Week 3: Pharm: Recreational Drugs

• Alcohol and Its Misuse

• The most commonly used and abused psychoactive agent in the United States

• Some therapeutic use

• Primarily used for non-medical purposes

• Moderate consumption: Prolongs life and reduces risk of dementia and cardiovascular disorders

• Excessive consumption: Diminishes quality and quantity of life

• There is a lot of controversy around benefits of alcohol (red wine is good for you)

• Basic Pharmacology of Alcohol

• Central Nervous System (CNS) Effects

  • Acute effects

  • General depression of CNS function

  • Enhances GABA-mediated inhibition

  • Dose-dependent

  • Activation of the reward circuit

  • Binds with 5-HT3 receptors

• Chronic Effects

  • Two neuropsychiatric syndromes

  • Wernicke’s encephalopathy: Confusion, nystagmus, and abnormal ocular movements; readily reversible with thiamin

  • Korsakoff’s psychosis: Polyneuropathy, inability to convert short-term memory into long-term memory, and confabulation (unconscious filling of gaps in memory with fabricated facts and experiences) are not reversible

  • Impact on cognitive function

  • Effects on sleep

• Other Pharmacologic Effects

  • Cardiovascular system: Abuse of alcohol results in direct damage to the myocardium, increasing the risk of heart failure and elevation of blood pressure

  • Glucose metabolism

  • Bone health

• Patho

• Respiration: Alcohol depresses respirations

• Liver: Nonviral hepatitis

• Stomach: Erosive gastritis

• Kidney: Alcohol is a diuretic

• Pancreas: Pancreatitis

• Cancer: Breast and colorectal cancer

• Pregnancy and lactation: Fetal alcohol spectrum disorder and fetal alcohol syndrome

• Impact on longevity

• Basic Pharmacology of Alcohol

• Pharmacokinetics

  • Absorption

  • Distribution

  • Metabolism

  • Blood levels

    • In the United States, 0.08% defines intoxication

    • Earliest effects at 0.05%

    • When blood alcohol level exceeds 0.4%, there is a substantial risk of respiratory depression, peripheral collapse, and death

• Tolerance

• Physical dependence

• Drug interactions

  • CNS depressants

  • Nonsteroidal anti-inflammatory drugs

  • Acetaminophen

  • Disulfiram

  • Antihypertensive drugs

• Quitting ❌alcohol 🍺cold 🥶 turkey 🦃 can 👍lto seizureses 😬, coma 💤, and 🫰 death 💀!

• Overdose

• Acute overdose

• Vomiting, coma, and pronounced hypotension and respiratory depression

• Aspiration

• Alcohol-induced hypotension: Direct effect on peripheral blood vessels

• Hypotension cannot be corrected with vasoconstrictors (eg, epinephrine)

• Hypotension can lead to renal failure and cardiovascular shock

• Alcohol poisoning is treated like poisoning with all other general CNS depressants

• Precautions and Contraindications

• Peptic ulcer disease

• Liver disease

• Pregnancy

• Epilepsy

• Dose-related increase in the risk of breast cancer

• Increases the risk of cancer of the liver, rectum, and aerodigestive tract

• Serious adverse effects if combined with CNS depressants, nonsteroidal anti-inflammatory drugs, acetaminophen, vasodilators, and disulfiram

• Alcohol use disorder:

  • Relapsing disorder

  • Impaired control over drinking

  • Preoccupation with alcohol consumption

  • Use of alcohol despite awareness of adverse consequences

  • Distortions in thinking

  • Influenced by genetics as well as psychosocial and environmental factors

    • Alcoholism is a cycle 🌀

• Drugs for alcohol use disorder:

• Drugs used to facilitate withdrawal

  • Benzodiazepines

  • Chlordiazepoxide [Librium, others]

  • Clorazepate [Tranxene]

  • Oxazepam [Serax]

  • Lorazepam [Ativan]

• Adjuncts to benzodiazepines

  • Carbamazepine (antiepileptic drug)

  • Clonidine (alpha-adrenergic blocker)

  • Atenolol and propranolol (beta-adrenergic blockers)

• Drugs used to maintain abstinence

  • Disulfiram

  • Naltrexone

  • Acamprosate

• Other drugs used for the treatment of alcohol abuse

  • B vitamins

  • Thiamin

  • Folic acid

  • Cyanocobalamin

  • Vitamin supplements

  • Fluid replacement therapy

  • Antibiotics

• Nicotine and smoking:

  • Cigarette smoking remains the greatest single cause of preventable illness and premature death

  • In Canada, smoking kills more than 230,000 adults each year; this is just under 1 of every 5 deaths

• Mechanism of action of nicotine:

• Effects of nicotine result from actions at nicotinic receptors:

  • Can activate nicotinic receptors found in the autonomic ganglia, the adrenal medulla, the carotid body, the aortic arch, and the central nervous system

• Actions in the central nervous system mimic those of cocaine and other highly addictive substances

• Pharmacokinetics

• Pharmalogic effects

  • Cardiovascular

    • It constricts blood vessels, accelerates the heart, and increases the force of ventricular contraction

    • The net result is elevation of blood pressure and increased cardiac work

  • Gastrointestinal

    • Increases secretion of gastric acid

    • Augments tone and motility of gastrointestinal smooth muscle

    • Can promote vomiting

  • Central nervous system

    • Stimulates respiration and produces an arousal pattern on an electroencephalograph

    • Moderate doses can cause tremors; high doses can cause convulsions

    • Psychological effect

  • Pregnancy and lactation

    • Exposure during gestation can harm fetus

    • Nicotine in breast milk can harm nursing infant

    • Pharmaceutical nicotine is safer than tobacco smoke

    • It is reasonable to consider using nicotine therapy during pregnancy to help a patient quit smoking

• Nicotine and Smoking

• Tolerance

• Dependence

• Acute poisoning

  • Treatment: Reducing nicotine absorption and supporting respiration

  • Activated charcoal

  • Ventilatory assistance

• Chronic toxicity from smoking

• “5 A’S” Model for treating tobacco use and dependence

• Ask (screen all patients for tobacco use)

• Advise tobacco users to quit

• Assess willingness to make a quit attempt

• Assist with quitting (offer medication and provide or refer to counselling)

• Arrange follow-up contacts, beginning within the first week after the quit date

• Nicotine chewing gum

• Double the cessation success rate

• Adverse effects: Mouth and throat soreness, jaw muscle ache, eructation (belching) and hiccups

• Chew the gum slowly and intermittently for about 30 minutes

• Avoid eating or drinking while chewing, and wait 15 minutes before chewing.

• Nicotine lozenges

• Double the cessation success rate

• Adverse effects: mouth irritation, dyspepsia, nausea, and hiccups

• Allow lozenge to dissolve in mouth over 20to 30 minutes

• No eating or drinking for 15 minutes before dosing and while the lozenge is in the mouth

• Do not chew or swallow the lozenge.

• Nicoderm CQ and Nicotrol

• Doubling the cessation success rate

• Adverse effects: short-lived erythema, itching, and burning occur under the patch

• Applied once a day to clean, dry, non-hairy skin of the upper body or upper arm

• Application sites should be changed daily and not reused for at least one week.

• Nicotine Inhaler

• Doubles the cessation success rate

• Adverse effects: Dyspepsia, coughing, throat irritation, oral burning, and rhinitis

• Frequent puffing over 20 minutes

• It should not be used by patients with asthma

• Bupropion SR [Zyban, Buproban]

• Atypical antidepressant

• Reduces the urge to smoke and reduces some symptoms of nicotine withdrawal, such as irritability and anxiety

• Adverse effects: Dry mouth and insomnia

• Varenicline [Chantix, Champix]

• Partial agonist at nicotinic receptors

• The most effective aid for smoking cessation

• Atypical antidepressant

• Adverse effects: Nausea, sleep disturbances, headaches, abnormal dreams, constipation, dry mouth, flatulence, vomiting, and altered sense of taste

• Serious neuropsychiatric effects

• Cardiovascular events

• U.S. authorities have banned the use of varenicline by truck drivers, bus drivers, airplane pilots, and air traffic controllers

• Case study

• You are working at a family clinic. Your patient is a 17-year-old young man who came in today for a sports physical examination. Upon completing a substance abuse history, he shares that he has been smoking for the past year. He read on the Internet that nicotine is a natural substance from the nightshade family and that there are not as many harmful effects as the media lets on. He would like you to answer the following questions:

1. Can I become addicted to cigarettes?

• Yeah

1. How can cigarettes be so harmful if they are made from natural substances?

• Anything in your lungs that is not air is bad for you

• Processed

• Over 2000 substances

• Chemically complex that cause issues

1. Are there treatments available for quitting smoking?

• Yeah there is gum, patches, lozenges, medications, counselling, spray, and inhalation

• Major drugs of abuse

• Opioids

• Psychostimulants

• Depressants

• Psychedelics

• Dissociative drugs

• Anabolic steroids

• Miscellaneous drugs of abuse

• Marijuana

• d-Lysergic acid diethylamide (LSD)

• Heroin, Oxycodone, and other opioids

• Major drugs of abuse: Heroin, oxycodone, and meperidine

• Most opioids are Schedule II

• Patterns of abuse

• Subjective and behavioural effects

• Preferred drugs and routes of administration

• Heroin

• Patterns of use

• Greatest use among 18- to 25-year-olds

• All segments of society

• The first exposure is usually social or for pain management

• Subjective and behavioural effects

• Moments after IV injection: Sensations of pleasure, relaxation, warmth, and thirst

• Followed by euphoria

• Initial use causes nausea and vomiting

• Initially, it may also cause an overall sense of dysphoria

• Preferred drugs and routes of administration

• Opioid of choice for street use

• High lipid solubility

• IV route preferred, but also smoking and nasal inhalation

• Oxycodone

• Opioid is similar to morphine

• Intended as controlled-release drug [OxyContin]

• Abusers crush tablet

• Snort powder or dissolve in water for IV

• The entire dose absorbed immediately, with high risk of death

R-r-r-roll💿up⬆to2⃣the🤩party🥳with🧶my🧚crazy🤪pink💝wig💇🏼

• Meperidine

• Nurses and healthcare providers who abuse opioids often select meperidine

• Highly effective in oral route (unlike injections, leaves no sign)

• Minimal effect on smooth muscle: Fewer problems with constipation and urinary retention

• Tolerance and physical dependence

• Tolerance

  • Prolonged use

  • Effects for which tolerance develops

  • Effects for which tolerance does not develop

• Cross-tolerance

• Physical dependence

  • Long-term use

  • Abstinence syndrome

  • Acute phase and second phase

• Alcholics have a low dependence on depressants and anxiety medications like Benzodiazapines

• Treatment of acute toxicity

• Triad of symptoms and treatment

  • Respiratory depression

  • Coma

  • Pinpoint pupils

• Naloxone [Narcan]: Careful titration

• Opioid detoxification

• Detoxification

  • Clonidine-assisted withdrawal

    • Centrally acting alpha2-adrenergic agonist

    • Most effective against symptoms related to autonomic hyperactivity (nausea, vomiting, diarrhea)

    • Provides modest relief from muscle aches, restlessness, anxiety, and insomnia

    • Does not diminish opioid craving

• Rapid withdrawal

• Ultrarapid withdrawal

  • Administration of naloxone or naltrexone: Immediate withdrawal

  • The withdrawal process accelerated

  • Ultrarapid procedure: General anesthesia or heavy sedation with IV midazolam [Versed]

  • In both procedures, clonidine may be added to ease symptoms

  • No more effective than standard withdrawal techniques

  • Considerably more expensive

• Methadone substitution (much better option) Tapering (3 weeks or 1 month)

  • Long-acting oral opioids

  • The most commonly used agent

  • Approximately 10 days

• Buprenorphine

  • Substituted for opioids, the addict is physically dependent on

  • Prevents symptoms of withdrawal

• Drugs for long-term opioid addiction management

• Three groups of medications

  • Opioid agonists, opioid agonist-antagonists, and opioid antagonists

• Methadone

  • Maintenance and suppressive therapy

• Buprenorphine

  • Maintenance therapy and detox facilitation

• Naltrexone

  • Discourages renewed opioid abuse

• Sequelae of compulsive opioid use

• Few direct detrimental effects

• Individuals on methadone maintenance can be successful socially and at work

• Indirect hazards: Septicemia, cellulitis, abscesses, endocarditis, tuberculosis, hepatitis C, HIV, and foreign body emboli

• Accidental overdose

• General CNS depressants

• Barbiturates, benzodiazepines, alcohol, and other agents

• Benzodiazepines have unique properties

• Barbiturates

• Depressant effects are dose-dependent

  • Mild sedation to sleep to coma and death

• Subjective effects similar to those of alcohol

• Agents with a short to intermediate duration of action have highest abuse incidence and are Schedule II

  • Amobarbital, pentobarbital, and secobarbital

• Tolerance

• Physical dependence

• Withdrawal

• Acute toxicity

  • Maintain respiration and remove drug

  • Naloxone reverses opioid poisoning, but it is not effective against barbiturate poisoning.

• Benzodiazepines

• Benzodiazepines (Schedule IV)

  • Much safer than barbiturates

  • Overdose is rare when taken alone and orally

  • Risk increased with IV or with other depressants

• Tolerance

• Physical dependence and withdrawal techniques

• Acute toxicity

• Flumazenil [Romazicon]

• Psychostimulants

• CNS stimulants (Schedule II) with a high potential for abuse

  • Methamphetamines

  • Cocaine

• Can stimulate the heart, blood vessels, and other structures under sympathetic control

• The nods. They start nodding and pass out; they dont wake up

• Cocaine

• CNS effect similar to that of amphetamines

• Two forms are used by abusers:

  • Cocaine

  • “Crack”

• Can produce local anesthesia, vasoconstriction, and cardiac stimulation

• Acute toxicity

  • Mild overdose: agitation, dizziness, tremor, blurred vision.

  • Severe overdose: hyperpyrexia, convulsions, ventricular dysrhythmias, hemorrhagic stroke, angina pectoris, myocardial infarction.

  • Treatment: intravenous diazepam or lorazepam, nitroprusside, hypertonic sodium bicarbonate, and aspirin.

• Chronic toxicity

  • Intranasally: atrophy of the nasal mucosa and loss of sense of smell

  • Extreme cases: necrosis and perforation of the nasal septum

  • Injury to the lungs can occur from smoking cocaine.

  • Use during pregnancy

• Treatment of cocaine addiction

  • Anticocaine vaccine

  • Disulfiram (antabuse)

• Cocaine

  • Cocaine hydrochloride

    • White powder

    • Diluted for sale

    • Taken intranasally

  • Cocaine base: commonly called “crack:

  • Heated for use

  • Taken by IV injection

• Methamphetamines

• In abuse, usually taken orally, snorted, smoked, or IV

• Also called “ice” or “crystal meth,”

  • Form of dextroamphetamine

  • Smoked, snorted, or inserted into rectum

• Effects

  • Arousal, euphoria, and a sense of increased physical strength and mental capacity

  • Hallucinations, psychotic states, and sympathomimetic actions

• Adverse cardiovascular effects

  • Hypertension

  • Angina pectoris

  • Dysrhythmias

  • Cerebral and systemic vasculitis, renal failure, stroke

  • Vasoconstriction can be relieved with an alpha-adrenergic blocker, e.g., phentolamine.

  • Cardiac stimulation can be reduced with a mixed alpha and beta blocker (eg, labetalol)

• Other adverse effects

  • Significant weight loss

  • Fetal effects

  • “Meth mouth” (severe tooth decay, disinegrated gums)

• Tolerance, dependency, and withdrawal

  • Treatment: cognitive behavioural therapy, matrix model, bupropion [Wellbutrin, Zyban], modafinil [Provigil, Alertec], and lbudilast.

• Marijuana

• Cannabis sativa (hemp)

  • Marijuana and hashish are derivatives

  • Common names: “grass,” “weed,” "pot.”

• Most commonly used illicit drugs in the United States, although it is now legal in some states

• Psychoactive substance

  • Delta-9-tetrahydrocannabinol (THC)

• Routes

  • Smoking

    • 60% of THC content is absorbed; effects begin in minutes and peak within 20 to 30 minutes

  • Oral

    • Most of THC is inactivated by first-pass effect

• Increased production of prostaglandin E2

  • Behaviors

  • Euphoria

  • Sedation

  • Hallucinations

  • Therapeutic uses

  • Antiemetic

  • Appetite stimulant

  • Neuropathic pain

• Effects

  • Low to moderate dose

  • High dose

  • Long-term use

  • Schizophrenia

• Cardiovascular

  • Dose-related increase in heart rate

• Respiratory

  • Acute: Bronchodilation

  • Chronic: Airway constriction

• Reproduction

  • Males and females affected

• Altered brain structure

  • Hippocampal volume, left hemisphere

• Tolerance and dependence

• Therapeutic use of Marijuana

• Approved uses for cannabinoids

• Unapproved uses for cannabinoids

• Medical research on marijeuna

• The legal status of medical marijuana

• Synthetic Marijuana

• Comparison of marijuana with alcohol

  • Aggressive behaviour is rare with marijuana use

  • Less loss of judgment with marijuana

  • Increased appetite with marijuana: Fewer problems with nutritional deficiencies

  • Marijuana produces increased toxic psychosis, dissociative phenomena, and paranoia, more so than alcohol does.

• Psychedelics

• d-Lysergic acid diethylamide (LSD)

  • Acts on the brain’s serotonin receptors

  • Routes: Oral, IV, smoked

  • Alters the following (as otherwise occurs only in dreams):

    • Thinking

    • Feelings

    • Perception

    • Relationship to environment

• Saliva: causes dream-like state of unreality

• Mescaline

  • From peyote cactus

• Psilocybin

• Psilocin

• Dimethyltryptamine

• Dissociative drugs

• Phencyclidine (PCP) and ketamine

  • Original use: Surgical anaesthetics

  • Recreational use: Distort sight and sound and produce dissociation

  • Act in the cerebral cortex and limbic system

• PCP easily synthesized and manufactured by amateurs

• Routes: Oral, intranasal, IV, smoking

• Phencyclidine (PCP)

  • Effects

  • Low to moderate doses, high doses

• Toxicity

• Ketamine

  • Similar to PCP in structure, mechanism, and effects

• Shorter duration of effects

• Dextromethorphan

• Over-the-counter (OTC) cough suppressant

  • Low dose for antitussive: No psychologic effects

  • Doses 5 to 10 times higher: produce euphoria, disorientation, paranoia, altered sense of time, and hallucinations

• Also used in combination cold products

• Highly abused by adolescents and teenagers because of accessibility and low cost

• 3, 4: Methylenedioxymethamphetamine

• Common names: MDMA, ecstasy

  • A complex drug with stimulant and psychedelic properties

  • Structurally related to methamphetamine (stimulant) and mescaline ( hallucinogen),

    • Low doses: Mild LSD-like psychologic effects

    • Higher doses: Amphetamine-like effects

  • Promotes release of neurotransmitters

  • Usually taken orally; also snorted, injected, or taken by rectal suppository

• Adverse effects

  • Can injure serotonergic neurons, stimulate the heart, and dangerously raise body temperature

• Neurologic effects

  • Seizures, spasmodic jerking, jaw clenching, teeth grinding

  • Confusion, anxiety, paranoia, panic

• Inhalants

• The term can refer to many drugs; common characteristic is administration by inhalation

  • Anesthetics

  • Volatile nitrites

  • Organic solvents

• Anabolic Steroids

• Androgens

  • Taken to enhance athletic performance

  • Increase muscle mass and strength

  • Massive doses often used have high risk for adverse effects

  • Most are classified as Schedule III drugs

• Question 1

Answer B

Rationale: pregnant and lactating women should be advised to avoid alcohol entirely.

• Question 2

Answer C

Rationale: people who consume moderate amounts of alcohol live longer than those who abstain. The life span is even greater if the person drinks moderately and performs regular exercise.

• Question 3

Answer A

Rationale: The long-term use of alcohol produces physical dependence, and abrupt withdrawal produces an abstinence syndrome. When the degree of physical dependence is low, withdrawal symptoms (e.g., disturbed sleep, weakness, nausea, anxiety, and mild tremors) are mild and last less than a day. By contrast, when the degree of dependence is high, withdrawal symptoms can be severe. Initial symptoms appear 12 to 72 hours after the last drink and continue for 5 to 7 days. Early manifestations include cramps, vomiting, hallucinations, and intense tremors; heart rate, blood pressure, and temperature may rise, and tonic-clonic seizures may develop. As the syndrome progresses, disorientation and loss of insight occur. A few alcoholic patients (<1%) experience delirium tremens (severe persecutory hallucinations). In extreme cases, alcohol withdrawal can result in cardiovascular collapse and death.

• Question 4

The nurse is providing teaching about smoking cessation to a patient with heart disease who smokes 1 to 1½ packs of cigarettes per day. Which statement should the nurse include?

1. The reduction of nicotine use will decrease blood pressure.

2. Weight loss occurs with the decreased use of nicotine.

3. Smoking decreases the heart rate and increases the respiratory rate.

4. Smoking causes a decreased workload for the heart.

Answer: A

Rationale: Nicotine in low doses (such as smoking 1 to 1½ packs per day) causes the following pharmacologic effects: elevation of blood pressure, weight loss, and increased heart rate and cardiac workload. Smoking cessation will reduce blood pressure, heart rate, and cardiac workload; it will also stimulate the appetite and result in possible weight gain.

• Question 5

The nurse completed smoking cessation teaching for a patient with peptic ulcer disease. Which statement by the patient indicates that more teaching is indicated?

1. “Nicotine can increase problems with vomiting.”

2. “Smoking could have caused the ulcers in my stomach.”

3. “If I switch to nicotine patches, my stomach will start to heal.”

4. “Smoking causes an increase in the amount of stomach acid.”

Answer: C

Rationale: Nicotine influences gastrointestinal function primarily by activating nicotinic receptors in the parasympathetic ganglia, thereby increasing the secretion of gastric acid and augmenting the tone and motility of gastrointestinal smooth muscle. In addition, nicotine can promote vomiting. Nicotine-induced vomiting results from a complex process that involves nicotinic receptors in the aortic arch, the carotid sinus, and the central nervous system. Nicotine can cross membranes easily, and it is widely distributed throughout the body.

• Question 6

After being admitted to the hospital, a patient indicates a willingness to make an attempt to quit smoking. It is most appropriate for the nurse to do what?

1. Advise the patient that insurance will not cover medications.

2. Assist the patient with strategies to stop smoking.

3. Ask the patient to find a support group after discharge.

4. Encourage the patient to use electronic cigarettes.

Answer: B

Rationale: The overall intervention strategy is summarized in the “5 A’s” model for treating tobacco use and dependence: Ask (screen all patients for tobacco use); Advise tobacco users to quit; Assess willingness to make a quit attempt; Assist with quitting (offer medication and provide or refer to counselling); and Arrange follow-up contacts, beginning within the first week after the quit date.

• Question 7

The nurse instructs the patient about how to use nicotine chewing gum [Nicorette]. The nurse determines that teaching is successful if the patient makes which statement?

1. “I will not eat or drink for 1 hour before chewing the gum.”

2. “The gum is safe during the first 3 months of pregnancy.”

3. “Chewing the gum rapidly reduces belching and hiccups.”

4. “I should chew the gum slowly for about 30 minutes.”

Answer: D

Rationale: Nicotine chewing gum must be chewed to release the nicotine. The most common adverse effects are mouth and throat soreness, jaw muscle ache, eructation (belching), and hiccups. Using optimal chewing techniques minimizes these problems. Patients should be advised to chew the gum slowly and intermittently for about 30 minutes. Rapid chewing can release too much nicotine at one time, which results in effects similar to those of excessive smoking, such as nausea, throat irritation, and hiccups. Because foods and beverages can reduce nicotine absorption, patients should not eat or drink while chewing or for 15 minutes before chewing. It is not known whether using nicotine gum during pregnancy is safe.

• Question 8

A patient is admitted to the healthcare facility for the treatment of cocaine addition. It is most appropriate for the nurse to do what?

1. Administer delta-9-tetrahydrocannabinol (THC) to reduce withdrawal symptoms.

2. Give regular doses of naloxone [Narcan] to precipitate immediate withdrawal.

3. Provide individual and group psychosocial therapy with a focus on drug counseling.

4. Initiate maintenance therapy with tapering doses of methadone [Methadose].

Answer: C

Rationale: The cornerstone of cocaine addiction treatment is psychosocial therapies (both individual and group counseling). THC is delta-9-tetrahydrocannabinol, or marijuana. Naloxone and methadone are used for opioid addictions.

• Question 9

The nurse cares for a patient who has used marijuana daily for the past 7 years. The nurse should assess the patient for which manifestations of excessive use of marijuana?

1. Hallucinations, delusions, and paranoid behavior

2. Disheveled appearance, lack of interest, and flat affect

3. Increased appetite, improved sense of humor, and euphoria

4. Impaired memory, slow reaction time, and altered judgment

Answer: B

Rationale: Long-term, excessive use of marijuana is associated with a behavioral phenomenon known as amotivational syndrome, characterized by apathy, dullness, poor grooming, reduced interest in achievement, and disinterest in the pursuit of conventional goals. High doses of marijuana result in hallucinations, delusions, and paranoia. Low to moderate doses of marijuana can cause euphoria and relaxation; gaiety and a heightened sense of the humorous; increased sensitivity to visual and auditory stimuli; enhanced sense of touch, taste, and smell; increased appetite and ability to appreciate the flavor of food; and distortion of time perception. Moderate doses of marijuana can produce undesirable responses (for example, impairment of short-term memory; decreased capacity to perform multistep tasks; slowed reaction time and impairment of motor coordination; altered judgment and decision making; temporal disintegration; depersonalization; decreased ability to perceive the emotions of others; and reduced interpersonal interaction

• Question 10

A patient is admitted to the emergency department with psychotic behavior related to an overdose of phencyclidine (PCP). Which action by the nurse is most appropriate?

1. Administer ammonium chloride to raise the urine pH.

2. Instruct the patient to take slow, deep breaths.

3. Administer an IV fluid bolus to prevent hypotension.

4. Place the patient in a quiet room with dim lighting.

Answer: D

Rationale: Psychotic reactions that occur with phencyclidine overdose are best managed by isolation from external stimuli. “Talking down” (eg, controlled breathing) is not effective. Severe hypertension (not hypotension) may occur and can be managed with diazoxide, a vasodilator. Elimination of phencyclidine can be accelerated by acidification (lowering the pH) of the urine with ammonium chloride. Acidification of the urine promotes phencyclidine excretion by reducing tubular reabsorption of this weak base.

• Question 11

Which of the following is the most commonly abused opioid by healthcare providers?

1. Meperidine [Demerol]

2. Oxycodone [OxyContin]

3. Hydromorphone [Dilaudid]

4. Morphine sulfate
   

Answer: A

Rationale: Among healthcare providers who abuse opioids, meperidine is a drug of choice; meperidine is orally active, causes minimal pupillary constriction, and causes less constipation and urinary retention than other opioids.