Foundation of Addiction Medicine 2019

Cannabis: Psychological
effects

• A dreamy state with an increased tendency to
fantasize

• State of euphoria, well being and enjoyment.
• Generally followed by a period of drowsiness.

• Perceptual and sensory distortions.

• Can prolong reaction time and impair coordination
• Sounds and colors may become more intense

• Restlessness, fear and even panic may spoil the
experience (“bad trip”).
• There may be driven activity (subject knows that
one’s activities are meaningless, yet is unable to
control them).

-51-

What is this???

52

Synthetic marijuana

• Synthetic marijuana isn’t marijuana

• Structurally related to THC, the active compound
in marijuana

• Basically, five types:
– JWH-018
– JWH-073
– JWH-200
– CP-47,497
– Cannabicyclohexanol

• First synthesized at Clemson in the 1980s for
research purposes

53

Growing
Popularity

• Intense high than cannabis

• Affordability

• Easy access (online)

• Avoidance of Detection

• JWH-018: aminoalkylindole
cannabinoid : the
commonest SC

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•The problem: Stronger & longer-lasting
than THC

•Better binding to receptors (high
affinity/potency) AND each binding event
has greater effect (full agonist) (4x higher
affinity for CB1, 10x for CB2)

•Longer half-life so effects longer lasting

•Products of break-down (metabolites)
also psychoactive

•More likely, and longer-lasting adverse

effects (especially if dosing is based on

cannabis) Rosenbaum et al., 2012

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SC Intoxications presenting to
Emergency

• Agitated behavior, psychosis, anxiety

• Seizure. Rhabdomyolysis and hyperthermia

• Acute Kidney Injury

• Myocardial Ischemia and infarction

• Majority of symptoms are self-limiting except the
severe agitation/ seizures/psychosis which need
in-patient care

• No antidote and difficulty to distinguish from other
recreational drugs of abuse

• Benzodiazepines sufficient
Slide courtesy: Dr Prabhat Chand
56

Cannabis vs. Synthetic

Cannabinoids: Effects Seen in

Clinical Cases

• Most symptoms are • Symptoms not typically
similar to cannabis seen after cannabis
intoxication: intoxication:

– Tachycardia – Seizures

– Reddened eyes – Hypokalemia

– Anxiousness – Hypertension

– Mild sedation – Nausea/vomiting

– Hallucinations – Agitation

– Acute psychosis – Violent behavior

– Memory deficits – Coma

SOURCES: Hermanns-Clausen et al. (In Press), Addiction; Rosenbaum et al. (2012). Journal 57
of Medical Toxicology; Forrester et al. (2011). Journal of Addictive Disease; Schneir et al.
(2011). Journal of Emergency Medicine.

Opium

58

Heroin (Smack)

59

Synthetic opioid overdose crisis!!

• A total of 34 synthetic opioids, including 26
fentanyl analogues, were reported to UNODC early
warning advisory by countries in the past five years.

• Most of those synthetic opioids have been
reported since 2016.

• The fentanyl analogues reported by most countries
included furanylfentanyl, acetyl fentanyl, ocfentanil
and butyrfentanyl.

• Non-medical use of fentanyl self-reported in that
survey is minimal (0.1 per cent of the population
aged 12 years and older)

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Synthetic opioid overdose crisis
cont..

• BUT illicit fentanyl and its analogues are increasingly found
in the analysis of drug samples, including of heroin.

• Illicit fentanyl is reportedly mixed into heroin as well as
other illicit drugs such as “ecstasy”, or sold as counterfeit
prescriptions opioids.

• Unaware users are suffering from fatal overdose incidents.

• There were almost 64,000 overdose deaths in the United
States in 2016, with opioid overdose deaths accounting for
over 70 per cent of the total.

• The number of overdose deaths related to synthetic opioids
(include fentanyl, fentanyl analogues and tramadol)
doubled in the past year.

61

Fentanyl

• It is a powerful synthetic opioid analgesic that is
similar to morphine but is 50 to 100 times more
potent.

• Non-pharmaceutical fentanyl is sold in the
following forms: as a powder; spiked on blotter
paper; mixed with or substituted for heroin; or as
tablets that mimic other, less potent opioids.

• Fentanyl works by binding to the body's opioid
receptors- produces euphoria, drowsiness, nausea,
confusion, constipation, sedation, tolerance,
addiction, respiratory depression and arrest,
unconsciousness, coma, and death.

• The high potency of fentanyl greatly increases risk
of overdose, especially if a person who uses drugs
is unaware that a powder or pill contains fentanyl.

62

Substance Use & Misuse: ISSN: 1082-6084 (Print) 1532-2491 (Online) Journal

Goldman et al. Harm Reduction Journal (2019) 16:3

63

Tramadol & Tapentadol

• Synthetic Opioid
• Mu receptor + Monoamine receptor inhibitors
• Marketed as having less addictive potential-
post-surveillance data showed otherwise.
• In 2017, the WHO Expert Committee on Drug
Dependence reported growing evidence of misuse
of tramadol/ tramadol-associated deaths in many
countries (particularly in Africa and the Middle
East).
• Recommended a critical review of the substance

64

• 524,00 tramadol capsules seized and analyzed in
Ghana in 2017

➢ 40 per cent of the had a content of 120 mg of tramadol,
➢ 18 per cent had a content of 200 mg,
➢ 19 per cent had a strength of 225 mg per capsule.

• About 87 per cent of the tramadol seized
originated in India.

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Commonly used ATS

A group of psycho stimulant drugs

•Amphetamine

•Methamphetamine and their derivatives

• Methcathinone, Fenetylline
• 4-methylmethcathinone (mephedrone)

•Methylphenidate

• Ephedrine, Pseudoephedrine (precursors)

Slide courtesy: Dr Sures6h6 M

Methamphetamine Pills and
Powder

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Expanding market: Amphetamine-type
stimulants

World Drug Report, 2018

ATS seized • Total ATS seizures: highest
worldwide ever

• Amphetamine and
methamphetamine
constitute considerable
share of burden of disease,
rank second only after
opioids

• Users of amphetamines
increased

• Methamphetamine seizures
up, East and South-East Asia
competing with North
America

• “Ecstasy” seizures stable

68

Methamphetamine: interregional trafficking
flows

World Drug Report, 2018

Expanding market in East/South-East Asia. Rising treatment demand
in some regions.

69

Slide courtesy: Dr Pratima Murt7h0y

71

Slide courtesy: Dr Suresh M

Amphetamine type stimulants use
in India

Study done by UNODC ROSA, 2015

https://www.unodc.org/documents/southasia//reports/ATS_Report_fi

Demographics Mean ± SnDal_voerrsion.pdf

n (%)

Age 25.7 ± 5; Median age:
25

Gender: Females 25 (25%)

Marital status: Single 62 (62%)

College level 63 (63%)
education

Full time or part time 53 (53%)
employed

Occupation: 19 (19%)
Business

Income: Rs 30001 & 19 (19%) 72
above
Slide courtesy: Dr Suresh M

ATS induced Psychosis

(1) Presence of prominent hallucinations or
delusions.

(2) Hallucinations or delusions develop during, or
soon after, intoxication or withdrawal from ATS.

(3) Psychotic symptoms are not actually part of a
psychotic disorder that is not substance-induced
(i.e., psychosis was prior to ATS use, or persists
longer than one month after ATS intoxication or
withdrawal).

Slide courtesy: Dr Suresh M73

Risk factors for ATS Psychosis

• Drug use: Binge use and its duration, Dose, Duration of
use, Polydrug use

• Sleep deprivation

• Psychological vulnerability; Family history of psychiatric
disorder

• Substantive overlap between markers of genetic
vulnerability to ATS psychosis and schizophrenia

Edwards & Mooney, CNS Drugs. 2014 December ; 28(12): 1115–714 126

Neurobiology of ATS Psychosis

Hsieh, Stein and
Howells, frontiers
in Human
Neuroscience, 2014

75

Quantities of ketamine seized globally
and number of countries reporting
ketamine seizures, 2012–2016

76

User’s acute experiences

Emergence

phenomena

• Stimulant

• Sense of melting into
people or things

• Distorted perceptions
e.g. feeling "as big as

DOSE the universe" or "as
small as an electron",
often simultaneously

• Visions and
hallucinations

• Spiritual and out of
body experiences

• K-hole Slide courtesy: Dr A De sou77sa

Ketamine- mechanism of action

78

79

80

Number of new psychoactive substances
reported annually, 2009–2016

Source: UNODC, early warning advisory on new

psychoactive substances. 81

NPS reported to UNODC by the
end of 2017

• Synthetic cannabinoids constitute the largest category in terms
of the number of different substances reported (251 substances)

• It is followed by synthetic cathinones (148) and
phenethylamines (136).

• Only a comparatively small number of tryptamines, piperazines,
aminoindanes and plant-based NPS are reported annually.

• The category of “other substances”includes structurally diverse
substances

• It has grown considerably since 2014, totalling 155 substances
by the end of 2017.

• This category includes NPS-derivatives of prescription
medicines, including fentanyl analogues and derivatives of
benzodiazepine.

82

Proportion of new psychoactive
substances, by psychoactive
effect group, December 2017

Source: UNODC, early warning advisory on new

psychoactive substances. 83

Annual quantities of Synthetic new
psychoactive substances (NPS) seized
globally, 2012 to 2016

Source: UNODC, early warning advisory on new

psychoactive substances. 84

State with highest quantity of seizure and
respective drugs, 2017; The Times of India,
February 14, 2017

Slide courtesy: Dr Pratima Murth8y5

Annual quantities of Plant-based new
psychoactive substances (NPS) seized
globally, 2012 to 2016

Source: UNODC, early warning advisory on new

psychoactive substances. 86

Kratom

87

Kratom

• Kratom is a tropical tree (Mitragyna speciosa)
native to Southeast Asia.
• It is not currently an illegal substance and
• Can be easily order on the internet as a green
powder in packets labeled "not for human
consumption." or as pill, capsule, an extract or
gum.
• Leaves that contain psychotropic compounds-
mitragynine and 7-α-hydroxymitragynine

88

Kratom

• Mitragynine

✓ in large dose- interact with opioid receptors- producing
sedation, pleasure, and decreased pain

✓ in small amounts- interacts with other receptor systems
in the brain to produce stimulant effects- increased
energy, sociability, and alertness instead of sedation.

• Reported health effects of kratom use include:

✓ Nausea/Itching/Sweating/dry
mouth/constipation/increased urination /loss of
appetite/seizures/hallucinations

• Controversy: Medicinal value??

✓ To treat withdrawal of opioid/alcohol

89

Kratom

• Is kratom addictive?

➢ Probably Yes (compulsive use/ withdrawal
symptoms)

• Can a person overdose on kratom?

➢ At least 44 deaths related to its use- most kratom
associated deaths appear to have resulted from
adulterated products (other drugs mixed in with
the kratom) or taking kratom along with other
potent substances, including opioids,
benzodiazepines, alcohol

➢ In 2017, the Food and Drug Administration (FDA)
began issuing a series of warnings about kratom.

90

Quantities of khat seized
worldwide,
2012–2016 (tons)

91

Khat

• Khat (Catha edulis) is a shrub cultivated mainly in East Africa
and the Arabian Peninsula.

• Use has been a traditional practice in those areas.
• Traditionally, khat leaves are consumed in a fresh state,

within 48 hours of being harvested.
• Slow down the process of decay, khat leaves are often dried

before being transported long distances.
• Khat leaves contain cathinone, a substance with stimulant

effects.
• Recently, the use of khat has spread to Asia, Europe and

North America, first among immigrants from the countries of
traditional use and from there, into other communities.
• Not under international control
• Many national jurisdictions do not allow the import of khat
leaves.

92

93

Times they are a changing…..

• In the PAST, the war on drugs was traditional
warfare, a battle against easily recognizable foes
• Detection by crime labs was relatively
straightforward
• Scientists could evaluate their actions and
toxicology
• Even the public knew what they should look and
act like
• Established treatment protocol

Slide courtesy: Dr Pratima Mur9t4hy

Times they are changing…..

• TODAY …... more elusive • Notoriously difficult to
foes predict how a drug
structure tweaking will
• Some chemical variations of affect potency, activity, or
old drugs toxicology

• Legal largely by design • Some people opt for
• Many are unrecognizable substances that elude legal
testing….even if they are
by name, except to the more potent and dangerous
well-informed

• Rapid innovation in the • Misperception that some of
design of drugs of abuse the products are natural,
challenges legal systems therefore harmless

• More information on online • Drugs effect and its
drug forums than through treatment is also unclear
scientific publications
Brock TG 2012

Slide courtesy: Dr Pratima Murthy 95

Thanks

96

Common Dr Venkata Lakshmi
Assessment Narasimha
Instruments
AUDIT and MD Psychiatry
PHQ-9 PDF in Addiction

Medicine
DM in Addiction
Psychiatry (2nd year)
Centre for Addiction

Medicine
NIMHANS

97

Case young vs old

16 years old boy went with 52 years old man was
his friends for a dinner and drinking 90ml spirits for 19
had 3 beers he drove his years and increased for 1
bike under intoxication had year due to wife death and
a head injury and brought landed up in hospital with

to neuro-casualty ascites and ALD.

98

Introduction- Background

PROACTIVE HEALTH PROBLEMS IN IS THERE A SAFE LIMIT
APPROACH SPECTRUM FOR DRINKING??

99

AUDIT- WHO screening instrument,
1989, not diagnostic
2001
Assists in brief assessment-
Hazardous, Dependence,
Harmful

Framework for intervention

It is Validated

100