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Detoxification/Withdrawal
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Goals
Differences between adolescent and adult patterns of use, effects on brain, concerns with detoxification/withdrawal.
Understand top concerns with particular substances Alcohol Opiates/opioids Cannabinoids Methamphetamine/cocaine/stimulants
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Adolescent Brain
Continues to develop until 20s Back to front
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Main Points
Different patterns of use Alcohol: binge vs. daily Polypharmacy as a general rule
Substances effect adolescent differently
The younger age at initiation the more risk for abuse/dependence
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Alcohol
Pattern of Use Binge type Less likely to be daily drinkers
Less sensitive to the sedating effects of alcohol Higher BAC More blackouts More damage
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What does this mean in corrections?
More likely to overdose than go through medically significant withdrawal
What happens with alcohol overdose? Increasing BAC leads to increasing
sedating effects Loss of muscle control, stupor, coma,
death Death from aspiration, choking,
respiratory depression
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What happens with Alcohol Withdrawal
Requires significant duration of daily drinking with tolerance 60% who meet criteria for dependence will
experience some symptoms of withdrawal (>90% mild to moderate)
6-24 hours from last drink Changes to major neurotransmitters in brain
Enchances GABA-major inhibitory neurotransmitter
Homeostatic changes Increase in blood pressure, heart rate,
anxiety, n/v, seizure, death
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CIW-A
Clinical Institute Withdrawal Assessment
Questionnaire /Assessment done by clinician/nurse
Score 10 or more needs medical treatment/evaluation
What to do if limited nursing?
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J Clin Psychopharmacol 1991; 11:291-295
CIWA-Ar Scale
Nausea and Vomiting Tremor Paroxysmal sweats Anxiety Agitation Tactile disturbances
Auditory disturbances Visual disturbances Headache, fullness in head Disorientation
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Opioids/opiates
Heroin Prescription Drugs
Hydrocodone (vicodin, norco) Oxycodone Morphine Methadone
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CDC- National Epidemic of Overdose Deaths
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Rates of Opioid Pain Reliever (OPR) overdose deaths, OPR treatment Admissions and Kilograms of OPR sold
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Drug overdose death rate and rate of opioid pain relievers sold in the US- 2008
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Effects of Opioids Sedation Pupil Constriction Slurred speech Impaired attention/memory Constipation/ urinary retention Nausea Confusion/delirium Seizures Slowed heart rate Respiratory depression
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What does this mean for corrections? Overdose potential
Depends on which opiate: ▪ Onset of action.▪ Hydrocodone (peak .5hr, duration 3-4 hours)▪ Methadone (peak: 2-4 hours, duration 24 hours)
▪ Tolerance of individual▪ Tolerance to respiratory depression may be slower than tolerance to
euphoric effects
Symptoms of overdose:▪ Triad: ▪ Altered LOC▪ Respiratory Depression (RR<12)▪ Miotic Pupils
Withdrawal Cows
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Management of Opioid Overdose
Basic life support Assess Ventilation▪ Support ventilation
Naloxone hydrochloride – opioid antagonist▪ .4mg to .8mg, may have to be repeated▪ May need higher doses and multiple repeated
doses over time
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Opioid Withdrawal
Not life-threatening but so uncomfortable prompts relapse.
Onset of symptoms depends on the duration of use and ½ life of drug used Heroin: onset 4-6 hours Methadone: onset: 36 hours
Neurophysiologic rebound in target organs
The generalized CNS suppression during use is replaced by CNS hyperactivity.
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Clinical Opiate Withdrawal Scale- COWS
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Treatment
Supportive measures Medication assisted
clonidine
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Psychostimulants
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Medical Morbidity-Acute Intoxication
CVS Ventricular
irritability Hypertension Tachycardia Myocardial
Infarction Neurologic
Seizure Stroke Hyperthermia
Rhabdomyolysis Acute Renal Failure Insomnia
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Chronic Methamphetamine Use CVS
Cardiomyopathy Myocardial
Infarction Strokes
Pulmonary Pulmonary
Hypertension COPD
Neurologic Memory Impairment Deficits in judgment Poor impulse control
Infectious HIV/Hepatitis C Skin infections Complications IVDA
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MA Psychiatric Morbidity
Psychosis Acute:▪ Classically paranoid▪ Persecutory delusions▪ Ideas of Reference▪ Heightened
awareness Chronic:▪ Psychosis can persist
after acute episode or recur with little or no further MA use.
▪ Sensitization
Mood Disorder Mania during
intoxication Depression during
withdrawal Anxiety
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Management of Intoxication
Confirm diagnosis by urine toxicology screen
Gastric lavage or activated charcoal for ingestion
Seizures: Diazepam Psychosis /Agitation: Diazepam +/-
antipsychotic Hyperthermia: external cooling
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Withdrawal from Methamphetamine Hyperarousal
Agitation, severe craving, nightmares Vegetative Symptoms
Decreased energy, craving sleep, increased appetite
Anxiety-related symptoms Anxiety, loss of interest, anhedonia,
psychomotor retardation Severe dysphoria, mood volatility,
irritability and sleep pattern disruption
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Cannibinoids
Drug of choice- most daily marijuana use
Intake: Adverse events: paranoia, increased
blood pressure/HR
Withdrawal Symptoms similar to nicotine withdrawal No real treatment for withdrawal
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Synthetic Cannibinoids
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Synthetic Cannibinoids- spice, KQ
Mixture of herbs or dried, shredded plant material that is typically sprayed with chemicals that are similar to THC
Street names: Spice, K2, Black Mamba, Blaze, JWH-018, 073, Kronic(added BZ), krypton (added opioid)
Typically smoked Sold in Europe since 2002-2004.
Widely available for purchase on Internet in 2006
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2010: states began banning product 2011: schedule 1 drug First cannibinoid identified was JWH-018
and CP47,497. Now there are well over 20 new synthetic cannabinoids.
10 -100 more potent than THC Strong affinity to CB1 receptors
Responsible for psychoactive effects Central and peripheral nervous sx, Cardiovascular system
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Some of herbal ingredients added may have psycho-active potential (opioid-like, Bz,etc)
Onset 3-5 minutes Duration of action: 1-8 hours
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Physiologic Response- CB1 Activation
Depends on dose Mood effects
Euphoria and dysphoria Hyperactivity, anxiolysis and anxiety
Perceptual effects Change in time perception Hallucinations/psychotic states Paranoia Depersonalization/dissociation
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Cognition effects: Fragmented thinking Short term memory impairment
Motor effects Ataxia, loss of coordination, slurred
speech Immunosuppressive Cardiovascular effects
Increased heart rate, orthostatic hypotension
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Toxicology effects
Unpredictable toxicology Adverse effects are dose dependent Emerging evidence that adverse
effects are more severe Especially in teens (as is Marijuana)
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Seizures Psychosis
Growing acceptance that cannabis use may increase the risk of psychosis and/or psychosis like conditions. Cannabis risk is mild.▪ 41% increased risk in developing psychosis for
cannabis users v. non-cannabis users▪ 109% increase for heavy cannabis users
Commonly reported in SC users▪ Clearly associated with both the onset and
exacerbation of recurrent psychotic episodes
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Mood and Anxiety Anxiety Catatonia
Cardiovascular effects Increased heart rate Pediatrics: Adolescents presenting with
chest pain, confirmed myocardial infarction.