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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When the drug is withdrawn, several physiological reactions occur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.”
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.
