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What Are These Drugs?

Updated March 2009

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I. INTRODUCTION

Clinicians caring for substance-using patients need to have a basic knowledge of the substances their patients may be using. Included here are some of the more commonly used substances with a brief explanation of how and why people use them and some of the negative consequences. This knowledge may help clinicians understand their patients’ choices and challenges, as well as formulate counseling messages and motivational interviewing strategies.

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II. BENZODIAZEPINES

Updated September 2007

 Benzodiazepines
What are they?
  • Benzodiazepines are sedatives often prescribed for anxiety, panic attacks, and insomnia
  • For illicit use, may be obtained on the street or from physicians
  • High potency formulations such as alprazolam and clonazepam are often most sought after
Street names
  • Benzos
  • Sticks
  • Downers
How are they used?
  • Orally
Why do people use them?
  • Reduce anxiety
  • Cause sedation
  • Enhance the effects of other depressants
  • Offset the side effects of stimulants
Acute effects
  • Sedation
  • Psychomotor retardation
  • Ataxia
  • Drowsiness
  • Memory impairment
  • Disinhibition
  • Respiratory depression
Chronic effects
  • May worsen depression
Withdrawal
  • Anxiety, insomnia, tremulousness, headache
  • Seizures and death can occur
  • In some cases, withdrawal is very similar to that seen in alcohol dependence
  • There may be a prolonged withdrawal syndrome characterized by insomnia, anxiety, and sensory hypersensitivity, which may contribute to inability to maintain abstinence
Pregnancy/Fetal issues
  • Sedation
  • “Floppy baby syndrome”
  • Dependence with withdrawal signs, including hypertonia, restlessness, irritability, and possibly seizures
Comments
  • Benzodiazepine misuse is common among methadone patients and contributes to the nodding observed in some patients
  • Benzodiazepines are also frequently implicated in mixed-drug overdoses

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III. COCAINE

Updated September 2007

Cocaine
What is it?
  • Derived from the coca plant
  • Two principal forms: powder (cocaine hydrochloride) and solid (“crack” or “base”)
  • Crack cocaine has a more rapid and intense effect, but both forms are the same drug with the same physiology
Street names
  • Coke
  • Nose candy
  • Blow
  • Crack
  • Rock
How is it used?
  • “Powder” cocaine is usually sniffed or dissolved in water and injected
  • Crack cocaine is usually smoked. Some people inject it after first dissolving it in an acidic solution (like vitamin C or lemon juice)
  • When smoked or injected, the euphoria (rush) is rapid, intense, and short lived (3-10 minutes); may last up to 30 minutes when sniffed
Why do people use it?
  • Euphoria
  • Alertness and confidence
  • Increased sexual interest
Acute effects
  • Increased heart rate and blood pressure
  • Loss of appetite
  • Anxiety with paranoid ideation
  • Lowered seizure threshold
  • Arrhythmias
  • Vasospasm, which may lead to myocardial infarction or cerebral vascular accident
  • Hyperthermia, which can be fatal
  • Extreme dysphoria and despondency often follow the euphoria, leading users to binge
Chronic effects
  • Weight loss
  • Dysphoria
  • Depression
  • Nasal perforation
  • Accelerated HIV disease progression
Withdrawal
  • No physical syndrome of withdrawal
  • Craving for more cocaine can be intense
Pregnancy/Fetal issues
  • Risk of spontaneous abortion, premature labor, abruptio placentae, and low birth weight
  • Debate in the literature over long-term effects on development, but most studies have not found a strong effect
  • Reduced placental blood flow
  • Intrauterine fetal growth restriction
  • Fetal cerebrovascular incident
Comments
  • Under federal law, possession of ≥5 grams of crack cocaine or ≥500 grams of powder carries a mandatory penalty of 5 years in prison

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IV. MARIJUANA

Updated September 2007

Marijuana
What is it?
  • Derived from the flowers and leaves of the Cannabis sativa plant
  • Hashish is the concentrated resin
  • Primary active ingredient is Δ9-THC, but a number of other chemicals are believed to have a role in its effects
  • Cannabinoids act on receptors that also respond to endogenous CNS ligands
Street names
  • Pot
  • Weed
  • Reefer
  • Dope
  • Joint
  • Blunt
How is it used?
  • Smoked or ingested orally
Why do people use it?
  • Euphoria
  • Relaxation
  • Perceptual alterations
  • Intensification of sensory experiences
Acute effects
  • Increased heart rate
  • Impairment of short-term memory and motor skills
  • Increased appetite
  • Conjunctival injection
  • Sometimes anxiety and panic
Chronic effects
  • Cannabis smokers may be at increased risk for chronic bronchitis and respiratory cancers
  • Most studies have not found any irreversible long-term effects on cognition, although debate continues
  • The possibility that use of marijuana at a young age raises the risk of schizophrenia is also under debate
Withdrawal
  • Sleep and appetite disorders
  • Irritability and anxiety sometimes accompany abrupt cessation of chronic marijuana use
Pregnancy/Fetal issues
  • No evidence of fetal malformations
  • Various inconsistent results include associations with lower birth weight and childhood cancers
  • Placental vascular abnormalities
  • Intrauterine fetal growth restriction
Comments
  • Medically, marijuana has been found to increase appetite, reduce nausea, and relieve pain. Debate continues on efficacy and risk in comparison with other medications.

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V. MDMA (ECSTASY)

Updated September 2007

MDMA (Ecstasy)
What is it?
  • MDMA is a synthetic analogue of amphetamine
Street names
  • Ecstasy
  • E
  • X
How is it used?
  • Ingested orally, intranasally, and sometimes injected
  • Effects last 3-5 hours
Why do people use it?
  • Euphoria
  • Sensory enhancement
  • Empathy
  • Energy
Acute effects
  • Increased heart rate, bruxism, tremor, anorexia, anxiety, dry mouth
  • Rarely: seizures, hyperthermia leading to disseminated intravascular coagulation (DIC), and organ failure
  • MDMA users are often advised to stay well hydrated; however, consuming large amounts of hypotonic fluids with MDMA has been documented to lead to hyponatremia (MDMA increases release of antidiuretic hormone)
Chronic effects
  • Long-term damage to serotoninergic neurons in animal studies, but this has not been clearly shown in humans
  • Anecdotal evidence that chronic use leads to depression
Withdrawal
  • No withdrawal syndrome, but some people use it compulsively
Pregnancy/Fetal issues
  • No data which controls for other variables
Comments
  • MDMA was first synthesized in 1912 and was used in psychotherapy in the 1970s
  • Recreational use began in the 1980s at which point it was classified as Schedule I
  • The FDA has approved a research protocol on the use of MDMA in post-traumatic stress disorder

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VI. OPIATES

Updated September 2007

Opiates
What are they?
  • Originally derived from the poppy plant, although there are now also semi-synthetic (e.g., heroin) and synthetic (e.g., methadone) classes
  • Most commonly used to treat severe or chronic pain
  • For illicit use, may be obtained on the street or from physicians
  • High potency formulations such as OxyContin® are often most sought after
Street names
  • Dope
  • Smack
  • Junk
  • Horse
  • Manteca
  • Generally sold in $10 bags, 10 of which make a “bundle”
How are they used?
  • Orally, nasally inhaled, smoked, injected intravenously or subcutaneously
Why do people use them?
  • Opiates reduce pain, but opiate abusers experience feelings of sedation, euphoria, analgesia, and a “rush”
Acute effects
  • Sedation, euphoria
  • Respiratory depression
  • Decrease in blood pressure and heart rate
  • Noncardiogenic pulmonary edema has been associated with acute opiate use
Chronic effects
  • Many of the medical consequences of opiate use are effects of the route of administration and not the drug itself
  • Injection can lead to endocarditis, abscess formation, clots, skin tracks, and scarring
  • Infected needles can transmit hepatitis B and C, and HIV infection
Withdrawal
  • Can be divided into early, middle, and late phases:
    • Early: yawning, sweating, teary eyes, and runny nose
    • Middle: restless sleep, dilated pupils, gooseflesh, tremor, irritability
    • Late: an increase in all early and middle signs and symptoms with an increase in blood pressure, nausea, vomiting, diarrhea, abdominal cramps, labile mood, depression, muscle spasm, weakness, and bone pain
  • Heroin withdrawal usually starts 8-12 hours after the last use and peaks at 48 hours, lasting from 5-10 days
  • Methadone withdrawal generally begins 24-48 hours after the last dose; it is somewhat more gradual in onset but lasts several weeks
Pregnancy/Fetal issues
  • If a woman who is dependent on opioids becomes pregnant, the clinician should discuss treatment options with her, informing her that methadone maintenance is preferred to detoxification with its attendant risks of withdrawal and relapse. If she is already enrolled in a methadone maintenance program, the clinician should advise her to continue it.
  • Opiate withdrawal during pregnancy can lead to spontaneous abortion or premature labor

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VII. ALCOHOL

Updated September 2007

Alcohol
What is it?
  • Ethanol, derived from a variety of plant sources
How is it used?
  • Oral ingestion
Why do people use it?
  • To feel pleasure, relax, decrease anxiety and sexual inhibitions
  • Among persons with alcohol dependence, alcohol is ingested to avert uncomfortable withdrawal symptoms
Acute effects
  • Signs and symptoms of alcohol intoxication (increased severity according to amount of alcohol consumed):
    • Diminished muscular coordination
    • Confusion, nystagmus, ataxia, dysarthria
    • Nausea, vomiting, diplopia, sluggish pupils
    • Hypothermia, cold sweats, stupor, amnesia
    • Risk of coma
Chronic effects System
Chronic Effect
Nervous system Insomnia, anxiety, cerebellar dysfunction, optic neuropathy, peripheral neuropathy, seizures, Wernicke-Korsakoff syndrome
Cardiac Arrhythmia, cardiomyopathy, worsening hypertension
Hepatic Fatty liver, hepatitis, cirrhosis with complications (e.g., gynecomastia, testicular atrophy, ascites, varices, encephalopathy)
Gastrointestinal Gastritis, peptic ulcer disease, pancreatitis
Musculoskeletal Myopathy, osteoporosis
Metabolic Chronic malnutrition, vitamin deficiencies, including thiamine, folate, and vitamin B12
Dermatologic Spider angiomata, palmar erythema
Hematologic/
Immunologic
Anemia, thrombocytopenia, decreased WBC function
Cancer Increased risk of cancer of the liver, pancreas, mouth, tongue, pharynx, larynx, and esophagus
Withdrawal
  • Occurs 6-60 hours after last drink
  • Manifested by tremors, sweats, flush, anxiety, insomnia, anorexia, nightmares, diarrhea, nausea, vomiting, aches, abdominal cramps, restlessness, and elevated vital signs
  • Withdrawal can last 3-5 days
    • Major withdrawal (DTs) is manifested by confusion; markedly elevated vital signs; agitation, often with belligerence; pronounced tremor; diaphoresis; and hallucinations. Even if treated, mortality is between 1% and 3%
    • Withdrawal seizures are usually isolated, although can be recurrent (25%).
    • Persistent mild withdrawal consists of sleep disturbances, mild tremors, anxiety, and depression and can last for several weeks to months
  • Treatment of withdrawal consists of benzodiazepine taper protocols usually titrated to signs and symptoms
Pregnancy/Fetal issues
  • In the United States, 1 in 300-1000 births have fetal alcohol syndrome or fetal alcohol effect. Hallmarks of fetal alcohol syndrome include:
    • Fetal growth retardation
    • Facial dysmorphism
    • Central nervous system dysfunction
Comments
  • Pharmacologic treatments for alcohol dependence and to help prevent relapse include:
    • Disulfiram: causes aversive symptoms if alcohol is ingested
    • Naltrexone (oral or injectable): opioid antagonist that blunts the pleasurable effects of and craving for alcohol
    • Acamprosate: mechanism is unknown, can help sustain abstinence

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VIII. KETAMINE

Updated September 2007

Ketamine
What is it?
  • Ketamine hydrochloride
  • Developed as an animal anesthetic
  • Dissociative anesthetic similar to PCP
Street names
  • K
  • Vitamin K
  • Special K
  • A K-hole is a deeply dissociated state
How is it used?
  • Smoked, intravenously, orally, inhaled
Why do people use it?
  • One of the “club drugs”
  • Hallucinogen-like, visual illusions, distortion of body image
Acute effects
  • Increase in blood pressure, hallucinations, anxiety, muscle rigidity, feelings of strength and special insights
  • Impaired motor skills, judgment, and speech
Chronic effects
  • Protracted psychosis similar to that seen with PCP
Withdrawal
  • None, craving can develop
Pregnancy/Fetal issues
  • Neuronal cell death in the fetus seen in experimental studies

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IX. GHB

Updated September 2007

GHB
What is it?
  • Gamma Hydroxybutyrate (similar to sedatives)
  • Developed as an anesthetic
Street names
  • Liquid ecstasy
  • Grievous bodily harm
How is it used?
  • Clear liquid, powder, or pill most often taken orally
Why do people use it?
  • Mild euphoria
  • Body builders use it to build muscles (growth hormone release)
Acute effects
  • Mild euphoria, relaxation; at high levels: loss of consciousness, seizures, vomiting
Chronic effects
  • Tolerance and dependence
Withdrawal
  • 1-6 hours after use: anxiety, restlessness, insomnia, tremor, confusion, delirium, hallucinations, tachycardia, elevated BP, nausea, and vomiting
Pregnancy/Fetal issues
  • Little known
Comments
  • Effects of any dose are very unpredictable

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X. METHAMPHETAMINE

Updated September 2007

Methamphetamine
What is it?
  • Synthetic stimulant similar to cocaine but with longer period of effect
Street names
  • Crystal
  • Tina
  • Speed
  • Crank
How is it used?
  • Orally, intravenously, smoked, intranasally, rectally
Why do people use it?
  • Weight loss
  • Reduced fatigue, sustained alertness
  • “Rush”
  • Energy
  • Increased interest in sex
Acute effects
  • Smoking can produce a high of 7-24 hours in duration
  • Increased energy and alertness, elevated mood, dilated pupils, increased heart rate and blood pressure, decreased appetite, tremors, sweats, headache
Chronic effects
  • Psychosis, depression
  • Memory loss
  • Dependence
  • Insomnia
  • Tolerance (develops in several weeks)
  • Damage to dopamine- and serotonin-containing neuron terminals
Withdrawal
  • Extreme fatigue (“crash effect”)
  • Depression
  • Paranoia
Pregnancy/Fetal issues
  • Neonatal behavior problems (hyperirritable, poor feeding, lethargy)
  • Increase in placental abruptions
  • Reduced gestational age
  • Low birth weight, length, and head circumference
  • Reduced placental blood flow
  • Intrauterine fetal growth restriction
  • Fetal cerebrovascular incident
Comments
  • Use has spread from the west coast of the US to the east, particularly among MSM where it is associated with high-risk sexual activity

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XI. ANABOLIC-ANDROGENIC STEROIDS

Updated February 2009

Anabolic-Androgenic Steroids
What are they?
  • A class of steroid hormones related to
    testosterone
Street names
  • Arnolds
  • Stackers
  • Gym candy
  • Weight trainers
  • Pumpers
  • Juice
  • Roids
  • Sticks
How are they used?
  • Orally, injected, or transdermally
Why do people use them?
  • Legally prescribed to treat body wasting and endocrine disorders
  • Athletes misuse for enhanced performance
  • Others misuse for improved physical appearance
Short-term effects
  • Increased muscle mass and strength when combined with training
Chronic effects
  • For men:
    • Testicular atrophy, reduced sperm count
  • For women:
    • Hirsutism, changes in menstrual cycle
  • Severe acne
  • Mood swings, association with aggression
  • Potential liver damage, increases in LDL and decreases in HDL, high blood pressure
Withdrawal
  • Rare
  • Mood swings, depression, fatigue, restlessness, loss of appetite, insomnia, reduced sex drive, and steroid cravings
Pregnancy/Fetal issues
  • Can cause development of male features in the female fetus and female features in the male fetus
Comments
  • Prevalence of adverse effects unclear

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XII. PCP

Updated April 2009

PCP
What is it?
  • Phencyclidine
  • Developed as an intravenous anesthetic
  • Dissociative anesthetic similar to Ketamine
Street names
  • Angel dust
  • Wack
  • Ozone
  • Rocket fuel
  • Love boat
How is it used?
  • Smoked, orally, inhaled, may be smoked with marijuana
Why do people use it?
  • Hallucinogen-like, visual illusions, distortion of body image, euphoria
Acute effects
  • Increase in blood pressure, elevated heart rate, body temperature
  • Decreased awareness
  • Schizophrenic behavior, mood disturbances, anxiety
Chronic effects
  • Memory loss, difficulties with speech and thinking
  • Protracted psychosis similar to that seen with ketamine
Withdrawal
  • Rare; physical distress, lack of energy, depression
Pregnancy/Fetal issues
  • Can lead to low birth weight, poor muscle control, brain damage, and withdrawal syndrome if used frequently
Comments
  • While intoxicated, PCP abusers may become violent or suicidal and are therefore dangerous to themselves and others. High doses of PCP can also cause seizures, coma, and death (though death more often results from accidental injury or suicide during PCP intoxication).
  • Because PCP can also have sedative effects, interactions with other central nervous system depressants, such as alcohol and benzodiazepines, can also lead to coma.

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REFERENCES

American Academy of Pediatrics Committee on Drugs. Use of psychoactive
medication during pregnancy and possible effects on the fetus and
newborn. Pediatrics 2000;105:880-887.

Dickinson WE, Mayo-Smith MF, Eickelberg SJ. Management of sedative-hypnotic intoxication and withdrawal. In: Graham AW, Schultz TK, Mayo-Smith MF, et al (eds). Principles of Addiction Medicine. 3rd ed. Chevy Chase, MD: American Society of Addiction Medicine; 2003: pp. 633-649.

Lowinson JH, Ruiz P, Millman RB, et al (eds). Substance Abuse: A Comprehensive Textbook. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.

Benzodiazepines
Longo LP, Johnson B. Addiction: Part I. Benzodiazepines – Side effects, abuse risk and alternatives. Am Fam Physician 2000;61:2121-2128.

Cocaine
Baum MK, Rafie C, Lai S, et al. Crack-cocaine use accelerates HIV disease progression in a cohort of HIV-positive drug users. J Acquir Immune Defic Syndr 2008;48:577-580.

Hyman SE. A 28-year-old man addicted to cocaine. JAMA 2001;286:2586-2594.

Zuckerman B, Frank DA, Mayes L. Cocaine-exposed infants and developmental outcomes: “Crack kids” revisited. JAMA 2002;287:1990-1991.

Marijuana
Campbell FA, Tramer MR, Carroll D, et al. Are cannabinoids an effective
and safe treatment option in the management of pain? A qualitative
systematic review. BMJ 2001;323:13-16. [Abstract]

Grant I, Gonzalez R, Carey CL, Natarajan L, et al. Non-acute (residual) neurocognitive effects of cannabis use: A meta-analytic study. J Int Neuropsychol Soc 2003;9:679-689.

Kalant H. Adverse effects of cannabis on health: An update of the literature since 1996. Prog Neuropsychopharmacol Biol Psychiatry 2004;28:849-863.

Pope HG Jr. Cannabis, cognition, and residual confounding. JAMA 2002;287:1172-1174.

Smith NT. A review of the published literature into cannabis withdrawal symptoms in human users. Addiction 2002;97:621-632. [Abstract]

Tramer MR, Carroll D, Campbell FA, et al. Cannabinoids for control of chemotherapy induced nausea and vomiting: Quantitative systematic review. BMJ 2001;323:16-21. [Abstract]

Ecstasy
Montoya AG, Sorrentino R, Lukas SE, et al. Long-term neuropsychiatric consequences of “ecstasy” (MDMA): A Review. Harv Rev Psychiatry 2002;10:212-220.

Pentney AR. An exploration of the history and controversies surrounding MDMA and MDA. J Psychoactive Drugs 2001;33:213-221.

Alcohol
Saitz R. Clinical practice. Unhealthy alcohol use. N Engl J Med 2005;352:596-607.

Ketamine
Farber NB, Olney JW. Drugs of abuse that cause developing neurons to commit suicide. Brain Res Dev Brain Res 2003;147:37-45.

Olney JW, Wozniak DF, Jevtovic-Todorovic V, et al. Drug-induced apoptotic neurodegeneration in the developing brain. Brain Pathol 2002;12:488-498.

GHB
Executive Office of the President, Office of National Drug Control Policy. Fact Sheet: Gamma Hydroxybutyrate (GHB). Publication no. NCJ 194881; 2002. Available at: www.whitehousedrugpolicy.gov

Zvosec DL, Smith SW, McCutcheon JR, et al. Adverse events, including death,
associated with use of 1,4-butanediol. N Engl J Med 2001;344:87-94.
 
Methamphetamine
New York State Office of Alcoholism and Substance Abuse Services (OASAS). Available at: www.oasas.state.ny.us/index.cfm

Kuczkowski KM. The effects of drug abuse on pregnancy. Curr Opin Obstet Gynecol 2007;19:578-85.

Winslow BT, Voorhees KI, Pehl KA. Methamphetamine abuse. Am Fam Physician 2007;76:1169-1174.

Substance Abuse and Mental Health Services Administration. TIP 33. SAMHSA/CSAT Treatment Improvement Protocols. 1999: pp. 29-33.

Anabolic-Androgenic Steroids

Kanayama G, Hudson JI, Pope HG Jr. Long-term psychiatric and medical consequences of anabolic-androgenic steroid abuse: A looming public health concern? Drug Alcohol Depend 2008;98:1-12.

Sjöqvist F, Garle M, Rane A. Use of doping agents, particularly anabolic steroids, in sports and society. Lancet 2008;371:1872-1882.

PCP

NIDA National Institute on Drug Abuse. PCP/phencyclidine. Available at:
www.drugabuse.gov/DrugPages/PCP.html

Office of National Drug Control Policy. Hallucinogens Facts & Figures. Available at: www.whitehousedrugpolicy.gov

American Pregnancy Association. Using illegal street drugs during pregnancy: PCP. Available at: www.americanpregnancy.org/pregnancyhealth/illegaldrugs.html

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