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Recognizing Symptoms of Drugs of Abuse

Maricel Dela Cruz DO, MPH, FAWM It is the policy of the Intensive Osteopathic Update (IOU) organizers that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

All faculty in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

The content of this material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices. Faculty Disclosure

I have no relevant financial relationships to disclose.

The content of this material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices. Learning Objectives

• Define illicit and illegal drug abuse

• List common drugs of abuse as identified by the National Institute on Drug Abuse

• Describe evidence-based screening tools to recognize a history of drug abuse in the outpatient setting

• Describe signs and symptoms of drug abuse associated with common drugs of abuse

• Demonstrate the current recommendations regarding drug abuse screening as per the United States Preventive Services Task Force Definition

The use of illegal drugs or the use of prescription or over-the-counter drugs for purposes other than those for which they are meant to be used, or in large amounts.

Drug abuse may lead to social, physical, emotional, and job-related problems. Background

2018 National Survey on Drug Use and Health

More than 19% of all people ages 12 and older in the United States used an illicit drug in the past year

More than 53 million Americans

Illicit drug use is the most common cause of preventable morbidity and death in the United States Drug Use Screening in Adults

American Academy of Family Physicians. Screen Adults for Unhealthy Drug Use, Says Task Force. https://www.aafp.org/news/health-of-the-public/20200616uspstf-illicitdrugscreen.html. United States Preventive Services Task Force

June 9, 2020

United States Preventive Services Task Force. Unhealthy Drug Use: Screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/drug-use-illicit-screening. Recommendations

USPSTF recommends that clinicians screen patients 18 and older by asking about unhealth drug use

Screening should occur when accurate diagnosis, effective treatment and appropriate care can be offered or referred

Insufficient evidence to assess the balance of benefits and harms of screening for unhealthy drug use in adolescents ages 12-17 Evidence

USPSTF performed a systematic review that included 99 studies

28 studies focused on the accuracy of drug screening instruments

71 studies addressed specific therapies, such as psychosocial interventions, agonist therapy and naltrexone, to reduce drug use Screening Tools (Examples)

Substance Use Brief Screen (SUBS)

Tobacco, , Prescription Medication and Other Substance Use Tool (TAPS)

Drug Abuse Screening Test (DAST)

Single-Item Drug Frequency Questions (AUDIT-C, etc.) Substance Use Brief Screen (SUBS)

Han BH, Sherman SE, Link AR, Wang B, McNeely. Comparison of the Substance Use Brief Screen (SUBS) to the AUDIT-C and ASSIST for detecting unhealthy alcohol and drug use in a population of hospitalized smokers. Journal of Treatment. 2017. DOI: 10.1016/j.jsat.2017.05.014. , Alcohol, Prescription Medication and Other Substance Use Tool (TAPS)

https://cde.drugabuse.gov/sites/nida_cde /files/TAPS%20Tool%20Parts%20I%20and %20II%20V2.pdf Drug Abuse Screening Test (DAST) The Drug Abuse Screening Test (DAST) - United States ...www.uspreventiveservicestaskforce.org Drugs of Abuse List

Ethanol MDMA Club Drugs Over-the-Counter Medicines Prescription Medications Steroids (Anabolic) Synthetic Kratom Synthetic Marijuana Tobacco/ and Vaping

https://www.drugabuse.gov/drug-topics/commonly-used-drugs-charts Ethanol

Increase in neurotransmitter gamma- aminobutyric acid (GABA), an inhibitory neurotransmitter.

Suppresses the central nervous system.

Decrease in anxiety, poor fine motor skills, euphoria, stupor. https://openphoto.net/gallery/name/illustration/1505

Addiction, long term liver disease, cardiovascular disease and cancer. Club Drugs GHB – CNS , binds to the receptors of the inhibitory neurotransmitter GABA, particularly GABA-B.

Rohypnol (flunitrazepam) – CNS depressant, leads to anterograde amnesia, CNS depressant, binds to receptors of GABA, particularly GABA-A.

Ketamine – NMDA (N-methyl-D-aspartate) receptor antagonists, leads to anesthetic, analgesic and effects. Can lead to leukocytosis, low glucose and rhabdomyolysis. https://commons.wikimedia.o rg/wiki/File:AbuGnost_anaboli c_steroids_GHB_poppers_080 LSD – activates serotonin receptors (5HT2A receptors), 810_48.jpg modulates others (5HT2C and 5HT1A), leading to impaired cognition and induction of hallucinations. GABA-A versus GABA-B receptors

GABA-A receptors are GABA-B receptors are G- ligand-gated ion channels protein-coupled receptors (inotropic receptors), (metabotropic receptors), produce sedative and produce sedative effects. hypnotic effects with anti- Can lead to changes in convulsion properties. gene transcription.

https://www.researchgate.net/figure/Fig-3-Schematic- https://alchetron.com/GABA-receptor representation-of-the-GABA-B-receptor_fig2_286488910 Cocaine Base – crack, free base, rock crystals that vaporize when heated to smoke making a “crackling noise”; Salt – blow, coke, snow. , from leaves of plant, native to South America.

Leads to central and peripheral nervous system effects, blocking the reuptake of monoamine transporters (Dopamine, Norepinephrine and Serotonin). Tremor, alertness, hypertension, euphoria. Acute MI, aortic dissection, CVA, seizures. Hallucinations, hyperthermia, paranoia. Crack lung (diffuse alveolar damage. https://www.pexels.com/photo/black-black-and-white-business-cocaine-322251/ https://commons.wikimedia.org/wiki/File:Kokain_-_Cocaine.svg Hallucinogens Alter perception (awareness of surrounding objects and conditions), thoughts, and feelings.

Lead to hallucinations, or sensations and images that seem real though they are not. Primarily affect 5HT2A receptors (serotonin).

Can be found in plants and mushrooms or are human-made.

Ayahuasca, LSD, (), 4-phosphoryloxy-N, N- dimethyltryptamine (). https://commons.wikimedia.org/wiki/File:Peyote_Cactus.jpg https://en.wikipedia.org/wiki/File:Psilocybe_semilanceata_6514.jpg Inhalants

Chemical vapors or gases that produce a “high” when inhaled.

Solvents – benzene, toluene, xylene, acetone, naptha, hexane Aerosol Sprays – hair spray, spray paint, cooking spray, pressurized liquids or gases (fluorocarbon, butane)

Gases – (“laughing gas”), chloroform, halothane, https://www.lejeune.marines.mil/Ne ws/Article/511694/a-cheap-way-to- ether, butane lighters, propane tanks get-high-a-quick-way-to-die/ Nitrites – , butyl nitrite, cyclohexyl nitrite ()

Can cause cardiac sensitization (dysrhythmias), methemoglobinemia. Kratom

Southeast Asian tropical tree with weak opioid effects.

Used as a supplement to treat chronic pain and opioid withdrawal.

Smoked or brewed in tea; can also chew on leaves.

Stimulant-like effects at lower doses, opioid at higher.

Withdrawal can occur when stopped. potential.

https://commons.wikimedia.org/wiki/File:Kratom_leaves.jpg Marijuana

Dried leaves, flowers, stems, and seeds from the hemp plant, sativa. Plant contains the chemical delta-9- (THC) and other related compounds. Partial agonist of CB1 and CB2 receptors.

Extracts can also be made from the cannabis plant.

Giddiness, feeling of well being, euphoria, relaxation, altered perception of time, drowsiness, diminished coordination, increased appetite, increased risk of psychosis, diminished cognitive function, withdrawal.

https://pixabay.com/photos/marijuana-leaves-cannabis-green-3678222/ MDMA (3,4-methylenedioxymethamphetamine)

Ecstasy, Lover’s Speed, Molly, X. Sympathomimetic, Hallucinogenic and Psychedelic Effects. Increased energy and pleasure, enhanced tactile stimulation. Indirect effect on the serotonin receptor (5HT2A). Stimulates release of dopamine, serotonin and norepinephrine, as well as cortisol, oxytocin and ADH. Can last up to 3-6 hours, repeated doses to maintain high. 10x greater serotonin release than , causing intense mood effects.

https://commons.wikimedia.org/wiki/File:MDMA2.jpg Methamphetamine

Chalk, crank, crystal, glass, ice, meth. Oral, smoke, snort, inject. Blocks reuptake of monoamines (dopamine, norepinephrine, serotonin). Stimulates dopamine release causing a longer duration of action. Sympathomimetic, dysrhythmias, hypertension, hyperthermia, acute MI, insomnia, seizures, stroke, rhabdomyolysis. Weight loss, impaired verbal and learning. Cardiomyopathy, psychiatric disorders. https://commons.wikimedia.org/wiki/File:Suspectedmethmouth09-19-05closeup.jpg

https://commons.wikimedia.org/wiki/File:Crystal_Meth.jpg Over the Counter Medicines

Dextromethorphan (cough Loperamide (antidiarrheal) medicine), -like, PCP () like

https://www.kadena.af.mil/News/Article- Display/Article/419479/parents-warned-about-dangers-of-dxm/ https://www.flickr.com/photos/144891950@N08/48727233267 Prescription Medications

Prescription CNS Valium, Klonopin, Xanax, Ambien, Lunesta, Sonata,

Prescription Opioids , , Oxymorphone, , , Fentanyl

Prescription Dextroamphetamine, Dextroamphetamine/ (Adderall), (Ritalin, Concerta) Anabolic Steroids

Synthetic variations of the male sex hormone testosterone Anabolic-androgenic steroids Muscle building, increased male sex characteristics Gear, Juice, Roids, Stackers

Kidney disease, kidney failure, liver damage, tumor growth, acne, cardiomyopathy, elevated blood pressure, cholesterol derangement, increased risk of stroke and heart attack. Synthetic Cannabinoids (K2/Spice)

Cannabinoid-like action, different chemical structure than marijuana-derived cannabinoids. Herbal mixtures, similar effects as marijuana. Can contain dried plant materials.

Smoked or ingested. Liquid forms in e-cigarettes. Do NOT resemble THC in chemical structure (not on UDS).

Marketed as “safe,” sprayed onto dried plant material.

Direct agonists on CB1 receptor. Long lasting effects due to https://www.afspc.af.mil/News/Article- Display/Article/249903/salvia-and-spice- affinity for CB1 and not CB2 (24 hours or more). anything-but-nice-for-air-force-members/ Synthetic Cathinones (Bath Salts)

Bloom, Cloud Nine, Flakka, Lunar Wave, Vanilla Sky, Cosmic Blast, etc. Related to , stimulant found in the plant of Eastern Africa and South Asia. Cheaper substitute for other stimulants. White powder or crystal. Ingested, insufflated (snorted), smoked. Not detected on UDS. https://commons.wikimedia.org/wiki Similar effects as cocaine and methamphetamines. /File:Cathinone_general.png Excited delirium, agitation, paranoia, etc. Tobacco/Nicotine and Vaping Tobacco plant, grown for its leaves. Dried and fermented before being put into tobacco products. Nicotine, can lead to addiction. Nicotinic acetylcholine receptors in the brain, leading to peripheral vasoconstriction, elevated blood pressure, tachycardia, increased cardiac output, enhanced mental alertness and cognitive function. Increased risk of MI, atherosclerosis. Depressant effects include muscle relaxation and anxiety reduction. Nicotine content in vaping concentrations can be high. Additives in e-liquid.

https://www.flickr.com/photos/87735223@N02/24305025757

https://www.pikist.com/free-photo-iscoi Opioids

• Miosis • Mild hypotension • Bradycardia • Respiratory depression and lethargy • Hypoxia • Hypercarbia • Coma • Aspiration pneumonitis after coma https://www.flickr.com/photos/ksrecomm/40542895134 Heroin

Opioid derived from morphine; mu receptor.

Natural substance taken from the seed pod of various poppy plants grown in Southeast and Southwest Asia, Mexico and Colombia.

White or brown powder, or a black sticky substance known as black tar heroin (crude processing methods that leave behind impurities).

Reversed by .

https://commons.wikimedia.org/wiki/File:Heroin_-_Heroine.svg Mortality due to heroin has increased at least 5-fold in the United States over 10 years

Roughly 69,000 deaths in 2018 due to opioids

Nearly half of young injection heroin users reported using oral prescription opioids prior to IV heroin

https://commons.wikimedia.org/wiki/File:Heroin.JPG Fentanyl

Powerful synthetic opioid analgesic, 50-100 times more potent than morphine. Dosed in micrograms versus milligrams when pharmaceuticals are used. Full opioid agonist with high potency, especially at the mu receptor.

Analgesia and CNS depression.

Onset is less than 60 seconds, half-life of 90 minutes and duration of action of 30-60 minutes. Reversed with naloxone, may need greater amounts.

https://commons.wikimedia.org/wiki/File:Fentanyl-2D-skeletal-A.png

Used to tranquilize large animals 10,000x more potent than morphine

https://en.wikipedia.org/wiki/File:Carfentanil.svg Fentanyl and Carfentanil

Distributed within illicit drug markets “Cut” heroin and other opioids sold on the street to intensify their effects Due to their potency, small quantities may cause toxic effects and death Increasing doses of the opioid antagonist naloxone may be necessary to reverse https://www.flickr.com/photos/berniedup/11929466215 respiratory depression May need a naloxone drip in the hospital Gray Death

• Combination • Fentanyl • Carfentanil • Heroin • Synthetic Opioid, U-47700 • Responsible for a series of overdose fatalities in the United States • Increasing doses of the opioid antagonist naloxone may be necessary to reverse respiratory depression • May need a naloxone drip in the hospital

https://commons.wikimedia.org/wiki/File:Sample_of_U-47700.png Drug Enforcement Administration

DEA is protecting the nation’s prescription drug supply chain.

During the unprecedented health emergency caused by the ongoing coronavirus (COVID-19) pandemic, the health and safety of our communities is DEA’s top priority. DEA is responding appropriately to ensure Americans continue to have access to necessary medications and controlled substances. DEA’s efforts include supporting prescribing practices that limit exposure, enabling uninterrupted access to practitioners, and safeguarding a consistent and reliable drug supply. https://www.dea.gov/ Question 1

All of the following are examples of screening tools for drug abuse EXCEPT:

1. Substance Use Brief Screen (SUBS) 2. Tobacco, Alcohol, Prescription Medication and Other Substance Use Tool (TAPS) 3. Drug Abuse Screening Test (DAST) 4. The Alcohol Use Disorders Identification Test (AUDIT-C) 5. Clinical Institute Withdrawal Assessment for Alcohol (CIWA) Question 2

What is the mechanism of action of Kratom?

1. GABA receptor agonism 2. Weak opioid receptor agonism 3. Muscarinic receptor antagonism 4. Norepinephrine receptor antagonism 5. NMDA receptor agonism Question 3

Which statement is true?

1. The USPSTF recommends screening by asking questions about unhealthy drug use in adults age 18 years or older. 2. The USPSTF does not recommend screening by asking questions about unhealthy drug use in adults 18 years or older. 3. The USPSTF recommends screening by asking questions about unhealthy drug use in children less than 18 years old. 4. The USPSTF does not recommend asking questions of any patient about unhealthy drug use. 5. The USPSTF recommends asking leading questions regarding drug abuse in all patient. Question 4

What is used as a reversal agent for opioid overdose?

1. 2. Physostigmine 3. Methylene Blue 4. Dantrolene 5. Naloxone Question 5

What over the counter medication is often abused secondary to its similar effect to the illicit drug, PCP (phencyclidine), or ketamine?

1. Loperamide 2. 3. Guaifenesin 4. Melatonin 5. References • Klega AE and Keehbauch JT. Stimulant and use: primary care management. American Family Physician. 2018;98(2):85-92. • Mooney L. Drugs of abuse: what clinicians need to know. MedScape. 2017. https://reference.medscape.com/slidaeshow/drugs-of-abuse-ref06006623. • Wood E. Strategies for reducing opioid-overdose deaths – lessons from Canada. New England Journal of Medicine. 2018;378(17):1565-1567. • Blendon RJ and Benson JM. The public and the opioid-abuse epidemic. New England Journal of Medicine. 2018;378(5);407-411. • National Institute on Drug Abuse. Drug Topics. https://www.drugabuse.gov/drugs-abuse. • United States Drug Enforcement Administration. https://www.dea.gov/. • American College of Medical Toxicology. https://www.acmt.net/. • Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/coronavirus. • American Academy of Family Physicians. Screen Adults for Unhealthy Drug Use, Says Task Force. https://www.aafp.org/news/health-of-the-public/20200616uspstf-illicitdrugscreen.html. • United States Preventive Services Task Force. Unhealthy Drug Use: Screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/drug-use-illicit-screening. Thank You