that specified by the law. Designer drugs, the amendment added to controlled substances act as part of the anti drug abuse of 1986, created a new category controlled substance analog, used for drugs in schedule 1 and 2, treated as schedule1 drugs without any redeeming social value 543
education
late adolescents and young adults have similar rates, no nice tidy relationship between education levels and drug use, college more likely to use drugs at some point, number using declines, college grads less likely to be current users, 520
societal costs of prohibition
legal marijuana would save 7.7 bil a year un gov expenditure on enforcement of prohibition, 5.3 savings would fall to state and local gov. the remainder to fed, 6.2 tax revenue, 531
Drug dealers
major player in drug diversion, pay people for pain clinic shopping, visiting numerous pain physicians and multiple prescriptions, recruit a pharmacy technician who can pilfer drugs for fraud prescriptions, purchase a portion of indigent patients or VA patients prescribed drugs, blatant health care fraud, counterfeiting MRIs as a prop to use 533
health problems
many result from route of administration, some result directly from drugs action. Drug effects: medical problem, injury more common in presence of substance abuse, as is suicide, overdose, combination of drugs create probs not associated when they are alone, rhabdomyolysis and stroke (methadone and heroine) Route of administration:injection:skin infection, cellulitis, absence from poor injecting. Needle sharing: increased risk of infectious disease, HIV, hepatitis C, Intravenous use: cardiovascular probs, pseudo aneurysms, endocarditis Inhaled: respiratory problems, body packing: ingestion of drugs as part of the drug trade to avoid detection, lead to overdose or death. Illicit drug manufacture: meth prime example, cooked, injury from chemical burns, anhydrous ammonia, explosions, fumes pollute the home and present dangers for family members, children, after home is sold may need to decontaminate entire house, 40,000 dollars, the longer it was used to cook meth, the greater the contamination of wallpaper, wooden doors, woodwork, ductwork, cabinet, virtually everything Social circumstances: sex work to finance drug habit or cover basic expenses, increase risk of HIV and array of STD, tattoos and body piercing, do it yourself, failure to use sterile techniques, tuberculosis most common among people with drug problems, poor health and poverty 524
Hoffman-laroche rohypnol
marketed in Europe and latin America, slipped into women drinks, in comb. With alc. They have addictive effect, made it turn white, assist date rape victims, Initial reports of drug in media may be inaccurate, flunitrazepam, internet urban myth Perdue Pharma, oxycotin, false marketing, 534
gender
men higher illicit drug use than women, 11.6 versus 6.9, younger age group 9.6 to 9.5, females more likely to use prescription drugs for non medical use, 520
Drugs of Abuse other alcohol
more attention to alcohol because of their wider use 517
prescription drugs
much larger parts of US drug prob., friends or fam number one and free diversion of legally prescribed medications, oxycotin, pill mills, southeast, fly by night pseudo pain clinic, high dose of opiods to anyone, internet pharmacies tale of 10 pills, when the quantity of drugs needed is beyond the amount that a friend will hand out for free, diversion of legally prescribed medications, internet pharmacies: rogue pharmacies, unregulated, saves money, sub-potent, super-potent, or expired or counterfeit or containing wrong ingredient, 533
Use Patterns as an indicator of abuse potential:
nicotine users with substance use disorder, 538 users with substance use disorder chart
Facts versus myths
not only material provided its frequently the information that isnt provided, california seizure, students say it is very easy to get pot, CAMP, does no good, republican county board, total drug arrests is misleading increase in drug arrests attributable to marijuana, 531
Early Control Efforts
originally considered therapeutic agents and prescribed, typical narcotic addict at end of 1800s was white female been prescribed narcotics for female problems, many patent medicines contained array of drugs, cocaine initially touted as being useful in weaning people from opiates, seen effective in treating addiction, quickly became apparent it was addictive, in 1898 heroine introduced Bayer Laboratory, same research made aspirin, heroine was a cough depressant, improve lung function, heroine probs wouldnt have been manufactured, within a decade discovered heroine doesnt improve lungs, dope doctors, ready availability of all drugs in over counter preparations sparked 2 key pieces of US legislation 526
toxicity and overdose
overdose, lethal dose, LD 50, originated in toxicology lab studies, represents the amount of drug at which half of the animals to which is administered die, midpoint where people die, effective dose ED50, the dose that 50 percent of animals need to take to get the desired effects, size of windows between dose needed to get desired effects and where death occurs, little margin for error, lethal dose to effective dose is safety ratio. Chart applies to 155 pound adult, differences in safety ratio of different drugs, most toxic substances have lethal dose less than 10 times effective dose, heroin, isobutyl nitrite, and GHB, next most toxic is ratios from 10to 20 include alcohol, cocaine, codeine, DXM, ecstasy, meth, 540
emergency or temporary scheduling
part of the comprehensive crime control act an amendment to controlled substances act was passed to allow immediate action in delaing with drugs shown up on the street and not covered by existing schedule, head of DEA authority can declare drug as schedule 1 temporary, until research can be conducted, 543
employment status
possible that higher rate of drug use among unemployed may be a result of unemployment, appears to be the case with alcohol use, employment status correlated with drug use patterns, 520
reducing drug diversion
psychoactive properties, can reduce abuse potential, failure to look at this is what cause a delay in FDA approval of buprenorphine in treatment of heroin, has abuse potention when crushed and injected, reduce likelihood of abuse when manufactured as suboxone an additional drug naloxone is combined with buprenorphine. Naloxone is opiate antagonist and block opiates. Presented only when naloxone is injected. If taken orally suboxone the naloxone has no effect, if the person is already on opiate then inject naloxone the person goes into immediate withdrawal, oxycotin, subutex, pregnant clients, naloxone can cross placenta and fetus into opioid withdrawal. 534
legal highs: another example
recent arrival, related to illicit drugs, synthesized to be different to avoid being considered a controlled substance analog, cousins, not being illegal not only on the web but also in convenience stores or delis, they are all natural or without harsh chemicals, one group is 544 Synthetic cannabinoids: names as spice, K2 sold in small packets. Synthetic Cathinones: take offs on the stimulants of the amphetamine class, include bath salts, jewelry cleaner, plant food, meow meow, mephedrone or other cathinones are the active ingredients Synthetic drug prevention act: emergency law, banned 26 different chemicals thought to be used in manufacture of these drugs 544
Legal Status
single major factor is legal status that affects the way we view and respond to substance abuse, perceptions of danger are tied more to legal status than its pharmacological properties, "them", Different from "us", seen existing in urban inner cities in minority group, or within immigrant groups, long historical precedent, how federal money is spent, large proportion of money is spent on the war on drugs, is not for treatment or prevention, goes to policing efforts, border patrol, coast guard, third of all money spent went to precention treatment ie demand reduction, majority went to supply reduction, dramatic change from early 1980s, expenditures for both essentially equal, dramatic rise in prison population attributed primarlity to drug related offenses and mandatory sentences for drug related offences, especially worrisome minorities are most likely, not higher rates of use among this population, Harm Reduction: recognition that while preventing may be long range goal the interim there are steps that can be taken to reduce negative consequences associated with use, problematic when illegal drugs are involved, might be seen as condoning, replace fear tactics with facts see people as needing treatment rather than criminal sanctions 525
sources of drugs
sources vary, 532
abuse potential
speed of action related to route, injection most rapid onset of action then smoking then oral ingestion, marijuana smoking or food, cocaine smoking snorting or injecting, 537
illicit drug labs
stimulants synthetic drugs not prescription, is made in small labs in rural areas, meth, kitchen can serve as lab, ease chem required easily obtained, fed law, cold meds with ephedrine and pseudoephedrine, ammonia in meth, fumes, 533
Comparisons with alcohol
striking diff. between proportions and nature of crimes atrributable to drinking and drug use. alcohol associated with crimes against people twice as likely to homicide, 6 times in assalts, 10 times in sexual assaults, other drug use associated with crime against property, 8 times in robs, 10 times in larceny, 2 times in auto theft. drug arrests account for largest portion of arrests at 13 percent, DWI 3 spot, alcohol related arrests would be number 1 if liquor law violations 24 percent of all arrests 523
the market
there will always be a market for drugs, making illegal does not make market evaporate, intro to organized crime during prohibition, 528