Understanding Medications and Interactions with Illicit Drug Use

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Understanding Medications and Interactions
withIllicit Drug Use

• by
• Paul L. Doering, M.S.
• Distinguished Service Professor of Pharmacy
  Practice
• College of Pharmacy
• University of Florida

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Pharmacists Know a Lot About Drugs, but

• Many curricula do not contain coursework in
  substance abuse
• Thus, they are not schooled in this other use
  of pharmaceutical products
• Most have limited personal experience with
  recreational drugs (thankfully)
• But, pharmacists are often sought out by parents,
  family members, etc. for help

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THREE DRUG EXPERTS FROM THE 1960s
James Marshall Hendrix Born- 11/27/42 Died-
9/18/70
Paul Louis Doering Born- 2/25/49 Not Dead Yet
Janis Lyn Joplin Born- 1/19/43 Died- 10/4/70
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Mental Health and Drugs

• About 1/3 of adults with any mental disorder also
  have a co-occurring substance abuse disorder,
  including
• Depression
• Schizophrenia
• Bipolar disorder
• Anxiety disorder

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Key Point

• The neurotransmitters, receptor sites, and other
  brain mechanisms involved in mental and emotional
  problems and illnesses are the same ones affected
  by psychoactive drugs

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Dont it seem odd.

• That people with normal brain chemistry are
  trying desperately to get theirs out of whack
  while,
• Those with abnormal brain chemistry are trying
  just as hard to get theirs back to normal??

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Psychiatric Medications

• Antipsychotics
• e.g., Haldol, Thorazine, Zyprexa, Prolixin
• Antidepressants
• e.g., tricyclic antidepressants, selective
  serotonin reuptake inhibitors (SSRIs)
• Bipolar medications
• e.g., lithium, valproic acid
• Antianxiety agents
• e.g., benzodiazepines, buspirone, barbiturates

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Serotonin imbalances
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Dopamine imbalances
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Norepinephrine, epinephrine
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Other neurotransmitters

• Endorphin, enkephalin
• GABA
• Acetylcholine
• Cortisone
• Histamine
• Anandimide

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Two Types of Substance-related Disorders

• Substance use disorders
• Substance dependence
• Substance abuse
• Substance-induced disorders
• Intoxication
• Withdrawal
• Delerium, amnestic disorder, sleep disorder

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Susceptibility

• Some are born with brain chemistry that makes
  them susceptible to certain mental illnesses
• If the genetically susceptible brain is then
  stressed by a hostile environment or psychoactive
  drug use, there is an increased likelihood of
  developing mental illness

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Example

• Heredity can affect the formation of dopamine
  receptor sites and the ability of the brain to
  produce dopamine.
• Schizophrenia- brain has too much dopamine
• Cocaine stimulates release of dopamine, thus
  long-term or high-dose use can induce a
  schizophrenia-like psychosis

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Environmental factors

• Continued stress depletes norepinephrine and that
  can cause depression
• Some react by running away, falling apart,
  becoming extremely angry, or using psychoactive
  drugs

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Examples of substance-induced mental disorders

• Stimulant-induced psychotic disorders
• Alcohol-induced mood disorders
• Marijuana-induced delirium

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Pre-existing Mental Illness

• Has a clearly defined mental illness and then
  gets involved in drug
• e.g., the teen with major depression who
  discovers methamphetamine

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The difficulty

• A neurotic is the person who builds a castle in
  the air. A psychotic is the person who lives in
  it. And the psychiatrist is the person who
  collects the rent.

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Brain Disorders in Americans (1-year prevalence)
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Drugs that mimic schizo-phrenia and psychosis

• Cocaine and amphetamine- toxic psychosis
• Steroid psychosis
• CNS stimulants- paranoia
• Psychedelics- dissociation
• Barbiturate withdrawal- extreme agitation

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Temporary drug-induced depression associated with

• Excessive alcohol use
• Stimulant withdrawal (cocaine and amphetamine)
• Comedown phase of psychedelic (e.g., LSD) drug use

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Bipolar disorder or drug reaction?

• Toxic effects of
• Stimulant abuse
• Psychedelic

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Anxiety disorder or drug effects?

• Toxic effects of stimulant drugs
• Withdrawal from opioids
• Withdrawal from opioids
• Withdrawal from alcohol

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Alcohol-induced mental illnesses

• Impulse control problems
• Sleep disorders
• Anxiety
• Depression
• Psychosis
• Dementia

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Stimulant-induced mental illness

• Impulse control problems
• Mania
• Panic disorder
• Depression
• Anxiety
• Psychosis
• Cognitive impairment

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Marijuana-induced mental illness

• Delerium
• Psychosis
• Panic
• Amotivational syndrome

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Groovin to the Beat...
...at the Deans Disco
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Serotonin cells in red
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Neurons release serotonin
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Serotonin vesicles
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Serotonin Receptors
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Peak effect (about 1 hour)
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Serotonin Reuptake Transporters
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Monoamine Oxidase
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Coming down from XTC
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Coming down some more
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The Serotonin Factory
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Down regulation of receptors
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Pharmaceutical Drugs are In

• Obtained from legal prescriptions
• Given or sold among friends
• Stolen from medicine cabinets
• Stolen from pharmacies

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Prescription Drug Abuse

• DAWN data suggest that prescription drugs
  account for about 25-30 of all drug abuse

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Pharmaceutical vs Street Drugs

• Safer
• identity
• purity
• less HIV / hepatitis risk
• Safer because "it's just a prescription drug"
• Low or no acquisition cost
• Medicaid, Workers Comp, private insurance, VA,
  Indian Health Service

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Pharmaceutical vs Street Drugs

• Less legal risk than illicit drugs
• Easily obtainable from practitioners

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Prescription Drug Abuse

• Effective controlled substances are commonly
  prescribed for legitimate patients
• As controlled substances are prescribed more
  often, there is greater availability of the drug
• Thus, there is greater opportunity for diversion

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Prescription Drug Abuse

• Street value dependent on
• brand vs generic
• quick onset
• intensity
• short duration of action
• whether a product can be injected or snorted
  successfully

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Methamphetamine and other stimulants

• Synonyms
• crank, ice, meth, crystal, speed
• Mental Effects
• euphoria, irritability, anxiety, confusion,
  paranoia, poor judgment
• Physical Effects
• increased HR, BP, pulse, RR, temp,
• Dangers
• cardiovascular toxicity, seizures, psychosis

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Ephedrine Products
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Stimulant Identification
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Stimulant Identification
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The Different Faces of Ritalin
Concerta ER 54 mg
Concerta ER 18 mg
Concerta ER 36 mg
Ritalin 10 mg
Ritalin 5 mg
Ritalin SR 20 mg
Ritalin LA 20 mg
Ritalin LA 30 mg
Ritalin LA 40 mg
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OxyContin (oxycodone HCl)
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Morphine
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Codeine
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Hydrocodone
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Oxycodone
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Methadone
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Meperidine
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Comparisons
Morphine
Codeine
Hydrocodone
Oxycodone
Methadone
Meperidine
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Narcotics Identification
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Narcotics Identification
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Narcotics Identification
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Narcotics Identification
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Depressants Benzodiazepines and
non-benzodiazepines
Valium 2 mg
Valium 5 mg
Valium 10 mg
Xanax 0.5 mg
Xanax 1 mg
Xanax 2 mg
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'Skittling' New Drug Of Choice For Some Teens
Product Sold On Store ShelvesOctober 22, 2003
Ingredients Dextromethorphan Chlorpheniramine
Maleate
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Other Products Containing Dextromethorphan
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Buying DXM in Bulk