Instructions: Spend 5-10 minutes reviewing the case below and considering the questions that follow. Case Study 2
J.T. is a new patient who arrives in the office; he is a 30-year-old thin male with no stated medical history. He complains that he has trouble sleeping, and he appears restless and slightly agitated. He is tachycardic and hypertensive and on exam has a cough. On exam, he has poor dentition and severe gum disease; his pupils are dilated. He is requesting medication to help him sleep.
1. What class of drugs do you suspect Mr. Smith may be using?
2. Would you expect any psychological or neurologic effects in addition to the symptoms listed?
3. Is there a specific antidote to prescribe to counteract the substance that J.T. is suspected of using?
Despite their name, hallucinogens do not consistently cause hallucinations. 48 These are divided into two categories including classic hallucinogens and dissociative drugs.
excessive sweating, panic, paranoia and psychosis, and bizarre behaviors. Long-term effects include persistent psychosis and hallucinogen persistent perception disorder, which are evident in individuals with mental illness. Dissociative Hallucinogens Common dissociative drugs include: •
and increases in blood pressure, heart rate and body temperature; long term effects may include speech problems, memory loss, weight loss, anxiety and depression, or suicidal thoughts. Treatment of Hallucinogen Use Disorder and Intoxication No known hallucinogen-specific antidotes exist. Treatment of patients who are intoxicated following the use of hallucinogens must be monitored closely. Benzodiazepines are commonly used to treat the side effects to protect that patient from complications of agitation that are listed previously. Supportive treatment with intravenous fluids and monitoring of vital signs is important. The use of neuroleptics such as Haldol can be considered if the agitation is not completely controlled with the use of appropriate doses of benzodiazepines. At this time, no approved pharmaceutical treatment for hallucinogen use disorder is available. Inhalant Use Disorder Inhalants are substances that produce chemical vapors that can be inhaled to induce psychoactive or mind-altering effects. The range of chemicals with a variety of pharmacologic effects are found in hundreds of products. Precise categorization of these products is difficult, but generally they are identified as volatile solvents, aerosols, gases, and nitrates. 51 • Solvents include paint thinner, gasoline, lighter fluid, and glue. • Aerosols include spray paint, hair spray, and vegetable oil sprays. • Gases include propane tanks, whipped cream aerosols, and butane lighters and nitrous oxide. • Nitrates include room odorizrs and leather cleaner.
Classic Hallucinogens
Common classic hallucinogens include 49 :
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D-lysergic acid diethylamide (LSD) is one of the most potent mind-altering chemicals. It is a clear or white odorless substance found in a fungus that grows on rye or grains. Psilocybin originates from mushrooms in tropical and subtropical regions of South America, Mexico, and United States Peyote (mescaline) is a small spineless cactus with mescaline as its main ingredient. DMT (N,N-dimethyltryptamine) is a powerful chemical found in plants in the Amazon. Ayahuasca is a tea from these plants, called hoasca, aya, and yage. 251-NBOMe is a synthetic hallucinogen similar to both LSD and MDMA, but much more potent.
PCP (phencyclidine), also known as “angel dust,” which was developed as a general anesthesia but is no longer used because of serious side effects. Now it is found in a variety of forms. Users snort PCP powder, swallow tablets and capsules, or smoke the drug by applying it (in powder form) to a leafy substance such as marijuana. In addition, users increasingly are dipping marijuana or tobacco cigarettes in liquid PCP and smoking them. Ketamine is a dissociative anesthetic for animals and humans and is a noncompetitive N-methyl-d-aspartate receptor antagonist. It is commonly used medically as an analgesic and sedative but is also being explored for its therapeutic effects that offer a potential alternative treatment for depression, suicidal ideation, substance use disorders, and PTSD. 50 This has also been used as a date rape drug. Dextromethorphan (DXM) is an over-the- counter cold and cough medicine. Salvia is a plant common to southern Mexico and Central and South America. This drug is ingested by chewing fresh leaves and drinking the extracted juice.
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Classic hallucinogens temporarily disrupt communication through the brain and spinal cord. Additionally, some interfere with serotonin, which regulates mood, sensory perception, sleep, hunger, body temperature, sexual behavior, and intestinal muscle control. These hallucinogens cause individuals to see images, hear sounds, and feel sensations that seem real, which generally begin within 20-90 minutes and can last from 15 minutes to 12 hours. These are commonly referred to as a trip by the individual. The short-term effects can range from tachycardia and nausea to seeing intense colors and changes sense of time. Other short-term effects of hallucinogens include increased blood pressure, tachypnea, and hyperthermia, loss of appetite, dry mouth, spiritual experiences, relaxation, uncoordinated movements,
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Dissociative hallucinogens interfere with glutamate, which regulates pain perception, environmental response, emotion, learning and memory. Dissociative drugs can cause numbness, disorientation, loss of coordination, hallucinations,
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