Recreational Drugs - TODS Meeting

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3/20/2015Really Dumb JokeRecreational Drugs What day is “Star Wars Day”?Bart Johnson, DDS, MSDirector, Swedish GPRSeattle Special Care DentistryCredit where Credit Due!May the Fourth be with you. Many thanks to Hal Crossley (U. Maryland)who was inspirational in starting this series If you ever have a chance to hear him speak,“it’s a trip”!!! Disclaimer Thankfully, drugs have minimally touched mylife and those of my family Warning! This lecture is blunt A few stories will follow There is no better teacher than someone whohas real experience; if my info needs a bit of“realism tweaking”, please let me know! FunCrazyKNOWLEDGABLE!!Disturbing picturesDifficult themesMay hurt your personalexperiences It is totally okay to leave “There cannot be light without dark”I want my lecture to be the best it possibly can be1

3/20/2015For more information Resources National Institute of Drug Abuse for Drug-Free America www.Drugfree.orgDrug AbuseDefinitionsDrug Addiction “A treatable disease”Can become addicted to almost anything “A preventable behavior”Can have social use without addiction, but itis still abuse (“chippers”)Drug Dependence The patient’s body needs the drugWill go through withdrawal if the drug isdiscontinuedDoes not have the psychiatric element seenin addiction2

3/20/2015Dependence Facts: Dependence 10% of population is chemically dependentChemical dependency is a primarily chronicprogressive diseaseFacts: Addiction Critical Psychiatric/Behavioral Elements: Need more drug to producesame effect Addiction Preoccupation with obtaining the drugCompulsive use despite adverse consequencesRelapse after periods of abstinenceDenial of a problemToleranceFacts: Greatest addictive drug is crack cocaine but nodependenceMany drug addicts have very controllingpersonalities they want to let the drug takethem to the edge, then control itWithdrawal Physical Doses increaseCosts increaseDesperate measures increase Greatest physical dependency comes frombenzodiazepines at higher dosesMarijuana does not create physical dependenceCaffeine causes mild dependency“Worst case of flu I’ve ever had” Men typically stealWomen typically turn to prostitutionChildren can be sold for prostitution tofeed parents’ habits Insomnia, vomiting, diarrhea3-10 days of feeling horribleSweating, yawning, runny eyes/noseChillsCold/clammy skin with piloerection (“cold turkey”)Abdominal pain / crampsLeg twitches (“kicking the habit”)Desire to avoid this can lead to relapse3

3/20/2015Withdrawal Predisposing factorsPsychological Loss of the highs can bring depressionDesire to escape the depression can lead torelapseGenetics “Addictive personality”Environmental Witnessing violenceEarly physical/sexualabuse NicotineAlcoholSocial (key)AbuseAddictionChange in relationships withfamily or friendsEmotional instability Hostile, angry, uncooperativeInability to focus, hyperactiveUnusually tired, lethargic, decreased motivationSleeplessness followed by long “catch up” sleepDeceitful or secretiveMakes endless excuses Behavioral changes Children of abusing parentsPeers who use drugsExperimentation“Gateway drugs”Signs and SymptomsInformation from:Behavioral changes Drug availability Pathway to addiction: Signs and SymptomsPsychosocial How can I tell if mykids are on drugs? Silent, uncommunicativeLoss of inhibition; loud, obnoxiousbehavior; laughing at nothingSullen, withdrawn, depressedUnusually clumsy, stumbling,lack of coordination, poor balanceSigns and Symptoms Personal Appearance Messy, careless appearanceLong sleeves in warm weather (hides marks)Burns or soot on fingers or lipsRed, flushed cheeks or facePoor hygiene4

3/20/2015Signs and Symptoms Personal Habits Signs and Symptoms Smell of smoke on breath or clothesHiding/covering behaviors: Home/Car issues Missing: Chewing gum/mints/air fresheners to cover odorsSecretive phone calls/texting/EmailsEye drops for red eyesLocked bedroom doorsSneaking out Evidence: Signs and Symptoms Health Issues NosebleedsRunny noseFrequently sickNausea/VomitingWeight gain/lossHeadachesSkin lesions(picking frommeth/cocaine) Excessive thirstSoresSweatySeizuresDepressionEyedroppers, rolling papers, lighters, bongs made oftoilet paper rolls and aluminum foilSigns and Symptoms AlcoholRxsCigarettesMoneyValuablesSchool/work issues Loss of interest in school and extracurricularsDrop in gradesTruancyFailure to do schoolworkNeurotransmittersWhat is the NormalPhysiology of theBrain?5

3/20/2015A Fascinating Observation Understanding substance abuse has given usrich initial data about brain biochemistry Ironic, huh? Lemonade from lemons!Endplate Physiology Endplate has vesicles full of neurotransmittersReceptor side has appropriate receptorsHopefully vesiclesupply andreceptors arebalancedAcetylcholine Found at most synapse endplates Alzheimer’s is a deficiency of this neurotransmitterEndplate Physiology Endplate has reuptake ports 90% of neurotransmitters arereused frugal body!Endplate also has autoreceptorsthat match the neurotransmitter When synaptic cleft is full, theyshut off vesicle release.Acetylcholine Nicotinic receptors Ach receptors that also respond to nicotineIon ChannelsFast / brief responseBlocked by curareFound at first synapse6

3/20/2015CN SSOMATICAChAcetylcholineStriated MuscleAUTONOMIC, SYMPATHETICACh NHeartNNESmoothMuscleMuscarinic receptors GlandsAch receptors that also respond to muscarine7-transmembrane protein that triggers secondarymessenger system with G proteinsSlow / prolonged responseBlocked by atropineFound at second synapse,mostly parasympatheticNAChAChMSweatGlandsSome BloodVesselsAChNAdrenalMedullaENEMHeartAU TONOMIC ,PA RASYMPATHETICAChNAChMSmoothMuscleGlandsMany complexinterrelationships!Dopamine Your “pleasure” neurotransmitter Corpus striatum/pleasure center releasesDopamine GABA Inhibitory neurotransmitter; depresses brainactivityChloride Ion ChannelFound throughout theneuroaxisEspecially evident in areasof the brain dealing withemotional responses Involved in warm, bubbly feelings and orgasmGABA Many depressant drugs occupy GABA receptors BenzodiazepinesBarbituratesAlcoholParty drug GHBLimbic system7

3/20/2015Norepinephrine Primarily in thesympathetic autonomicnervous systemStimulates alpha and betareceptorsPrimes body for survivalresponsesSerotonin Depression is believed to be an imbalanceof serotonin supply and demand May have reduced serotonin May have insufficient receptors to trigger aresponse May actually have too many receptors Affects mood melancholy if insufficient “I can laugh with my friends, but my heart is notsmiling”Serotonin SSRI’s block thereuptake ofSerotonin, liftingthat melancholyBecause normal serotoninsupply cannot fill them all,they feel depressedEndorphins/Enkephalins SerotoninNatural mu receptor agonistsFemales have more receptors than males,tolerate pain betterEndorphins/Enkephalins Can be addictive “Runner’s high”: endorphinsreleased during exerciseMay build tolerance needlonger distances to reach thehighCan have withdrawal runners who get injured canbecome very morose8

3/20/2015Substance AbuseClassesOpiates Hallucinogens PeyotePsilocybinMyristicinLSDPCPBufotenin / Toad LickingNitrous OxideVolatile solventsOthers eOxycodoneHydrocodoneStimulants CocaineAmphetaminesMeth, Crystal methEcstasy and derivativesCaffeineMephedrone/MethyloneAmyl Nitrite and Butyl NitriteAtropine-containing substancesOthers Tobacco Depressants BarbituratesAlcohol Prescription Medications Steroids Anabolic steroidsCigarettes/CigarsSnuff Opiates/opioids (analgesics/anti-diarrheals)CNS depressants (barbiturates/benzos)Stimulants (amphetamines)9

3/20/2015DefinitionsOpiates Definitions Opium: Papaver somniferum: Narcotics/Narcosis/NarcolepsyOpiates: From opiumOpioids: Has opiate-like propertiesOpiate/Opioid Classes 10% Morphine0.5% Codeine (methylated morphine)Natural: Semisynthetic: Opiate/Opioid Classes Synthetic: arafluorfentanyl (China White)MorphineCodeineDiacetylmorphine (Heroin)Hydromorphone eOpiates/Opioids Pharmacology Codeine, Heroin, andthe semi-synthetics areconverted to morphinein the bodyCycle is high for 3-4hours, come down for2-3 hours Withdrawal starts 6-8hours after last dose10

3/20/2015Opiates/Opioids Why used/abused: Opiates/Opioids Rush of euphoria! Why used/abused: Lasts 1-2 minutesLike sexual release,provides release oftensionFollowed by peaceful sedation Opiates and Pain Facts: Secondary Effects: Opiates/Opioids People in pain willsequester narcotics totheir pain centersAs the pain diminishes,the narcotics move to filltheir addictive centersControl of acute pain foran appropriately shortterm does not createaddictionOpiates/OpioidsAltered salivary bufferingSugar cravingsDehydration (from sugar cutting agents) Heaviness/distanceAlternates between wakefulness and drowsinessCNS sedation/cloudingof mental processDeep satisfaction/comforting glowProblems seem far awaySide Effects: N&VConstipationRespiratory depression / AsphyxiaConstricted pupils (miosis)CNS depression (narcosis; “on the nod”)Histamine release: Flushed appearanceHypotensionItchy noseOpiates/Opioids Secondary Effects: All of the above, plus being high and nottoothbrushing Dental cariesDry skinDry mouth26 y/o patient11

3/20/2015HeroinHeroin Source: Heroin How used: How used: Injected Most addicts need it injected once tolerance sets inSmoked (pulmonary transmucosal)How used: Requires larger doses for a good highHeroin HeroinOral (not typically taken this way)Snorted (nasal transmucosal) Morphine plus glacial acetic acid, heat andpressure DiacetylmorphineManufactured in SE/SW Asia, Colombia andMexicoMost coming intothe USA is 100%pureDoses Insufflation 5-20 mg/doseInjection 5-10 mg/doseHeroin How used: The highs disappear with tolerance: “After a short while, I took heroin to prevent withdrawal, notto get high”Lethal dose is usually 200 mgSome experienced addicts can hit300-500 mg/day12

3/20/2015Heroin Injection techniques Heroin Dissolve with heat and water, injectInjection techniques “Smack”: Heroin Injection techniques Injection techniques Popping: Injection techniques If dose is too large tosolubilize, put thepowder in syringe,enter vein, pull upblood, inject, repeatLooks brown: “Gravy”Heroin Heroin“Jerking off”: IV access becomesimpossibleSQ injections; almostalways get infected andgive a classic sore thatscars overLeave tourniquet on until drug is in vein to allow tightbolus to “smack” the brainSweet spots: Lateral canthus of eye, under tongue, penile veinsHeroin Injection techniques Popping: May nick capillaries/vein (cut down) and useeyedropper to infuse medication13

3/20/2015Heroin Injection notes Heroin Cutting:Tracks: Scars form fromchronic infectionOften hiddenwith tattoosMy IV on theback of the guy’skneeConcentrationAmountStart with 1 kilo of 100% heroin. easily smuggled (2.2 lbs)100%1 kiloAdd 1 kilo of sugar (usually mannose)50%2 kilosTo each of those, add 1 kilo of sugar.Continue.Continue.Continue(this is the % dose commonly used)25%4 kilos12.5%8 kilos6.25%16 kilos3.125%32 kilos1 kg 1,000 gm 1,000,000 mg about 100,000 – 200,000 IV dosesHeroin Cutting: Mannose Quinine Commonly usedTastes bitter; added to reduce sweetness and fool thebuyerAnti-malarial: Originally added due to spread ofmalaria by dirty needlesTalc Another non-sweet cutting agent“Millions of splinters” into the lungs: FibrosisHeroin Injection Diseases MalariaTetanusPneumoniaPulmonary fibrosisBacterial endocarditisMyocarditisHepatitis (How to avoid it? “We make sure the yellow guy is thelast to use the needle”)Heroin Urine test 300 ng/ml is considered positiveTest will be positive for 2-3 days after last doseRandom testing has proven to be thegreatest deterrent for substance abuse14

3/20/2015Challenging problem!Prescription Opiates 1 in 5 teens has abused Rx pain relieversSigns of abuse: “A free high, straight from themedicine cabinet” Oxycodone “Oxy”, “O.C.”, “Percs”Favorite of the prescription-abusers Other Rx Narcotics Converted to morphine in vivoFastest uptake of any of the Rx narcoticsHydrocodone (“Vike”)Hydromorphone Taken orally or solubilized and injected“Pill fill” fibrosisOxycontin: Slow-release Worth 1/mgstreet valueOther Rx Narcotics Medicine bottles withoutillnessRx bottles missingDisrupted sleeping/eatingpatternsFentanyl OMFS/Anesthesiologist favorite drug of abuse100x more potent than morphineOften injected under watchband or underwearelastic to hide track marksSizzurp/Purple Drank Rx Cough syrup with codeineMix with candy such as Jolly RanchersMix with SodaBright colors/sweet taste easy to keep drinking and ODSaid to give an instanteuphoric high15

3/20/2015A Few Final Words on Opiates Chronic narcotic users feel more pain Receptors dullExogenous opiates cause both receptor andautoreceptors to fill Fools body into thinking you do not need more, soproduction shuts downMany relapses occur waiting for the body to beginmaking endorphins/enkephalins againMy two patients On narcotic Rx rehabGood kids from good familiesBoth with very carious teeth Tens of thousands of dollars ofcare necessaryIt was very easy to gethookedBart’s StoryMarijuana*Unless in WA or CO !Definitions Common names: PotGrassHashHempKhif Giggle smokeMary JaneWeedRoachRopeGateway drug Peak years for 1st time MJ use are 14-16 y/o Adolescent mind is still developing Regular exposure to psychoactive agents doesirreparable harmLinked to: Teenage mental illnessSuicide / AccidentsPregnancy / STDs16

3/20/2015Gateway drug Not generally addictive, no withdrawal The Plant That said, addiction can happen Two common species: Cannibis sativa Makes users think other drugs will be similarOther drugs used to combat negative effectsof MJ Hemp: RopePaperCloth(Historically) BowstringsHas been known to be used for over 8,000 yearsMJ has approximately 450500 different chemicals Sex of the plant is very important Only the females have psychoactive drugs Cuttings are put it under a grow lightIf it flowers, it is a femaleMale plants are destroyedMarijuana seeds do not contain Δ-9 THC Not illegal to possess23 of which are psychoactiveΔ-9 THC is the major oneHigh levels benzo(a)pyreneMuch research devoted towhat the active agents areand what they do The PlantAlways odd numberThe PlantStems have strong fiber Has Δ-9-TetrahydrocannabinolLeaves always serrated and in clusters of 5-7-9 The PlantCannibis indica No Δ-9 THCEndocannabinoidsAlternate Drug Forms Hashish: Sticky unadulterated resinscraped from the tops of thecultivated female plantsIsopropyl alcohol extraction;made into slabsEaten, smoked, tea3x concentration of Δ-9 THCFar more potent thanMarijuana leaves17

3/20/2015Alternate Drug Forms Sensimilla: General Information “Without seeds”Flowers from female plants never fertilized,therefore no seedsHighest concentration of psychoactive drug as theTHC has not been reduced by the seedsSource: Some states allow “personal use” supplyMost marijuana is now imported into USA Law enforcement has beensuccessful eradicating farms How used Pharmaceutical oral tablets Much more damaging than tobaccocigarettes Combustion temperature is much higher Bong/Hookah/Water pipe Not illegal to sell or possessCools smoke and removeswater-soluble impurities Δ-9 THC is lipid soluble; notremovedOral damageSmoked differently Helicopter patrolsElectricity monitoringSmoking Marijuana“Marinol”Not as effective as the natural plantMost users do not like this versionSmoking Marijuana“BC bud”Cigarette boatsGoal is to keep it in thelungs longerMy Old Lady Her story Loose toothRampant perio diseaseOral changes consistent withchronic heatingRemoving impurities resultsin a much higher blood levelof Δ-9 THC18

3/20/2015My Old Lady Had to recommend she use aBong to lessen the impact onher teeth and oral tissuesPharmacologic Effects Δ-9 THC mechanism of action is complex Sigh how do I get myself intothese situations?Endocannabinoids function with brainneuromodulationBlunts release of neurotransmittersInhibits: Pharmacologic Effects Biggest problem with MJ ismemory loss Peer pressure/encouragement Why use it? Euphoria (sense of well-being)Dreamy state of relaxation (“stoned, dude ”)Dulled thinking is the shortterm effectPermanent memory loss is thelong-term consequenceUsers who quit often remarkon how clear their thinkingbecomes once stoppedWhy use it? LearningMovementMemorySaid to be less damaging than liquor“Not habit forming, no withdrawal, no hangover,cheaper”WRONG!!Side Effects Distortion of time and spaceDisinhibition19

3/20/2015Side Effects Red eyesSometimes very dilated pupilsWhy use it? Unconcerned about personal problems Adolescents escaping problems of growing up“Amotivational Syndrome” Side Effects Increased appetite (munchies) Decreased cognition Disoriented behavior (Dysphoria)Paranoia Side EffectsEffect of the drug on HypothalamusGood for HIV and cancer patients Side Effects Distortion of time and space Objects look farther away traffic accidentsMotor impairment lasts longer than euphoriaLasts for 24-48 hours. impaired professionals onMonday morningLack of ambition, motivation, personal achievement“It made things I worried about seem unimportant”Trouble making decisionsRemembering simple things like spellingProcrastination due to memory issuesPoor concentrationShortened attention spanAll are magnified in theadolescent brainSide Effects Suppression of immune systemDamage to lung tissue20

3/20/2015What’s the WA Law Now?Testing Federal guidelines 100 ng/mlFat soluble, sequesters in lipid stores Can detect Δ-9 THC in the urine of the casualuser for 2-4 daysIn the heavy user, can detect x 30-60 daysSecondary exposureto MJ smoke will testnegativeWhat’s the CO Law Now?Washington Law Summary Legalizes use of MJ in adults 21 y/oCannot grow for personal use unlessauthorized for medicinal purposesPossession of 1 oz MJ, or 16 oz of “solidinfused forms”, or 72 oz “liquid infused” islegalSet legal DUI limits to 5 ng/mLColorado Law Summary Recreational: Adults 21 y/o can grow up to six plants in aprivately locked spacePossess up to 1 oz while drivingGift up to 1 oz to other 21 y/o adultsPrivate use only; public consumption is illegalTourists can use it in-state, but cannot transportacross state linesColorado Law Summary Medicinal: Adults 21 y/o can grow up to six plants in aprivately locked spacePossess up to 2 oz while drivingMDs can give permission to possess morePrivate use only; public consumption is illegalCannot use in a manner which may endangerothers (i.e, driving)Can only buy from a dispensary, not a pharmacy(due to Federal designation as a Class I drug)21

3/20/2015Colorado “Fun” Facts: June 2014 had 24.7M in salesJanuary to June, 2014 had 115M in sales 20M in taxes120 recreational dispensaries500 medical dispensaries WA just started, so we need to catch up ClassesHallucinogens “Are you willing to experiment withyour sanity?”Classes Tryptamine derivatives Dimethyltryptamine (DMT),Diethyltryptamine (DET),Dipropyltryptamine (DPT)Toad Licking (Bufotenin)PsilocinPsilocybin (phosphorylatedPsilocin)Lysergic Acid DiethylamideLysergic Acid MonethylamideMorning glory seedsClasses Amphetamine analogues Dimethoxyamphetamine (DMA)Peyote (Mescaline)MyristicinPhencyclidine (PCP)Ketamine22

3/20/2015General Information Most resemble three major neurotransmitters: The mode of action is not known Users of hallucinogens tend to stay with themPolysubstance abuse is rareWhy use Hallucinogens? Changes the way we experience rea

3/20/2015 3 Dependence Facts: 10% of population is chemically dependent Chemical dependency is a primarily chronic progressive disease Caffeine causes mild dependency Dependence Facts: Greatest physical dependency comes from benzodiazepines at higher doses Marijuana does not create physical dependence Addiction

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