MDMA or Ectasy

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
  • HIV/AIDS

Depressants

• Opioids (e.g. morphine, heroin, and 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, and 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
  • withdrawal
    • anxiety, seizures, and delirium
      • similar to alcohol
    • life-threatening cardiovascular collapse
    • additive affects with alcohol
• Benzodiazepines
  • intoxication
    • amnesia, ataxia, stupor/somnolence, and 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

Stimulants

• Amphetamines
  • mechanism
    • simulates biogenic amine (DA, NE, and 5HT) release
  • intoxication
    • mental status changes
      • euphoria, impaired judgment, delusions, hallucinations, and prolonged wakefulness/attention
    • sympathetic activation,
      • psychomotor agitation, pupillary dilation, hypertension, tachycardia, fever, and cardiac arrhythmias
  • withdrawal
    • depression, lethargy, headache, stomach cramps, hunger, and 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
• Cocaine
• Caffeine
• Nicotine

Hallucinogens

• PCP
• LSD
• Marijuana; Tetrahydrocannabinol (cannabis)