Natural Alkaloids: occur naturally in Opium. Synthetics: chemically produced narcotic analgesics...

Natural Alkaloids: occur naturally in Opium.

Synthetics: chemically produced narcotic analgesics with no relation to opium but produce similar effects.

Three Characteristics

1. Relieve pain

2. Produce withdrawal signs in dependant users when drug use stops

3. Will suppress withdrawal signs of chronic morphine administration

Hydrocodone (Vicodin)

Codeine

Morphine

Percodan Percocet

OxyContin

Demerol

Opium

Natural Narcotic Analgesics

Opium Processing

Ready for shipment

Various Colors of Heroin

Heroin ready for insufflation

Heroin Baggies

Powder to Injection

Powder to Injection

Track Marks

Needle Abuse

Heroin Girl

Heroin Street SlangSmack

Thunder

Hell dust

Big H

Nose drops

Down

H 800 bags of heroin

Methadone

Methadone

Developed in Germany during WWII

First marketed in the us in 1947

Prescriptions for methadone have increased by nearly 700% from 1998 thru 2006.

Methadone

http://www.deadiversion.usdoj.gov/drugs_concern/methadone/methadone_presentation0407_revised.pdf

http://www.deadiversion.usdoj.gov/drugs_concern/methadone/methadone_presentation0407_revised.pdf

http://www.deadiversion.usdoj.gov/drugs_concern/methadone/methadone_presentation0407_revised.pdf

Methadone Maintenance Therapy “MMT”

The patient remains physically dependant on an opioid but is freed from the uncontrolled, compulsive & disruptive behavior. - Improved subjects health

- Decreased criminal activity

- Increased employment

Effects are similar to morphine although they develop more slowly and last longer

Withdrawal symptoms are slower and milder

Advantages:Cannot be injected

Longer duration than Heroin

Methadone

Relieves moderate to severe pain

Suppress coughing

Methadone Uses

Maintenance

Daily dose of Methadone allows the Heroin addict to function normally with no physical need for up to 24 hours

Typical Clinic

Typical Clinic

Current Methadone Use

DAWN – Drug Abuse Warning Network

Emergency Department Visits, 2005

Tolerance

The same dose of the drug will produce diminishing

effects.

Steadily larger dose is needed to produce the same

effects

If using a “normal” dose he/she may exhibit little or no evidence of psychophysical impairment.

Even tolerant users, when impaired, usually exhibit clinical evidence (vitals & eyes)

Impairment is more evident with new users or tolerant users who exceed “normal” dose.

Tolerance

DependenceNeurons adapt to the repeated drug

exposure

Only function normally in the presence of the drug

When the drug is withdrawn, several physiological reactions occur

Psychophysical Indicators

Divided attention

impairment

Poor coordination and balance

No nystagmus.

Pupils will be constricted.

Eyelids will be droopy.

Eye Indicators

Ptosis

Miosis

General Indicators

Track marks“On the nod”Slowed reflexesLow, slow, raspy speechFacial itchingDry mouthEuphoriaFlaccid muscle toneInability to concentrate

1. Relief from the symptoms of withdrawal

2. Euphoria3. Relief from pain

Psychological Effects

ChillsAches of the muscle or jointsNauseaSweatingGoose bumpsYawningTearing of the eyesRunny noseVomiting

Signs and Symptoms of Withdrawal

Begin 8-12 hours

Intensify for 14-24 hours

Insomnia at 24-36 hours

Peak 2-3 days

5-10 days clear

Acute Action Vs WithdrawalAnalgesiaResp depressionEuphoriaRelaxation & SleepTranquilizationDecreased BPConstipationMiosisHypothermiaDrying of secretionsReduced sex driveFlushed warm skin

Pain & irritabilityPanting & yawningDysphoria & depressionRestlessness & InsomniaFearfulness & HostilityIncreased BPDiarrheaMydriasisHyperthermiaTearing & runny noseSpontaneous ejaculationChilliness & “gooseflesh”

Psychopharmacology by Meyer & Quenzer

Drug Cravings

When someone has a relapse, the primary cause is psychological, but physiological mechanisms play an important part in this process.

After months or years of being drug-free, an individual may crave a drug because of the pleasant physiological effects that occur while using the substance.

plpnemweb.ucdavis.edu

Drug CravingsThis supports the idea that psychological

factors may play a role in physiological factors.

Drug addiction causes long-term changes in the brain.

Psychologically, many individuals have relapses because they want to forget about their current situation, while physically the corticotropin-releasing hormone can trigger a drug craving when the individual feels stressed (Carlson, 2004).

Classic Evaluation Results

Slow internal clock – drowsy

Slow deliberate movement on SFSTs

BP, pulse & temp will be down

Miosis <3.0mm

Reaction to light will be little to none

If the drug is wearing off HIPPUS may be evident

Duration Of Effects

Drug Onset Duration

Heroin

Methadone

Dilaudid

Percodan

5-30 Minutes

5-30 Minutes

15 Minutes

15 Minutes

4-6 Hours

Up to 24 Hours

5 Hours

4-6 Hours

Downside

“Downside Effect: An effect that may occur when the body reacts to the presence of a drug by producing hormones or neurotransmitters to counteract the effects of the drug consumed.”

Methods Of Ingestion

Injected

Smoked

Snorted

Suppositories

Other conditions that may cause similar symptoms

Extreme fatigue

Head injury

Hypotension

Severe depression

Diabetic reaction

Overdose Signs and Symptoms

NARCAN

Slow and shallow breathingClammy skinBlue lipsPale or blue bodyExtremely constricted pupils

FINDINGS OF THE REASSESSMENT

Participants at the 2007 Reassessment of Methadone-Associated Mortality reported six overall findings:

FINDINGS OF THE REASSESSMENT

1. Methadone-associated deaths continue to rise as supported by medical examiner, toxicology, and other data sources.

2. Males 35 and older had the highest rate of methadone-associated deaths, approximately twice that of females.

Substance Abuse and Mental Health Services Administration

FINDINGS OF THE REASSESSMENT

3. The reason for the majority of methadone-associated deaths is often unknown, but if known, is largely the result of accidental exposures.

4. All forms of methadone distribution continue to rise, with the greatest increases in distribution for the tablet form and going to pharmacies.

Substance Abuse and Mental Health Services Administration

FINDINGS OF THE REASSESSMENT

5. Prescriptions for methadone have risen, although they are far lower than for other opioids.

6. Circumstances of methadone-associated deaths vary by State, suggesting a complex phenomenon.

Substance Abuse and Mental Health Services Administration

Three primary scenarios were seen in methadone associated deaths:

1)Accumulation to toxic levels of methadone during the start of opioid treatment or pain management due to overestimation of tolerance and methadone’s long, often variable, half- life .

2) Misuse of diverted methadone by individuals with little or no opioid tolerance.

3) Synergistic effects of methadone in combination with other CNS depressants (i. e., alcohol, benzodiazepines or other opioids).

NH 2 2 12 33 37 29 51 25.5 3.9

Maine 6 20 13 43 36 55 61 10.2 4.6

Maryland 7 18 20 24 40 96 145 20.7 2.6

Mass 10 8 23 24 36 58 93 9.3 1.4

UnitedStates

1999 2000 2001 2002 2003 2004 2005Ratio2005:1999

total 786 988 1,456 2,360 2,974 3,849 4,462 5.7 1.5

Methadone deaths by stateMethadone deaths

per 100,000 population 2005

Trends in methadone deaths and death rates

• From 1999 to 2005, poisoning deaths increased 66 percent from 19,741 to 32,691 deaths

• Whereas the number of poisoning deaths mentioning methadone increased 468 percent to 4,462

• Since 1999, between 73 and 80 percent of poisoning deaths mentioning methadone have been classified as unintentional (3,701 such deaths in 2005),

• An additional 11 to 13 percent being of undetermined intent

• 5 to 7 percent as suicides,

• Less than 1 percent as homicides

Trends in methadone deaths and death rates

Age

• Age-specific rates for methadone death are higher for persons age 35-44 and 45-54 years than for those younger or older

• for those in each of the 10-year age groups covering the span 25-54 years, the rates in 2004 were four to six times the rates in 1999.

• The largest increase was for young persons 15-24 years; the rate in 2005 was 11 times that in 1999.

• The rate for those 15-24 years, however, was unchanged from 2004 to 2005.

Age

Half-life

• The half-life of a drug is the name given to the time it takes for blood levels of a drug to drop to 50% of the peak concentration.

• The half-life of methadone depends upon whether it is a first dose or a dose given as part of an ongoing program.

Single, first dose

The apparent half-life of a single oral dose of methadone is shorter than that in extended use.

This is because much of the initial dose becomes distributed into the tissue reservoirs and is therefore not available in the blood stream.

Single, first dose

Following ingestion of oral methadone blood levels rise for about 4 hours and then begin to fall.

The apparent half-life of a single first

dose is 12-18 hours with a mean average of 15 hours.

Half life of Methadone

1. Relief from the symptoms of withdrawal

2. Euphoria3. Relief from pain

Psychological Effects

Why do they take Why do they take narcotic analgesics? narcotic analgesics?

Half life of OpiodsGeneric Brand Half-life

Buprenorphine Buprenex® 2.2

Codeine Tylenol® III 3

Diacetylmorphine Heroin 2

Dihydrocodeine Synalgos®-DC 3

Fentanyl Duragesic® 2

Hydrocodone Vidodin® 4

Hydromorphone Dilaudid® 3

Levorphanol Levo-Dromoran® 12

Meperidine Demerol® 1.5

Methadone Dolophine® 24

Morphine MS Contin® 2

Oxycodone Percocet® 3

Oxymorphone Numorphan® 1.5

Propoxyphene Darvon® 9

http://www.heroinhelper.com

OverdoseMethadone users expect the euphoria of other analgesics.

When they don’t get the euphoria they dose again or do another analgesic.

The Methadone level builds (consider the half life)

Subject’s breathing slows to a point of death

Defense Tactics

During preliminary exam we ask “Are you sick or injured?”

“Is you pain under control?

“How long have you been on your current dose?”

“Is the dose increasing or decreasing?”

It is the pain, not the Methadone, It is the pain, not the Methadone, that causes the impairment.that causes the impairment.

BuprenorphineA partial opiate agonist:

it blocks withdrawal and craving without producing a strong narcotic high.

Compound that binds to

receptors to cause a change in body function

BuprenorphineNaltrexone is an opiate

antagonist that causes unpleasant side-effects for opiate users;

It is added to prevent diversion and abuse because its effects are felt most acutely when the pills are crushed in order to be injected intravenously.

BuprenorphineThe FDA said Subutex should be used at the

beginning of treatment, while Suboxone should be used for maintenance.