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Intoxication/Withdrawal (Substance use disorder - problematic pattern of…
Intoxication/Withdrawal
Substance use disorder
- problematic pattern of use, within 12 mo period, significant impairment or distressed demonstrated by 2+ of
larger amounts/longer period of use than intended
persistent desire/can't cut down or control use
a lot of time spent trying to get, use, or recover from use
craving/urge to use
recurrent use causing failure at major obligations
continued use despite recurrent problems caused by use
important activities given up/reduced by use
recurrent use in physically hazardous situations
tolerance/withdrawal
continued use despite knowledge of problem
Cocaine
mechanism
- competitive blockade of dopamine reuptake by dopamine transporter, blocks reuptake of noradrenaline/serotonin, block initiation/conduction of nerve impulses (local anesthetic)
intoxication
- SNS overactivation - HR/BP fluctuation, N/V, weight loss, confusion, seizure, coma, psychomotor agitation/retardation
overdose
- delirium, tactile hallucinations (ants), hyperthermia, seizure, sudden death (cardiac/vascular)
withdrawal
- dysphoric mood, fatigue, unpleasant dreams, sleep issues, suicidal ideation (tx - symptomatic - often benzos)
Amphetamines
mechanism
- release and prevent reuptake of noradrenaline and dopamine, act as MAOI (prevent degradation of NTs); designer amps also release serotonin
effects
- similar to cocaine - SNS overactivation, maybe more jaw clenching (esp ecstasy), euphoria and self-confidence, delirium, psychosis, looks like mania
MDMA/ecstasy
- increased emotional openness, euphoria, increased insight - use in psychotherapy? - long term use --> depression due to serotonin depletion; likely neurotoxic
crystal meth
- more fat soluble - more BBB penetration > addictive
bath salts
- beta-ketone amphetamines - serotonin like properties - lots of agitation/disorganization of thought, doesn't show up on tox
withdrawal
- similar to cocaine, lots of sleep disruption, suicidal ideation, irritability
PCP (phencyclidine) - dissociative anesthetic w/ hallucinogen effects
mechanism
- antagonist @ NMDA glu receptors (psychosis); activation of dopaminergic neurons
intoxication
low dose (1-5 mg): CNS depressant,
nystagmus
moderate dose (5-15 mg): HTN, dysarthria, increased muscle tone (breakdown - fighting against restraints can make it worse)
high dose (20+ mg): fever, rhabdomyalosis, renal failure, seizure, depressed breathing ,death
bizzare, violent behavior - anesthetic effects can lead to severe bodily injury
tx: isolate in nonstimulating environment, benzos for agitation, antipsychotics can make it worse!
Ketamine
dissociative anesthetic
auditory and visual hallucinations
profound respiratory depression
LSD
mechanism
- serotonin receptor agonist
effects
- pupillary dilation, tachycardia, sweating, tremors, visions
adverse effects
- panic, depression, confusion, fear of insanity, looks like acute paranoid or anxiety reaction
treatment
- reassurance, benzos, antipsychotics last resort
Marijuana (delta-9-tetrahydrocannabinol = THC)
effects
- psychoactive = euphoria, relaxation, effects on memory, paranoia or anxiety in some, decrease IOP, increased conjunctival blood flow, increased HR, muscle relaxation, dry mouth
mechanism
- cannabinoid receptors - vision, memory, pain, inflammation
withdrawal
- irritability, anxiety, depressed mood, restlessness, weight loss, abdominal pain
K2 - synthetic cannabinoid - 10x more receptor affinity than THC - hallucinations, aggression
Alcohol, benzos, barbs
mechanism
- binding sites on GABA receptor - increase affinity for GABA
intoxication
- disinhibition, relaxation --> nystagmus --> emotional volatility/blackouts --> decreased resp drive/coma/death
withdrawal
- can kill!!!! watch for autonomic hyperactivity, tremor, seizure, psychosis
w/drawal tx
- start benzos ATC and slowly taper, flumenazil for overdose, carbamazepine to lower seizure risk