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Updated: Apr 14 2022

Signs and Symptoms of Drug Abuse (by Drug)

  • 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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