SUBSTANCE ABUSE

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SUBSTANCE ABUSE

• Andrzej Kokoszka

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SUBSTANCE ABUSE

• Substance abuse is a pattern of abnormal
  substance use that leads to impairment of
  occupational, physical, or social functioning.
• Substance dependence is substance abuse plus
  withdrawal symptoms, tolerance, or a pattern of
  repetitive use.

General information
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SUBSTANCE ABUSE

• Withdrawal is the development of physical or
  psychological symptoms after the reduction or
  cessation of intake of a substance.
• Tolerance is the need for increased amounts of
  the substance to achieve the same positive
  psychological effect.
• Cross-tolerance is the development of tolerance
  to one substance as the result of using another
  substance.

General information
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SUBSTANCE INTOXICATION

• A. The development of a reversible
  substance-specific syndrome due to recent
  ingestion of (or exposure to) a substance.
• Note Different substances may produce similar or
  identical syndromes.
• B. Clinically significant maladaptive behavioral
  or psychological changes that are due to the
  effect of the substance on the central nervous
  system (e.g., belligerence, mood lability,
  cognitive impairment, impaired judgment, impaired
  social or occupational functioning) and develop
  during nr shortly after use of the substance.
• C. The symptoms are not due to a general medical
  condition and are not better accounted for by
  another mental disorder.

DSM-IV TR
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SUBSTANCE WITHDRAWAL

• A. The development of a substance-specific
  syndrome due to the cessation of (or reduction
  in) substance use that has been heavy and
  prolonged.
• B. The substance-specific syndrome causes
  clinically significant distress or impairment in
  social, occupational, or other important areas of
  functioning.
• C. The symptoms are not due to a general medical
  condition and are not better accounted for by
  another mental disorder.

DSM-IV TR
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SUBSTANCE ABUSE

• A. A maladaptive pattern of substance use leading
  to clinically significant impairment or distress,
  as manifested by one (or morel of the following,
  occurring within a 12-month period
• (1) recurrent substance use resulting in a
  failure to fulfill major role obligations at
  work, school, or home (e.g., repeated absences or
  poor work performance related to substance use
  substance-related absences, suspensions, or
  expulsions from school neglect of children or
  household)
• (2) recurrent substance use in situations in
  which it is physically hazardous (e.g., driving
  an automobile or operating a machine when
  impaired by substance use)
• (3) recurrent substance-related legal problems
  (e.g., arrests fur substance-related disorderly
  conduct)
• (4) continued substance use despite having
  persistent or recurrent social or interpersonal
  problems caused or exacerbated by the effects of
  the substance (e.g., arguments with spouse about
  consequences of intoxication, physical fights)
• B. The symptoms have never met the criteria for
  Substance Dependence for this class of substance

DSM-IV TR
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SUBSTANCE DEPENDENCE

• A maladaptive pattern of substance use, leading
  to clinically significant impairment or distress,
  as manifested by three (or more) of the
  following, occurring at any time in the same
  12-month period
• (1) tolerance, as defined by either of the
  following
• (a) a need for markedly increased amounts of the
  substance to achieve intoxication or desired
  effect
• (b) markedly diminished effect with continued use
  of the same amount of the substance
• (2) withdrawal, as manifested by either of the
  following
• (a) the characteristic withdrawal syndrome for
  the substance (refer to Criteria A and B of the
  criteria sets for Withdrawal from the specific
  substances)
• (b) the same (or a closely related) substance is
  taken to relieve or avoid withdrawal symptoms
• (3) the substance is often taken in larger
  amounts or over a longer period than was intended
• (4) there is a persistent desire or unsuccessful
  efforts to cut down or control substance use
• (5) a great deal of time is spent in activities
  necessary to obtain the substance (e.g., visiting
  multiple doctors or driving long distances), use
  the substance (e.g., chain-smoking), or recover
  from its effects
• (6) important social, occupational, or
  recreational activities are given up or reduced
  because of substance use
• (7) the substance use is continued despite
  knowledge of having a persistent or recurrent
  physical or psychological problem that is likely
  to have been caused or exacerbated by the
  substance (e.g., current cocaine use despite
  recognition of cocaine-induced depression, or
  continued drinking despite recognition that an
  ulcer was made worse by alcohol consumption)

DSM-IV TR
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SUBSTANCE DEPENDENCE

• Specify if
• With Physiological Dependence evidence of
  tolerance or withdrawal (i.e., either Item 1 or 2
  is present)
• Without Physiological Dependence no evidence of
  tolerance or withdrawal (i.e., neither Item 1
  nor 2 is present)
• Course specifiers
• Early Full Remission
• Early Partial Remission
• Sustained Full Remission
• Sustained Partial Remission
• On Agonist Therapy
• In a Controlled Environment

DSM-IV TR
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SUBSTANCE INTOXICATION DELIRIUM

• A. Disturbance of consciousness (i.e., reduced
  clarity of awareness of the environment) with
  reduced ability to focus, sustain or shift
  attention.
• B. A change in cognition (such as memory deficit,
  disorientation, language disturbance) or the
  development of a perceptual disturbance that is
  not better accounted for by a preexisting,
  established, or evolving dementia.
• C. The disturbance develops over a short period
  of time (usually hours to days) and tends to
  fluctuate during the course of the day.
• D. There is evidence from the history, physical
  examination, or laboratory findings of either (1)
  or (2)
• (1) the symptoms in Criteria A and B developed
  during substance intoxication
• (2) medication use is etiologically related to
  the disturbance ,
• Note is diagnosis should be made instead of a
  diagnosis of substance intoxication only when the
  cognitive symptoms are in excess of those usually
  associated with the intoxication syndrome and
  when the symptoms are sufficiently severe to
  warrant independent clinical attention.
• Note The diagnosis should be recorded as
  substance-induced delirium if related to
  medication use.
• Code Specific substance intoxication delirium

DSM-IV TR
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SUBSTANCE WITHDRAWAL DELIRIUM

• A. Disturbance of consciousness (i.e., reduced
  clarity of awareness of the environment) with
  reduced ability to focus, sustain, or shift
  attention.
• B. A change in cognition (such as memory deficit,
  disorientation, language disturbance) or the
  development of a perceptual disturbance that is
  not better accounted for by a preexisting,
  established, or evolving dementia.
• C. The disturbance develops over a short period
  of time (usually hours to days) and tends to
  fluctuate during the course of the day.
• D. There is evidence from the history, physical
  examination, or laboratory findings that the
  symptoms in Criteria A and B developed during, or
  shortly after, a withdrawal syndrome.
• Note This diagnosis should be made instead of a
  diagnosis of substance withdrawal only when the
  cognitive symptoms are in excess of those usually
  associated with the withdrawal syndrome and when
  the symptoms are sufficiently severe to warrant
  independent clinical attention.
• Code Specific substance withdrawal delirium

DSM-IV TR
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CANNABIS

• drug prepared from the hemp plant, Cannabis
  sativa
• There are various forms of this drug , for
  example
• kif in Morocco
• dagga in South Africa
• ganja in India

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Cannabis - history

• Throughout the centuries it has been used both
  medicinally and as an intoxicant. The major
  psychoactive component is tetrahydrocannabinol,
  commonly known as THC found in mid-60. At
  present, other cannabinoids have been isolated
  and their possible biochemical activities are
  being explored. Psychoactive compounds are found
  in all parts of plant, with the greatest
  concentration in the flowering tops. The content
  of these compounds varies greatly from plant to
  plant, depending on genetic and environmental
  factors.
• Marijuana is a domestic product with diverse
  trafficking sources. The application of advanced
  agricultural techniques has resulted in powerful
  strains of marijuana being produced in the United
  States, primarily in California and Kentucky,

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CANNABIS Drug taking
Cannabis has been smoked, eaten in cakes, and
drunk in beverages. In Western cultures marijuana
is prepared most often as a tobaccolike mixture
that is smoked in a pipe or rolled into a
cigarette
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Cannabis physiological effects

• generally cannabis seems to exaggerate the
  pre-existing mood
• Low doses produce a sense of well-being,
  increases appetite, relaxation, and sleepiness.
• Higher doses cause mild sensory distortions,
  altered time sense, loss of short-term memory,
  loss of balance, and difficulty in completing
  thought processes.
• Toxic doses can result in feelings of
  depersonalization, severe anxiety and panic, and
  a toxic psychosis, along with hallucinations,
  loss of insight, delusions, and paranoia.
  Recovery after stooping drug use is quick.

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Cannabis physiological effects

• Toxic doses can result in feelings of
  depersonalization, severe anxiety and panic, and
  a toxic psychosis, along with hallucinations,
  loss of insight, delusions, and paranoia.
  Recovery after stooping drug use is quick.
• Chronic users experience lung problems associated
  with smoking and a decrease in motivation (the
  amotivational syndrom) luck of desire to work
  and increased apathy

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Cannabis - physiological effects

• Physiologically- the heart rate increases and
  blood vessels of the eye dilate, causing
  reddening, and the appetite for food is
  stimulated. A feeling of tightness in the chest
  and a lack of muscular coordination may also
  occur.
• There is no withdrawal syndrome

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Marijuana
The most common adverse psychological effect of
acute Cannabis consumption is anxiety.
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Cannabis - Medical use in USA california

• -reduction pressure within the eye in glaucoma
  patients
• -stimulation the appetite of AIDS patients with
  wasting syndrome
• -softening cancer-related nausea and vomiting

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Cannabis - epidemiology

• A survey in the late 1970s indicated that at
  least 43 million Americans had tried the drug. In
  the 1980s, however, surveys of high school and
  college students showed that marijuana use was
  steadily declining.
• The 1998 National Household Survey on Drug Abuse
  found that 11 million Americans use marijuana
  regularly, and 77 of drug users use marijuana,
  either alone or with other drugs of abuse

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Cocaine
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Cocaine stimulant drug

• An alkaloid drug derived from the leaves of the
  coca bush. It blocks local nerve conduction,
  producing local anesthesia when applied to mucous
  membranes. It was first used medically in 1884 by
  Carl Koller, an Austrian ophthalmologic surgeon,
  for operations involving the eye, nose, and
  throat.
• Cocaine blocks reuptake of neuronal dopamine,
  serotonin, norepinephrine

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Cocaine - crack
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Cocaine - drug traffiking

• Coca, from which cocaine is made, is grown
  primarily in Bolivia and Peru and smuggled by
  small aircraft or boat into Colombia, where it is
  refined in jungle laboratories into cocaine. A
  65 to 370 purchase of coca leaves, when
  converted to a kilogram of cocaine hydrochloride,
  increases in value to 1,900 to 5,000. At the
  wholesale level in Miami, at a purity level of
  between 85 and 95, the kilo is sold for between
  18,000 and 27,000. When it reaches the
  street-sale level, it can yield 300,000.

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Cocaine - drug taking

• In powder form as cocaine hydrochloride the drug
  is inhaled, or "snorted," and is rapidly absorbed
  through the nasal mucous membranes.
• Cocaine neutralized by alkali produces small,
  pebble-sized crystals of drug, called "crack,"
  which is smoked as a faster route of
  administration.
• Cocaine and its products of hydrolization are
  detectable in the urine even at high doses for up
  to 3 weeks.

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Cocaine - drug effects

• feelings of exceptional well-being and enhanced
  mental and physical capacity, hyperalertness,impai
  red judgement. individuals are more gregarious or
  withdrawn, maladaptive behaviour, restlessness,
  vigilance, anxiety, visual or tactile
  hallucinations(worms under the skin), seldom
  psychosis
• Cocaine increases heart rate, decreases hunger,
  others pupillary dilatation, perspiration,
  chills, nausea, vomiting, dryness of the mouth
  and nose.
• The effects last for about 2 hours, allowing the
  experience to be repeated.

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Cocaine - medical complication

• abnormal heart rhythms and heart attacks, which
  can cause sudden death, strokes, or strokelike
  episodes, as well as convulsions. Overdoses cause
  marked elevation in heart rate, blood pressure,
  and body temperature, metabolic acidosis,
  dehydration and may lead to death.
• Septal nasal necrosis
• Malnutrition, severe weight loss, blood
  contamination, prominent ecchymosis, pulmonary
  dysfunction, rhabdomyolysis, subarachnoid
  hemorrhages, myocardial infarction

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Cocaine - withdrawal symptoms

• phase 1- first 24 hs. depression, suicidal
  ideation, insomnia, anxiety, irritability,
  intense cocaine craving
• phase2- first few days cocaine craving,
  irritability, low mood
• phase3 - milder craving

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Cocaine - acute management

• Diazepam, propranolol for anxiety, agitation
• Haloperidol or others antipsychotics for
  psychosis
• Managament of hyperpyrexia and cardiac arrythmia

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Amphetamine How does it work in brain?

• group of synthetic drugs that are strong
  stimulants of the central nervous system.
• Amphetamines work by blocking reuptake of
  dopamine, serotonin and norepinephrine. They also
  release dopamine from its storage

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Amphetamine - Types of CNS stimulants

• Dextroamphetamine (Dexedrine) D-2-amin-1-phenylop
  ropan is the major member of the class,
• Amphetamine sulfate-benzedrine
• Free-base amphetamine
• methamphetamine (Methedrine or "speedice)
• phenmetrazine (Preludin),
• methylphenidate (Ritalin).
• Each differs in potency and action.

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Amphetamine - History Using in medicine

• First synthesized in 1897, amphetamines were
  introduced into medical practice in 1936. They
  were used as diet pills and as "pep pills," or
  "uppers," for staying awake.
• Treatment of fatigue and depression, attention
  deficit hyperactivity syndrome (ADHD),
  narcolepsy, and as appetite suppressants.

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Amphetamine - Drugs effect

• They raise the heart rate and blood pressure,
• increase alertness,
• improve mood to elation,
• other symptoms agitation, loqacity, pupillary
  dilation,.

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Amphetamine - Bad run

• Repeated intravenous injections of amphetamines
  produce a "rush"- an orgasm-like reaction,
  followed by a feeling of mental alertness and
  marked euphoria. After several days of such use,
  subjects may enter a paranoid schizophrenia like
  state and develope delusions, that bugs are
  crawling under their skin, which leads to
  characteristic scratches and abrasions..
  Amphetamine overdoses can be fatal for persons
  with high blood pressure or cardiac problems.

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  Amphetamine - withdrawal syndroms

• sleep,
• depressed mood,
• hunger
• amotivation
• irritability

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A new pattern of amphetamine abuse

• methamphetamine base crystals ("ice") are
  smoked, like "crack" cocaine. Intoxication may
  last for several hours after a single smoke.
  Additional modifications of the chemical
  structure of amphetamine have produced a number
  of amphetamine homologs, including the so-called
  "STP," MDMA or "Ecstasy," which have weak
  hallucinogenic actions.

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Amphetamine - Acute managment

• In the case of amphetamine overdose, acidifying
  the urine with vitamin C speeds the elimination.
  To treat paranoid and delusional
  symptoms-antipsychotic medications, countinuing
  for days to weeks
• Withdrawal symptoms are cured by suitable drugs

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MDMA Extasy

• synthetic drug. The letters MDMA are an
  abbreviation of its chemical name,
  methylenedioxymethamphetamine. The drug is
  related to the amphetamines and the
  hallucinogens. It was used legally by some
  psychotherapists in the 1970s and early 1980s for
  its effect in inducing a state of apparently
  enhanced self-awareness.

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EXTASY

• MDMA had gained popularity as a recreational
  drug, particularly among college students.it is
  promoted as mood drug without distracting and
  perceptual changes. Although long-term effects on
  the nervous system of MDMA are not yet known,
  side effects such as fatigue and sleeplessness
  are observed.
• Parkinsonian syndromes, seizures, myocardial
  infarction, hyponatremia and a few deaths have
  been reported.

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MDMA
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PCP

• PCP means phencyclidine (in a slang name known as
  Angel dust)
• It is noncompetitive NMDA/glutamate receptor
  antagonist and has effects on serotonergic and
  dopaminergic system as well.

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PCP - Drug Effects

• volatile emotions from euphoria to anxiety,
• detachment,
• disorientation,
• distortions of body image,
• loss of sense of body movement control,
• Agitation, aggressive behaviour
• sometimes delirium, delusions,, flashbacks.

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PCP - Physical symptoms

• numbness,
• rapid eye movements (particularly vertical
  nystagmus-important clinical sign) ,
• muscle rigidity, ataxia,
• sweating, rapid heart rate, and hypertension.
• PCP's effects depend on the amount taken, and an
  overdose can be fatal.

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PCP - Overdose

• Hypersalivation,
• hyperthermia,
• involuntary movements,
• coma
• neuroleptic malignant syndrome,
• rhabdomyolisis leading to renal failure

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PCP - Acute managament

• Diazepam iv., occasionally antipsychotics
• PCP elimination is enhanced by ammonium chloride,
  ascorbic acid, cranberry juice
• Antipsychotic with anticholinergic effect should
  be avoided

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LSD and other hallucinogenics

• LSD-lysergic acid diethylamid
• mescaline
• Substances found in species of mushroom
• MDA-3,4-methylenedioxyamphetamine
• MDMA-3,4 methylenedioxymetamphetamine

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LSD

• LSD, or D-lysergic acid diethylamide, also known
  as LSD-25 and "acid," is a prototype of the
  hallucinogenic drug class. The effects of LSD
  were discovered in 1943 when a small amount was
  accidentally ingested by Swiss chemist Albert
  Hofmann. Hofmann first synthesized the drug while
  studying derivatives of alkaloids from the ergot
  fungus, a parasitic fungus of rye and wheat

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LSD

• LSD stimulates the sympathetic nervous system,
  but its action is complex and as yet not fully
  known.
• It produces dilation of the pupils and increases
  in pulse rate, blood pressure, and temperature.
• LSD can cause sensory distortions, with vivid
  visual and sometimes auditory hallucinations.

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LSD

• Emotional and subjective responses vary widely
  and may include difficulty in concentration, loss
  of identity, feelings of unreality, seemingly
  magical insights, depression, anxiety, and
  sometimes panic and terror.
• LSD does not produce physical dependence, but
  psychological dependence and tolerance can
  develop

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LSD

• LSD is potent in very small doses as little as
  35 micrograms can produce measurable effects.
• It has been used experimentally in the study of
  mental illness and has also been used to treat
  various psychiatric conditions and alcoholism.
• At present, however, LSD has no proven medical
  use and its general use, manufacture, and sale
  are illegal

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LSD - Flashback

• Recurrences of experiences occuring originally
  during intoxication with halucinogens weeks or
  months after the drug was last taken

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Psilocybin

• The active substance contained in the fruiting
  bodies of the Psilocybe mexicana mushroom, among
  others, psilocybin is a potent hallucinogen.
  Taken orally or injected, it produces effects
  similar to those of the chemically unrelated LSD,
  and cross-tolerance has been experienced between
  psilocybin, LSD, and mescaline

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mushrooms
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psylocibin
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Curiosity

• The use of mushrooms in religious rituals to
  induce visions by the Indians of Mexico has been
  documented as far back as the 16th century. The
  use of psilocybin is illegal

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Opioids
opium
morphine
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Opioids acting

• There are several subtypes of opioid receptors?,
  ?, ?, ?, ?
• ? receptor has selective affinity for heroin,
  meperidine, methadon and mediates anlgesia,
  euphoria, sedation,meiosis, and respiratory
  depression. There are some indyviduals seem to be
  prone to opioid addiction because of hypothesized
  hypoactivity of the endogenous opioid system.
• Depandence and tolerance is produced by
  neuroadaptive changes at receptor sites. In locus
  coeruleus it inhibits production of
  norepinephrine ,and in contrast opioid withdrawal
  increases noradrenergic activity. From these
  findings we use clonidine for detoxification

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Opioids - Drug trafficking

• Heroin begins as opium selling at less than 100
  a kilogram refined into a powder, it may have a
  street value of 800,000 a kilogram. The opium
  poppy is cultivated in the Golden Triangle of
  Myanmar (Burma), Laos, and Thailand and The
  Golden Crescent of Southwest Asia includes parts
  of Iran, Afghanistan, and Pakistan.
• Mexico is the source of "brown heroin," In more
  recent years, Mexico has been the source of
  "black tar" heroin, a less refined but more
  potent and very dangerous form of the substance.

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Opioids - Comorbidity

• Among people addicted to opiates, the prevalence
  of psychiatric disorders from axis1 and axis2 is
  high. Treatment, both disorders and addiction is
  very difficult.

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Heroin

• an opiate, meaning a drug derived from opium.
  Chemically it is diacetylmorphine. It was first
  developed in Germany in 1898 as a stronger and
  supposedly nonaddictive form of morphine. (The
  name was originally a trade name that anticipated
  heroic achievements by the drug in medical
  practice), however physicians learned that it was
  in fact highly addictive .

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morphine

• One of the principal alkaloids of opium, is a
  narcotic drug used in medicine for its analgesic
  effects. Morphine is extracted from the dried
  milky juice of the unripe seed capsule of the
  opium poppy.
• It was first isolated by the German chemist F. W.
  A. Serturner in the early 1800s.
• Morphine in medicine is extremely effective in
  relieving severe pain, in case of gallstones and
  terminal cancer and in cases where other
  analgesics fail. It is also used for its calming
  or sedating effects.

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Opioids - Drug effects

• euphoric effect on patients,
• pupillary constriction(pinpoint pupils),
• side effects that may be manifested in the
  disorders of respiratory and circulatory system,
• decreased gastrointestinal motility,
• slurred speech, sedation, impairment in attention
  and memory.
• In addition, morphine has an emetic effect
  (induces vomiting) and is a general depressant

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OPIOIDS - OVERDOSE

• respiratory depression,
• coma,
• pupillary constriction,
• is treated by 0.4 mg Naloxon in repeated doses

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Opioids - withdrawal symptoms

• milde- flulike syndrome- dysphoria, yawning,
  lacrimation, sweating, rhinorrhea, piloerection,
  pupillary dillatation, hypertension, disrupted
  sleep,
• severe- deep muscle and joint pain, chills,
  nausea,vomiting, diarrhea, ambdominal pain,
  weight loss, fever, gooseflesh

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Opioids - Drug taking

• Heroin varies in purity( from 16 to 90). Purer
  forms can be snorted. The others are taken i.v.
• It is used either alone or combined with cocaine
  or amphetamines under such street names as
  "Speedballs.",
• concomitant alkohol use is common

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.
look out !

• Synthetic opiates, such as phentanyl are used by
  individuals who have easy access, such as nurses,
  physicians, and especially anesthesiologist

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Drug maintenance

• Instead of using drug from the street abusers get
  methadone .
• It dimishes drug seeking behaviour, increases
  personal productivity, decreases crime and HIV
  infection, giving constant opioid blood level.
• Half-life of methadon is 24-36 hs, it blunts the
  euphoric response to heroin
• You should start from dosage of 30-40 mg. P.o.,
  and based on signs of withdrawal you should
  addict 5mg. a day to average dosage 60-80 mg. per
  day.

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methadone

• Several medications increaes methadon metabolism
  rifampicin, phenobarbital, phenytoin,
  carbamazepine. You are not allowed to
  administrate monoamine oxidase inhibitor among
  these patients.
• There is opiate agonist with longer half-life. It
  is l-?-Acetyl-methadol( LAAM). Patients are
  treated 3 times a week.
• Another mu-receptor mixed agonist-antagonist
  buprenorphine can be used in out-patient
  maintenace therapy.

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Organic solvents inhalants

• Inhalants is the term used for a wide variety of
  hydrocarbon industrial solvents which are inhaled
  for the high they produce .These include
  gasoline, paint thinner, glue, rubber cement,
  acrylic paint sprays, shoe polish, degreasers,
  cleaning fluids, aeorosols. The toxic ingredients
  may be toluene, hexane, benzene,
  trichloroethylene, methylethylketone, and others.

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Inhalants - Drug effect

• Euphoria and a relaxed drunk feeling are followed
  by disorientation, slow passage of time,
  possibly hallucinations, uncoordination of gait,
  slurring of speech, nausea and vomiting, and even
  coma.
• Psychological dependence is associated with the
  use of inhalants.

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Inhalants - adverse physical effects

• liver and kidney damage,
• peripheral nerve damage ,brain damage,
• bone marrow suppression,
• and pulmonary disease.
• Some deaths have been associated with the use of
  inhalants from the direct effects or from
  asphyxia or the inhalation of vomit.

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Inhalants - epidemiology

• this group of chemicals is often abused by
  teenagers, particularly teenage boys.

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BARBITURATES

• Barbiturates are habit-forming drugs used as
  sedatives and hypnotics (see hypnotic drugs).
  They are white, crystalline, odorless derivatives
  of the chemical compound barbituric acid.
  Medically, these drugs are used to induce sleep,
  relieve anxiety and neuroses by inducing
  drowsiness, and control epileptic seizures.
  Barbiturates are also among the most widely
  abused drugs, being taken to cause a state of
  euphoria. Sometimes they are used in suicide
  attempts.

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Types of barbiturates

• There are
• Long-acting barbiturates, such as amobarbital,
  penetrate barrier, blood-brain slowly,
• Short-acting drugs, such as secobarbital,
  penetrate faster and are used to alleviate an
  inability to sleep.
• Ultrashort barbiturates, such as thiopental
  these are used as adjuncts to anesthesia (see
  anesthetics).

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Side effects of barbiturates

• drowsiness and an effect similar to that of an
  alcoholic hangover.
• Judgment and motor control are usually impaired,
  slurred speech, nystagmus.
• mood changes (such as depression) may occur.
• An overdose depresses the respiratory rate and
  may result in coma and death

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Barbiturates - withdrawal symptoms

• The human body develops a tolerance for
  barbiturates, and withdrawal symptoms (for
  example depression, aggressiveness, and
  irritability, nausea, disorientation,
  halicination, tremmulousness) occur once a person
  who is physically dependent on these drugs stops
  taking them

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BARBITURATES - treatment

• Close supervision in hospital
• Phenothiazines should be avoid bacause they may
  lower the seizure threshold
• Substitution by another anxiolytic drugs

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Nicotine

• is an extremely poisonous, colorless, oily
  liquid alkaloid. It is found mainly in the leaves
  of Nicotiana tabacum. Both nicotine and the
  tobacco plant are named for Jean Nicot, a French
  ambassador who sent tobacco from Portugal to
  Paris in 1560. Only two or three drops (less than
  50 mg) of the pure alkaloid placed on the tongue
  is rapidly fatal to an adult. A typical cigarette
  contains 15 to 20 mg of nicotine. However, the
  actual amount that reaches the bloodstream and
  hence the brain through normal smoking is only
  about 1 mg.

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Nicotine Addiction

• Nicotine, which resembles acetylcholine in shape
  fits in the acetylcholine receptors, thereby
  stimulates the nervous system. This gives the
  smoker an initial physical lift. Nicotine stays
  attached to the acetylcholine receptor for a
  relatively long time, blocking normal information
  transmission and acting like a depressant.The
  smoker has too much acetylcholine and becomes
  nervous, hypersensitive, and anxious. Thus, when
  smokers describe smoking as relaxing, what is
  really happening is that smoking suppresses their
  nicotine symptoms.

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What else does tobacco include?

• Chemicals in burning cigarette, pipe, or cigar
  contains formaldehyde, arsenic, cyanide,
  radioactive compounds, benzene, and carbon
  monoxide

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Nicotine - WITHDRAWAL syndrome

• Craving for tobacco
• Irritability
• Anxiety
• Difficulty concentrating
• Restlessness
• Decreased heart rate
• Increased eating

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Nicotine - risk factors

• Moderate genetic influence
• Strong association between (depressive disorder
  and anxiety disorder)
• Social influence
• Other drug abuse

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Nicotine - management

• Behavioral, cognitive, educational, self-help,
  pharmacological approaches
• Due to bad motivation, fear of weight gain,
  stresses, it is difficult

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Nicotine - replacement therapy

• Used to minimalize withdrawal syndrome
• There are different forms of medicament nicotine
  patches, nicotine gums, and nicotine intranasal
  spray, nicotine inhaler not available in POLAND
• Use of nicotine double the chance of Quitting,
  plus behavioral therapy four-fold higher chances

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Other drugs

• Bupropiron- an atypical antidepressant
• Nortriptiline-may also be adjunct in smoking
  cessation