questions 15

Signs and Symptoms of Drug Abuse (by Drug)

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Topic updated on 11/04/17 11:32pm

General Concepts
  • ALL addictive drugs act on the dopamine mesolimbic-reward pathway
  • Withdrawal symptoms are often the opposite of intoxication
    • e.g. miosis in opioid intoxication and mydriasis in withdrawal 
  • Depressant withdrawal is generally more life-threatening than stimulant withdrawal
  • Injection drug users at risk for
    • right-sided endocarditis
    • hepatitis and abscesses
    • overdose
    • hemorrhoids
    • AIDS
Depressants
  • Opioids (e.g. morphine, heroin, methadone)
    • intoxication 
      • nausea and vomiting with constipation
      • respiratory depression 
      • pupillary constriction (pinpoint pupils = miosis)
      • seizures (overdose is life-threatening)
      • for heroin use look for track marks (needle injections)
    • treatment for intoxication
      • naloxone/naltrexone
        • opioid receptor antagonist
      • symptomatic treatment
    • withdrawal
      • anxiety, insomnia, anorexia, sweating, dilated pupils, piloerection ("cold turkey"), fever, rhinorrhea, nausea, stomach cramps, diarrhea ("flulike" symptoms), muscle jerks, yawning
      • unpleasant but not life-threatening
    • treatment for withdrawal (examples mainly for heroin)
      • methadone
        • long-acting IV opiate
        • used for heroin detoxification or long-term maintenance
        • safe and used in pregnancy
      • suboxone
        • long acting oral administration with fewer withdrawal symptoms than methadone
        • naloxone + buprenorphine (partial opioid agonist)
        • naloxone is not active when taken orally, so withdrawal symptoms occur only if injected
          • intended to prevent overdose/enjoyment when suboxone is injected
  • Barbiturates
    • intoxication
      • respiratory/CNS depression
      • does not have a depression "ceiling"
    • treatment of intoxication
      • must treat withdrawal with barbiturates not benzodiazepines
      • symptom management
        • assist respiration
        • ↑ BP
    • withdrawal 
      • anxiety, seizures, delirium
        • similar to alcohol
      • life-threatening cardiovascular collapse
      • additive affects with alcohol
  • Benzodiazepines
    • intoxication
      • amnesia, ataxia, stupor/somnolence, minor respiratory depression
      • has a depression "ceiling"
      • additive affects with alcohol
      • treat with flumazenil (competitive GABA antagonist)
    • treatment for intoxication
      • flumazenil (competitive GABA antagonist) 
    • withdrawal
      • rebound anxiety
      • seizures (life-threatening), tremor
      • insomnia
    • treatment for withdrawal
      • long acting benzodiazepine (e.g. diazepam) to taper off dose
      • symptomatic treatment
  • Alcohol
    • see Alcohol topic
Stimulants
  • Amphetamines
    • mechanism
      • simulates biogenic amine (DA, NE, 5HT) release
    • intoxication
      • mental status changes
        • euphoria, impaired judgment, delusions, hallucinations, prolonged wakefulness/attention
      • sympathetic activation,
        • psychomotor agitation, pupillary dilation, hypertension, tachycardia, fever, cardiac arrhythmias
    • withdrawal
      • depression, lethargy, headache, stomach cramps, hunger, hypersomnolence
  • MDMA ("ecstacy")
    • mechanism
      • similar to amphetamines
      • effects 5-HT more than dopamine
        • may damage serotonergic neurons
    • intoxication
      • hyperthermia and social closeness
        • club drug
    • withdrawal
      • mood offset for several weeks
  • Cocaine
    • mechanism
      • block biogenic amine (DA, NE, 5HT) reuptake
    • intoxication
      • mental status changes
        • euphoria, psychomotor agitation, grandiosity, hallucinations (including tactile), paranoid ideations
      • sympathetic activation
        • ↓ appetite, tachycardia, pupillary dilation, hypertension, angina, sudden cardiac death, stroke (intense vasoconstriction)
      • stereotyped behavior
        • repetitive motions (e.g. digging through trash)
    • treatment for intoxication
      • benzodiazepines
      • neuroleptics
      • reduce blood pressure and body temperature
    • withdrawal
      • severe depression and suicidality, hyperphagia, hypersomnolence, fatigue, malaise, severe psychological craving
  • Caffeine
    • intoxication
      • restlessness and insomnia
      • ↑ diuresis
      • muscle twitching
      • cardiac arrhythmias
    • withdrawal
      • headache, lethargy, depression, weight gain
  • Nicotine
    • intoxication
      • restlessness, insomnia, anxiety, arrhythmias
    • withdrawal
      • irritability, headache, anxiety, weight gain, craving
    • treatment for cessation
      • bupropion (NE and dopamine reuptake inhibitor)
      • varenicline (partial nicotinic receptor agonist)
      • nicotine administration via other routes (patch, gum, lozenges)
Hallucinogens
  • PCP
    • intoxication
      • belligerence, impulsiveness, fear, homicidality, psychosis, delirium, seizures, psychomotor agitation, vertical and horizontal nystagmus, tachycardia, ataxia 
    • withdrawal
      • depression, anxiety, irritability, restlessness, anergia, disturbances of thought and sleep
    • note: ketamine is a similar drug; both are NMDA antagonists 
  • LSD
    • mechanism
      • action at 5-HT receptor
    • intoxication
      • visual hallucinations and synesthesias (e.g. seeing sound as color)
      • marked anxiety or depression, delusions, pupillary dilation
      • bad trip panic
    • withdrawal
      • largely no withdrawal because it does not effect dopamine
      • flashbacks years later
  • Marijuana
    • mechanism
      • binds to CB1/CB2 cannabinoid receptors
    • intoxication
      • euphoria, anxiety, disinhibition, paranoid delusions, perception of slowed time, impaired judgment, social withdrawal, ↑ appetite, dry mouth, hallucinations
        • largely psychological effects
      • amotivational syndrome
    • withdrawal
      • mild symptoms
        • irritability, depression, insomnia, nausea, anorexia
      • most symptoms peak in 48 hours and last for 5-7 days
      • can be detected in urine up to 1 month after last use
    • note: dronabinol is a cannabinoid used as an antiemetic


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Qbank (9 Questions)

TAG
(M1.PY.2) A 27-year-old female is brought to the Emergency Department by Fire Rescue after participating in a physical altercation with several commuters on the subway. She appears to be responding to hallucinations and is diaphoretic. Her vitals are as follows: T 100.5F (38C), HR 115, BP 155/90, RR 17. Her past medical history is notable for a previous ED visit for phencyclidine-related agitation. Which of the following physical findings would most strongly suggest the same diagnosis? Topic Review Topic

1. Prominent vertical nystagmus
2. Constricted but responsive pupils
3. Dilated, minimally responsive pupils
4. Conjunctival injection
5. Conjunctival pallor

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TAG
(M1.PY.18) A 43-year-old female presents to the ED with a severe case of left leg cellulitis. She is admitted for IV antibiotics. After 24 hours, the area of erythema has receded approximately 30%. The following day she is being prepared for discharge when she suddenly begins to complain of nausea and abdominal pain. On physical exam, she is febrile and has mydriasis and piloerection. What is the most likely cause of these new findings? Topic Review Topic

1. The patient's bacterial infection is no longer responding to the antibiotic regimen and she is showing signs of sepsis
2. The patient is having an allergic reaction to the antibiotic regimen
3. The patient is now showing signs of a pulmonary embolism as a result of a deep vein thrombosis
4. The patient is most likely withdrawing from an opiate that she uses chronically
5. The patient has acquired a nosocomial enteritis, as a result of her hospitalization and her antibiotic regimen

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TAG
(M1.PY.27) An 18-year-old male was brought to the emergency room after he caused an accident by driving at a slow speed as he was entering the freeway. He appears to have sustained no major injuries just minor scratches and lacerations, but appears to be paranoid, anxious, and is complaining of thirst. He has conjunctival injection and has slowed reflexes. A police officer explained that he had confiscated contraband from the vehicle of the male. Which of the following substances was most likely used by the male? Topic Review Topic

1. Phencyclidine (PCP)
2. Cocaine
3. Heroin
4. Alprazolam
5. Marijuana

PREFERRED RESPONSE ▶
TAG
(M1.PY.27) A 20-year-old college student presents to the emergency room complaining of insomnia for the past 48 hours. He explains that although his body feels tired, he is "full of energy and focus" after taking a certain drug an hour ago. He now wants to sleep because he is having hallucinations. His vital signs are T 100.0 F, HR 110 bpm, and BP of 150/120 mmHg. The patient states that he was recently diagnosed with "inattentiveness." Which of the following is the mechanism of action of the most likely drug causing the intoxication? Topic Review Topic

1. Increases presynaptic dopamine and norepinephrine releases from vesicles
2. Displaces norepinephrine from secretory vesicles leading to norepinephrine depletion
3. Binds to cannabinoid receptors
4. Blocks NMDA receptors
5. Activates mu opioid receptors

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TAG
(M1.PY.27) A 21-year-old female is brought by her brother to the emergency department after having a generalized tonic-clonic seizure one hour ago. She is slightly confused and has no recollection of her seizure. Her brother relayed that the patient has a history of severe anxiety for which she takes medication. For the past several days, he noticed that his sister exhibited body tremors, appeared to be agitated with quick mood changes, and, at times, was delirious. He states his sister recently ran out of her medications while visiting from out of town. Which of the following would best treat the patient's condition? Topic Review Topic

1. Diazepam
2. Methadone
3. Naloxone
4. Varenicline
5. Flumazenil

PREFERRED RESPONSE ▶
TAG
(M1.PY.27) An 18-year-old female is brought to the emergency department by her boyfriend. She is screaming uncontrollably. Eventually, she states that she is afraid that "death is near" but cannot give a rational reason for this thought. She reports both seeing colors "coming out of other people's mouths" and "hearing" these colors. The patient's boyfriend experienced similar sensory symptoms a few hours ago; he explains they were trying to have a "spiritual experience." Physical exam is significant for mydriasis, hypertension, hyperthermia, piloerection, tachycardia, and sweating. Upon which of the following receptors does the most likely drug she ingested act? Topic Review Topic

1. Cannabinoid
2. 5-hydroxytryptamine
3. NMDA
4. GABA
5. Mu opioid

PREFERRED RESPONSE ▶
TAG
(M1.PY.27) A 25-year-old male is brought to the emergency department by paramedics who picked up the individual at an electronic music festival. On physical exam, he is noted to have sunken eyes, dry skin and mucous membranes, and his skin does not rebound when pinched. Vital signs are BP 80/50 mmHg, HR 120 bpm, and T 103 F. Which of the following was most likely ingested by the patient? Topic Review Topic

1. Heroin
2. Ketamine
3. PCP
4. MDMA
5. LSD

PREFERRED RESPONSE ▶
TAG
(M1.PY.38) A 24-year-old female is brought to the ED from a nearby nightclub by the local police due to aggressive and violent behavior over the past hour. A friend accompanying the patient reports that the patient smoked marijuana that "seemed different" approximately one hour ago. The patient has never had this kind of reaction to marijuana use in the past. On examination, the patient is combative with slurred speech and active visual hallucinations; eye examination shows prominent vertical nystagmus. This patient's presentation can be best explained by intoxication with a substance that acts at which of the following receptors? Topic Review Topic

1. Serotonin
2. Cannabinoid
3. GABA
4. NMDA
5. Norepinephrine

PREFERRED RESPONSE ▶
TAG
(M1.PY.2014) A mother calls the psychiatrist, saying that she is concerned about her 18-year-old son who has become quite emaciated over the past several months. She has noticed that his pupils are enlarged, he has frequent nose bleeds, and he wears long sleeve shirts even in warm weather. His personality has changed quite dramatically as well, as he repeatedly steals from her and sells anything valuable in the house. He also has become overconfident, aggressive, and paranoid. Which of the following is a risk of the drug that the son is most likely using? Topic Review Topic

1. Serotonin syndrome
2. Sudden cardiac arrest
3. CNS white matter lesions
4. Irreversible schizophrenia-like psychosis
5. Increased risk of schizophrenia in predisposed patients

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