DRUGS OF ABUSE
o Blood pressure and pulse rate are
COCAINE
➢ Erythroxylon coca, crack, freebase CNS &
sympathetic stimulation
➢ a crystalline tropane alkaloid that is obtained from
the leaves of the coca plant
➢ a stimulant of the central nervous system and an
appetite suppressant.
➢ Cocaine increases alertness, feelings of well -being
and euphoria, energy and motor activity, feelings of
competence and sexuality.
➢ Anxiety, paranoia and restlessness are also
frequent. With excessive dosage, tremors,
convulsions and increased body temperature are
observed
Treatment:
• Benzodiazepines → seizures
• Labetalol → HPN
• Neuroleptics → psychosis
OPIATES AND OPIODS
➢ Opiates are a group of naturally occurring
compounds derived from the juice of the poppy
Papaver somniferum.
➢ Morphine is the classic opiate derivative used
widely in medicine
• Natural – opium, morphine
• Semi-synthetic – heroin & codeine
• Synthetic – methadone & meperidine
• Heroin (diacetylmorphine) is a well-known,
highly addictive street narcotic
• Hydromorphine (dilaudid)
• Oxycodone (Oxycontin)
A. MECHANISM OF TOXICITY
- Stimulate a number of specific opiate
receptors in the CNS, causing sedation and
respiratory depression
- Death results from respiratory failure, usually
as a result of apnea or pulmonary aspiration of
gastric contents
B. TOXIC DOSE
- Varies
C. CLINICAL PRESENTATION
- With mild or moderate overdose:
o Lethargy
o Pupils are small, “pinpoint size”
decreased
o Bowel sounds are diminished
o Muscles are usually flaccid
- With higher doses
o Coma, accompanied by respiratory
depression
o Apnea, resulting to sudden death
o Noncardiogenic pulmonary edema
- After opioid overdose
o Seizures (meperidine)
o Have mixed agonist and antagonist
effects
D. DIAGNOSIS
- Qualitative screening of the urine
- Electrolytes,
- glucose,
- arterial blood gases or oximetry,
- chest x-ray,
- stat serum
- acetaminophen or salicylate levels (if ingested
overdose was a combination product)
E. TREATMENT
- Administer naloxone, a specific opioid
antagonist,
o 0.4-2 mg IV
o Repeat dose every 2- 3 minutes if there
is no response,
o up to a total dose of 10-20 mg if opioid
overdose is strongly suspected.
Naloxone: short duration (2-3 hours)
• Effect is shorter than opiods
• Do not release Px until the last dose of
naloxone:
o In general, if naloxone as required
to reverse opioid-induced coma, it
is safer to admit the patient for at
least 6-12 hours of observation.
AMPHETAMINES
➢ Phenylisopropylamine
➢ is a psychostimulant drug that is known to
produce increased wakefulness and focus in
association with decreased fatigue and appetite
➢ Dextroamphetamine (Dexedrine) and
methylphenidate (Ritalin)
➢ are used for the treatment of narcolepsy and for o Intracranial hemorrhage or
attention-deficit disorders in children hyperthermia
➢ Several amphetaminelike drugs (benzphetamine, o Hyperthermia results from seizures
diethylpropion, phedimetrazine, phenmetrazine, and muscular hyperactivity and may
and phenteramine) are marketed as prescription cause brain damage, rhabdomyolysis
anorectic medications
➢ Methamphetamine, 3,4- - Chronic effects include:
methylenedioxymethamphetamine (MDMA, o Weight loss
ecstasy) and several other amphetamine o Cardiomyopathy
derivatives as a number of prescription drugs, are o Stereotypic behavior (such as picking
used orally and intravenously as illicit stimulants at the skin)
o Paranoia
A. MECHANISM OF TOXICITY o Paranoid psychosis
- activates the sympathetic NS via CNS o Psychiatric disturbances
stimulation, peripheral release of o Fatigue, hypersomnia, hyperphagia,
catecholamines, inhibition of neuronal depression (after cessation of habitual
reuptake of catecholamines, or inhibition of use)
monoamine oxidase
- rapidly eliminated in acid urine D. DIAGNOSIS
- Specific levels
B. TOXIC DOSE o Can be detected in urine and gastric
- 1 mg/kg = life threatening samples, providing confirmation of
exposure
C. CLINICAL MANIFESTATION o Quantitative serum levels do not
- Acute CNS effects: correlate well with severity of clinical
o Euphoria- effects and are not generally available
o Talkativeness o Amphetamine derivatives and
o Anxiety adrenergic amines will crossreact in
o Restlessness immunoassay
o Agitation - Other useful laboratory studies
o Seizures o Electrolytes, glucose, BUN, and
o Coma creatinine, CPK, urinalysis, urine
o Intracranial hemorrhage owing to dipstick test for occult hemoglobin,
hypertension or cerebral vasculitis ECG and ECG monitoring, CT scan of
(inflammatory destruction of blood the head
vessels)
E. TREATMENT
- Acute peripheral manifestations: - There is no specific antidote.
o Sweating - Phentolamine and nitroprusside (parenteral
o Tremor vasodilators) for hypertension
o Muscle fasciculations - Treat tacharrhythmias with propanolol or
o Rigidity esmolol
o Tachycardia - Renal elimination of dextroamphetamine may
o Hypertension be enhanced by acidification of the urine but
o Acute myocardial ischemia and is not recommended because of the risk of
infarction aggravating the nephrotoxicity of
o Inadvertent intraarterial injection may myoglobinuria
cause vasospasm resulting in gangrene

- death caused by:

o Ventricular arrhythmia
o Status epilepticus
ECSTACY - Hashish contains 3-6% and hashish oil 30-50%
THC
➢ MDMA (methylenedioxymethamphetamine)
C. CLINICAL PRESENTATION
A. MECHANISM OF ACTION
- Subjective effects after smoking a marijuana
- serves as a false neurotransmitter → release of
cigarette:
catecholamines & inhibition of MOA, also
o Euphoria
stimulates β & a receptors (similar to
o Palpitations
amphetamine)
o Heightened sensory awareness
o Altered time perception followed after
B. TOXIC DOSE
about 30 minutes by sedation
- 50-150 mg
- Severe intoxication may result in
o Impaired shot-term memory
C. TREATMENT
o Depersonalization- feeling as though
- Labetalol, Nitroprusside, or Nifedipine for HPN
one is in a dream or movie
o Visual hallucinations
MARIJUANA o Acute paranoid psychosis
o May also precipitate panic reaction
➢ Consists of leaves and flowering parts of the plant - Physical findings may include
Cannabis sativa
o Tachycardia
➢ Usually smoked in cigarettes (“joints” or “reefers”)
o Orthostatic hypotension
or pipes or added to food
o Conjunctival injection
➢ Resin from the plant may be dried and compressed o Incoordination
into blocks called hashish
o Slurred speech
➢ Contains a number of cannabinoids; the primary
o Ataxia
psychoactive one is delta-9- tetrahydrocannabinol
o Stupor with pallor, conjunctival
(THC)
injection, fine tremor, and ataxia (in
➢ THC is used as an experimental treatment for children after eating marijuana
emesis associated withcancer chemotherapy and
cookies)
for glaucoma
- Other health problems include
➢ hashish or hash oil
o Salmonellosis and aspergillosis from
➢ most commonly used illegal drug
use of contaminated marijuana
➢ It remains the most widely used prohibited drug
- IV use of marijuana extract or hash oil may
especially in Baguio for two reasons. It is easily
cause:
available and it is cheaper than “shabu”. In fact,
o Dyspnea
many users say they get it for free.
o Abdominal pain
o Fever
A. MECHANISM OF TOXICITY
o Shock
- THC may have stimulant, sedative, or
o Disseminated IV coagulation
hallucinogenic actions depending on the dose
o Acute renal failure
and time after consumption
o Death
- Also been observed are catecholamine release
(resulting in tachycardia) and inhibition of D. DIAGNOSIS
sympathetic reflexes (resulting in orthostatic
- Specific levels
hypotension)
o Cannabinoid metabolites may be
detected in the urine by enzyme
B. TOXIC DOSE
immunoassay for up to several days
- Toxicity is dose-related, but there is much after single acute exposure or weeks
individual variability, influenced in part by prior
after chronic THC exposure
experience and degree of tolerance
o Urine levels do not correlate with
- Typical marijuana cigarettes contain 1-3% THC, degree of intoxication or functional
but more potent varieties may contain up to impairment
15% THC
 - Other useful laboratory studies
o Electrolytes, glucose
E. TREATMENT
- Emergency and supportive measures
- Specific drugs and antidotes. There is no
specific antidote.
- Decontamination
o Prehospital. Administer activated
charcoal. Ipecac-induced emesis may
be useful for initial treatment.
o Hospital. Administer activated
charcoal and cathartic.
- Enhanced elimination. None.
LYSERGIC ACID DIETHYLAMIDE (LSD) AND OTHER
HALLUCINOGENS
➢ LSD- lysergic acid diethylamide “acid”, an ergot
derivative
➢ LSD and other hallucinogens have become known
as entactogens (“to touch within”), and several
have been used for personal experimentation as
well as clinically to facilitate psychotherapeutic
interviews
A. MECHANISM OF TOXICITY
- LSD and many other agents are thought to alter
the activity of serotonin and dopamine in the
brain
- inhibits serotoninergic firing → symphathetic
stimulation and hallucinations
- Central and peripheral sympathetic stimulation
may account for some of the side effects such
as anxiety, psychosis, dilated pupils, and
hyperthermia
B. TOXIC DOSE
- Toxic dose is highly variable depending on the
agent and the circumstances
- Generally, entactogenic effects do no appear to
be dose-related
- Paranoia or panic attacks may occur with any
dose and depend on the surroundings and the
patient’s current emotional state
- Hallucinations, visual illusions and
sympathomimetic side effects are dose-related
C. CLINICAL PRESENTATION
- Mild to moderate intoxication
o A person experiencing a “bad trip” is
conscious, coherent and oriented but
is anxious and fearful and may display
paranoid or bizarre reasoning
o A person with dose related
sympathomimetic side effects may
also exhibit tachycardia, mydriasis,
diaphoresis, bruxism (grinding of
teeth), short attention span, tremor,
hyperreflexia, hypertension, and fever
- Life-threatening toxicity
o Intense sympathomimetic stimulation
and includes seizures, sever
hyperthermia, hypertension, and
cardiac arrhythmias
o Hyperthermic patients are usually
obtunded, agitated, or thrashing
about, diaphoretic and hyperreflexic
o Untreated hyperthermia may result in
hypotension, coagulopathy,
rhabdomyolysis and multiple organ
failure
o Use of 2,5-dimethoxy-4-
bromoamphetamine (DOB) has
resulted in ergotlike spasm, circulatory
insufficiency, and gangrene
D. DIAGNOSIS
- Based on a history of use and the presence of
signs of sympathetic stimulation
- Diagnosis of hyperthermia requires a high level
of suspicion and use of a thermometer
- Specific levels
o Serum drug levels are neither widely
available nor clinically useful in
emergency management
o Amphetamine derivatives (DOB, STP,
MDA, MDMA, etc.) will cross-react in
screening procedures for
amphetamine class drugs
- Other useful laboratory studies
o Electrolytes, glucose, BUN, creatinine
o In hyperthermic patients: obtain
prothrombin time, creatinine
phosphokinase (CPK), urinalysis
dipstick for occult blood
(myoglobinuria will be positive)
E. TREATMENT
- Emergency and supportive measures B
- Specific drugs and antidotes
o There is no specific antidote
 o Sedating doses of diazepam (2-10 mg) o Thiamine- (prevention of Wernicke-
may alleviate anxiety, and hypnotic Korsakoff syndrome)
doses (10-20 mg) can induce for the o Disulfiram (Antabuse ® ) ( used to stop
duration of the “trip” (usually 4-10 alcohol addiction)
hours)
NICOTINE
- Decontamination
o (1) Administer activated charcoal, if • active ingredient to tobacco for the addictive
available. In general do not induce effect
emesis, because it is relatively • Lethal dose:
ineffective and is likely to aggravate o adults: 40-60 mg
psychologic distress. o child: 1.5 – 2 mg/kg
o (2) Hospital. Administer activated • Treatment: activated charcoal, gastric lavage
charcoal and a cathartic
- Enhanced elimination NITROUS OXIDE
o These procedures are not useful • laughing gas
o Although urinary acidification may • may cause diffusional hypoxia
increase the urine concentration of • hysterical laughing
some agents, it does not significantly
• Treatment: Oxygen
enhance total body elimination, and
may aggravate myoglobinuric renal
failure

MORNING GLORY FAMILY

• Argyreia nervosa (wood rose) &

• Ipomea violacea (Morning Glory)
• related to LSD but more GI effects

MESCALINE

• peyote cacitus (Lophophora williamsil)

“buttons”

PHENCYCLIDINE (PCP)

• dissociative anesthetic, “angel dust”

• Signs & symptoms: coma, acute brain
syndrome (disorientation, psychosis, coma)
• Treatment: Diazepam for seizures,
Nitroprusside for HPN

ETHANOL

• grain alcohol, neutral spirit

• responsible for major medical &
socioeconomic problems
• Alcohol content:
o beer: 4-5%
o wine: 10-14%
o distilled spirits:
o whiskey, vodka, rum, brandy): 30-50%
• Metabolites: acetaldehyde, acetic acid
• Signs & symptoms: CNS depression, acid-base
imbalance
• impaired thermal regulation, hypoglycemia
• Treatment: