13.Drug dependence

Drugs

• Definition: Drugs are substances used to promote and maintain health.

• Misuse of Drugs: Often misused for relief from tension or escapism from social/family problems.

Types of Drugs

Stimulants

• Provide a sense of well-being.

Depressants

• Act as sedatives.

Drug Dependence (UQ)

• Definition: A compulsion to take drugs for desired effects or to prevent unpleasant withdrawal symptoms.

• Drugs of Dependence:

  • Cause psychological dependence (soft drugs)

  • Cause psychological and physical dependence (hard drugs).

• Hard Drugs: Cause severe physical dependence (e.g., morphine, heroin, alcohol).

• Soft Drugs: Do not cause physical dependence but cause psychological dependence (e.g., cannabis, LSD).

Routes of Drug Administration

• Inhalation: Nicotine, ganja.

• Ingestion: Opium, barbiturates.

• Snorting: Cocaine (fastest route).

• Skin Popping: Subcutaneous injections (heroin, morphine).

• Mainlining: IV injections (morphine, pethidine).

Characteristics of Dependence

1. Morphine Type:

   • Strong desire to continue use.

   • Tolerance developed.

   • Withdrawal symptoms within 8 hours, subsiding by 2-3 days.

2. Barbiturate Type:

   • Strong desire, high tolerance.

   • Maximum withdrawal symptoms in 2-3 days, subsiding slowly.

3. Cocaine Type:

   • Overpowering desire to continue.

   • Rapid tolerance development with no withdrawal symptoms.

4. Cannabis Type:

   • Psychic dependence.

   • No withdrawal symptoms, no tolerance.

5. Amphetamine Type:

   • Persistent need to continue.

   • Tolerance development, potential for hyper-excitement and psychosis.

Psychological Dependence Only (UQ)

• Amphetamine

• Caffeine

• Cannabis

• Cocaine

• LSD

• Mescaline

• Tobacco

Both Psychological and Physical Dependence (UQ)

• Morphine

• Pethidine

• Heroin

• Methadone

• Alcohol

• Barbiturates

• Codeine

• Benzodiazepines

• Phencyclidine (Angel dust/Peaspill)

• Meprobamate

• Methaqualone

• Mandrax: Methaqualone + Diphenhydramine

Dependence Types:

• Narcotics and depressants: cause both psychological and physical dependence.

• Stimulants and hallucinogens: cause psychological dependence.

• Drugs notorious for causing dependence: morphine, pethidine, heroin, methadone, alcohol.

General Characteristics of Dependent Drugs:

1. Tolerance

2. Withdrawal symptoms

3. Dependence syndrome

4. Harmful effects (mental and physical)

Alcohol Drug Dependence

• Common Withdrawal Syndrome:

  • Hangover

• Symptoms of Withdrawal Syndrome:

  • Delirium tremens

  • Alcoholic seizures

  • Hallucinosis

• Laboratory Findings:

  • GGT (gamma-glutamyl-transferase) raised to 40 IU/L in 80% of alcohol-dependent individuals.

Classification of Alcohol Dependence:

1. Alpha Alcoholism: No psychological or physical dependence.

2. Beta Alcoholism: No psychological or physical dependence, but cirrhosis develops.

3. Gamma Alcoholism: Physical and behavioral complications.

4. Delta Alcoholism (French): Strong psychological or physical dependence due to long-term use.

5. Epsilon Alcoholism: Dipsomania develops leading to potential lethal drinking.

Treatment for Alcohol Withdrawal:

• Medications:

  • Chlordiazepoxide (80–200 mg/day)

  • Diazepam (40–80 mg/day)

Treatment for Alcohol Dependence:

1. Deterrent Agents (Alcohol Sensitizing Drugs):

   • Disulfiram

   • Calcium carbimide

   • Metronidazole

   • Nitrafural

   • Methylthiotetrazole

2. Anti-craving Agents:

   • Acamprosate

   • Naltrexone

   • Fluoxetine (Clonidine)

Opioids

• Common Dermatological Manifestation: 'Railroad tracks' (track marks).

• Withdrawal Symptoms Start: 12-24 hours after last use.

Signs and Symptoms of Opioid Withdrawal:

• Nausea, vomiting, abdominal cramps

• Diarrhea, yawning

• Lacrimation, rhinorrhea

• Pupillary dilatation, insomnia

• Tachycardia, muscle cramps

• Piloerection (goosebumps)

• Elevated BP, temperature, respiratory rate

• Withdrawal syndrome severity is worse in heroin than morphine.

Treatment for Opioid Intoxication:

• Naloxone and Naltrexone

Withdrawal Treatment:

• Methadone,

Detoxification

• Clonidine, Levo-alpha-acetylmethadol (LAAM), Propoxyphene, Diphenoxylate, Buprenorphine, Lofexidine

Maintenance Treatment:

• Methadone

• Alternate options: Buprenorphine, LAAM

Cocaine

• Dependence Type:

  • Mild physical but strong psychic dependence.

• Tolerance:

  • May develop; cocaine addicts can tolerate up to 10 gm/day.

• Withdrawal Symptoms:

  • Minimal or nil withdrawal symptoms but strong psychic dependence persists.

• Gender Factors:

  • Females are 3.3 times more likely to become dependent than males.

Treatment for Cocaine Addiction:

• Bromocriptine

• Amantadine

• Desipramine or Imipramine

• Psychotherapy: Most important aspect of treatment.

Cannabis

• Dependence and Withdrawal: Psychic dependence without withdrawal syndrome; no tolerance developed.

• Effects: Starts within a few hours, lasting for 4-5 days.

• Amotivational Syndrome: Characterized by lethargy and lack of interest in daily activities.

• Treatment: Psychotherapy and symptomatic treatment.

Barbiturates

• Dependence: Marked physical and psychological dependence; rapid tolerance development.

• Withdrawal Symptoms: Severe symptoms in those taking >600-800 mg/day, including:

  • Tremors

  • Hypertension

  • Seizures

  • Psychosis resembling delirium tremens.

• Progression: Symptoms worsen by about 72 hours; coma and death possible.

• Treatment: Conservative management; pentobarbital substitution in forensic medicine.

Amphetamine

• Origins: Derived from ephedrine; CNS stimulant.

• Usage: Can be taken by snorting, smoking, ingestion, or intravenous administration.

• Abusers: Common among students and athletes seeking to combat sleep and fatigue.

• Symptoms: Similar to cocaine abuse.

• Acute Intoxication includes:

  • Cardiovascular Symptoms: Tachycardia, hypertension, cardiac failure.

  • CNS Symptoms: Anxiety, seizures, euphoria, insomnia.

• Chronic Use: Paranoid hallucinatory syndrome similar to paranoid schizophrenia; high tolerance; severe withdrawal symptoms.

• Methamphetamine: Superior to amphetamine and included in athlete doping tests.

Designer Drugs (MDMA and Analogues)

• Derivatives: 3-4 Methylene-dioxy-methamphetamine (MDMA), 3-4 Methylene-dioxyamphetamine (MDA), 3-4 Methylene-dioxyethyl-amphetamine (MDE or MDEA).

• Classification: Known as hug drug, club drug, or rave drug.

• Interactions: MDMA + Marijuana referred to as 'love boat'.

• Mechanism: Interaction with serotoninogenic neurons in the CNS.

• Street Names: Ecstasy, Molly, Adam.

• Treatment for Overdose: Symptomatic treatment.

LSD (Lysergic Acid Diethylamide)

• Street Names: "Acid" and "Microdot".

• Dependence: Psychic dependence with no physical withdrawal syndrome; tolerance develops briefly.

• Effects: Commonly referred to as a 'trip'. Symptoms include:

  • Altered sensory perceptions (e.g., seeing sounds and hearing colors)

  • Hallucinations and illusions

  • Floating sensations

• Flashbacks: Recurrence of drug effects long after use.

• Treatment: Anxiolytics for anxiety.

Inhalants (Solvent Abuse)

• Types:

  • Solvents: Paint thinners, gasoline, glue, toluene, petrol, kerosene, acetone.

  • Gases: Butane, propane, refrigerant gases, ether, chloroform, halothane.

  • Nitrites: Cyclohexyl nitrite, amyl nitrite.

• Acute Symptoms: Produce stimulatory effects such as euphoria and enhanced musical appreciation; overdoses can cause:

  • Syncope

  • Suffocation

  • Cardiac failure and death.

Nicotine (Nicotiana tabacum)

• Characteristics: Active ingredient in cigarettes; causes dependence, tolerance, and withdrawal symptoms.

• Nicotine affects cholinergic receptors.

• Increases release of acetylcholine, serotonin, and beta-endorphins.

• Treatment Options:

  • Nicotine Replacement Therapy:

    • Gum

    • Spray

    • Others

  • Medications:

    • Bupropion

    • Clonidine

Postmortem Findings in Drug Abuse

1. Signs of Wasting

2. Froth at the Nostrils

3. Enlargement of Regional Lymph Nodes

4. Body Markings:

   • Tattoos covering scars.

   • Linear needle track scars (often pigmented).

   • Punctate areas of black discoloration from carbonaceous material ("turkey skin").

   • Multiple skin infections leading to atrophic scars ("tissue paper scars").

5. Abscesses on Body

6. Edema of Upper Limbs due to thrombophlebitis.

7. Nasal Septal Perforation in habitual cocaine users.

Internal Findings Related to Drug Use

1. Congestion, edema of lungs, bronchopneumonia.

2. Pleural and pericardial effusion.

3. Fatty changes and portal hepatic triaditis.

4. Splenomegaly.

5. Brain edema and necrosis involving globus pallidus and hippocampus.

Factors Related to Drug Dependence

1. Personal Factors:

   • Physical and mental illness.

   • Stressful life events.

   • Failure to achieve goals.

2. Social and Environmental Factors:

   • Living and working environment.

   • Peer influence and availability of drugs.

   • Common misuse among healthcare professionals.

3. Drug Factors:

   • Some drugs cause significant dependence (both physical and psychological).

   • Examples: LSD causes psychological dependence comparable to physically addictive drugs.

4. Tolerance:

   • Users may develop tolerance requiring increased doses to achieve effects.

Preventive Measures

1. Mass education via media about the social menace of drug abuse.

2. Establishment of de-addiction centers by government and NGOs.

   • Effective treatment and rehabilitation programs.

3. Implementation of stringent laws against drug trafficking.

   • Law administration should be free from influence.

Body Packers and Stuffers (UQ)

• Body Packers:

  • Smugglers ingest drug-filled balloons or condoms.

  • Typically carry cocaine or brown sugar.

  • Use constipating agents (e.g., Lomotil) to avoid bowel movements during transport.

• Body Pushers:

  • Insert drug packets into vagina or rectum.

• Some keep drugs in cheek pouches.

• Body Stuffers: Individuals who hastily swallow drug packets to avoid detection. This practice poses risks due to the packets not being designed for gastrointestinal transport, increasing the likelihood of rupture.

• Rupture of Packets: Toxicity becomes evident when packets rupture, potentially leading to poisoning or death (known as body packer syndrome).

• Autopsy Findings: Body packers will have several carefully packed bags of drugs, while body stuffers typically have only two or three.

Detection Methods (UQ)

• X-ray: May reveal plastic drug packets; however, results are not always definitive.

• CT Scan with Contrast: More effective in identifying the presence of drug packets.

• Bedside Ultrasound: A non-invasive technique for quickly assessing multiple drug packets, especially in the gastric area.

Treatment Approaches

1. Glucose Saline: Administer as necessary.

2. Airway Maintenance: Ensure that the airway is clear and functional.

3. Electrolyte Correction: Address imbalances that may occur.

4. Symptomatic Treatment: Provide any additional care based on symptoms.

Drug Trafficking Regions

Golden Triangle

• Countries Involved: Myanmar, Thailand, Laos, and parts of southern China.

• Characteristics: Known for rampant opium production and drug trafficking.

Golden Crescent

• Geographic Area: Pakistan, Afghanistan, and Iran.

• Opium Production: Responsible for approximately 90% of the world's opium production and illegal trade.

Golden Quadrangle

• Specific Areas: Varanasi, Lucknow, Bareilly, Barabanki, and Badawan (in UP) and parts of Rajasthan.