Nicotine
Karen Drexler, M.D.
VAMC Atlanta
Nicotine History
Use of tobacco has been traced to early American civilizations
Maya "solar incense"
Juan Ponce de Leon (1512)
Pope Urban III condemned tobacco (1642)
Cigarettes mass produced in Durham, NC (1884)
% of males who smoked was 70% in 1947.
Nicotine History
While tobacco consumption is declining locally, it is rising globally.
Remains the nations most heavily advertised product
$4 billion in 1990
Over 2x the budget of the NCI
Young people continue to be a strategically important market
Nicotine Intoxication (Not in DSM)
Usually occurs in nicotine containing pesticides or "green tobacco sickness"
Nausea, vomiting
Abdominal pain, diarrhea
Headaches
Sweating, pallor
Dizziness, weakness, confusion
- Convulsions
- Hypotension
- Coma
- Death
Nicotine Withdrawal (DSM-IV)
Abrupt cessation of tobacco use
Dysphoric or depressed mood
Insomnia
Irritability, frustration, or anger
Anxiety
- Difficulty concentrating
- Restlessness
- Decreased heart rate
- Increased appetite or weight gain
Nicotine: Medical Complications
Chief avoidable cause of premature death and morbidity
50% of smokers die prematurely
Acute myocardial infarction
Cerebrovascular accidents
Chronic obstructive pulmonary disease
Lung and other cancers
Smoking is contraindicated in patients with:
Heart disease
Hypertension
Diabetes
COPD
Peptic ulcer disease
Nicotine Treatment
"Cold Turkey"
Nearly half of all living adults who ever smoked have quit
Most did so "on their own"
Most "cold turkey"
Of those who try to stop on their own, 47.5% succeeded
AHCPR (1996)
Systematically identify all smokers and strongly advise them to quit smoking
Nicotine Treatment
Personalize the health message
Provide brochures and literature on health benefits and how-to-quit.
Discuss costs and benefits
Encourage patient to set a quit date
Offer medication, education, follow-up
Reinforce success, offer more intensive intervention if necessary.
Stages of Change
Nicotine treatment medications
Nicotine replacement
Gum
Patch
Nasal spray
Buproprion (Zyban)
Cannabis
Most widely used illicit substance in Western Society
"Pot", "Herb", "Weed", "Boom", "Mary Jane", "Gangster", "Chronic"
Upper leaves and flowering tops of Cannabis sativa (Indian hemp)
Delta-9-tetrahydrocannabinol (THC) is the major active drug
Smoked as a cigarette, blunt, pipe, etc.
Cannabis Epidemiology
Monitoring the Future
Use in the past year by high school seniors
In 1979, 50.8%
In 1992, 21.9%
In 1997, 38.5%
Daily use in the past month, by high school seniors
- In 1979, 10.3%
- In 1992, 1.9%
- In 1997, 5.8%
Cannabis: Pharmacology
Highly lipid soluble
When smoked, onset within minutes, lasts 2 to 4 hours
When ingested, onset variable, may lead to higher doses and more adverse effects
Metabolized in the liver
Metabolites excreted in bile, feces, and urine
Cannabis Intoxication
Maladaptive psychological sx:
euphoria
anxiety
slowed time
impaired judgment
social withdrawal
impaired motor coordination
Physical signs:
Conjunctival injection
Increased appetite
Dry mouth
Tachycardia
Cannabis: Medical Complications
Slowed learning/ memory impairments
Difficulty maintaining attention
Daily productive cough
Chronic bronchitis (3 to 4 joints = 20 tobacco cigarettes)
Small birth weight infants
Impaired motor development in infants who received THC in breast milk
Cannabis: Psychological Complications
Anxiety reactions
Panic attacks
Hallucinations/ delusions
Schizophrenia-like psychosis
Delirium
Amotivational or aberrant motivational syndrome
Cannabis: Treatment
"Talking down" from anxiety reactions and hallucinations
Calm, gentle reassurance
Quiet, warm, supportive atmosphere
Benzodiazepines, if necessary
Antipsychotics, if necessary
Cannabis: Treatment
Treatment of delirium
Close monitoring
Evaluation to rule out other causes
Antipsychotics, benzodiazepines
Rehabilitation
Particular attention to adolescents
12-step
Cognitive-behavioral
Inhalants
Diverse group of substances
Alkyl nitrites:
- Amyl nitrite- "amies" "poppers" "snappers"
- Butyl nitrite- "rush" "locker room"
Gases:
- Nitrous oxide: "whippets"
- Ether, chloroform, halothane
Solvents:
- Glues, paints, paint thinner, gasoline, lighter fluid, nail polish remover, cleaning solutions
Inhalants: Pharmacology
Highly lipid soluble
Quickly absorbed
Effects last minutes up to 1 hour
Users typically repeat inhalations
Neurobiology:
Reduce excitatory impulses
Nitrites are also smooth muscle relaxants and dilate blood vessels
Inhalants: Epidemiology
Monitoring the future
Annual rate of inhalant use among high school seniors:
In 1976, 3.0%
In 1995, 8.0%
In 1997, 6.7%
Inhalants: Effects
"Rush"- rapid onset of euphoria
Sensation of floating
Decreased inhibitions
Nitrous oxide
Giddy laughter
Aliphatic nitrites
Enhancement of orgasm
Tinnitus, eye irritation, light sensitivity
Inhalant Intoxication: DSM-IV
Maladaptive behavioral or psychological changes
Belligerence
Assaultiveness
Apathy
Impaired judgment
Impaired social or occupational functioning
Inhalant Intoxication: Signs
Dizziness
Nystagmus
Incoordination
Slurred speech
Unsteady gait
Lethargy
Depressed reflexes
Tremor
Generalized muscle weakness
Blurred vision or diplopia
Stupor or coma
Euphoria
Psychomotor retardation
Inhalants: Medical complications
General:
Headache
Nausea/ vomiting
Diarrhea
Acidosis, hyperchloremia
Asphyxiation/Anoxia
Bronchitis/ pneumonia
Death
Solvents:
Arrhythmias, sudden death
Carcinogenesis
Abortion
Developmental abnormalities
Neuropathies
Fluorocarbons: (halothane)
Cardiotoxicity
Hepatorenal toxicity
Inhalants: Psychiatric complications
Dementia
Cerebellar syndrome (Toluene)
Dysmetria and dysarthria (benzene)
Delirium
Psychosis
With delusions
With hallucinations
Depression
Anxiety
Personality changes
Inhalants: Treatment
Intoxication:
Hospitalization and treatment of arrhythmia, seizures, coma, renal tubular acidosis, hepatorenal toxicity
Rehabilitation:
Intensive, comprehensive drug rehabilitation
Attention to adolescent issues