Several psychotropic substances are used for their effects on mood and other mental functions. Many of the severe problems are due to withdrawal of the drug. Symptomatic behaviour common to illicit drugs includes:
rapid disappearance of clothing and personal belongings from home
signs of unusual activity around hang-outs and other buildings
loitering in hallways or in areas frequented by addicts
spending unusual amounts of time in locked bathrooms
inability to hold a job or stay in school
rejection of old friends
using the jargon of addicts
Illicit drugs taken by injecting drug users in Victoria, Australia in 2005 were:
Source: Illicit drug reporting system
A summary of the effects of illicit or hard street drugs is presented in TABLE 21.4.
Table 21.4Illicit substance abuse: a summary of hallmarks ||Download (.pdf) Table 21.4 Illicit substance abuse: a summary of hallmarks
|Drug ||Physical symptoms ||Look for ||Dangers |
|Amphetamines including methamphetamines (3 forms) |
|Aggressive or agitated behaviour, giggling, silliness, euphoria, rapid speech, fever, confused thinking, anorexia, insomnia, extreme fatigue, dry mouth, shakiness, anxiety ||Jars of pills of varying colours, chain smoking; white powder and crystals can also be snorted or injected ||Hypertension, death from overdose, hallucinations, paranoia, may cause temporary psychosis, stroke, cardiac arrest |
|Ecstasy (methylene-dioxymethamphetamine) ||Anxiety, panic, sweating, ‘loving’ feelings, jaw clenching, teeth grinding, bizarre overactive behaviour, hallucinations, increased heart rate, BP and body temperature, confidence, feelings of happiness and love ||Small tablets of various colours, shapes, sizes and designs, also comes in powder and capsules ||Convulsions, risk of death from heart attack, cerebral haemorrhage, hyperthermia, fluid imbalance with hyponatraemia, acute kidney failure, DIC, liver toxicity, hangover, depression |
|Fantasy (gamma-hydroxybutyrate) ||Relaxation and drowsiness, dizziness, relaxed inhibition/euphoria, increased sexual arousal, impaired mobility and speech || |
Colourless, odourless liquid
Also powder and capsules
|Tremors and shaking, amnesia, coma, convulsions, death from high doses |
|Barbiturates ||Drowsiness, stupor, dullness, slurred speech, drunk appearance, vomiting ||Pills of various colours ||Death from overdose or as a result of withdrawal, addictions, convulsions |
|Cannabis/marijuana ||Initial euphoria, floating feeling, sleepiness, lethargy, wandering mind, enlarged pupils, lack of coordination, craving for sweets, changes of appetite, memory difficulty ||Strong odour of burnt leaves, small seeds in pocket lining, cigarette paper, discoloured fingers ||Inducement to take stronger narcotics, recent medical findings reveal that prolonged usage causes cognitive defects, precipitates or exacerbates schizophrenia |
|Glue sniffing ||Aggression and violence, drunk appearance, slurred speech, dreamy or blank expression ||Tubes of glue, glue smears, large paper or plastic bags or handkerchiefs ||Lung/brain/liver damage, death through suffocation or choking |
|LSD (lysergic acid diethylamide) ||Severe hallucinations, feelings of detachment, incoherent speech, cold hands and feet, vomiting, laughing and crying ||Cube sugar with discolouration in centre, strong body odour, small tube of liquid ||Suicidal tendencies, unpredictable behaviour, chronic exposure causes brain damage, LSD causes chromosomal breakdown |
(a) opioids (e.g. heroin)
|Stupor/drowsiness, marks on body, watery eyes, loss of appetite, running nose, constricted pupils, loss of sex drive, agitation ||Needle or hypodermic syringe, cotton, tourniquet—string, rope, belt, burnt bottle, caps or spoons, bloodstain on shirt sleeve, glass in envelopes ||Death from overdose, mental deterioration, destruction of brain and liver, hepatitis, embolisms |
|(b) cocaine ||Similar effects to amphetamines—muscle pains, irritability, paranoia, hyperactivity, jerky movements, euphoria, dilated pupils ||Powder: in microwave ovens; inhaled, snorted or injected ||Hallucinations, death from overdose—sudden death from arrhythmias, seizures, mental disorders, severe respiratory problems |
A list of street drugs and their slang names is presented in TABLE 21.5.
Table 21.5A street drug dictionary ||Download (.pdf) Table 21.5 A street drug dictionary
|Amphetamines or uppers || |
|Benzedrine ||Roses, beanies, peaches |
|Dexedrine ||Dexies, speed, hearts, pep pills, fast, go-ee, uppers, sulphate |
|Methamphetamines ||Meth, crystals, white light, ice, whiz |
|Drinamyl ||Purple hearts, goof balls |
|Amphetamine derivatives || |
|Ecstasy ||E, eggs, eckies, XTC, ‘the love drug’, Mitsubishis, MDMA, vitamin E, X, Adam, death |
|Crank ||Crystal M, crank |
|Hallucinogens || |
|LSD ||Acid, blue cheer, strawberry fields, barrels, sunshine, pentagons, purple haze, peace pills, blue light, trips |
|Cannabis (Indian hemp) || |
| 1 Hashish (the resin) ||Hash, resin |
| 2 Marijuana (from leaves) ||Pot, tea, grass, hay, weed, locoweed, Mary Jane, rope, bong, jive, Acapulco gold |
| Cigarettes ||Reefers, sticks, muggles, joints, spliffies, head, smoko, ganga |
| Smoking pot ||Blow a stick, blast a joint, blow, get high, get stoned |
|Narcotics || |
|Morphine ||Morph, Miss Emma |
|Heroin ||H, Big H, Big Harry, GOM (God’s own medicine), crap, junk, horse dynamite (high-grade heroin), lemonade (low-grade heroin). Injection of dissolved powder: mainlining, blast, smack. Inhalation of powder: sniffing |
|Cocaine ||Coke, snow, lady of the streets, nose candy, ICE, snort, C, flake, rock, blow, vitamin C, crack, shabu, baby |
|H & C ||Speed balls |
|Oxycontin ||Hillbilly heroin |
|Miscellaneous || |
|Fantasy ||GBH (grievous bodily harm), liquid G, liquid E, liquid ecstasy, liquid X, fantasy |
|Barbiturates ||Devils, barbies, goof balls |
|Benzodiazepines ||Rowies, moggies |
|Ketamine ||‘K’, vitamin K, special K, K hole |
|Solvents ||Chroming |
Opioid (narcotic) dependence
This section will focus on heroin dependence, although opioids such as codeine and controlled dose agents such as oxycodone and morphine are problematic.
Typical profile of a heroin-dependent person15
Male or female: 16–30 years
Family history: often severely disrupted, such as parental problems, early death, separation, divorce, alcohol or drug abuse, sexual abuse, mental illness, lack of affection
Personal history: low threshold for toleration, unpleasant emotions, poor academic record, failure to fulfil aims, poor self-esteem
First experiments with drugs are out of curiosity, and then regular use follows with loss of job, alienation from family, finally moving into a ‘drug scene’ type of lifestyle
Inhalation (see FIG. 21.6)
Intravenous heroin injection signs: linear tracks and scarring from repeated venepunctures along the course of a vein. Less common sites are the lower leg, dorsum of foot, neck and dorsal vein of penis.
Photo courtesy John Jagoda
‘Meth mouth’ in a young man actively smoking methamphetamine
Opioid withdrawal effects14,15
These develop within 12 hours of ceasing regular usage. Maximum withdrawal symptoms usually occur between 36 and 72 hours and tend to subside after 10 days.
A secondary abstinence syndrome is identified15 at 2–3 months and includes irritability, depression and insomnia.
Complications of opioid dependence
Overdose reaction: agitation, respiratory depression—may include fatal cardiopulmonary collapse. Since the early 2000s opioid deaths have fallen from peak levels of the 1990s, when there was a glut of heroin.
Injection site: scarring, pigmentation, thrombosis, abscesses, ulceration (especially with barbiturates)
Distal septic complications: septicaemia, infective endocarditis, lung abscess, osteomyelitis, ophthalmitis
Viral infections: hepatitis B, hepatitis C (refer to CHAPTER 58), HIV infection (refer to CHAPTER 27)
Neurological complications: transverse myelitis, nerve trauma
Physical disability: malnutrition
Alienation from family, loss of employment, loss of assets, criminal activity (theft, burglary, prostitution, drug trafficking)
Management is complex because it includes the medical management not only of physical dependence and withdrawal but also of the individual complex social and emotional factors. The issues of impaired liver function, hepatitis B and C and HIV prevention also have to be addressed. Sociological tests for these illnesses should be considered.
Patients should be referred to a treatment clinic and then a shared-care approach can be used. The treatments include cold turkey (abrupt cessation) with pharmacological support, acupuncture, high doses of vitamin C, methadone substitution and drug-free community education programs.
Maintenance programs that include counselling techniques are widely used for heroin dependence. Acute toxicity requires injections of naloxone.
Buprenorphine controlled withdrawal (short term) is used to prevent the emergence of a withdrawal syndrome in contradistinction from buprenorphine maintenance, where there is an extended treatment period.
Note: If autonomic signs, use clonidine 5–15 mg/kg/day (o) in 3 divided doses for 7–10 days then taper off. If anxiety and agitation, use diazepam 5–20 mg (o) qid (with care). Clonidine can be used as first-line treatment because of relative safety but buprenorphine is preferred to clonidine and methadone for the management of opioid withdrawal. Avoid benzodiazepines unless supervision is available.
Maintenance programs for long-term opioid dependence14
There are currently three alternative programs—methadone, buprenorphine and naltrexone—which are substitutes for heroin and other opioids.
Seek specialist advice before starting treatment. The dose needs to be determined individually according to past use and initial response to methadone.
Buprenorphine 2–8 mg sublingual, once daily initially, increase to 8–24 mg daily or alternative days once stabilised. It is less dependent and prone to overdose than methadone but can precipitate withdrawal if used too soon.
Care is required in giving naltrexone to a person physically dependent on opioids. A naloxone challenge test is used.14 If no evidence of withdrawal give:
The natural history of opioid dependence indicates that many patients do grow through their period of dependence and, irrespective of treatments provided, a high percentage become rehabilitated by their mid-30s.
Stimulant substance abuse
The stimulants include amphetamines and their analogues, ephedrine, designer drugs such as MDMA and ‘fantasy’, cocaine and certain appetite suppressants. The amphetamines include the common methamphetamine, dexamphetamine and the original amphetamines.
The drugs also include crack, which is a cocaine base where the hydrochloride has mostly been removed, usually in a microwave oven. Crack can be inhaled or smoked (see FIGS 21.6 and 21.7). Ice is the crude form of methamphetamine, a derivative of amphetamine (FIG. 21.7). Speed is dexamphetamine.
Methamphetamine ice with pipe
Ecstasy is another ‘designer’ drug which is an amphetamine derivative—methylenedioxy-methamphetamine (MDMA). It has high abuse potential, some hallucinogenic properties and a tendency to neurotoxicity, as proved on PET brain scans. It is popular in rave parties. Deaths have occurred, reportedly in association with relative dehydration or excessive hydration. Treatment for overdosage involves correction of fluid and electrolyte disturbances. An increasingly popular drug is fantasy (gamma-hydroxybutyrate), which has sedative and anaesthetic effects similar to alcohol. A popular party drug, it is implicated as a ‘date rape’ drug. There is no specific antidote.13 Another party drug is ketamine, which is a short-acting anaesthetic with hallucinogenic properties. It can produce nausea and vomiting if used with alcohol. Like fantasy, treatment of overdosage is symptomatic. Local anaesthetics can be dangerous in amphetamine users because of cardiotoxicity.
Transient toxic psychosis
Increased sexual behaviour
This syndrome should be suspected in people whose occupation involves shift work, interstate transport driving or multiple jobs presenting with the following symptoms:
Psychological support and encouragement, e.g. CBT
Desipramine (or similar tricyclic antidepressant) 75 mg (o) nocte (increasing as necessary)
Bromocriptine 1.25 mg (o) bd has also been used for cocaine withdrawal
Hallucinogens in use include lysergic acid diethylamide (LSD), phencyclidine (angel dust), the tropical plant products (Kava and Betel nuts) and many synthetics. Symptoms include psychotic behaviour, including severe hallucinations. Withdrawal from these drugs is not usually a problem but ‘flashbacks’ can occur. Treatment, especially where there is fear or anxiety, is diazepam 10–20 mg (o) statim.
Treatment (medication to counter symptoms)14
Cannabis is a drug that comes from the plant Cannabis sativa, the Indian hemp plant. It is a stimulant and a hallucinogen. It contains the chemical tetrahydrocannabinol, which makes people get ‘high’. It is commonly called marijuana, grass, pot, dope, hash or hashish. Other slang terms are Acapulco gold, ganga, herb, J, jay, hay, joint, reefer, weed, locoweed, smoke, tea, stick, Mary Jane, Panama red and spliffy (see TABLE 21.5). Marijuana comes from the leaves, while hashish is the concentrated form of the resinous substances from the head of the female plant and can be very strong (it comes as a resin or oil). The drug is usually smoked as a leaf (marijuana) or a powder (hashish), or hashish oil is added to a cigarette and then smoked. The effects of taking cannabis depend on how much is taken, how it is taken, how often, whether it is used with other drugs and on the particular person.16 The effects vary from person to person. The effects of a small-to-moderate amount include:
feeling of well-being and relaxation
woozy, floating feeling
lethargy and sleepiness
talkativeness and laughing a lot
red nose, gritty eyes and dry mouth
unusual perception of sounds and colour
nausea and dizziness
loss of concentration
looking ‘spaced out’ or drunk
lack of coordination
delusions and hallucinations (more likely with larger doses)
a form called skunk or mad weed causes paranoia
The effects of smoking marijuana take up to 20 minutes to appear and usually last 2 to 3 hours and then drowsiness follows.16 The effect on psychomotor function is similar to alcohol and this can impair driving skills. The main problem is habitual use with the development of dependence; dependence (addiction) is worse than originally believed.
Long-term use and addiction
The influence of pot has a severe effect on the personality and drive of the users. They lose their energy, initiative and enterprise. They become bored, inert, apathetic and careless. A serious effect of smoking pot is the inability to concentrate and loss of memory. Some serious problems include:
deterioration of academic or job performance
anxiety and paranoia
respiratory disease (more potent than tobacco for lung disease): causes COPD, laryngitis and rhinitis
often prelude to taking illicit drugs
becoming psychotic (resembling schizophrenia): the drug appears to unmask an underlying psychosis16
impaired ability to drive a car and operate machinery
Sudden withdrawal produces insomnia, night sweats, nausea, depression, myalgia, irritability and maybe anger and aggression. However, the effects are often mild with recovery within a few days in many, but heavy users have a severe withdrawal.
No specific pharmacological treatment is available. CBT is advisable.
The best treatment is prevention. People should either not use it or limit it to experimentation. If it is used, people should be prepared to sleep it off and not drive.
The apparent positive effects of anabolic steroids include gains in muscular strength (in conjunction with diet and exercise) and quicker healing of muscle injuries. However, the adverse effects, which are dependent on the dose and duration, are numerous.
Adverse effects in women are:
masculinisation—male-pattern beard growth
suppression of ovarian function
changes in mood and libido
In adult men, adverse effects are:
Severe effects with prolonged use include:
liver function abnormalities, including hepatoma
tumours of kidneys, prostate
In prepubescent children there can be premature epiphyseal closure with short stature.