APhA- CH 11 Summary

Drug Abuse & Addictive Substances (by Maya & Pearl Pages: 175-183)
First Part = Maya Bbashi
Substance

Slang name

Methods
of abuse
Orally
injection

Effects

Androgenic
anabolic
steroids(synthetic
derivatives of
testosterone)

Roids

Barbiturates
(they are CNS
depressants)

Barbs-downers

Ingestion- *At high doses they become general anesthetics and

injection
their effects will become-ataxia-depressed reflexeshypotension-respiratory depression
*they should not combined with drugs or substance
causes sedation(alcoholic drinks-prescription pain
medication-OTC cold and allergy drugs) witch lead
to slow berating alone or also slow heart.

Cocaine
(it is CNS
stimulant)

Snow-crackrock

Sniffingsnortinginjectingsmoking
*cocaine
is poorly
absorbed
orally

Men:testicles shrinking
Reduce in sperm count-infertility-baldnessgynecomastia- risk for prostate cancer
Women: facial hear-male pattern baldness-changes
or cessation in menstrual cycle-clitoris enlargementdeepened voice
Adolescents:stunted growth and accelerated puberty
changes
Others: jaundice-fluid retention-hypertension-acnemood swings(manic-like symptoms)

Cause hyper-stimulation and euphoric effects (

dilated pupils-hypertension-tachycardia-increased
temperature
Prolonged cocaine snorting cause ulceration in nose
mucous membranes-damage the nasal septum which
may cause it collapse
The deaths are result of cardiac arrest or seizures
followed by respiratory arrest

Dextromethorphan DXM-DMrobo-rojovelvet

Ethanol
(CNS depressant)

Various
namesalcoholic
drinks

Orally
(drinking
cough
syrup)
Snorting
(powder
which is
extracted
from
syrups)
Ingestion

*dextrorphan is the active metabolite witch is

related to phencyclidine(PCP) and ketamine in
structure (they may contribute in the abuse)
Hyper-excitability-lethargy-ataxia-slurred speechsweating-hypertension- nystagmus-heightened sense
of perceptual awareness-altered time perceptionvisual hallucination
*it has been sold as (ecstasy).

At high dose: hypotension-hypoglycemiarespiratory depression and death

Acute: ataxia-sedation-emesis-slurred speech
Chronic: esophageal varices-hepatic failure with

GHB
(CNS depressant)

Heroin

Liquid ecstasy- Ingestion

soap-easy laygeorgia home
boysomatomaxscoop
rievous bodily
harm
Smack-HInjectionskag-junk
smokingsnorting

Inhalant

Various

Inhaling

Injected drugs

Shooting upmainlining

Injection

Ketamine
(it is anesthetic)

K cat-special
K
Vitamin K
Valium

Injectionsnorting

LAD
(hallucinogen)

Acid- L
blotter-cubes
sugar-dots

Ingestion
(tabletcapsuleliquid)

ascites malnutrition
abused for euphoric-sedative-anabolic effects
it causes coma and seizures
*GHB+methamphetamine=increase seizures
*GHB+alcohol =nausea+breathing difficulty
*GHB has two precursors GBL and BD
INVOLVED IN POISONING-OVERDOSEDATERAPES-DEATHS
Cause: euphoria (rush)followed by alternately
wakeful and drowsy state(on the nod)
CNS and respiratory depression-miosis(pinpoint
pupils)-pulmonary edema(can occur)
Abuse is associated with fatal overdose-spontaneous
abortion-collapsed veins-infections( HIV-AIDS and
hepatitis)
*variety of chemical vapors causes psychoactive
effects
*inhalants abuse =short term intoxicating(only few
minutes)+CNS depressant(similar to anesthetics)
*successive inhalation=loss of inhibition and control
*continued use of inhalants may lead do coma
*in some cases prolong use =heart failure and
death(sudden sniffing death)
*risk of transmitting or acquiring HIV-hepatitisinfections(bacterial-fungal)
*chronic use: collapsed veins-infection of the heart
lining and valves-skin abscesses-cellulitis-liver
disease
*EMBOLI can form when there is insoluble
materials in tablets(which is used to prepare
injecting mixture )
*in certain doses :dreamlike states and
hallucinations
*in high doses: delirium-amnesia-impaired motor
function-hypertension-depression-potentially fatal
respiratory depression
1-physical effects: mydriasis(dilated pupils)increase in temperature-tachycardia-hypertensionsweating-loss of appetite-dry mouth-tremors
2-sensational and feeling changes
*in sufficient doses LSD cause visual hallucinations
+delusions

Second Part = Pearl Chris

1. MARIJUANA:
Slang:

Pot, herb, weed, grass, widow, ganja, hash.

Cannabis - Bubble gum, Northern Lights, juicy fruit, Afghani #1
Skunk varieties.

Methods of abuse:

Ingestion - Mixed with food or brewed in tea.

Smoking - joint, nail, bong, blunt.

Health Effects:
Severe terror.
Fear of losing control.
Fear of insanity, despair, and death.
Fatal accidents.
Flashbacks.
Delirium, conjunctivitis, food craving.
Short-term memory, learning problems, distorted perception, loss of coordination, tachycardia.
Burning and stinging of mouth and throat with heavy cough like smokers.
Drug craving and withdrawal.
Risk of heart attack quadruples in first hour of smoking marijuana.
Active chemical THC (delta-9-tetrahydrocannabinol).
2. MDMA (3, 4 methylenedioxymethamphetamine):
Slang: Ecstasy, Adam, XTC, Hug, beans, love drug.
Methods of abuse:
Ingestion.
Snort.
Inject.
Suppository.
Health Effects:
Stimulant and hallucinogenic.
Increases pulse and BP.
High doses---->malignant hyperthermia-rhabdomyolysis.
Confusion, depression, insomnia, craving, paranoia days to weeks after use.
Physical symptomsmuscle tension, teeth clenching, nausea, blurred vision, fainting, chills and
sweating.
Contents of MDMA may include caffeine, dextromethorphan, heroin, and mescaline.
MDMA like substance paramethoxyamphetamine (PMA) led to death due to hyperthermia.
3. METHAMPHETAMINE:
Slang: Crank, meth, speed, chalk, ice, crystal, glass.

Methods of abuse:
Ingestion.
Snorting.
Injection.
Smoking.
Health Effects:
Addictive stimulant.
Produces euphoria, irritability, insomnia, confusion, tremors, anxiety, paranoia, aggression.
High doses ---> HTN, tachycardia, stroke, arrhythmia, CV collapse, death.
Hyperthermia and convulsion -->death.
Prolonged use-->extreme anorexia, tooth decay, lesions.
4. NICOTINE:
Slang: Various names.
Methods of abuse:
Smoking (cigarettes)
Chewing (tobacco)
Health effects:
CNS stimulant and sedative, highly addictive.
Stimulation-->depression and fatigue --> Dependence.
Women on OCP more than 30 years with increased cardio and cerebrovascular risk.
Pregnant women--->Stillborn, premature, low birthweight.
Daily cough, phlegm, frequent respiratory infections.
Tar in cigarette ---> higher risk of lung cancer, emphysema, bronchial disorder.
Carbon monoxide--->cardiovascular diseases.
Dependency and withdrawal.
5. OPIOIDS:
Slang: Various.
Methods of abuse:
Ingestion.
Injection.
Health effects:
Include morphine, codeine, oxycodone (MS Contin), propoxyphene (Darvon), hydrocodone (Vicodin),
hydromorphone (Dilaudid), meperidine (Demerol)
Drowsiness, constipation.
Large dose-->coma, hypotension, respiratory depression, also death.
Dependence, craving, withdrawal.
6. PCP (phencyclidine)
Slang:
Angel dust, Ozone, wack, rocket fuel.
Combined with marijuana called killer joint or crystal superglass.

Methods of abuse:
Snorting.
Smoking (applied to leaf like mint).
Ingestion.
Health effects:
Addictive hallucinogen, sedative--->compulsive PCP-seeking.
Violent, suicidal, dangerous to self and others.
Low doses --->slight tachypnea, moderate tachycardia, and HTN, shallow respirations, profuse
sweating, numbness of extremities, muscular incoordination.
High doses--->decreased BP, pulse, respirations. Nausea, vomiting, blurred vision, drooling, coma,
death (due to suicide)
Physiological effect--->low dose--->change in body awareness. High dose--->illusion, hallucination
like schizophrenia.
7. ROHYPNOL (flunitrazepam):
Slang: Rophie, roofie, roach, rope, date rape drug, forget me.
Methods of abuse: Ingestion.
Health effects:
Smuggled drug.
Sedative hypnotic--->muscle relaxant and amnesia.
Mixed with alcohol can incapacitate-->rape---> amnesia.
Clonazepam (Klonopin) and alprazolam (Xanax) abused like Rohypnol.
8. STIMULANTS, AMPHETAMINES AND RELATED COMPOUNDS:
Slang: Speed, dexies, uppers.
Methods of abuse:
Ingestion.
Snorting (tablets)
Health Effects:
CNS stimulant. Addictive if misused.
High dose-->arrhythmia, HTN, hyperthermia, hostility and paranoia.

APPROACHES TO TOXIC EXPOSURES AND ANTIDOTOES

Approaches to Toxi Exposures By Kate N. Bellew
Pages 183-185
1. Inhaled poison. Immediately get the person to fresh air.
2. Poison on the skin. Remove any contaminated clothing and flood skin with water for at least 15 minutes.
3. Poison in the eye. Remove contact lenses. Flood the eye with water pouring from a large glass 2-3 inches
from the eye for 15-30 minutes.
4. Swallowed poison. If the victim is conscious and does not have convulsions and can swallow give a small
glass (2-4oz) of water immediately. Call the poison center for advice.
Other consideration:
Avoid wasting time to find antidotes at home.
Do not use home remedies such as salt water, mustard powder, raw eggs, hydrogen peroxide.
Call 911 or an ambulance if the victim is not breathing or has have seizures or is unresponsive.
For another situation contact a poison center.
Decontamination of GIT
Ipecac syrup has questionable effectiveness, and its use is generally avoided.
Gastric lavage involves placing a tube onto the stomach through a nostril or the mouth and repeatedly
washing out the stomach contents with a water or saline solution. (Questionable effectiveness if it is
performed more than 1hour after ingestion of the toxin.
Activated charcoal given orally is often the only treatment necessary if the toxin is absorbed and it
is used within 1-2 hours of ingestion of the toxin.
Cathartics such as magnesium citrate are not routinely used.
Whole bowel irrigation can be considered if the toxin is slowly or poorly absorbed.
Ipecac syrup
Contraindication: pronounced sleepiness, coma or seizures, ingestion of caustics, aliphatic
hydrocarbons, and fast acting agents that produce coma or seizers (TCA, Ca channel blockers, beta
blockers). Time since ingestion 1hour or more.
Adverse effects: diarrhea, sleepiness, protracted vomiting which can complicated administration of oral
therapies.
Activated charcoal
Used to absorb poisons in alter or comatose patient as a slurry by mouth or through a lavage tube.
Contraindications: ingestion of caustics, aliphatic hydrocarbons, heavy metals (Na, Li, Fe or Pb) or
simple alcohols, if bowel sound is absent.
Advantages: rapid onset of action, nonspecific action for a wide variety of chemicals and reasonable
effectiveness within 1hour of ingestion.
Disadvantages: messy, difficult to administer, may remove beneficial drugs with the toxin.
Cathartics (Mg citrate; MgSO4; Na2SO4 and sorbitol)
Previously used as an adjunct with activated charcoal to decrease GIT transit time, but their efficacy is
unproved. Fluid and electrolyte disturbances are possible.

Whole bowel irrigation

Generally used to wash out the GIT tract when charcoal may be inappropriate (e.g Li or Fe ingestion)
and the toxin is suspected to be in the GIT tract.
Use larger volumes of polyethylene glycol electrolyte solutions than the amounts conventionally used
for bowel preparation. Administer per mouth or through a gastric or duodenal tube for treatment for
poisoning.
Contraindications: ingestion of caustic or aliphatic hydrocarbons, absent bowel sound or GIT
obstruction.
Adverse effects: Nausea and vomiting
Advantages include prompt whole bowel evacuation, but is messy procedure because of rectal effluent.
Other Hospital-based therapy
Supportive and systematic care, multiple doses of activated charcoal, hemodialysis and use of antidotes

Antidotes

By Ahmed Hashem
Page: 185-190

Acetylcysteine (NAC):
Indications: To treat acute Acetaminophen overdose.
MOA: Protect liver by Supplying glutathione to reacts with Acetaminophen metabolite.
Adverse effects: Oral = nausea, vomiting. IV = anaphylactic reactions (rash, wheezing, hypotension).
Atropine:
Indications: Poisoning of Organophosphates, carbamates & Bradycardia
Nontoxicologic: pre-anesthetic agent (for antisecretory effects), ophthalmic mydriasis& cycloplegia.
C.I: glaucoma, reflux esophagitis, obstructive uropathy, ulcerative colitis, paralytic ileus, myasthenia
gravis.
Pralidoxime: - dephosphorylates acetylcholinesterase regenerating its activity.
Indications: poisoning due to pesticides and organophosphates which have anticholinesterase activity and
in the control of overdosage by anticholinesterase drugs used in the treatment of myasthenia gravis.
ADEs: blurred vision, diplopia and impaired accommodation, dizziness, nausea, tachycardia,
hyperventilation, and muscular weakness.
Digoxin immune Fab (Digibind, DigiFab): - sheep antibody
- Binds to digoxin in plasma, enhances elimination in urine.
Indications: sever digoxin intoxication (symptoms: ventricular arrhythmias, second or third degree heart
block not responsive to atropine & hyperkalemia > 5 mEq/L)
ADEs: hypokalemia, hypotension.
Dose (in # of vials) = (Serum digoxin level in ng/mL) x (weight in kg) / (100).
Flumazenil: - Competitive antagonist of benzodiazepine receptor in CNS.
Indications: reversal of the sedative effects of benzodiazepines
C.I: - Mixed overdoses that can decrease seizure threshold (tricyclic antidepressants, haloperidol,
bupropion, lithium).
- In patients given benzodiazepine for control of a potentially life-threatening condition (e.g. control of
intracranial pressure or status epilepticus).
ADEs: agitation, sweating, abnormal vision, dizziness.
Naloxone: - Opioid competitive antagonist, competes at three CNS receptors (mu, kappa and delta).
Indications: - reversal of narcotic depression, including respiratory, CNS depression, induced by opioids.
ADEs: - In postoperative patients >> hypertension, dysrhythmias
- Use in opiate-dependent patient can cause withdrawal. Withdrawal convulsions in neonates.

Toxin
Acetaminophen
Organophosphates
Carbamates
Digoxin
Benzodiazepines
Oipoids
Anticholinergic compounds
Heavy metal poisoning (Arsenic,
Lead, Mercury)

-blockers
Ca-channel blockers
Cyanide

Ethylene glycol, methanol

Iron
Isoniazid
Mthemoglobinemia
Salicylate
Snake bite
(rattlesnake, cottonmouth,
copperhead)
Tricyclic antidepressants,
Agents with type 1a antiarrhythmic
effects
Warfarin, superwarfarins

Heparin

Antidote
Acetylcysteine
(NAC)
Atropine
Pralidoxime HCl
Atropine
Digoxin immune antibody
fragment
Flumazenil
Naloxone
Nalmefene
Physostigmine salicylate
Succimer
(heavy metal chelating agent)
Dimercaprol
( chelating agent)
For patients unable to tolerate
succimer
Glucagon
Ca chloride 10%
Glucagon
Cyanide antidote kit:
1. Amyl nitrite
2. Na nitrite 3%
3. Na thiosulfate

Trade name
Mucomyst
Acetadote

Hydroxocobalamin

Cyanokit

Ethanol 10%
Fomepizole
Deferoxamine
Pyridoxine
(vitamin B6)
Methylene blue
Na bicarbonate
Crotalidae polyvalent immune
Fab(ovine)

Protopam
Digibind, DigiFab
Romazicon
Narcan
Revex
Antilirium
Chemet
BAL

GlucaGen
GlucaGen

Antizol
Desferal

Causes alkaline diuresis

CroFab

Na bicarbonate
(alkalinization)
Fresh frozen plasma
Vit. K1
Protamine

Mephyton,
AquaMEPHYTON

Poison Control & Disaster preparedness by Maria & Talha

Poison Control Center (PCC) (Available 24h)

Maria Rameriz: Page 191 -193

Determines true poison. Recommend first aid & programs & materials. Refers for further investigation & treatment.
Monitors.
Poison Prevention Packaging Act 1970 -> Use safety caps (most drugs). Exceptions (birth control pills, nitroglycerin).
Pharmacy Requirements
Maintain available: Antidote information, approved stock Antidotes & Others emergency drugs. Phone number PCC.

Agent
Smallpox
(variola virus)
Direct-Aerosol
Anthrax
(Bacillus
anthracis)

Gram +
Spore-rod
No contagious

Biological agents that may be used in a Terrorist attack

Clinical Features
Treatment
Like mild viral illness for 2 to 4 days
Non specific
Then rash (face, extremities) onset.
Vaccine within 4 days and to
Pustules->sacbs->pitted scars (3 weeks)
close contacts.
Cutaneous: Small papule->vesicle (1-2)
FDA:
Necrotic painless ulcer.Maybe: fever, malaise,
headache, regional lymphadenopathy.
Inhalation: Like viral illness (sore throat,

mild fever,muscle aches,malaise). Min. productive

cough, nausea or vomiting, chest disconfort ->
resp. faliure -> shock
Gl: Distress -> fever -> signs
septicemia, bloody vomit, diarrhea.
Aerosolised: fever, cough, mucopurulent
Plague
(Yersinia pestis) sputum, hemoptysis, chest pain. 1-6 day
Pneumonic plague severe pneumonia. Septic shock and
mortality without treatment.
Butulism (Clostri- Acute paralisis. Bulbar palsies (diplopia,
dium botulinun)

dysarthria, dysphonia & dysphagia 12-72h).

Feedborne
or airbone
No contagious
Tularemia

Respiratory muscles paralisis or

upper airway obstruction.

(Francisella
tularensis)

No contagious

Inhalation
Nonspecific febrile illness (3-5). Incipient
pneumonia, pleuritis, hilar lymphadenopathy.
Respiratory failure, shock maybe death

Ciprofloxacin or doxycicline

kids + Adults. Levofloxacin 18+

Maybe Amoxicillin or penicillin
Profilaxis: 60 days
Vaccine IM for prevent 18 to 65
years old at high risk

Streptomycin or Gentamycin
& Others

Antitoxin (within 24h).

Suportive care. (Mechanical
ventilation)

Streptomycin, Gentamicin,
chloramphenicol, doxycycline,
ciprofloxacin

PEP: doxycycline or ciprofloxacin.

Viral
hemorrhagic
fevers
(filoviruses,
arenaviruses)
Bunyaviruses
Flaviviruses

Filoviruses: Ebola & Marburg high fever

2-21 days. Maculopapular rash on
trunk later day 5 (bleeding: petechiae,
ecchymosis, disseminated intravascular
coagulation & hemorrhages )
Lassa & new world Arenaviruses (manchupo)

Similar to filoviruses but gradual onset

of rash, hemorrhagic diathesis & shock

Supportive
Maintain fluid & electrolyte balance,
circulatory volume & BP.

Ricin
(Castor beans)
Inhib protein
synthesis

Inhalation: Cough & dyspnea. Lung: severe

Inflammation & filled with fluid.
Skin might be cyanotic or flush red.
Ingestion: GI internal bleeding.
Injec: Kill closest muscles and lymph nodes then
Spread
All 3 types Death from multiple organ failure

Supportive.

By Talha
Chemical Threats
Chemical Name

Clinical Features

Treatment

These are Organophosphates =>

attach to & inhibit
Acetylecholinestrase=> miosis;
vomiting; diarrhea; salivary
/nasal/lacrimal/dermal secretions;
paralysis; seizures & resp. failure.

Rapid decontamination

(Military name)
Nerve Agents

(G&V; Sarin(GB);
Soman (GD); Tabun(GA);
Cyclohexyl sarin (GF)

Antidotes = Atropine (reverse muscarinic

symptoms) & Pralidoxime (restore
Ach.esterase.).
Diazepam/Lorazepam for seizures.

Well absorbed via all routes

=>symptoms within minutes 18
hours
Blister Agents

Mustards & Nitrogen

Mustards; Lewisites;
Chlorasine;
Phosgeneoxime (CX)

Blood Agents
Arsine (SA)
Cyanide Gases = >
Hydrogen Cyanide (AC)
& Cyanogen ChlorideCK)
Cyanide Solids => Kcyanide (KCN) & Nacyanide (NaCN)

Mustards => Blistering effect =>

damage skin, eyes & lungs.
Liquids cause burns & scarring.
All forms Absorbed via skin &
distribute systemically =>
hypovolemia, shock & organ
damage (Lewisites); bone marrow
suppression (N. mustards); necrotic
tissue damage (CX).
Arsine Gas = Nausea, Vomiting &
2ndry Renal failure(1-2Hrs-11Days)

inhalation of Cyanide => breath

(in 15 sec); convulsions (30 sec);
stop Resp. (2-4 min); stop heartbeat
(4-8 min).

Sulphur & N. mustards and CX = No

Antidote, only avoid contact &
decontamination.
British Antilewisites = Antidote for Lewisites.
Given = IM/Topical.
Chlorasine = Atropine sulfate for eyes.

Arsine = Symptomatic approach for

hemolysis (normally without chelation).
Cyanide binds with cytochrome oxidase.
Cyanide = 2 Antidotes
1 Cyanide-Antidote-Kit = Na-nitrite & Nathiosulfate. Na-nitrite = > Induce
Methemoglobin in RBC to bind e Cyanide n
release cytochrome oxidase. Na-thiosufate
convert cyanide into thiocyanate which
renally excreted.
2 Cyanokit = Hydroxycobalamine which

combine e cyanide to form non-toxic

cyanocobalamine (Vit B12)
Choking & Pulmonary
Agents

Phosgen (CG); Diphosgen

(DP); Cl; HCL; NO

Phosgen = Prototype agent = eyes,

nose, throat & lung irritation and
edema up-to 48 Hrs.
Others = Immediate irritation &
delayed potential effects.

All agents are gases.

Phosgen & All Others = No specific Antidote.
Only decontamination & symptomatic
treatment.

Include CNS & Resp. Depressants e

hallucinating properties.

Antidotes = Naloxone for opiods &

Physostigmine for Anticholinergics.

Others = Cannabinoids, Opiods,

Lysergic Acid (LSD), etc

Others = Decontamination & sup. Treatment

Riot Control & Tear

Gases

Lacrimators = Chloroacetophenone
(CN); Chloropicrin (PS);
Bromobenzylcyanide (CA);
Dibenzoxazepine (CR).

No Antidote.

Vomiting Agents

Irritant Gases = Adamsite (DM);

Diphenylchloroarsine (DA);
Diphenylcyanoarsine (DC)

Symptomatic treatments for Sneezing,

Coughing & vomiting.

Incapacitating Agents

Decontamination & Symptomatic treatment.

Radiological Threats
Radiological & nuclear weapons and materials involving Radio-nucleotides produce topical &
systematic effects (immediate/delayed).
Radiation Emergency Assistance Center/Training Site (REAC/TS) = Guidance on treatment center.
Stable-Iodine supplements (Na/K iodide Tablets, etc.) help reducing uptake of radioiodine by thyroid.
Prussian blue 500mg Capsules = Treatment of exposures of Radioactive Cesium & Thallium.
Ca & Zinc salts of DTPA in IV & Aerosols for pts who exposed to Dirty Bombs radio-nucleotides.

Emergency Preparedness
CDC maintains Strategic National Stockpile (SNS) for rapid deployment of life-saving pharmaceuticals,
antidotes & other supplies in US to use in any kind of Threats.
CHEMPACK is stock of drugs to treat Nerve Agents.
Congrats guys for finishing CH 11. Keep it Up
THE END