APhA- CH 11 Summary Drug Abuse & Addictive Substances (by Maya & Pearl Pages: 175-183) First Part = Maya Bbashi SubstanceSlang nameMethods of abuse Effects Androgenic anabolic steroids(synthetic derivatives of testosterone) RoidsOrally injection Men:testicles shrinking Reduce in sperm count-infertility-baldness-gynecomastia- risk for prostate cancer Women: facial hear-male pattern baldness-changes or cessation in menstrual cycle-clitoris enlargement-deepened voice Adolescents:stunted growth and accelerated puberty changes Others: jaundice-fluid retention-hypertension-acne-mood swings(manic-like symptoms) Barbiturates (they are CNS depressants) Barbs-downersIngestion-injection *At high doses they become general anesthetics and their effects will become-ataxia-depressed reflexes-hypotension-respiratory depression *they should not combined with drugs or substance causes sedation(alcoholic drinks-prescription pain medication-OTC cold and allergy drugs) witch lead to slow berating alone or also slow heart.

Cocaine (it is CNS stimulant) Snow-crack-rock Sniffing-snorting-injecting-smoking*cocaine is poorly absorbed orally Cause hyper-stimulation and euphoric effects ( dilated pupils-hypertension-tachycardia-increased temperature Prolonged cocaine snorting cause ulceration in nose mucous membranes-damage the nasal septum which may cause it collapse The deaths are result of cardiac arrest or seizures followed by respiratory arrest DextromethorphanDXM-DM-robo-rojo-velvet Orally (drinking cough syrup)Snorting (powder which is extracted from syrups) *dextrorphan is the active metabolite witch is related to phencyclidine(PCP)and ketamine in structure (they may contribute in the abuse) Hyper-excitability-lethargy-ataxia-slurred speech-sweating-hypertension- nystagmus-heightened sense of perceptual awareness-altered time perception-visual hallucination *it has been sold as (ecstasy). Ethanol (CNS depressant) Various names-alcoholic drinks IngestionAt high dose: hypotension-hypoglycemia-respiratory depression and death Acute: ataxia-sedation-emesis-slurred speech Chronic: esophageal varices-hepatic failure with ascites malnutrition GHB (CNS depressant) Liquid ecstasy-soap-easy lay-georgia home boy-somatomax-scooprievous bodily harm Ingestion abused for euphoric-sedative-anabolic effects it causes coma and seizures *GHB+methamphetamine=increase seizures *GHB+alcohol =nausea+breathing difficulty *GHB has two precursors GBL and BD INVOLVED IN POISONING-OVERDOSE-DATERAPES-DEATHS HeroinSmack-H-skag-junk Injection-smoking-snorting Cause: euphoria (rush)followed by alternately wakeful and drowsy state(on the nod) CNS and respiratory depression-miosis(pinpoint pupils)-pulmonary edema(can occur) Abuse is associated with fatal overdose-spontaneous abortion-collapsed veins-infections( HIV-AIDS and hepatitis) InhalantVariousInhaling *variety of chemical vapors causes psychoactive effects *inhalants abuse =short term intoxicating(only few minutes)+CNS depressant(similar to anesthetics) *successive inhalation=loss of inhibition and control*continued use of inhalants may lead do coma *in some cases prolong use =heart failure and death(sudden sniffing death) Injected drugsShooting up-mainlining Injection*risk of transmitting or acquiring HIV-hepatitis-infections(bacterial-fungal) *chronic use: collapsed veins-infection of the heart lining and valves-skin abscesses-cellulitis-liver disease *EMBOLI can form when there is insoluble materials in tablets(which is used to prepare injecting mixture ) Ketamine (it is anesthetic) K cat-special K Vitamin K Valium Injection-snorting *in certain doses :dreamlike states and hallucinations *in high doses: delirium-amnesia-impaired motor function-hypertension-depression-potentially fatal respiratory depression LAD (hallucinogen) Acid- L blotter-cubes sugar-dots Ingestion (tablet-capsule-liquid) 1-physical effects: mydriasis(dilated pupils)- increase in temperature-tachycardia-hypertension-sweating-loss of appetite-dry mouth-tremors 2-sensational and feeling changes*in sufficient doses LSD cause visual hallucinations +delusions Second Part = Pearl Chris 1. MARIJUANA: Slang: Pot, herb, weed, grass, widow, ganja, hash. Cannabis - Bubble gum, Northern Lights, juicy fruit, Afghani #1 Skunk varieties. Methods of abuse: Ingestion - Mixed with food or brewed in tea. Smoking - joint, nail, bong, blunt. Health Effects: Severe terror. Fear of losing control. Fear of insanity, despair, and death. Fatal accidents. Flashbacks. Delirium, conjunctivitis, food craving. Short-term memory, learning problems, distorted perception, loss of coordination, tachycardia. Burning and stinging of mouth and throat with heavy cough like smokers. Drug craving and withdrawal. Risk of heart attack quadruples in first hour of smoking marijuana. Active chemical THC (delta-9-tetrahydrocannabinol). 2.MDMA (3, 4 methylenedioxymethamphetamine): Slang:Ecstasy, Adam, XTC, Hug, beans, love drug. Methods of abuse: Ingestion. Snort. Inject. Suppository. Health Effects: Stimulant and hallucinogenic. Increases pulse and BP. High doses---->malignant hyperthermia-rhabdomyolysis. Confusion, depression, insomnia, craving, paranoia days to weeks after use. Physical symptomsmuscle tension, teeth clenching, nausea, blurred vision, fainting, chills and sweating. Contents of MDMA may include caffeine, dextromethorphan, heroin, and mescaline. MDMA like substance paramethoxyamphetamine (PMA) led to death due to hyperthermia. 3.METHAMPHETAMINE: Slang:Crank, meth, speed, chalk, ice, crystal, glass. Methods of abuse: Ingestion. Snorting. Injection. Smoking. Health Effects: Addictive stimulant. Produces euphoria, irritability, insomnia, confusion, tremors, anxiety, paranoia, aggression. High doses ---> HTN, tachycardia, stroke, arrhythmia, CV collapse, death. Hyperthermia and convulsion -->death. Prolonged use-->extreme anorexia, tooth decay, lesions. 4.NICOTINE: Slang:Various names. Methods of abuse: Smoking (cigarettes) Chewing (tobacco) Health effects: CNS stimulant and sedative, highly addictive. Stimulation-->depression and fatigue --> Dependence. Women on OCP more than 30 years with increased cardio and cerebrovascular risk. Pregnant women--->Stillborn, premature, low birthweight. Daily cough, phlegm, frequent respiratory infections. Tar in cigarette ---> higher risk of lung cancer, emphysema, bronchial disorder. Carbon monoxide--->cardiovascular diseases. Dependency and withdrawal. 5.OPIOIDS: Slang:Various. Methods of abuse: Ingestion. Injection. Health effects: Include morphine, codeine, oxycodone (MS Contin), propoxyphene (Darvon), hydrocodone (Vicodin), hydromorphone (Dilaudid), meperidine (Demerol) Drowsiness, constipation. Large dose-->coma, hypotension, respiratory depression, also death. Dependence, craving, withdrawal. 6.PCP (phencyclidine) Slang: Angel dust, Ozone, wack, rocket fuel. Combined with marijuana called killer joint or crystal superglass. Methods of abuse: Snorting. Smoking (applied to leaf like mint). Ingestion. Health effects: Addictive hallucinogen, sedative--->compulsive PCP-seeking. Violent, suicidal, dangerous to self and others. Low doses --->slight tachypnea, moderate tachycardia, and HTN, shallow respirations, profuse sweating, numbness of extremities, muscular incoordination. High doses--->decreased BP, pulse, respirations.Nausea, vomiting, blurred vision, drooling, coma, death (due to suicide) Physiological effect--->low dose--->change in body awareness.High dose--->illusion, hallucination like schizophrenia. 7.ROHYPNOL (flunitrazepam): Slang:Rophie, roofie, roach, rope, date rape drug, forget me. Methods of abuse:Ingestion. Health effects: Smuggled drug. Sedative hypnotic--->muscle relaxant and amnesia. Mixed with alcohol can incapacitate-->rape---> amnesia. Clonazepam (Klonopin) and alprazolam (Xanax) abused like Rohypnol. 8.STIMULANTS, AMPHETAMINES AND RELATED COMPOUNDS: Slang:Speed, dexies, uppers. Methods of abuse: Ingestion. Snorting (tablets) Health Effects: CNS stimulant.Addictive if misused. High dose-->arrhythmia, HTN, hyperthermia, hostility and paranoia. APPROACHES TO TOXIC EXPOSURES AND ANTIDOTOESApproaches to Toxi Exposures By Kate N. Bellew Pages 183-185 1. Inhaled poison. Immediately get the person to fresh air. 2. Poison on the skin. Remove any contaminated clothing and flood skin with water for at least 15 minutes.3.Poisonintheeye.Removecontactlenses.Floodtheeyewithwaterpouringfromalargeglass2-3inches from the eye for 15-30 minutes. 4.Swallowedpoison.Ifthevictimisconsciousanddoesnothaveconvulsionsandcanswallowgiveasmall glass (2-4oz) of water immediately. Call the poison center for advice. Other consideration: Avoid wasting time to find antidotes at home. Do not use home remedies such as salt water, mustard powder, raw eggs, hydrogen peroxide. Call 911 or an ambulance if the victim is not breathing or has have seizures or is unresponsive. For another situation contact a poison center. Decontamination of GIT Ipecac syrup has questionable effectiveness, and its use is generally avoided. Gastriclavageinvolvesplacingatubeontothestomachthroughanostrilorthemouthandrepeatedly washingoutthestomachcontentswithawaterorsalinesolution.(Questionableeffectivenessifitis performed more than 1hour after ingestion of the toxin. Activated charcoal given orally is often the only treatment necessary if the toxin is absorbed and it is used within 1-2 hours of ingestion of the toxin. Cathartics such as magnesium citrate are not routinely used. Whole bowel irrigation can be considered if the toxin is slowly or poorly absorbed. Ipecac syrup Contraindication:pronouncedsleepiness,comaorseizures,ingestionofcaustics,aliphatic hydrocarbons,andfastactingagentsthatproducecomaorseizers(TCA,Cachannelblockers,beta blockers). Time since ingestion 1hour or more. Adverse effects: diarrhea, sleepiness, protracted vomiting which can complicated administration of oral therapies.Activated charcoalUsed to absorb poisons in alter or comatose patient as a slurry by mouth or through a lavage tube. Contraindications:ingestionofcaustics,aliphatichydrocarbons,heavymetals(Na,Li,FeorPb)or simple alcohols, if bowel sound is absent. Advantages:rapidonsetofaction,nonspecificactionforawidevarietyofchemicalsandreasonable effectiveness within 1hour of ingestion. Disadvantages: messy, difficult to administer, may remove beneficial drugs with the toxin. Cathartics (Mg citrate; MgSO4; Na2SO4 and sorbitol) Previously used as an adjunct with activated charcoal to decrease GIT transit time, buttheir efficacy is unproved. Fluid and electrolyte disturbances are possible. Whole bowel irrigation GenerallyusedtowashouttheGITtractwhencharcoalmaybeinappropriate(e.gLiorFeingestion) and the toxin is suspected to be in the GIT tract. Uselargervolumesofpolyethyleneglycolelectrolytesolutionsthantheamountsconventionallyused forbowelpreparation.Administerpermouthorthroughagastricorduodenaltubefortreatmentfor poisoning. Contraindications:ingestionofcausticoraliphatichydrocarbons,absentbowelsoundorGIT obstruction.Adverse effects: Nausea and vomiting Advantages include prompt whole bowel evacuation, but is messy procedure because of rectal effluent. Other Hospital-based therapy Supportive and systematic care, multiple doses of activated charcoal, hemodialysis and use of antidotes

AntidotesBy Ahmed HashemPage: 185-190 Acetylcysteine (NAC): Indications: To treat acute Acetaminophen overdose.MOA: Protect liver by Supplying glutathione to reacts with Acetaminophen metabolite.Adverse effects: Oral = nausea, vomiting.IV = anaphyl actic reactions (rash, wheezing, hypotension).Atropine: Indications: Poisoning of Organophosphates, carbamates & Bradycardia Nontoxicologic: pre-anesthetic agent (for antisecretory effects), ophthalmic mydriasis& cycloplegia.C.I:glaucoma, reflux esophagitis, obstructive uropathy, ulcerative colitis, paralytic ileus, myasthenia gravis. Pralidoxime: - dephosphorylates acetylcholinesterase regenerating its activity.Indications: poisoning due to pesticides and organophosphateswhich have anticholinesterase activity and in the control of overdosage by anticholinesterase drugs used in the treatment of myasthenia gravis.ADEs: blurred vision, diplopia and impaired accommodation, dizziness, nausea, tachycardia, hyperventilation, and muscular weakness. Digoxin immune Fab (Digibind, DigiFab): - sheep antibody - Binds to digoxin in plasma, enhances elimination in urine.Indications:sever digoxin intoxication (symptoms: ventricular arrhythmias, second or third degree heart block not responsive to atropine & hyperkalemia > 5 mEq/L) ADEs: hypokalemia, hypotension. Dose (in # of vials) = (Serum digoxin level in ng/mL) x (weight in kg) / (100).Flumazenil: - Competitive antagonist of benzodiazepine receptor in CNS.Indications: reversal of the sedative effects of benzodiazepines C.I: - Mixed overdoses that can decrease seizure threshold (tricyclic antidepressants, haloperidol, bupropion, lithium). - In patients given benzodiazepine for control of a potentially life-threatening condition (e.g. control of intracranial pressure or status epilepticus).ADEs: agitation, sweating, abnormal vision, dizziness.Naloxone: - Opioid competitive antagonist, competes at three CNS receptors (mu, kappa and delta).Indications: - reversal of narcotic depression, including respiratory, CNS depression, induced by opioids.ADEs: - In postoperative patients >> hypertension, dysrhythmias - Use in opiate-dependent patient can cause withdrawal. Withdrawal convulsions in neonates. ToxinAntidoteTrade name Acetaminophen Acetylcysteine (NAC) Mucomyst Acetadote OrganophosphatesAtropine Pralidoxime HCl Protopam CarbamatesAtropine DigoxinDigoxin immune antibody fragment Digibind, DigiFab BenzodiazepinesFlumazenilRomazicon Oipoids Naloxone Nalmefene Narcan Revex Anticholinergic compoundsPhysostigmine salicylateAntilirium Heavy metal poisoning (Arsenic, Lead, Mercury) Succimer (heavy metal chelating agent) Dimercaprol ( chelating agent) For patients unable to tolerate succimer Chemet BAL -blockersGlucagonGlucaGen Ca-channel blockersCa chloride 10% Glucagon GlucaGen CyanideCyanide antidote kit: 1. Amyl nitrite 2. Na nitrite 3% 3. Na thiosulfate Hydroxocobalamin Cyanokit Ethylene glycol, methanolEthanol 10% Fomepizole Antizol IronDeferoxamineDesferal IsoniazidPyridoxine (vitamin B6) MthemoglobinemiaMethylene blue SalicylateNa bicarbonateCauses alkaline diuresis Snake bite (rattlesnake, cottonmouth, copperhead) Crotalidae polyvalent immune Fab(ovine)CroFab Tricyclic antidepressants,Agents with type 1a antiarrhythmic effects Na bicarbonate (alkalinization) Warfarin, superwarfarinsFresh frozen plasma Vit. K1 Mephyton, AquaMEPHYTON HeparinProtamine Poison Control & Disaster preparedness by Maria & Talha Poison Control Center (PCC) (Available 24h) Maria Rameriz: Page 191 -193 Determines true poison. Recommend first aid & programs & materials. Refers for further investigation & treatment. Monitors. Poison Prevention Packaging Act 1970 -> Use safety caps (most drugs). Exceptions (birth control pills, nitroglycerin). Pharmacy RequirementsMaintain available: Antidote information, approved stock Antidotes & Others emergency drugs. Phone number PCC. Biological agents that may be used in a Terrorist attack AgentClinical FeaturesTreatment SmallpoxLike mild viral illness for 2 to 4 days Non specific (variola virus)Then rash (face, extremities) onset.Vaccine within 4 days and toDirect-AerosolPustules->sacbs->pitted scars (3 weeks)close contacts. AnthraxCutaneous: Small papule->vesicle (1-2)FDA: (Bacillus anthracis)Necrotic painless ulcer.Maybe: fever, malaise,Ciprofloxacin or doxyciclineGram +headache, regional lymphadenopathy. kids + Adults. Levofloxacin 18+ Spore-rodInhalation: Like viral illness (sore throat, Maybe Amoxicillin or penicillinNo contagiousmild fever,muscle aches,malaise). Min. productiveProfilaxis: 60 days cough, nausea or vomiting, chest disconfort ->Vaccine IM for prevent 18 to 65 resp. faliure -> shockyears old at high risk Gl: Distress -> fever -> signs septicemia, bloody vomit, diarrhea.PlagueAerosolised: fever, cough, mucopurulent Streptomycin or Gentamycin (Yersinia pestis)sputum, hemoptysis, chest pain. 1-6 day & Others Pneumonic plaguesevere pneumonia. Septic shock and mortality without treatment.Butulism (Clostri-Acute paralisis. Bulbar palsies (diplopia, Antitoxin (within 24h).dium botulinun)dysarthria, dysphonia & dysphagia 12-72h). Suportive care. (MechanicalFeedborne Respiratory muscles paralisis or ventilation) or airboneupper airway obstruction.No contagious TularemiaInhalation (FrancisellaNonspecific febrile illness (3-5). IncipientStreptomycin, Gentamicin,tularensis) pneumonia, pleuritis, hilar lymphadenopathy.chloramphenicol, doxycycline,No contagious Respiratory failure, shock maybe death ciprofloxacin PEP: doxycycline or ciprofloxacin. Viral hemorrhagic Filoviruses: Ebola & Marburg high fever Supportive2-21 days. Maculopapular rash on feverstrunk later day 5 (bleeding: petechiae, Maintain fluid & electrolyte balance,(filoviruses, ecchymosis, disseminated intravascular circulatory volume & BP. coagulation & hemorrhages )arenaviruses) Lassa & new world Arenaviruses (manchupo)

BunyavirusesSimilar to filoviruses but gradual onset Flavivirusesof rash, hemorrhagic diathesis & shockRicinInhalation: Cough & dyspnea. Lung: severe Supportive.(Castor beans) Inflammation & filled with fluid. Inhib protein Skin might be cyanotic or flush red.synthesisIngestion: GI internal bleeding.

Injec: Kill closest muscles and lymph nodes then Spread All 3 types Death from multiple organ failure By Talha Chemical Threats Chemical Name(Military name) Clinical FeaturesTreatment Nerve Agents (G&V; Sarin(GB); Soman (GD); Tabun(GA); Cyclohexyl sarin (GF) These are Organophosphates=> attach to & inhibit Acetylecholinestrase=> miosis; vomiting; diarrhea; salivary /nasal/lacrimal/dermal secretions; paralysis; seizures & resp. failure. Well absorbed via all routes =>symptoms within minutes 18 hours Rapid decontamination Antidotes = Atropine (reverse muscarinic symptoms) & Pralidoxime (restore Ach.esterase.). Diazepam/Lorazepam for seizures. Blister Agents Mustards & Nitrogen Mustards; Lewisites; Chlorasine; Phosgeneoxime (CX) Mustards => Blistering effect => damage skin, eyes & lungs. Liquids cause burns & scarring. All forms Absorbed via skin & distribute systemically => hypovolemia, shock & organ damage (Lewisites); bone marrow suppression (N. mustards); necrotic tissue damage (CX). Sulphur & N. mustards and CX = No Antidote, only avoid contact & decontamination. British Antilewisites = Antidote for Lewisites. Given = IM/Topical. Chlorasine = Atropine sulfate for eyes. Blood Agents Arsine (SA) Cyanide Gases = > Hydrogen Cyanide (AC) & Cyanogen ChlorideCK) Cyanide Solids => K- cyanide (KCN) & Na- cyanide (NaCN) Arsine Gas = Nausea, Vomiting & 2ndry Renal failure(1-2Hrs-11Days) inhalation of Cyanide => breath (in 15 sec); convulsions (30 sec); stop Resp. (2-4 min); stop heartbeat (4-8 min).Arsine = Symptomatic approach for hemolysis (normally without chelation). Cyanide binds with cytochrome oxidase. Cyanide = 2 Antidotes 1 Cyanide-Antidote-Kit = Na-nitrite & Na-thiosulfate. Na-nitrite = > InduceMethemoglobin in RBC to bind e Cyanide n release cytochrome oxidase.Na-thiosufate convert cyanide into thiocyanate which renally excreted.2 Cyanokit = Hydroxycobalamine which combine e cyanide to form non-toxiccyanocobalamine (Vit B12)Choking & Pulmonary Agents Phosgen (CG); Diphosgen (DP); Cl; HCL; NO Phosgen = Prototype agent = eyes, nose, throat & lung irritation and edema up-to 48 Hrs. Others = Immediate irritation & delayed potential effects. All agents are gases. Phosgen & All Others = No specific Antidote. Only decontamination & symptomatic treatment. Incapacitating Agents Include CNS & Resp. Depressants e hallucinating properties. Others = Cannabinoids, Opiods, Lysergic Acid (LSD), etc Antidotes = Naloxone for opiods & Physostigmine for Anticholinergics. Others = Decontamination & sup. Treatment Riot Control & Tear Gases Lacrimators = Chloroacetophenone (CN); Chloropicrin (PS); Bromobenzylcyanide (CA); Dibenzoxazepine (CR). No Antidote. Decontamination & Symptomatic treatment.Vomiting Agents Irritant Gases = Adamsite (DM); Diphenylchloroarsine (DA); Diphenylcyanoarsine (DC) Symptomatic treatments for Sneezing, Coughing & vomiting. Radiological Threats Radiological & nuclear weapons and materials involving Radio-nucleotides produce topical & systematic effects (immediate/delayed). Radiation Emergency Assistance Center/Training Site (REAC/TS) = Guidance on treatment center. Stable-Iodine supplements (Na/K iodide Tablets, etc.) help reducing uptake of radioiodine by thyroid.Prussian blue 500mg Capsules = Treatment of exposures of Radioactive Cesium & Thallium. Ca & Zinc salts of DTPA in IV & Aerosols for pts who exposed to Dirty Bombs radio-nucleotides. Emergency Preparedness CDC maintains Strategic National Stockpile (SNS) for rapid deployment of life-saving pharmaceuticals, antidotes & other supplies in US to use in any kind of Threats. CHEMPACK is stock of drugs to treat Nerve Agents. Congrats guys for finishing CH 11. Keep it Up THE END