Pharmacology: Stimulants, Depressants and Hallucinogens

Hi everyone and welcome to today’s class
on stimulus, depressants and hallucinogens. You can see in your window
that you have the ability to send me a chat message whenever you are ready and
wanting to ask a question if anything comes up and I will try to answer it as
we go and I will also hang out after class if you have any other questions.
I’m going to kind of fly through this material. I’ve added a bunch of handouts
within the class so you can access some of the stuff that you know. I would just
be reading to you which is kind of boring anyway. So here we go oops and I
used the wrong scripts live shot. Anyway the objectives today we’re going to
define stimulus depressants and hallucinogens we’ll discuss their
mechanisms of action symptoms of intoxication symptoms of withdrawal
short and long-term effects common street names and then we’re going to
talk about differential diagnosis now a lot of you are familiar with some of the
symptoms of intoxication and withdrawal I think it’s really important that we
look at differential diagnosis though so we can sort of get an idea in our minds
as clinicians are we dealing with symptomatic
intoxication or maybe a manic episode so before we get started a couple little
side notes the method of administration will greatly affect the intensity and
duration of onset for various drugs it doesn’t matter whether we’re talking
stimulants depressants you know yada yada so oral is your slowest it’s got to
go through the gastric system you know and it takes a lot a lot longer
inhalation through snorting is a lot faster
smoking is faster injection is super fast rectal suppository surprisingly is
also super fast and skin patches where it’s absorbed directly through the skin
is also another relatively fast method of administration
you’ll notice with some of the skin patches like the fentanyl patches if
somebody gets ahold of those they also may adulterate the patch with other
drugs in order to have multiple substances going into their system
concurrently so trucks affects everyone differently based on their size weight
and health whether the person’s used to taking to it whether other drugs are
taken concurrently the amount taken and the strength of the drug now if we’re
talking illegally produced drugs you never know what you’re going to get what
is cut with but it’s also important to pay attention to the individual person I
know for myself I’m a lightweight what a doctor prescribes to me for you know for
pain or for muscle relaxers or anything like that I take whatever is prescribed
and I cut it in half because it is you know just way too strong for me if I
take you know the full quote adult dose so we need to pay attention to that with
our clients and not minimize if they’re only only taking a certain amount they
may be more reactive to it likewise if they’ve developed a
tolerance they may be able to take a lot more one of the young women I worked
with when I was supervising a detox facility she was you know maybe 105
pounds soaking wet and she could inject 15 crushed oxys in one sitting I’m like
oh Lord you know half of an oxy and I’m just
like sitting on the couch drooling so you can see where tolerance can develop
really quickly and you know she’s a lot smaller than me and taking a whole lot
more so just be aware of that okay so what are stimulants stimulants are
substances that act to excite the central nervous system caffeine and that
amines cocaine these are our general stimulant drugs that we’re going to talk
about stimulus increase alertness attention and energy as well as
elevating blood pressure heart rate and respiration sometimes people use them to
counteract the effects of some of the other drugs that they’ve taken if
they’ve taken depressants or some that has slowed them down they may use
stimulants in order to kind of wake back up they’re used to treat asthma and
other respiratory problems obesity neurological disorders ADHD narcolepsy
and occasionally depression so there are medical uses for them but we do know
that they are highly susceptible to abuse stimulants enhance norepinephrine
and dopamine norepinephrine is your wake-up chemical and dopamine is your
feel-good chemical so you wake up and you feel good so that sounds like a
winner to me increases in dopamine can induce a feeling of euphoria when
stimulants are taken non-medically again it depends on the person if you go to
Starbucks and you get at all or whatever it is brew coffee you’re gonna get so
much caffeine that you may feel a buzz and that’s not necessarily you know
that’s that’s that’s food it’s not like you’re abusing the coffee so we’ll talk
about that a little bit more later even medically prescribed levels if
stimulants can give somebody the feeling of a buzz if they’re less tolerant to it
and they need to talk with their doctor about that
yada-yada norepinephrine also increases blood pressure and heart rate constricts
blood vessels increases blood glucose and opens up breathing passages it’s
your fight-or-flight on one of your fight-or-flight chemicals it says let’s
get ready to go let’s get that blood pressure up let’s get the heart pumping
and let’s make it so we can breathe so we can get through this
yeah well that can be good and it can be bad the increase in norepinephrine or
noradrenaline and dopamine happens in four ways in the brain and I’m going to
go over this simply because if you’re taking the addictions counselor exam you
may be tested on the mechanism of action so we are going to talk about it for a
minute they can bind to the presynaptic membrane causing the release of dopamine
so remember you have the presynaptic membrane the synaptic space
and the post-synaptic so if it binds to that basically the opening door and it
opens the door up it causes the release of dopamine into the synaptic space it
can interact with dopamine containing synaptic vesicle vesicles releasing free
dopamine into the nerve terminal so again it can push that dopamine out
there into the space basically between the two doorways it can bind to the Mao
is or Mao s monoamine oxidase in dopin dopaminergic neurons and prevent the
degradation of dopamine leaving free dopamine and the nerve terminal
basically it’s binding to things to keep the dopamine from breaking down and
being reabsorbed so it’s keeping that dopamine and the space longer so more
can be sent through the channel and it can bind to the dopamine reuptake
transporter causing it to act in Reverse and transport free dopamine out of the
nerve terminal so there are a lot of different ways that’s messing with that
mechanism of action normally we have a little squirt of dopamine it sits in the
in the synaptic space it’s absorbed as much as it needs and then all the excess
is sucked back up we’re kind of monkeying with that effect right now
basically it’s making dopamine more available we know that dopamine is our
super reinforcing reward chemical so when more that’s available people get a
stronger feeling of euphoria so signs of stimulant intoxication if somebody comes
into your class maybe you’re teaching an IOP class maybe they’re just coming in
for an assessment they’re going to feel pretty good they’re gonna have increased
energy increased confidence mental alert alertness sexual arousal possibly
itching and scratching large pupils large pupils as opposed to our opiates
that we’ll talk about later where we’ve got pinpoint pupils
dry mouth fast heartbeat and breathing teeth grinding reduced appetite and
excessive sweating so if they are chewing on a lollipop for a sucker
or you know sometimes a tongue depressor or a toothpick you might want to kind of
investigate that we also have a lot of people who come into treatment who are
you know they’re just a little bit high-strung anyway maybe they have an
anxiety disorder or maybe they’re excited to be there whatever the case
may be we don’t want to assume that someone is pumped up on stimulants right
away but it is a good idea to kind of pay attention to some of this stuff and
look for signs of intoxication and it could be that they just pounded back to
redbulls before they came into group whether your facility tolerates that or
not is you know a policy thing but it’s important for them to realize that just
because caffeine is you know available at meetings doesn’t mean that it is okay
to abuse to excess abuse or use to excess so stimulant withdrawal this is
fun and I’m being sarcastic in the four to six days after stimulant use the
following effects may be experienced restless sleep and exhaustion
so the norepinephrine and dopamine has gotten all out of whack which means the
serotonin has gotten all out of whack and serotonin helps us sleep which means
circadian rhythms are probably out of whack because we have a lot of people
who use stimulants and you know no surprise don’t sleep so they may be up
for 24 hours three days a week without sleeping or without sleeping much so in
the four to six days after the body is going I’ve got nothing left to give
they’re exhausted but the sleep is restless and unrefreshing headaches
dizziness and blurred vision paranoia hallucinations and confusion so they may
feel like they’re seeing things or hearing things and start to get really
paranoid irritability mood swings and depression anxiety and insomnia so
looking at this these are also symptoms of anxiety when you have restless
exhaustion headaches sometimes people if they go into a little bit of a panic
panic attack will start to feel like they’re getting dizzy and they might
start to get a little bit irritable again looking at differential diagnosis
I don’t want to assume that every symptom is the result of a drug use
likewise I don’t want to assume that every symptom is the result of a mental
health issue we need to ferret it out as we get to know people and try to figure
out which one is causing which obviously if you’re doing urine screens you’re
gonna have a pretty good idea about any illicit substances they may be taking
but unless you’ve got a really really amped up on-site drug panel you’re
probably not going to know how much caffeine or nicotine that they’ve been
Justin methamphetamine just a little bit of a tidbit here has a substantially
longer half-life than cocaine which can lead to a more intense and protracted
withdrawal so withdrawal from methamphetamine is rough it was really
rough and it can last a lot longer because a half-life is the amount of
time it takes for the half of the substance to get out of the body so for
caffeine you know just caffeine since we all well most of us probably drink it
half-life for caffeine is six hours so if you drink a big cup of coffee at noon
it is not going to be fully out of your body until midnight so if you have
methamphetamine and it takes longer to get out of the system than other
stimulants you know we’re talking more than four to six days it’s going to be
more like two weeks that the person may be experiencing symptoms during this
period chronic methamphetamine users may have episodes of violent behavior
paranoia anxiety confusion and insomnia it’s amazing what happens when the
neurotransmitters start to get wonky especially when we start talking about
norepinephrine which is our fight-or-flight mom nor okay
you can see where that might be a problem okay another one I felt like it was really
important to mention because even if you’re not working with drug addicts
themselves or if you are and they are trying to work out and get themselves
physically healthier which is great don’t get me wrong
turning to supplements that have stimulants in them can be
counterproductive to their recovery the list of the dod list of supplements to
avoid has 40 supplements on there that have medications that have any are not
medications but drugs in them that haven’t even been studied on humans so 11 of them were found to contain better
beta methyl phenyl ethyl l-‘alameen yeah if you can’t pronounce it probably
shouldn’t be eating it BMP EA and only three of those
supplements actually listed that it had that in it so if a client comes to you
and says I’m taking this stimulant supplement but no it doesn’t have any
the bad stuff in it since they’re not really well regulated it’s important to
educate them that yeah it may still you don’t know exactly what’s in there like
I said the Department of Defense found 40 supplements that actually still had
some of these in them and they are not ones that soldiers should be taking back
to coffee one of my favorite things toxic overdoses or toxic doses of coffee
can be anywhere depending on what you’re reading from five grams to 10 grams per
day for an adult that’s a lot a gram is a thousand milligrams so you know you’re
really popping it back some people are more sensitive if you’re taking certain
medications that are already stimulants then 5 grams may be way more than you
can actually handle so for example a cup of coffee may
anywhere from 80 to 175 milligrams we’re talking a normal cup or not talking you
know the giant mugs that you know Red Bull Red Bull actually only has eighty
milligrams in it and monster only has 86 but they also have other herbs and
things in them that are designed and sugar
they’re designed to work synergistically with the caffeine to amp people up and
they do I mean people feel like their hearts
gonna pound out of their chests sometimes a Starbucks short which is a
little tiny brewed coffee is a hundred and eighty milligrams so if you get a
tall that’s almost 360 milligrams it’s 616 ounces that’s a lot in one sitting
stack or two is a common pre-workout supplement that athletes will take
especially bodybuilders and you know people who are weight training that
aren’t competing where they are regularly drug tested one capsule of
stock or two has 200 milligrams of caffeine which is the same as one tablet
of vibrant a lot of us you know depending on how old you are if you’re
you know around my age vibran was big when we were in college and kind of in
high school being aware of how much caffeine it has because you can develop
a tolerance to caffeine as well you can also develop a sensitivity to caffeine
and stimulants so if someone is taking the take-home message is if someone is
taking over-the-counter stuff in addition to illicit drugs in addition to
prescription meds they may be creating a cocktail that is just a recipe for a
heart attack we need to encourage them to be aware of
what they’re putting in their body possible side effects for stimulants
include hostility have you ever been around somebody who’s
had too much coffee and they’re really amped up and they’re just like they
they’re sort of freaking out that’s the hostility we’re talking about
they may not be able to be patient they may be
feeling that fight-or-flight chemical fight-or-flight reaction that’s going on
and they’re just like okay I gotta get it and anything that stands in their way
could be perceived as negative paranoia psychotic symptoms unsafely elevated
body temperature stimulus ramped us up they’re also going to elevate our body
temperature we don’t really want to cook ourselves from the inside irregular
heartbeat and heart failure seizures and exacerbation of existing anxiety if you
take somebody who is already kind of anxious has panic attacks regularly has
issues where their their heart rate increases panic attacks like I said and
you give them stimulants what do you think is gonna happen they’re going to
have an exacerbation it’s going to intensify those anxiety symptoms coke I
believe a question came in coke I believe has about 65 milligrams in it
but you can actually Google caffeine calculator and there are caffeine
calculators online that you can help people use they can put their drinks and
their you know various things that they eat in them because chocolate has
caffeine too bummer and figure out exactly how much caffeine they’re
ingesting per day long term effects of stimulants reduced appetite restless
sleep or messing with this serotonin and melatonin were messing with circadian
rhythms dry mouth and dental problems reduced immunity the body’s just going
I’ve got no more to give it’s diverting energy from other places
trouble concentrating shortness of breath and difficulty breathing
paranoia depression and suicidal ideation how does that come from
happy chemicals and fight-or-flight response well at a certain point you run
out of gas and you just can’t do it anymore and it
starts to sort of have the opposite effect because
the person is trying to get dopamine there’s no dopamine left they’ve already
it’s it’s gone through that post synaptic terminal and their body
couldn’t make more fast enough norepinephrine SATA balance one of the
presentations we did last week talked about dopamine norepinephrine gaba and
serotonin they all work in a balance with one another so when one goes up
some of the others go down and they can actually suppress one another so the
long-term effects of using stimulants or depression and suicidal ideation what
does the person do when they feel depressed and suicidal when they
normally abuse stimulants that make them feel happy and euphoric use more
stimulants we know that we’re gonna have to help people get through this period
while their brain sort of recovers heart and kidney problems you’re putting an
awful awful tax on them when you’re ramping up your system quite that much
increased risk of stroke because of the increased blood pressure tolerance
confusion and sexual dysfunction chest pain and palpitations and seizures and
delirium so as a person develops a tolerance and they use more they become
more susceptible to side-effects common street names I’m not going to go through
all of these they are in your handout that’s in the class but there are a lot
of different street names most of our clients don’t expect us to know the
street names which is good because I don’t but if you happen to overhear a
conversation while you’re walking through the day room or you know in the
lobby or whatever if you know some of these buzzwords it can give you a clue
as to what’s going on and who’s selling what to whom because you know we all
know it happens and it even does it does even happen on our treatment center
properties no matter how much we try to control it there are going to be people
who try to bring contraband in so just being aware depressants exert the opposite effect of
stimulants they slow everything down depressants do a number of different
things the most prominent of which facilitates gaba which is our relaxation
chemical and inhibition of glutamatergic or mono Amon urge ik I hate trying to
say those activity now if you remember remember if you were in the presentation
last week gaba is actually synthesized from the breakdown of glutamine so when
we’re talking about the facilitation of gaba we’re talking about breaking down
more glutamine glutamine excite is an excitatory neurotransmitter so we need
to understand that if we are in inhibiting that or if we’re increasing
the breakdown of glutamine in order to make more gaba which will help people
relax then we’re going to start to feel kind of slower the mana limit ami nergic
receptors cover your dopamine noradrenaline and serotonin
so there’s noradrenaline also nor known as norepinephrine again so if we’re
going to inhibit norepinephrine again we’re going to slow people down some types
now stimulants there’s not as many when you’re talking about stimulants you’re
talking about like sudafed if as far as over-the-counter caffeine amphetamines
methamphetamines your ADHD drugs there there aren’t as many different
categories that stimulants fall in your depressants on the other hand is a wide
range your barbiturates and your benzodiazepines are both depressants now
barbiturates are not used as much anymore they’re your Barbra tall’s
phenobarbital is one that I’ve seen a lot in
hospice care it tends to be more prevalent more easier to get addicted to
more side-effects so people have moved towards using your benzodiazepines your
benzodiazepines will either end in lamb or Pam diazepam so when you when you’re
talking about benzos you’re talking about xanax valium
I believe Halcyon are your trade names inhalants yeah inhalants are actually
depressants if we have a lot of clients who work in the construction trade if
they are working in construction around paint gasoline glue aerosols of various
types especially in enclosed areas they may be experiencing sort of secondary
effects of enhance encouraging them to understand that so they understand why
their mood may be a little bit wonky encouraging them to try to avoid being
in closed up rooms where any of this is happening and please encourage c-level
management not to repaint the treatment facility while you have clients in there
if at all possible because it will have a depressant effect on a lot of your
clients muscle relaxants these are also depressants they’re designed to sort of
make those muscles including your heart slow down relax a little bit your non
benzo hypnotics like lunesta and sonata and your opiates so you’ve got
painkillers you’ve got sleeping pills you’ve got
muscle relaxants you’ve got random chemical inhalants benzos and
barbiturates Oh interesting little side note paints any of your glitter paints
are going to be more psycho reactive than your flat paints just be aware so
if you are working with someone who’s a paint Huffer if they are using the
reflective glittery paints they’re getting a much stronger
dose of the chemicals that cause the highs and make the Milan D generate and
all kinds of stuff 80% of the global opiate supply is used by Americans and
99 percent of global hydrocodone is used by Americans I’m wondering is that just
because our our medical system is that much better you know something to talk
about amongst yourselves direct health care costs are eight point seven times
higher for opiate abusers and this comes from the CDC and the annual cost of
opioid abuse in 2001 was eight point six billion and in 2007 had skyrocketed to
fifty five point seven billion and this is for opioid abuse not for people who
are in a pain management clinics seeking medically controlled treatment these are
for people who have crossed over from medical use to abuse opiates are a pain
killer a depressant and an antitussive I learned that when I was pregnant it was
kind of interesting at least to me that codeine is actually a cough syrup or can
be used as a cough syrup I digress types of drugs your opiates can be
natural synthetic or semi synthetic and whether you’re talking about natural
semi synthetic or synthetic they’re gonna have a similar action if they are
produced in a lab under controlled setting then they’re going to be more
even between batches so let’s talk about drug testing because drug testing for
opiates is really interesting in my very strange mind they can be detected in the
urine for two to four days heroin contains acetyl codeine codeine is
and to morphine so both codeine and morphine may be found in the urine after
codeine ingestion so if we’re doing an on-site urine test where you have the
little rapid test kits and somebody says I was taking codeine as prescribed by my
doctor but you also see morphine show up send it to the lab because it could just
be a byproduct of the metabolites of the codeine you really need to get a level
on what the morphine was oxycodone on the other hand does not produce a
positive response to routine screenings for opiates which target morphine and or
codeine it produces a different assay so you either need to have that panel on
your cups or you need it need to send it to the lab so oxycodone codeine and
morphine can show up differently heroin which contains acetyl codeine also may
end up showing up with the byproducts of codeine take-home message for that is if
somebody shows up positive and they swear they haven’t been using opiates
that they weren’t prescribed yada yada send it to the lab because they may be
telling the truth if patients are taking opiates or benzos for a medical purpose
send that your into the lab and monitor levels you know you’re not gonna know
exactly what the level is going to be for any individual person because
there’s a lot of factors that go into that but once you get a baseline for
patient ami then you know it should remain
approximately at that baseline and if it goes up significantly or down
significantly then you know we need to have a little treatment talk
buprenorphine can be abused although it has a ceiling effect the way they’ve
constructed buprenorphine it can be used but it only you can only get a high to a
certain point and then it has that ceiling effect where no matter how much
more you take you’re not going to feel any better buprenorphine needs to have
its own test as it produces another unique
metabolites so you know you can see why we have these cups that have like twelve
panels on them suboxone is buprenorphine and naloxone and it’s harder but not
impossible to abuse used at excessive amounts the naloxone will kick in which
is the opiate antagonist and start making someone go into sort of a detox
but suboxone is heavily traded and heavily used in the black market if you
will so now that we know that we have to have all kinds of different urine tests
for opiates and they may show up as different things that come out then
actually went in which is good and important and to know in and of itself
let’s talk about the short-term impact it depends heavily on the dose the route
of administration and previous exposure I will say here that the recovery if you
will or the reduction in tolerance to opiates goes away a whole lot faster
than the reduction in tolerance than the tolerance to other drugs so if someone
is clean and maybe they went through a program they’ve got 90 days under their
belt and they relapse if they relapse and use the same amount they were using
when they went into treatment they will very likely overdose because their body
can’t pick that anymore it’s already started to go back to where the average
person starts to feel the effects the sedative effects of the opiates
so short-term impacts like psychological euphoria a feeling of well-being
relaxation sedation disconnectedness and delirium I have a lot of patients who
are opiate abusers who report they take it because it makes them feel more
energetic it makes them feel better there ‘├╝ber selves it’s helping them
relax and get that feeling of well-being we need to look at that point if you’re
taking this drug in order to get this feeling this relaxation let’s look at
what are the underlying mental health symptoms that are going on or feelings
that we may need to address or coping skills we need may need to look at
physiological analgesia depressed heart rate and respiration constipation
flushing of the skin sweating pupils fixed and constricted and diminished
reflexes now some of your clients you’ll notice the flushing of the skin and the
fixed pupils they’ll try to pull their pull their hat down they may doze off a
little bit during class they may have a hard time staying awake and be nodding
off and they may be sweating when it’s not you know sweaty ball temperature in
your facility those are all things to take a look at if you have someone who’s
abusing opiates and you know you suspect a relapse side effects medical
complications among opioid abusers specifically when we’re talking about
depressants primarily arise from adulterants and non sterile injecting
practices it may include skin lung and brain abscesses collapsed veins
endocarditis which is inflammation of the lining around the heart hepatitis
and HIV so there’s a lot of bad mojo that happens once you start puncturing
veins alcohol or other depressants like benzodiazepines and even things like
muscle relaxers antihistamines over-the-counter stuff that may increase
the effects of CNS depressants so if something normally makes someone drowsy
i mean without getting real technical if there are warnings warning labels on it
then it may make you drowsy you could pretty well guess that there is some
sort of CNS depressant effect when we combine these things they work
synergistically it’s not one plus one equals two it’s like one plus one equals
seven so people need to be really careful because it’s super
easy to OD if you start mixing pain medications and histamines and alike brain changes and brain damage can occur
not only from having the neuro chemicals out of whack and wonky but it can also
occur because of injecting impurities into the blood system when people abuse
opiates specifically the brain eventually will stop or reduce the
production of its natural painkillers so people need to be weaned off of opiates
and they will feel more pain initially until their body kicks in and goes oh I
got to do this again okay I got it symptoms of intoxication constricted
pupils agitation scratching and picking now we typically think of scratching and
picking being a methamphetamine sort of thing but a lot of people get very very
itchy when they take opiates just kind of bear that in mind when you’ve got
clients coming in to your treatment center if they are coming in to group
and acting differently than normal some people are fidgety I’m fidgety I
don’t usually scratch and pick but I tend to be a little bit fidgety what is
normal for that person and watch to see you know if it changes over time symptoms of withdrawal now unlike benzos
opiates Rahl is generally not life-threatening I don’t want to say
it’s never life-threatening but generally the person they want to die
because they feel so awful but generally it does not cause a stroke heart attack
high blood pressure symptoms begin within six to twelve hours of the last
dose last five to ten days but it Peaks within three days so the first three
days of a detox for someone who is coming down off opiates is miserable and
and that’s you know not even a strong enough word
they may feel yawning drug craving irritability dysphoria depression and
flu-like symptoms just take the flu if you’ve ever had it and multiply at times
you know three that’s kind of what they feel like right now keeping them
hydrated providing palliative care is a lot of what you can do in a detox
situation detox issues tolerance decreases rapidly so overdosing during
relapse is easy this is why having antidotes is important even in your
treatment centers the biggest focus during opiate withdrawal is to provide
palliative care try to make them feel better so they can get through it and
stay hydrated so they don’t develop any secondary symptoms fentanyl now we have
fentanyl by prescription fentanyl patches fentanyl lollipops which I’m not
crazy about fentanyl is 30 to 50 times stronger than heroin overdose rates are
super high the difficulty in getting prescription opioids has led to an
increase in a demand for heroin so they figured out that okay heroin is really
expensive fentanyl is really really cheap to make so if we make fentanyl and
we cut the heroin with it then we make this super amped up heroin that we can
sell for high prices unfortunately a lot of people think they’re getting pure
heroin and they don’t adjust the dosage accordingly and overdose so nearly six
percent of 12th graders report using narcotics other than heroin for
recreational purposes it’s a big trend in on the East Coast and I don’t know
about the West Coast as much of going into your parents medicine cabinet and
getting opiates in order to put into it you there take yourself or
put into a bowl and then they have kind of what they call the skittles party
they just reach in and grab a handful of pills and pop them and see what happens
as far as other medications to help treat symptoms of withdrawal yes for
opiate withdrawal some people can go through a they can use suboxone in order
to taper down there’s a lot of controversy on that some people can use
methadone in order to taper down again more controversy on that that will
definitely slow down or reduce the intensity of the symptoms
it depends though on a whether the person can afford it and B whether they
want to go that route because of the controversy and the risk of getting
basically just switching the addiction over now I say that with caution because
there are some doctors who will work in an opiate treatment program whose
intention is to detox somebody off of the opiates over the course of a year or
two in order to make it a slow gradual process so there is not not the physical
crisis which in theory reduces the likelihood of relapse I did work for one
opiate treatment program that the attending physician was adamant not only
about drug screens about participation in the program but also about seeking
counseling because he realized that it wasn’t just about the medication if we
could get people relatively pain-free off the opiates that’s great but we
still needed to provide them tools to deal with whatever made them start using
in the first place whether it’s mental health or physical health or a
combination so yes other medications can be prescribed there are also antiemetics
they can be prescribed if your person is doing a lot of vomiting or diarrhea
which is why a lot of opiate with drawl in my opinion which you know what
do I know I think it’s better under medically supervised care and not done
on an outpatient basis that way there are nurses that can attend to these
secondary symptoms that are wildly unpleasant benzos are your anti
anxieties they’re also system depressants they’re
sedatives they can be hypnotic and anti anxiety and anxiety anticonvulsant and
most muscle relaxants some athletes are prescribed benzodiazepines after they
have a muscle strain in order to prevent muscle spasm in and help the muscle
recuperate more quickly I’m trying to keep an eye on our time here short
acting and long acting and your handout I put a table that shows the different
action of your different medications everything from Librium which we know is
commonly used in alcohol detox down to Valium and Xanax and halcion and some of
your longer acting drugs why is this important well if we know that something
stays in someone’s system for a half-life of 20 hours and they’re taking
it every four you can see where it might build up over time your benzos enhance
the effect of gabba gabba you remember is your common chemical that is
synthesized from glutamine ingestion of the therapeutic dosages may be
detectable for one to three days while extended use over a period of months or
years can extend excretion times for up to four to six weeks after cessation of
use so if you’re working with someone who’s on on benzo detox not only and
I’ll say it say it again later in the presentation benzo detox can be very
life-threatening I believe up to 30% of people actually have grand mal seizures
if they’re doing it not under physicians care so we don’t want to encourage
people to outpatient detox um so four to six weeks people may still
be excreting some of the benzos from their system which means they also may
be feeling some symptoms different tests are required for different benzos your
alprazolam which is your xanax lorazepam remember I said the lands and the Pam’s
lorazepam is your ativan clonazepam which is your klonopin don’t share necessarily the same metabolic pathways
due to individual differences between people and drugs a standard therapeutic
level is often hard to identify remember I said earlier this is true with opiates
too if you want to really figure out if someone’s taking it as prescribed you
need to get a baseline for that person and then monitor that but be aware that
our patients are very crafty and resourceful and they may try to
accentuate the effect of the benzos by using other CNS depressants that
wouldn’t be picked up on the urine screen some of them are like kava
valerian passion flower and histamines those sorts of things that you wouldn’t
necessarily pick up on a urine screen but they can greatly intensify the
effect of the benzo short-term impact drowsy blurred vision poor coordination
and nisha hostility it’s amazing how all these
drugs that people abuse can produce hostility anyway disturbing dreams
reduced inhibition and impaired judgment important important side note short-term
effect of benzos in the elderly is confusion the appearance of dementia and
potentially benzodiazepine overdose and I will get to the question on the detox
in just a second benzos do not leave the liver of the
person or are not metabolized as quickly and leave the
the elderly person nearly as quickly as the non-elderly so it is very easy for
people who are elderly to start to have pretty significant cognitive and
physical symptoms combining with other depressants has an exponential additive
effect roof and also benzodiazepine yeah benzodiazepine use for three months or
more was associated with an increased risk of Alzheimer’s disease up to 51%
which tips I guess I took that slide out the American Society of geriatric
medicine is actually recommended now that people who are elderly not be
prescribed anti-anxiety medications not be prescribed benzodiazepines
specifically because of their long half-life and the risk of causing
Alzheimer’s like symptoms and dementia so now using over-the-counter products
to clean your system before a drug screen there are a lot of different
products that can be used and yes the smoke shop smoke shops can carry them a
lot of our clients will order them offline
in addition they can find things like The Wiz inator which is a physical
representation if you will of the male anatomy in order to pass a drug test so
you can load that up with clean urine but they will also push water and in
order to flush it out of their system which can be noted even if they try to
take creatinine supplements you’ll see that their levels are all out of whack
if you send it to the if you send it to the lab in order to go through the mass
spec so yes there are a lot of different remedies out there if you will to help
people pass a drug test will it help well for your standard on-site piano cup
test yeah it will because it may get the
metabolite low enough so if you suspect that or even if you don’t best practice
for urine screening really is to randomly and periodically send the urine
off to the lab for a full mass spect to make sure you know what you’re dealing
with and see if the person is diluting benzo withdrawal sleep disturbance
irritability anxiety panic attacks difficulty in concentration dry heaves
and nausea muscular pain stiffness seizures and psychosis your symptoms for
benzos appear around the end of the half life period now if when you look at your
chart that’s in the handout for many of these drugs that may be twenty hours if
you don’t start seeing detox symptoms at four hours that’s why you need to look
at the half-life period the rebound anxiety and insomnia peak within a
couple of days but if you take somebody who already had anxiety and then they’ve
been abusing benzos the rebound anxiety is going to be almost unbearable so be
aware of this it may be it may really freak them out and I’ve seen people have
back-to-back panic attacks almost consistently for a couple of days
because the rebound anxiety was so bad and there are ways to handle that if
your attending chooses to withdrawal symptoms can last for two to four weeks
and protracted withdrawal is not uncommon in heavy and or long-term users
where they go through they have this withdrawal symptoms they start feeling
better and then one morning they wake up and it feels like somebody hit them with
a truck based on the information we have given that most sorry responding
to a question would benzos make symptoms worse in Alzheimer’s clients since
benzos produce symptoms of dementia and can produce also Alzheimer’s symptoms in
the elderly and since the majority of patients who get Alzheimer’s are elderly
my answer to that question would be yes if you’ve got someone who has
Alzheimer’s they’re probably elderly and giving them benzos is probably going to
exacerbate what symptomatology they currently have according to the dsm-5 a
grand mal seizure may occur in as many as 20 to 30 percent of individuals
undergoing untreated emphasis on untreated withdrawal from
benzodiazepines romaso con is a competitive antagonist that can reverse
the sedative and overdose effects of benzos but not of alcohol and other
sedatives so when we’re talking about our depressants if we’re specifically
talking about benzos there is a remedy if you will just like there is for
opiate overdose and quite honestly I hadn’t even heard of it until I started
doing this presentation which tells you that it’s not one of the more common
things to keep around in detox facilities benzos and the most
frequently used classic drugs for anxiety disorders 12.9% and on the
quizzes I do not test you on your percentages because you know that’s
information that you can find anywhere but it’s not relevant to clinical care
other depressants GHB acts on your gaba receptors to some athletes use GHB to
elevate human growth hormone it’s also used as a date-rape drug hey you know
not exactly exactly sure how the two of those go together but it is important to
understand that some athletes may test positive for GHB
non benzo sleep medications such as ambien lunesta and Sanada have a
different different chemical structure but act on some of the same brain
receptors as benzos and your bar battles are also used to reduce anxiety and help
with insomnia our clients if you if you work with patients with co-occurring
disorders our clients are likely to abuse these two categories of
medications so they’re probably not going to be prescribed them legitimately inhalants and i’m gonna fly through some
of these so we get out of here close to on-time anything around the house
especially anything with a petroleum base or that’s in an aerosol can be
huffed like I said if it has the glitter stuff to it it probably got more of a
punch than the flat and markers and that includes our dry erase markers that we
used when we write on whiteboards herbs and supplements valeri and melatonin and
passionflower and gaba supplements can all intensify other depressants muscle
relaxants like flexural atypical antipsychotics
seroquel trazodone medications that our patients are regularly prescribed if
they’re taking trazadone for their mental health and then they pull a
muscle and they go to the go to a different doctor and get flexural and oh
hey they take melatonin every night anyway to help them sleep you know they
may actually put themself into a respiratory distress it’s so important
to encourage our clients to let us know all the OTC stuff they take including
vitamins just so we can help them understand the interaction we’re not
judging we’re informing depressants street names a lot of them if you go to
the DEA website you can find the most current information on the different
depressant street names and there’s a link to that in your classroom
hallucinogens I’ve got five minutes they cause hallucinations they can be
found in some plants or can be man-made they can either cause hallucinations or
dissociation sort of an out-of-body experience it acts on serotonin and
glutamate systems which regulate your mood your sensory perception sleep
hunger temperature again sexual behavior again muscle control pain perception and
learning and memory so PCP is usually sold as a liquid or powder can be
snorted smoked injected or swallowed other dissociatives are ketamine which
is a common veterinary medication it’s odorless and tasteless and has amnesia
inducing dissociative properties which it has been used to facilitate sexual
assault dextromethorphan is a new one
well newer if you will that the youth are using now especially taking it
rectally they get the extra strength dextromethorphan and then they take it
rectally which gives them a dissociative high and then salvia divinorum also
known as diviner stage this is not the same as the Sylvia that you’ve got in
your garden unless you specifically ordered those seeds the Southie and the
garden to sell via splendens and the hummingbirds just love it
but it does not have the same effects as salvia divinorum LSD goes by a lot of
different names it’s a potent mood and perception ultra clear white odorless
water-soluble I know when I went to the big thing that we did in high school
before graduation a lot of people we’re taking LSD and having really bad trips
so it is used a whole lot in recreation among college and high school students
peyote comes from a spineless cactus and part of the crown or the button is
either chewed or brewed into a tea short and long-term impact again this is
in your handout the biggest thing we want to look at is the hallucinations
the dissociation and the potential for psychosis with the hallucinogens repeated use of PCP can result in long
term effects that may continue for a year or more but when we start talking
about hallucinogen persisting perceptual disorder those people who have
flashbacks years after taking the substance that’s a whole different
ballgame and they still don’t know exactly what causes that but they pretty
much have ruled out the there was a little bit left in my brain hypothesis so stimulants range from caffeine to
methamphetamine and amp up the system opiates benzos barbiturates alcohol and
inhalants are all depressants combination of depressants will have an
exponential effect we need to evaluate patients for exposure to all CNS
depressants intentional and incidental and I mean like cough medicine and pain
medicine in addition to psychotropic medicine that we don’t think of like
your atypical antipsychotics we don’t think of those necessarily as
depressants so we need to be aware of that there are a whole host of
hallucinogens from LSD to PCP peyote ketamine and dextromethorphan obviously
dextromethorphan is sold OTC and recent research indicated that persistent
perceptual disorder is not due to traces of the drug being freed up but it is due
to some sort of alteration in the brain chemistry they still don’t know what yet
so I made it under the wire with one minute and I am more than happy to stick
around and answer questions you can log into the classroom now and take your
quiz if you have time to do that otherwise you have access to take the
quiz for a while longer about a week I think my personal chat page is pure chat dot M
e /q c ue t VX if you have questions that come up after the session and you
know after we’ve actually closed out for the day and you want to you know shoot
them to me you can get me through my personal chat page or you can send a
support request to support at all CEUs com whatever’s easier for you okay
everyone have a wonderful rest of your afternoon and I will see you first day
maybe you

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