DRUGS OF ABUSE. Hiwa K. Saaed, PhD Department of Pharmacology & Toxicology College of Pharmacy, University of Sulaimani

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University of Sulaimani 1 Drugs of Abuse Using of chemicals for

momentarily escape his surroundings of poverty; a new gang member smokes

Molly to see what it is like; a prescription drug abuser injects heroin to

lonely widower drinks another shot of bourbon to help remember the past

1 1/9/19 DRUGS OF ABUSE Hiwa K. Saaed, PhD Department of Pharmacology & Toxicology College of Pharmacy, University of Sulaimani 1 Drugs of Abuse Using of chemicals for nontherapeutic effects on the body or mind: A boy inhales paint fumes to momentarily escape his surroundings of poverty; a new gang member smokes crack with his friends to feel like he belongs; a curious girl swallows a Molly to see what it is like; a prescription drug abuser injects heroin to substitute for the pain pills that are more difficult to obtain; and a lonely widower drinks another shot of bourbon to help remember the past and forget the present. Excessive use or misuse of drugs or alcohol for intoxicating or mind altering effects is considered substance abuse. 2 1

Common abused drugs Include: CNS stimulants (e.g., cocaine, amphetamines, nicotine), hallucinogens (e.g., LSD, mescaline, phencyclidine, and marijuana). general CNS depressants (e.g., ethanol), sedative hypnotics (e.

3 CNS stimulants These agents come from natural sources, such as plants, or are synthesized in legitimate or clandestine laboratories. Few clinical uses, Important as drugs of abuse.

2 Common abused drugs Include: CNS stimulants (e.g., cocaine, amphetamines, nicotine), hallucinogens (e.g., LSD, mescaline, phencyclidine, and marijuana). general CNS depressants (e.g., ethanol), sedative hypnotics (e.g., alprazolam, diazepam), opioid analgesics (e.g., heroin), inhalants (e.g., toluene, nitrous oxide, amyl nitrate). 3 CNS stimulants These agents come from natural sources, such as plants, or are synthesized in legitimate or clandestine laboratories. Few clinical uses, Important as drugs of abuse. A primary motivation for drug abuse appears to be the anticipated feeling of pleasure derived from the CNS effects of the drug. Factors that limit the therapeutic usefulness include: 1. Physiological Physical Dependence: 2. Psychological Dependence Addiction 3. Tolerance to the euphoric and anorectic effects 4 2

CNS stimulants are classified according to their action into: 1. Psychomotor stimulants cause: excitement, euphoria, decrease feeling of fatigue & Increase motor activity Ex.

3 CNS stimulants are classified according to their action into: 1. Psychomotor stimulants cause: excitement, euphoria, decrease feeling of fatigue & Increase motor activity Ex., Methylxanthines (caffeine, theobromine, theophylline), nicotine, cocaine, amphetamine, atomoxetine, modafinil, methylphenidate. 2. Hallucinogens (psychotomimetic): Affect thought, perception, and mood, therefore produce profound changes in thought patterns & mood, little effect on the brain stem & spinal cord Ex., Lysergic acid diethylamide (LSD), Phencyclidine (PCP), Tetrahydrocannabinol (THC), Rimonabant. 5 Psychomotor stimulants Q. What are Stimulants? Chemical structure are similar to monoamine neurotransmitters. All are indirect-acting sympathomimetics: 1. Many CNS stimulants release catecholamines, Therefore, their effects are abolished by prior treatment with reserpine or guanethidine Ex: amphetamine, dextroamphetamine, methamphetamine, methylphenidate (Ritalin), ephedrine, pseudoephedrine (a stereoisomer of ephedrine), tyramine. 2. Other CNS stimulants block the reuptake of catecholamines (NE and DA) and serotonin: EX. Cocaine, sibutramine (reduct), modafinil 6 3

of both NE and DA. 4. The methylxanthines are adenosine receptor antagonists.

NB: MAO and COMT inhibitors (indirect-acting adrenergic agonists), but they are not traditionally considered to be stimulants.

Attention Deficit Hyperactivity Disorder (ADHD); lack the ability to be involved in any one activity for longer than a few minutes.

4 Psychomotor stimulants 3. Antidepressants drugs with stimulant effects: Atomoxetine a relatively selective NE reuptake inhibitor (ADHD), Bupropion blocks the reuptake of both NE and DA. 4. The methylxanthines are adenosine receptor antagonists. Drugs within this class are NOT generally considered psychomotor stimulants, but they have distinct stimulant effects caffeine, theophylline. NB: MAO and COMT inhibitors (indirect-acting adrenergic agonists), but they are not traditionally considered to be stimulants. 7 Therapeutic Indications of CNS Stimulants Obesity (anorectic agents). Attention Deficit Hyperactivity Disorder (ADHD); lack the ability to be involved in any one activity for longer than a few minutes. Narcolepsy: It is a relatively rare sleep disorder, that is characterized by uncontrollable bouts of sleepiness during the day. It is sometimes accompanied by catalepsy, a loss in muscle control, or even paralysis brought on by strong emotion, such as laughter. Contraindications for CNS Stimulants: anorexia, insomnia, asthenia, psychopathic personality, a history of homicidal or suicidal tendencies. 8 4

1. Psychomotor stimulants A. methylxanthines 1. Theophylline (found in tea) : long-acting, prescribed for night-time asthma 2. Theobromine: found in cocoa. 3.

5 1. Psychomotor stimulants A. methylxanthines 1. Theophylline (found in tea) : long-acting, prescribed for night-time asthma 2. Theobromine: found in cocoa. 3. Caffeine: (short-acting) the most widely consumed found in coffee (200 mg/cup), carbonated soft drinks (60 mg/can), cocoa and chocolate 9 Mechanism of action: include Several mechanism have been proposed Mechanism of action of methylxanthine 1-It inhibits phosphodiesterase enz. camp calcium in CNS & heart calcium in Smooth muscles 2- Adenosine (A1, A2 and A3) receptors antagonist almost equally, which explains many of its cardiac effects A2 receptors antagonist responsible for CNS stimulation & smooth muscles relaxation 10 5

6 Actions a. CNS: decrease in fatigue, increased alertness: mg caffeine in 1 or 2 cups of coffees Anxiety & tremors- 1.5 g of caffeine: cups of coffee Spinal cord stimulation: 2-5 g (very high dose) Tolerance can rapidly develop Withdrawal symptoms: feeling of fatigue & sedation. b. CVS: at high dose of caffeine +ve inotropic and chronotropic effects on the heart, COP c. Diuretic action: mild urinary output of Na+, Cl - and K + d. Gastric mucosa: all methylxanthines stimulate secretion of HCl e. Respiratory smooth muscle: bronchodilator, Rx asthma replaced by β-agonists, corticosteroids. 11 Pharmacokinetics The methylxanthines are well absorbed orally. Caffeine distributes throughout the body, including the brain. The drugs cross the placenta to the fetus and is secreted into the mother's milk. All are metabolized in the liver, generally by the CYP1A2 pathway, the metabolites are then excreted in the urine. Adverse effects Moderate doses: insomnia, anxiety, agitation High doses: emesis, convulsion Lethal dose (10 gm of caffeine): cardiac arrhythmia Suddenly stop: lethargy, irritability, headache 12 6

7 B. Nicotine: Nicotine is the active ingredient in tobacco. Used in smoking cessation therapy, Nicotine remains important, because it is 2 nd only to caffeine as the most widely used CNS stimulant and 2 nd only to alcohol as the most abused drug. Actions of Nicotine: Low dose: ganglionic depolarization High dose: ganglionic blockade 13 Actions of Nicotine I. CNS: 1. Low dose: euphoria, arousal, relaxation, improves attention, learning, problem solving and reaction time. 2. High dose: CNS paralysis, severe hypotension (medullary paralysis) II. Peripheral effects: Stimulation of sympathetic ganglia and adrenal medulla BP and HR (harmful in HTN patients) Stimulation of parasympathetic ganglia motor activity of the bowel At higher doses, BP falls & activating ceases in both GIT and bladder 14 7

the acute lethal dose is 60 mg, 90% of nicotine inhaled in smoke is absorbed. Tolerance to toxic effects of nicotine develops rapidly.

8 Pharmacokinetics: highly lipid soluble absorbed everywhere (oral mucosa, lung, GIT, skin). Crosses the placental membrane, secreted with milk. Most cigarettes contain 6-8 mg of nicotine, by inhaling tobacco smoke, the average smoker takes in 1 to 2 mg of nicotine per cigarette. the acute lethal dose is 60 mg, 90% of nicotine inhaled in smoke is absorbed. Tolerance to toxic effects of nicotine develops rapidly. 15 Adverse effects: CNS; irritability and tremors Intestinal cramps, diarrhea HR & BP Withdrawal syndrome: nicotine is addictive substance, physical dependence on nicotine develops rapidly and can be severe. Bupropion: can reduce the craving for cigarettes Transdermal patch and chewing gum containing nicotine Varenicline 16 8

Varenicline (Chantix in the USA and Champix in Canada) Ò : partial agonist at Nn receptor in CNS.

Thus, it is useful as an adjunct in the management of smoking cessation in patients with nicotine withdrawal symptom. 17 C.

9 Varenicline (Chantix in the USA and Champix in Canada) Ò : partial agonist at Nn receptor in CNS. It produces less euphoric effects than those produced by nicotine itself (nicotine is full agonist at these receptors). Thus, it is useful as an adjunct in the management of smoking cessation in patients with nicotine withdrawal symptom. 17 C. Cocaine (highly addictive drug) Mechanism of action: blockade of reuptake of the monoamines (NE, serotonin and dopamine)thus, potentiates and prolongs the CNS and peripheral actions of these monoamines. Initially produces the intense euphoria or rush by prolongation of dopaminergic effects in the brain s pleasure system (limbic system). It is this immediate positive reinforcement, followed rapidly by the negative reinforcement, that makes the drug, particularly in this form, so addictive. Chronic intake of cocaine depletes dopamine. This depletion triggers the vicious cycle of craving for cocaine that temporarily relieves severe depression. 18 9

Cocaine Cocaine has minimal bioavailability when taken by the oral route. Instead, the cocaine hydrochloride powder is snorted, or solubilized and injected.

10 Cocaine Cocaine has minimal bioavailability when taken by the oral route. Instead, the cocaine hydrochloride powder is snorted, or solubilized and injected. The cocaine powder cannot be effectively smoked, as it is destroyed upon heating. However, crack cocaine, an alkaloidal form, can be smoked. 19 Actions: a. CNS-behavioral effects result from powerful stimulation of cortex and brain stem. Cocaine acutely increase mental awareness and produces a feeling of wellbeing and euphoria similar to that produced by amphetamine. Like amphetamine, cocaine can produce hallucinations and delusions of paranoia or grandiosity. Cocaine increases motor activity, and at high doses, it causes tremors and convulsions, followed by respiratory and vasomotor depression

11 Actions: b. Sympathetic NS: peripherally potentiate the action of NE fight or flight c. Hyperthermia: impair sweating & cutaneous vasodilation Perception of thermal discomfort d. local anesthetic action: blockade of voltage-activated Na + channel. Cocaine is the only LA that causes vasoconstriction, chronic inhalation of cocaine powder necrosis and perforation of the nasal septum Cocaine is often self-administered by chewing, intranasal snorting, smoking, or intravenous (IV) injection. 21 Adverse effects: Anxiety reaction that includes: hypertension, tachycardia, sweating, and paranoia. Because of the irritability, many users take cocaine with alcohol A product of cocaine metabolites and ethanol is cocaethylene, which is also psychoactive and cause cardiotoxicity. Depression: Like all stimulant drugs, cocaine stimulation of the CNS is followed by a period of mental depression. Addicts withdrawing from cocaine exhibit physical and emotional depression as well as agitation. The latter symptom can be treated with benzodiazepines or phenothiazines. Toxic effects: Seizures RX I.V diazepam fatal cardiac arrhythmias. propranolol 22 11

D. Amphetamine Is a non catecholamine, (shows neurologic and clinical effects quite similar to those of cocaine), dextroamphetamine is the major member of this class compounds.

12 D. Amphetamine Is a non catecholamine, (shows neurologic and clinical effects quite similar to those of cocaine), dextroamphetamine is the major member of this class compounds. methamphetamine (speed) is a derivative of amphetamine that can be smoked and it is preferred by many abusers. Methylenedioxymethamphetamine (also known as MDMA, or Ecstasy or Molly) is a synthetic derivative of methamphetamine with both stimulant and hallucinogenic properties. 23 Mechanism of action: Amphetamine, act by releasing intracellular stores of catecholamines. also inhibits MAO, high level CAOs are readily released into synaptic spaces. Actions: a. CNS: a combination of its dopamine and NE release enhancing properties. Amphetamine stimulates the entire cerebrospinal axis, brainstem, and medulla. This lead to increase alertness, decrease fatigue, depressed appetite, and insomnia. b. Sympathetic Nervous System: indirectly stimulating the receptors through NE release

13 Adverse effects: addiction, dependence, tolerance, and drug seeking behavior. a. CNS: insomnia, irritability, weakness, dizziness, tremor, hyperactive reflex, confusion, delirium, panic states, and suicidal tendencies, especially in mentally ill patients. -Chronic amphetamine use produce a state of amphetamine psychosis that resembles the psychotic episodes associated with schizophrenia. Overdoses are treated with chlorpromazine or haloperidol, which relieve the CNS symptoms as well as the HTN because of their α blocking effects. The anorectic effect of amphetamine is due to its action in the lateral hypothalamic feeding center. b. CVS: palpitations, cardiac arrhythmia, HTN, anginal pain, and circulatory collapse. Headache, chills, and excess sweating may also occur. c. GIT: anorexia, nausea, vomiting, abdominal cramps, and diarrhea. Contraindications: HTN, CV diseases, Hyperthyroidism, Glaucoma, Patients with a history of drug abuse 25 Narcolepsy: Amphetamine, methylphenidate. Recently, a new drug, modafinil and its R-enantiomer derivative, armodafinil, have become available to treat narcolepsy. Modafinil produces fewer psychoactive and euphoric effects as well as, alterations in mood, perception, thinking, and feelings typical of other CNS stimulants

14 Atomoxetine approved for ADHD in children and adults. It is a NE reuptake inhibitor (should not be taken by individual on MAOI). It is not habit forming and is not a controlled substance. 27 Methylphenidate (Ritalin) It has CNS stimulant properties similar to those of amphetamine and may also lead to abuse, although its addictive potential is controversial. It is taken daily by 4-6 million children in the USA. The pharmacologically active isomer, Dexmethylphenidate, has been approved in the USA for the Rx of ADHD. Methylphenidate is a more potent dopamine transport inhibitor than cocaine, thus making more dopamine available. It has less potential for abuse than cocaine, because it enters the brain much more slowly than cocaine and, does not increase dopamine levels as rapidly

15 Therapeutic uses: Methylphenidate has been used for several decades in the treatment of ADHD in children aged 6 to 16. It is also effective in the treatment of narcolepsy. Unlike methylphenidate, dexmethylphenidate is not indicated in the treatment of narcolepsy Adverse reactions: GIT effects are the most common; abdominal pain and nausea. Other reactions include anorexia, insomnia, nervousness, and fever. In seizure patients, methylphenidate seems to increase the seizure frequency, especially if the patient is taking antidepressants. Methylphenidate is contraindicated in patients with glaucoma. 29 E. Synthetic Cathinones bath salts, Cathinone is the psychoactive component in an evergreen shrub called Khat. Work in a manner very similar to cocaine and amphetamines. Bath salts are generally snorted or ingested, but they may also be injected. Ex., Methcathinone, butylone, methylene dioxypyrovalerone, and naphyrone These products are packaged and labeled in such a way as to circumvent detection, prosecution, and enforcement

16 1/9/19 31 Hallucinogens 2 16

17 II. Hallucinogens (psychotomimetic) A few drugs have the ability to induce altered perceptual states reminiscent of dreams, are accompanied by bright, colourful changes in the environment and by a plasticity of constantly changing shapes and colour. The individual under the influence of these drugs is incapable of normal decision making, because the drug interferes with rational thought. 33 A. Lysergic acid diethylamide Multiple sites in the CNS are affected by lysergic acid diethylamide (LSD). The drug shows serotonin (5-HT) agonist activity at presynaptic 5-HT1 receptors in the midbrain, and also stimulates 5-HT 2 receptors. Activation of the sympathetic nervous system occurs, which causes pupillary dilation, increased BP, piloerection, and increased body temperature

18 A. LSD Adverse effects: include hyperreflexia, nausea, and muscular weakness. High doses may produce long-lasting psychotic changes in susceptible individuals. Haloperidol and other neuroleptics can block the hallucinatory action of LSD and quickly abort the syndrome. 35 B. Tetrahydrocannabinol (THC) The main psychoactive alkaloid contained in marijuana is tetrahydrocannabinol (THC), which is available as dronabinol. THC can produce euphoria, followed by drowsiness and relaxation. The effects of marijuana on γ-aminobutyric acid (GABA) in the hippocampus diminish the capacity for short-term memory in users decreases muscle strength and impairs highly skilled motor activity, such as that required to drive a car. Its wide range of effects includes: appetite stimulation, xerostomia, visual hallucinations, delusions, and enhancement of sensory activity 36 18

Mechanism of action: THC receptors, designated CB1 receptors, have been found on inhibitory presynaptic nerve terminals. CB1 is coupled to a G protein.

19 Mechanism of action: THC receptors, designated CB1 receptors, have been found on inhibitory presynaptic nerve terminals. CB1 is coupled to a G protein. Interestingly, endocannabinoids have been identified in the CNS. These compounds, which bind to the CB1 receptors, are membrane-derived and are synthesized on demand, and they may act as local neuromodulators. 37 Mechanism of action: 38 19

Pharmacokinetics: The effects of THC appear immediately after the drug is smoked, but maximum effects take about 20 minutes. By 3 hours, the effects largely disappear.

20 Pharmacokinetics: The effects of THC appear immediately after the drug is smoked, but maximum effects take about 20 minutes. By 3 hours, the effects largely disappear. Dronabinol is administered orally and has a peak effect in 2 to 4 hours. Its psychoactive effects can last up to 6 hours, but its appetite-stimulant effects may persist for 24 hours. It is highly lipid soluble and has a large volume of distribution. THC itself is extensively metabolized by the mixed-function oxidases. Elimination: is largely through the biliary route. 39 Therapeutic uses of Dronabinol 1. as an appetite stimulant for patients with acquired immunodeficiency syndrome who are losing weight. 2. It is also sometimes given for the severe emesis caused by some cancer chemotherapeutic agents. Adverse effects: include increased heart rate, decreased blood pressure, and reddening of the conjunctiva. At high doses, a toxic psychosis develops. Tolerance and mild physical dependence occur with continued, frequent use of the drug

21 Rimonabant: Rimonabant: The CB1-receptor antagonist, 1.Obesity (decrease appetite and body weight in humans). 2.induce psychiatric disturbances, such as anxiety and depression, during clinical trials. 41 Phencyclidine: Phencyclidine (also known as PCP, or angel dust ) inhibits the reuptake of dopamine, 5-HT, and norepinephrine. The major action of phencyclidine is to block the ion channel regulated by the NMDA subtype of glutamate receptor. This action prevents the passage of critical ions (particularly Ca 2+ ) through the channel. Phencyclidine also has anticholinergic activity but, surprisingly, produces hypersalivation

22 Phencyclidine: Phencyclidine, an analog of ketamine, causes dissociative anesthesia (insensitivity to pain, without loss of consciousness) and analgesia. At increased dosages, anesthesia, stupor, or coma result, but strangely, the eyes may remain open. Increased sensitivity to external stimuli exists, and the CNS actions may persist for a week

23 III. Ethanol (EtOH) Alcohol is the most commonly abused substance in modern society. Alcoholism decreases life expectancy by 10 to 15 years. Ethanol exerts its desired and toxic effects through: enhancing the effects of the GABA, inducing the release of endogenous opioids, and altering levels of serotonin and dopamine. Ethanol is a selective CNS depressant at low doses, resulting in decreased inhibitions and the characteristic drunken behavior. At high doses, it is a general CNS depressant, which can result in coma and respiratory depression. 45 Ethanol Ethanol is absorbed from the stomach and duodenum, and food slows and decreases absorption. Peak ethanol levels: 20 minutes to 1 hour of ingestion. Ethanol is metabolized by alcohol dehydrogenase to acetaldehyde and then by aldehyde dehydrogenase to acetate in the liver. It is metabolized by zero-order elimination at approximately 15 to 40 mg/dl/h. There is a constant blood-to-breath ratio of 2100:

24 Acute & Chronic Ethanol Toxicity: Acute ethanol toxicity: medical management includes symptomatic supportive care and the administration of thiamine and folic acid to prevent/treat Wernicke encephalopathy and macrocytic anemia. Chronic ethanol abuse can cause profound damage to hepatic, cardiovascular, pulmonary, hematologic, endocrine, metabolic, and CNS. 47 Ethanol Withdrawal Sudden cessation of ethanol ingestion in a heavy drinker can precipitate withdrawal manifested by tachycardia, sweating, tremor, anxiety, agitation, hallucinations, and convulsions. Management of alcohol withdrawal: is a life-threatening situation that should be medically managed with symptomatic/supportive care, benzodiazepines, and longterm addiction treatment

25 Drugs used in the treatment of alcohol dependence: A. Disulfiram blocks the oxidation of acetaldehyde to acetic acid by inhibiting aldehyde dehydrogenase. This results in the accumulation of acetaldehyde in the blood, causing flushing, tachycardia, hyperventilation, and nausea. B. Naltrexone Naltrexone is a long-acting opioid antagonist that should be used in conjunction with supportive psychotherapy. Naltrexone is better tolerated than disulfiram. C. Acamprosate should also be used in conjunction with supportive psychotherapy. 49 IV. Prescription Drug Abuse Some commonly abused prescription drugs include opioids, benzodiazepines, and barbiturates, with opioids outpacing the other prescription drugs by a large margin. Visits to the emergency department related to misuse of pharmaceuticals now exceed those related to illicit drug use, and prescription pain relievers also now account for more deaths than heroin and cocaine combined

Drug abuse: Drug misuse Dependence abuse

Drug abuse: Drug misuse Dependence abuse Drug abuse: Use of drugs for non-medical purposes Drug misuse: wrong use of drugs: Wrong choice Wrong dose & wrong duration e.g. misuse of antibiotics Dependence is associated with abuse 1 Repeated, periodic