LEARNING OBJECTIVE: Recall drug abuse assessment and treatment procedures and patient handling techniques.
Drug abuse is the use of drugs for purposes or in quantities for which they were not intended. Drugs of
abuse may be swallowed, inhaled, snorted (or by nose drops), injected, or even absorbed through the skin, rectum, or vagina. When abused, therapeutic drugs become a source of “poison” to the body. Drug abuse can lead to serious illness, dependency, and death. Death is usually because of acute intoxication or overdoses.
Drugs of abuse can be classified in many different ways. This chapter will classify drugs of abuse based on the symptoms they produce: CNS depression, CNS stimulation, and hallucinations. The CNS depressants include narcotics, ethanol, barbiturates, non-barbiturate sedative-hypnotics (including benzodiazepines). The CNS stimulants include caffeine, nicotine, amphetamines, and cocaine. The hallucinogens include LSD, PCP, and marijuana.
Table 5-6 lists many of the most frequently abused drugs with their recognizable trade names, some commonly used street names, and observable symptoms of abuse.
The following sections contain specific information about commonly abused drugs, as classified in table 5-6, including availability and methods of administration.
Unfortunately, narcotic abuse is common, although it is rare among military personnel. This group of drugs includes the most effective and widely used pain killers in existence. Prolonged use of narcotic drugs, even under medical supervision, inevitably leads to physical and psychological dependence. The more commonly known drugs within this group are opium, morphine, heroin, codeine, and methadone (a synthetic narcotic). In addition, Darvon 7 and Talwin7 are included in this group because of their narcotic-like action. Next to cocaine (discussed later), heroin is the most popular narcotic drug because of its intense euphoria and long-lasting effect. It is far more potent than morphine but has no legitimate use in the United States. Heroin appears as a white, gray, or tan fluffy powder. The most common method of using heroin is by injection directly into the vein, although it can be sniffed. Codeine, although milder than heroin and morphine, is sometimes abused as an ingredient in cough syrup preparations. Symptoms of narcotic drug abuse include slow, shallow breathing; possible unconsciousness; constriction (narrowing) of the pupils of the eyes to pinpoint size; drowsiness; confusion; and slurred speech.
The narcotic user, suddenly withdrawn from drugs, may appear as a wildly disturbed person who is agitated, restless, and possibly hallucinating. Initial symptoms start within 2 to 48 hours and peak at about 72 hours. Although these signs and symptoms are not life-threatening, most users will state that they feel so bad they wish they were dead. The signs and symptoms ofwithdrawal immediately stop upon re-administering a narcotic and withdrawing the drug by tapering the dose over several days.
Alcohol is the most widely abused drug today. Alcohol intoxication is so common that it often fails to receive the attention and respect it deserves. Although there are many other chemicals that are in the chemical grouping of “alcohols,” the type consumed by people as a beverage (in wines, beers, and distilled liquors) is known as ethyl alcohol, ethanol, grain alcohol, or just “alcohol.” It is a colorless, flammable, intoxicating liquid, classed as a drug because it depresses the central nervous system, affecting physical and mental activities.
Alcohol affects the body of the abuser in stages. Initially, there is a feeling ofrelaxation and well-being, followed by confusion with a gradual disruption of coordination, resulting in inability to accurately and efficiently perform normal activities and skills. Continued alcohol consumption leads to a stuporous state of inebriation that results in vomiting, an inability to walk or stand, and impaired consciousness (sleep or stupor). Excessive consumption can cause loss of consciousness, coma, and even—in extreme cases — death from alcohol poisoning.
The potential for physical and psychological addiction is very high when alcohol is abused. The severely intoxicated individual must be closely monitored to avoid inhalation of vomit (aspiration) and adverse behavioral acts to the patient or others.
Withdrawal from alcohol is considered to be life-threatening and should be appropriately treated in a healthcare facility. Individuals withdrawing from alcohol are at a greater risk of serious complications or death than those withdrawing from narcotics. The effects of alcohol withdrawal include severe agitation, anxiety, confusion, restlessness, sleep disturbances, sweating, profound depression, delirium tremens (“DTs,” a particular type of confusion and shaking), hallucinations, and seizures.
Table 5-6.—Classification of Abused Drugs
Benzodiazepines have largely replaced barbiturates, or “downers,” as sedatives, hypnotics (sleeping pills), or anxiolytic (anti-anxiety) agents. Barbiturates are still used to treat various seizure disorders. They are classified based on their duration of action: ultra-short acting, short acting, intermediate acting, and long acting. Barbiturate use classically causes various degrees of CNS depression with nystagmus (eyes moving up and down, or side-to-side involuntarily), vertigo (sensation of the room spinning), slurred speech, lethargy, confusion, ataxia (difficulty walking) and respiratory depression. Severe overdose may result in coma, shock, apnea (stopped breathing), and hypothermia. In combination with ethanol or other CNS depressants, there are additive CNS and respiratory depression effects.
Prolonged use of barbiturates can lead to a state of physical and psychological dependence. Upon discontinued use, the dependant person may go into withdrawal. Unlike narcotic (opiate) withdrawal, barbiturate withdrawal is LIFE THREATENING! Depending on type ofbarbiturate, signs and symptoms start within 24 hours. The withdrawal syndrome includes nausea, vomiting, sweating, tremors (trembling or shaking), weakness, insomnia, and restlessness. These clinical findings progress to apprehension, acute anxiety, fever, increased blood pressure, and increased heart rate. If untreated, severe and life-threatening effects include delirium, hallucinations, and seizures. The signs and symptoms will stop upon re-administration of the barbiturate and by tapering the dose slowly over several days.
NONBARBITURATE SEDATIVE-HYPNOTIC INTOXICATION
Nonbarbiturate sedative-hypnotics (a “hypnotic” is a sleeping pill) have actions very similar to the barbiturates. However, they have a higher margin of safety; overdose and addiction require larger doses and addiction requires a longer time period to occur. Like the barbiturates, when combined with ethanol or other depressants, there are addictive CNS- and respiratory-depression effects. Most of the traditional, nonbarbiturate sedative-hypnotics are either no longer available (Methaquaalone, Ethchlorovynol, Glutethimide) or rarely used today (chloral hydrate) because of their profound “hangover effect.” Newer sedative-hypnotics are emerging for the temporarytreatment of insomnia. Benzodiazepines are widely used to treat seizure disorders, anxiety, muscle spasms, and insomnia.
The stimulants (“uppers”) directly affect the central nervous system by increasing mental alertness and combating drowsiness and fatigue. One group of stimulants, called amphetamines, is legitimately used in the treatment of conditions such as mild depression, obesity, and narcolepsy (sleeping sickness).
Amphetamines are also commonly abused. Usually referred to as stimulants, speed, or uppers, amphetamines can be taken orally, intravenously, or smoked as “ice.” Amphetamines directly affect the central nervous system by increasing mental alertness and combating drowsiness and fatigue. They are abused for their stimulant effect, which lasts longer than cocaine.
Amphetamines cause central nervous system stimulation with euphoria, increased alertness, intensified emotions, aggressiveness, altered self-esteem, and increased sexuality. In higher doses, unpleasant CNS effects of agitation, anxiety, hallucinations, delirium, psychosis, and seizures can occur. When stimulants are combined with alcohol ingestion, patients have increased psychological and cardiac effects.
Signs and symptoms associated with amphetamine use include mydriasis (dilated pupils), sweating, increased temperature, tachycardia (rapid pulse), and hypertension. Patients seeking medical attention usually complain of chest pain, palpitations, and shortness of breath.
“Heavy use” (involving large quantities) of amphetamines is physically addicting, and even “light use” (involving small amounts) can cause psychological dependence. Tolerance to increasingly higher doses develops and withdrawal can occur from these levels. Abruptly stopping chronic amphetamine use does not cause seizures or present a life-threatening situation. The withdrawal is typically characterized by apathy, lethargy, muscle aches, stomachaches, increased appetite, anxiety, sleep disturbances, and depression with suicidal tendencies.
Cocaine, although classified as a narcotic, acts as a stimulant and is commonly abused. It is relatively ineffective when taken orally; therefore, the abuser either injects it into the vein or “snorts” it through the nose. Its effect is much shorter than that of amphetamines, and occasionally the abuser may inject or snort cocaine every few minutes in an attempt to maintain a constant stimulation and prevent depression experienced during withdrawal (comedown). Overdose is very possible, often resulting in convulsion and death.
The physical symptoms observed in the cocaine abuser will be the same as those observed in the amphetamine abuser.
The group of drugs that affect the central nervous system by altering the user’s perception of self and environment are commonly known as hallucinogens. Included within this group are lysergic acid diethylamide (LSD), mescaline, dimethoxymethylamphetamine (STP), phencyclidine (PCP), and psilocybin. They appear in several forms: crystals, powders, and liquids.
The symptoms of hallucinogenic drugs include dilated pupils, flushed face, increased heartbeat, and a chilled feeling. In addition, the person may display a distorted sense of time and self, show emotions ranging from ecstasy to horror, and experience changes in visual depth perception.
Although no deaths have resulted from the drugs directly, hallucinogen-intoxicated persons have been known to jump from windows, walk in front of automobiles, or injure themselves in other ways because of the vivid but unreal perception of their environment.
Even though no longer under the direct influence of a hallucinogenic drug, a person who has formerly used one of the drugs may experience a spontaneous recurrence (flashback) of some aspect of the drug experience. The most common type of flashback is the recurrence of perceptual distortion; however, victims of flashback may also experience panic or disturbing emotion. Flashback may be experienced by heavy or occasional users of hallucinogenic drugs, and its frequency is unpredictable and its cause unknown.
Cannabis sativa, commonly known as marijuana, is widely abused and may be classified as a mild hallucinogen. The most common physical appearance of marijuana is as ground, dried leaves, and the most common method of consumption is smoking, but it can be taken orally. A commercially prepared product of the active ingredient in marijuana, tetrahydrocannabinol (THC), is dronabinol (Marinol R) available in the U.S. as a controlled Schedule II drug. Dronabinol is used for the treatment of nausea and vomiting in chemotherapy patients. It may also be useful in the treatment of acute glaucoma, asthma, and nausea and vomiting from other chronic illnesses. The individual response to the recreational use of marijuana varies and depends on the dose, the personality and expectation of the user, and the setting. Unexpected ingestion, emotional stress, or underlying psychiatric disorders can increase the possibility of an unfavorable reaction.
After a single inhaled dose of marijuana, a subjective “high” begins in several minutes and is gone within four hours. Marijuana causes decreased pupil size and conjunctivitis (reddening of the white of the eye). Smoking marijuana can increase the heart rate (tachycardia) for about two hours. It can slightly increase systolic blood pressure in low doses and can lower blood pressure in high doses. An increased appetite and dry mouth are common complaints after marijuana use.
Social setting influences the psychological effects associated with “usual doses” of marijuana smoking. Smoking in a solitary setting may produce euphoria, relaxation, and sleep. In a group setting, increased social interaction, friendliness, and laughter or giddiness may be produced. Subjectively, time moves slower, images appear more vivid, and hearing seems keener. High doses can cause lethargy, depersonalization, pressured speech, paranoia, hallucinations, and manic psychosis (imagining everything is wonderful in a way that is out of reality).
Inhalants are potentially dangerous, volatile chemicals that are not meant for human consumption. They are found in consumer, commercial, and industrial products intended for use in well-ventilated areas. The vapors they produce can be extremely dangerous when inhaled inadvertently or by design.
Substances in this category include adhesives (synthetic “glues”), paint, wet markers, lighter fluids, solvents, and propellants in aerosol spray cans, and air fresheners. Inhalants can be abused by “sniffing” (inhaling through the nose directly over an open container), “bagging” (holding an open bag or container over the head), or “huffing” (pouring or spraying material on a cloth that is held over the mouth and inhaling through the mouth). These methods usually use a bag or other container to concentrate and retain the propellant thereby producing a quick “high” for the abuser.
Persons who regularly abuse inhalants risk permanent and severe brain damage and even sudden death. The vapors from these volatile chemicals can react with the fatty tissues in the brain and literally dissolve them. Additionally, inhalants can reduce the availability and use of oxygen. Acute and chronic damage may also occur to the heart, kidneys, liver, peripheral nervous system, bone marrow, and other organs. Sudden death can occur from respiratory arrest or irregular heart rhythms that are often difficult to treat even if medical care is quickly available.
Signs and symptoms of inhalant abuse closely resemble a combination of alcohol and marijuana intoxication. Acute symptoms are very short-lived and are completely gone within two hours. Physical symptoms of withdrawal from inhalants include hallucinations, nausea, excessive sweating, hand tremors, muscle cramps, headaches, chills and delirium tremens. Thirty to forty days of detoxification is required, and relapse is frequent.
HANDLING DRUG-INTOXICATED PERSONS
As in any emergency medical situation, priorities of care must be established. Conditions involving respiratory or cardiac failure must receive immediate attention before specific action is directed to the drug abuse symptom. General priorities of care are: