Updated: 2/14/2019

Signs and Symptoms of Drug Abuse (by Drug)

Topic
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Questions
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General Concepts
  • ALL addictive drugs act on the dopamine mesolimbic-reward pathway
  • Withdrawal symptoms are often the opposite of intoxication
    • e.g. miosis in opioid intoxication and mydriasis in withdrawal 
  • Depressant withdrawal is generally more life-threatening than stimulant withdrawal
  • Injection drug users at risk for
    • right-sided endocarditis
    • hepatitis and abscesses
    • overdose
    • hemorrhoids
    • AIDS
Depressants
  • Opioids (e.g. morphine, heroin, methadone)
    • intoxication 
      • nausea and vomiting with constipation
      • respiratory depression 
      • pupillary constriction (pinpoint pupils = miosis)
      • seizures (overdose is life-threatening)
      • for heroin use look for track marks (needle injections)
    • treatment for intoxication
      • naloxone/naltrexone
        • opioid receptor antagonist
      • symptomatic treatment
    • withdrawal
      • anxiety, insomnia, anorexia, sweating, dilated pupils, piloerection ("cold turkey"), fever, rhinorrhea, nausea, stomach cramps, diarrhea ("flulike" symptoms), muscle jerks, yawning
      • unpleasant but not life-threatening
    • treatment for withdrawal (examples mainly for heroin)
      • methadone
        • long-acting IV opiate
        • used for heroin detoxification or long-term maintenance
        • safe and used in pregnancy
      • suboxone
        • long acting oral administration with fewer withdrawal symptoms than methadone
        • naloxone + buprenorphine (partial opioid agonist)
        • naloxone is not active when taken orally, so withdrawal symptoms occur only if injected
          • intended to prevent overdose/enjoyment when suboxone is injected
  • Barbiturates
    • intoxication
      • respiratory/CNS depression
      • does not have a depression "ceiling"
    • treatment of intoxication
      • must treat withdrawal with barbiturates not benzodiazepines
      • symptom management
        • assist respiration
        • ↑ BP
    • withdrawal 
      • anxiety, seizures, delirium
        • similar to alcohol
      • life-threatening cardiovascular collapse
      • additive affects with alcohol
  • Benzodiazepines
    • intoxication
      • amnesia, ataxia, stupor/somnolence, minor respiratory depression
      • has a depression "ceiling"
      • additive affects with alcohol
      • treat with flumazenil (competitive GABA antagonist)
    • treatment for intoxication
      • flumazenil (competitive GABA antagonist)
    • withdrawal
      • rebound anxiety
      • seizures (life-threatening), tremor
      • insomnia
    • treatment for withdrawal
      • long acting benzodiazepine (e.g. diazepam) to taper off dose
      • symptomatic treatment
  • Alcohol
    • see Alcohol topic
Stimulants
  • Amphetamines
    • mechanism
      • simulates biogenic amine (DA, NE, 5HT) release 
    • intoxication
      • mental status changes
        • euphoria, impaired judgment, delusions, hallucinations, prolonged wakefulness/attention
      • sympathetic activation,
        • psychomotor agitation, pupillary dilation, hypertension, tachycardia, fever, cardiac arrhythmias
    • withdrawal
      • depression, lethargy, headache, stomach cramps, hunger, hypersomnolence
  • MDMA ("ecstacy")
    • mechanism
      • similar to amphetamines
      • effects 5-HT more than dopamine
        • may damage serotonergic neurons
    • intoxication
      • hyperthermia and social closeness
        • club drug
    • withdrawal
      • mood offset for several weeks
  • Cocaine
    • mechanism
      • block biogenic amine (DA, NE, 5HT) reuptake
    • intoxication
      • mental status changes
        • euphoria, psychomotor agitation, grandiosity, hallucinations (including tactile), paranoid ideations
      • sympathetic activation
        • ↓ appetite, tachycardia, pupillary dilation, hypertension, angina, sudden cardiac death, stroke (intense vasoconstriction)
      • stereotyped behavior
        • repetitive motions (e.g. digging through trash)
    • treatment for intoxication
      • benzodiazepines
      • neuroleptics
      • reduce blood pressure and body temperature
    • withdrawal
      • severe depression and suicidality, hyperphagia, hypersomnolence, fatigue, malaise, severe psychological craving
  • Caffeine
    • intoxication
      • restlessness and insomnia
      • ↑ diuresis
      • muscle twitching
      • cardiac arrhythmias
    • withdrawal
      • headache, lethargy, depression, weight gain
  • Nicotine
    • intoxication
      • restlessness, insomnia, anxiety, arrhythmias
    • withdrawal
      • irritability, headache, anxiety, weight gain, craving
    • treatment for cessation
      • bupropion (NE and dopamine reuptake inhibitor)
      • varenicline (partial nicotinic receptor agonist)
      • nicotine administration via other routes (patch, gum, lozenges)
Hallucinogens
  • PCP
    • intoxication
      • belligerence, impulsiveness, fear, homicidality, psychosis, delirium, seizures, psychomotor agitation, vertical and horizontal nystagmus, tachycardia, ataxia 
    • withdrawal
      • depression, anxiety, irritability, restlessness, anergia, disturbances of thought and sleep
    • note: ketamine is a similar drug; both are NMDA antagonists 
  • LSD
    • mechanism
      • action at 5-HT receptor
    • intoxication
      • visual hallucinations and synesthesias (e.g. seeing sound as color)
      • marked anxiety or depression, delusions, pupillary dilation
      • bad trip panic
    • withdrawal
      • largely no withdrawal because it does not effect dopamine
      • flashbacks years later
  • Marijuana
    • mechanism
      • binds to CB1/CB2 cannabinoid receptors
    • intoxication
      • euphoria, anxiety, disinhibition, paranoid delusions, perception of slowed time, impaired judgment, social withdrawal, ↑ appetite, dry mouth, hallucinations
        • largely psychological effects
      • amotivational syndrome
    • withdrawal
      • mild symptoms
        • irritability, depression, insomnia, nausea, anorexia
      • most symptoms peak in 48 hours and last for 5-7 days
      • can be detected in urine up to 1 month after last use
    • note: dronabinol is a cannabinoid used as an antiemetic
 

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Questions (15)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.PY.18) A 43-year-old female presents to the ED with a severe case of left leg cellulitis. She is admitted for IV antibiotics. After 24 hours, the area of erythema has receded approximately 30%. The following day she is being prepared for discharge when she suddenly begins to complain of nausea and abdominal pain. On physical exam, she is febrile and has mydriasis and piloerection. What is the most likely cause of these new findings? Review Topic

QID: 100018
1

The patient's bacterial infection is no longer responding to the antibiotic regimen and she is showing signs of sepsis

3%

(3/105)

2

The patient is having an allergic reaction to the antibiotic regimen

7%

(7/105)

3

The patient is now showing signs of a pulmonary embolism as a result of a deep vein thrombosis

1%

(1/105)

4

The patient is most likely withdrawing from an opiate that she uses chronically

78%

(82/105)

5

The patient has acquired a nosocomial enteritis, as a result of her hospitalization and her antibiotic regimen

10%

(11/105)

M1

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(M1.PY.27) A 25-year-old man presents to the emergency department after paramedics picked him up from an electronic music festival. His temperature is 103°F (39.4°C), blood pressure is 167/105 mmHg, and pulse is 122/min. On physical exam, the patient is highly alert, agitated, and diaphoretic. Laboratory testing is significant for a serum sodium concentration of 130 mEq/L. Which of the following was most likely ingested by the patient? Review Topic

QID: 107039
1

Heroin

15%

(3/20)

2

Ketamine

0%

(0/20)

3

Phencyclidine

10%

(2/20)

4

3,4-methylenedioxymethamphetamine

65%

(13/20)

5

Lysergic acid diethylamide

5%

(1/20)

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(M1.PY.27) An 18-year-old male was brought to the emergency room after he caused an accident by driving at a slow speed as he was entering the freeway. He appears to have sustained no major injuries just minor scratches and lacerations, but appears to be paranoid, anxious, and is complaining of thirst. He has conjunctival injection and has slowed reflexes. A police officer explained that he had confiscated contraband from the vehicle of the male. Which of the following substances was most likely used by the male? Review Topic

QID: 107032
1

Phencyclidine (PCP)

6%

(6/100)

2

Cocaine

8%

(8/100)

3

Heroin

10%

(10/100)

4

Alprazolam

2%

(2/100)

5

Marijuana

73%

(73/100)

M1

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(M1.PY.27) A 21-year-old female is brought by her brother to the emergency department after having a generalized tonic-clonic seizure one hour ago. She is slightly confused and has no recollection of her seizure. Her brother relayed that the patient has a history of severe anxiety for which she takes medication. For the past several days, he noticed that his sister exhibited body tremors, appeared to be agitated with quick mood changes, and, at times, was delirious. He states his sister recently ran out of her medications while visiting from out of town. Which of the following would best treat the patient's condition? Review Topic

QID: 107036
1

Diazepam

58%

(19/33)

2

Methadone

6%

(2/33)

3

Naloxone

6%

(2/33)

4

Varenicline

0%

(0/33)

5

Flumazenil

21%

(7/33)

M1

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(M1.PY.27) A 20-year-old college student presents to the emergency room complaining of insomnia for the past 48 hours. He explains that although his body feels tired, he is "full of energy and focus" after taking a certain drug an hour ago. He now wants to sleep because he is having hallucinations. His vital signs are T 100.0 F, HR 110 bpm, and BP of 150/120 mmHg. The patient states that he was recently diagnosed with "inattentiveness." Which of the following is the mechanism of action of the most likely drug causing the intoxication? Review Topic

QID: 107033
1

Increases presynaptic dopamine and norepinephrine releases from vesicles

88%

(7/8)

2

Displaces norepinephrine from secretory vesicles leading to norepinephrine depletion

0%

(0/8)

3

Binds to cannabinoid receptors

0%

(0/8)

4

Blocks NMDA receptors

0%

(0/8)

5

Activates mu opioid receptors

0%

(0/8)

M1

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(M1.PY.27) An 18-year-old female is brought to the emergency department by her boyfriend. She is screaming uncontrollably. Eventually, she states that she is afraid that "death is near" but cannot give a rational reason for this thought. She reports both seeing colors "coming out of other people's mouths" and "hearing" these colors. The patient's boyfriend experienced similar sensory symptoms a few hours ago; he explains they were trying to have a "spiritual experience." Physical exam is significant for mydriasis, hypertension, hyperthermia, piloerection, tachycardia, and sweating. Upon which of the following receptors does the most likely drug she ingested act? Review Topic

QID: 107038
1

Cannabinoid

24%

(14/59)

2

5-hydroxytryptamine

22%

(13/59)

3

NMDA

32%

(19/59)

4

GABA

7%

(4/59)

5

Mu opioid

14%

(8/59)

M1

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(M1.PY.2014) A mother calls the psychiatrist, saying that she is concerned about her 18-year-old son who has become quite emaciated over the past several months. She has noticed that his pupils are enlarged, he has frequent nose bleeds, and he wears long sleeve shirts even in warm weather. His personality has changed quite dramatically as well, as he repeatedly steals from her and sells anything valuable in the house. He also has become overconfident, aggressive, and paranoid. Which of the following is a risk of the drug that the son is most likely using? Review Topic

QID: 107040
1

Serotonin syndrome

6%

(1/18)

2

Sudden cardiac arrest

61%

(11/18)

3

CNS white matter lesions

6%

(1/18)

4

Irreversible schizophrenia-like psychosis

11%

(2/18)

5

Increased risk of schizophrenia in predisposed patients

11%

(2/18)

M1

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(M1.PY.38) A 24-year-old female is brought to the ED from a nearby nightclub by the local police due to aggressive and violent behavior over the past hour. A friend accompanying the patient reports that the patient smoked marijuana that "seemed different" approximately one hour ago. The patient has never had this kind of reaction to marijuana use in the past. On examination, the patient is combative with slurred speech and active visual hallucinations; eye examination shows prominent vertical nystagmus. This patient's presentation can be best explained by intoxication with a substance that acts at which of the following receptors? Review Topic

QID: 100038
1

Serotonin

6%

(4/70)

2

Cannabinoid

6%

(4/70)

3

GABA

3%

(2/70)

4

NMDA

79%

(55/70)

5

Norepinephrine

4%

(3/70)

M1

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(M1.PY.2) A 27-year-old female is brought to the Emergency Department by Fire Rescue after participating in a physical altercation with several commuters on the subway. She appears to be responding to hallucinations and is diaphoretic. Her vitals are as follows: T 100.5F (38C), HR 115, BP 155/90, RR 17. Her past medical history is notable for a previous ED visit for phencyclidine-related agitation. Which of the following physical findings would most strongly suggest the same diagnosis? Review Topic

QID: 105612
1

Prominent vertical nystagmus

50%

(6/12)

2

Constricted but responsive pupils

17%

(2/12)

3

Dilated, minimally responsive pupils

25%

(3/12)

4

Conjunctival injection

8%

(1/12)

5

Conjunctival pallor

0%

(0/12)

M1

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