24.

MARIJUANA, HALLUCINOGENS, PHENCYCLIDINE, A N D INHALANTS

lane A. Kemedy, D.O.
1. What is marijuana? Marijuana is obtained from the cut and dried upper leaves, flowers, and stems of the cannabis plant. Its main psychoactive ingredient is delta-9-tetrahydrocannabinol (THC). The potency of THC in marijuana cigarettes varies greatly (1-1.5%), but has increased 1.5- to 30-fold since the 1970s. Hashish is obtained from dried resin secreted on the flowering tops (10-20% THC), and hashish oil is extracted with the use of organic solvents (15-30% THC). 2. Who uses marijuana? Marijuana, the most widely used illicit drug in the U.S., is often said to be a gateway drug for teens, but it also has been used socially for many years by adults. About one-third of the U.S. population has used marijuana, and in the age range of 18-2.5 years, about 60% have used it at least once.

3. How is marijuana taken?

Marijuana usually is prepared from dried leaves and flowers and smoked as a cigarette or in a pipe, although in some parts of the world it is taken in tea. It also may be eaten orally, commonly in brownies; the euphoria is less intense but longer lasting. Because extracts are not water-soluble, marijuana is not used intravenously.

4. What are the psychological and physical effects of marijuana? A person may feel euphoric, giddy with uncontrollable laughter, talkative, or sedated, and sensory perceptions may be enhanced. Short-term memory, attention span, and judgment are impaired; diffculty with abstract thinking and time distortion also occur. Anxiety, panic, paranoia, and dysphoria can result, and daily users may have chronic depression, irritability, and lethargy. Cannabis-induced psychosis has been reported but may be secondary to underlying psychotic disorder. Red eyes or conjunctival injection are a good clue of recent marijuana use. Common physical symptoms are increased heart rate, increased appetite, and dry mouth. Motor performance may be impaired for up to 10 hours after use. The effect of smoking marijuana peaks within 10-30 minutes, and intoxication may last several hours, depending on the dose. The effect of oral ingestion peaks within 45-60 minutes.
5. What are the medical consequences of marijuana use? Decreases in sperm count, testosterone levels, and luteinizing hormone have been reported. Pulmonary complications, such as chronic cough, bronchitis, and chronic obstructive pulmonary disease, are seen; however, because most marijuana smokers also are cigarette smokers, it is difficult to lay blame on marijuana. The carcinogens in cigarettes also are present in marijuana, but in increased amounts; thus the risk for malignancy may be increased.

6. What are the medical uses for THC? THC has been used to treat glaucoma (by lowering intraocular pressure), nausea and vomiting caused by chemotherapy, weight loss problems in patients with acquired immunodeficiency syndrome, and muscle spasm in multiple sclerosis. In general, THC has not been shown to be more effcacious than available prescription medications, and many patients do not like the psychoactive effect. Medical use of cannabinoids is an active focus of research, including a delivery system other than smoking, which has known harmful effects.
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7. Is tolerance or withdrawal associated with marijuana? Most chronic users report tolerance to the euphoric effects and a need for increased frequency or increased amount of marijuana to get the same effect. A withdrawal reaction has been reported with chronic use of very high doses, but it is rare and is not listed as a diagnosis in DSM-IV.

8. How long does THC stay in the urine? THC is fat-soluble and is excreted slowly. Casual users may have a positive urine screen for 5-10 days and chronic users for up to 30 days. 9. What is the amotivational syndrome? The amotivational syndrome has been described in several countries and several age groups of marijuana users, but in the U.S. it has been applied mainly to adolescents. Symptoms are apathy, disinterest, fatigue, and decrease in goal-directed activities. The syndrome has not been well researched and may not exist.
10. Is marijuana a gateway drug that leads to other drug use? PossibIy. A study of young men in Manhattan noted that of those who had not smoked marijuana, < 1% progressed to cocaine or heroin, whereas of those who were heavy marijuana users (> 1000 times), 82% used cocaine and 33% used heroin. It is unlikely that marijuana causes further drug use, but it may expose the young users to drug experience, risk-taking behavior, and people who use other drugs. 11. What are hallucinogens? Hallucinogens are said to produce sensory hallucinations without causing delirium or cognitive impairment; the hallucinations may be auditory, visual, olfactory, tactile, or gustatory. Often what is actually experienced is an illusion (distortion of an actual sensory perception) rather than a hallucination. 12. What is LSD? Lysergic acid diethylamide (LSD) or acid is a synthetic hallucinogen. 13. Who uses LSD? Data from the 1998 household survey revealed that about 10%of the population had used LSD at least once in their Iifetime-l.6% in the last year, and 0.7% in the past month. Recent use was most common in 18-25 year olds. In 1997, 14% of high school seniors reported using at least once. Whites were twice as likely to use either drug as African-Americans, and 1992 data from emergency departments revealed that over half of the LSD-related emergency visits were adolescents age 10-19 years. 14. How is LSD taken? LSD is usually taken orally, although it may be absorbed through the skin, dropped in the eyes, or injected intravenously. 15. What are the intoxication effects of LSD? Onset of effects begins in about 30 minutes, peaks at 2-3 hours and lasts about 8-12 hours. Effects are dose related. Perceptual and psychic changes occur, although the person usually recognizes that such changes are drug-induced. Effects may include depersonalization and derealization, a dreamlike state, illusions (melting face), synesthesias (hearing a color), intensification of sound and color, and prolonged afterimages (trails). A person feels excitation, distorted sense of time, peacefulness, or delusions, such as being able to fly. Hallucinations often are visual geometric figures; auditory hallucinations are rare. Bad trips, which include anxiety, fear of insanity, suicidal depression, and panic attacks, may occur in anyone (even people who have good trips). Injuries can occur from delusional behavior, such as trying to fly. Physical symptoms such as dizziness, weakness, motor restlessness, or nausea may occur initially, along with stimulant-like signs such as increased blood pressure and heart rate, fever, and dilated pupils. Sweating, tremors, incoordination, hyperreflexia, and blurred vision also may be present.

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16. Is tolerance or withdrawal associated with LSD? Tolerance to euphoria and perceptual experiences occurs rapidly (within a few days) with daily use, and most users report that they must wait several days between trips because of tolerance. Cross-tolerance exists with mescaline and psilocybin, but not with PCP. A withdrawal syndrome has not been identified, and animal studies show that LSD is not a highly reinforcing drug. Users rarely report compulsion or loss of control with LSD.
17. What are flashbacks? Called hallucinogen persisting perception disorder in DSM-IV, flashbacks are transient, distressful reexperiencing of hallucinogenic effects during abstinence. Usually the flashback is a visual distortion (illusion) or actual hallucination, such as shadows, colored or geometric objects, macropsia or micropsia, intensified color, halos, or afterimages. It generally is unpleasant and frightening. Flashbacks usually stop after several months of abstinence, but can last for years in some patients.

18. What are the adverse effects of LSD? Overdose has not been a problem, but patients may present to the emergency department with a bad trip (agitation and fear) or with injuries secondary to impaired judgment or delusions, such as trying to fly out of a second-story window. Bad trips usually are treated with a quiet room, low sensory stimulation, and talking down with support and reassurance. A benzodiazepine may be useful, especially with extreme anxiety and panic. A prolonged psychotic state may be associated with hallucinogens such as LSD and PCP, as well as with stimulants and even cannabis. Whether this state is drug-induced or an unmasking of preexisting psychotic illness remains controversial; sometimes it responds to antipsychotic medication. Persistent auditory or visual hallucinations also may respond to carbamazepine.
19. What other hallucinogens are abused? Similar symptoms and problems are seen with other hallucinogens; many have both amphetamine and hallucinogenic actions. Morning glory seeds and Hawaiian baby woodrose contain LSD derivatives, and the spices nutmeg and mace contain a substance related to methylene dioxyamphetamine (MDA). Mescaline from the peyote cactus, psilocybin from Mexican mushrooms (magic mushrooms), and bufotenin from toad skin are other natural hallucinogens.

20. What is ecstasy?

3,4-Methylene dimethylamphetamine (MDMA) is a synthetic substance called ecstasy, E, XTC, X, or Adam. Along with other designer drugs, ecstasy has been popular at raves, which are allnight dances in large warehouses with high-tech music and videos. MDMA may be taken as a pill or suppository, snorted as powder, or injected intravenously. Physically it has amphetamine-like effects; psychoactive effects include feelings of euphoria, spirituality, personal insight, and desire for intimacy. Fatal overdose has occurred as well as severe psychotic reactions, and animal studies suggest direct toxicity to serotonergic neurons.

21. What is phencyclidine? Phencyclidine (PCP), also called angel dust, sherm, or embalming fluid, was synthesized for use as a general anesthetic in the 1950s but was discontinued because of side effects such as delirium, agitation, hallucinations, and psychotic reactions. It also was used as an anesthetic for animals (thus the street names animal or horse tranquilizer), but this use also has been discontinued. 22. Who uses PCP? PCP is most commonly used in large cities such as Los Angeles, St. Louis, New York, and Washington, DC. It is most popular with black or Hispanic men in their 20s. 23. How is PCP used? What are its effects? Most frequently cigarettes (tobacco, marijuana, mint, oregano) are dropped in PCP and smoked, but PCP also may be taken orally, intravenously, or by nasal insufflation. Physical symptoms include

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elevation in blood pressure and body temperature, muscle rigidity, decreased pain sensation, and dilated pupils with both horizontal and vertical nystagmus. The psychoactive effect is euphoria and sometimes aggressive behavior. Bad trips are best treated with diazepam or neuroleptics with low anticholinergic profiles; restraints should be avoided because rhabdomyolysis has been reported.

24. What is ketamine?

Ketamine is a dissociative anesthetic that is used medically; it is a derivative of PCP with similar chemical structure and activity. Ketamine is occasionally abused, usually by health professionals with easy access.

25. What are inhalants? Volatile substances such as gasoline, glue, spray paint, solvents, and lighter fluids are inhaled (sniffed, huffed). They are inexpensive, easily accessible, and legal.
26. Who uses inhalants? About 20% of high school seniors in the U.S. have tried inhalants, and increasing numbers of children age 9-12 have been reported to experiment with their use. Although inhalant abusers are usually under 20 years old, emergency department visits among people 26 years and older have increased to 38% of total visits for inhalants. Whites, Native Americans, and Hispanics tend to use inhalants more than African Americans, and users are predominantly male. Although many inhalant users are experimenters or polysubstance abusers, a recent study showed that inhalant abusers were more than 5 times more likely to become intravenous drug users than non-inhalant users. 27. What are the effects of inhalants? A rapid-onset (seconds to minutes) and short-lived euphoria occurs with inhalation of volatile substances. The user feels excitement, disinhibition, light-headedness, and confusion. Hallucinations may occur as well as nausea, vomiting, headache, and blurred vision. There may be a rash around the nose and mouth, and the persons clothes, skin, or breath may smell of solvents.

28. What are the complications of inhalants?

Risk of sudden death due to cardiac arrhythmia, laryngospasm or asphyxiation Neurologic damage (in chronic users), with abnormal electroencephalogram, cerebellar degeneration, intellectual impairment, and dementia Impaired motor responses Memory loss Renal and hepatic toxicity Bone marrow suppression Pulmonary complications (chemical pneumonitis and emphysema in chronic users)

29. What is GHB? Gamma hydroxybutyrate is a neurotransmitter that affects a variety of systems, including sleep cycles, temperature regulation, and memory. Outside of the US., it has been used therapeutically in anesthesia, for narcolepsy, and to treat alcohol and opioid dependence. It also is a drug of abuse, as in low doses it gives mild euphoria, disinhibition, and increased libido, and in high doses, feelings of sedation. Aggression, judgment impairment, and violent combativeness have been seen, as well as ataxia, dizziness, nystagmus, respiratory depression, apnea, coma, and death. 30. Describe the treatment for abuse of marijuana, hallucinogens, PCP, inhalants, ecstasy, or GHB. Treatments have not been well studied. Users rarely seek treatment on their own and are usually under court order. Currently, little knowledge is available to guide treatment of these drug disorders. Most patients are young, and family participation is strongly encouraged. Most treatment approaches have aimed at achieving abstinence through support, limit-setting, and reinforcement techniques, Relapse prevention includes decreasing availability and acceptability of drug use.

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BIBLIOGRAPHY

I . Crowley TJ: Learning and unlearning abuse in the real world: Clinical treatment and public policy. NIDA Research Monograph No. 84. Washington, DC, U S . Government Printing Office, 1988, pp 100-121. 2. Clayton RR, Voss HL: Young men and drugs in Manhattan: A causal analysis. NIDA Research Monograph No. 39. Washington, DC,U S . Government Printing Office, 1981. 3. Dinwiddie SH: Abuse of inhalants: A review. Addiction 89:925-939, 1994. 4. Li 5. Stokes SA, Woeckener A: A tale of novel intoxication: A review of the effects of y-hydroxybutyric acid with recommendations for management. Ann Emerg Med 3 1:729-736, 1998. 5. Millrnan RB, Sbriglio R: Patterns of use and psychopathology in chronic marijuana users. Psychiatr Clin North Am 9533-545, 1986. 6 . Schutz CG, Chilcoat HD, Anthony JC: The association between sniffing inhalants and injecting drugs. Compr Psychiatry 35:99-105, 1994. 7. Solowij N: Ecstasy (3,4-methylenedioxymethamphetarnine). Cum Opin Psychiatry 6:41 I 4 1 5, 1993. 8. Steele TD, McCann UD, Ricaurte GA: 3,4-Methylenedioxymethamphetamine(MDMA, Ecstasy): Pharmacology and toxicology in animals and humans. Addiction 89539-551, 1994.

25. DUAL DIAGNOSIS: SUBSTANCE ABUSE AND PSYCHIATRIC ILLNESS

S. Tziporah Cohen, M.D., and Alan M.Jaco6son, M.D

1. What is meant by the term dual diagnosis?

It describes patients who have both a substance use disorder and another major psychiatric disorder. Examples include a cocaine-dependent patient with panic disorder and an alcoholic patient with major depression. The term is used to highlight the difference between such patients and patients with a single diagnosis; patients with a dual diagnosis have special diagnosis and treatment needs. Although dual diagnosis refers to all patients with concomitant diagnoses of substance abuse and other psychiatric illness, the population is highly heterogeneous. Both of the patients mentioned above, for example, have dual diagnoses, but their disorders may require very different treatments.

2. Is dual diagnosis common? Yes. Dual diagnosis is extremely common and often unrecognized. Of patients with a substance use disorder, approximately 50% have at least one other psychiatric disorder, most commonly a mood or anxiety disorder. Conversely, almost 30% of patients with other psychiatric disorders also have a history of substance abuse.
3. Why is it important to determine whether a patient has both a substance use and another psychiatric disorder? The importance of identifying substance abuse in a patient with a psychiatric disorder cannot be
overstated. In general, patients with a dual diagnosis have higher morbidity, lower likelihood for initial treatment success, higher relapse rates, increased rates of hospitalization, and decreased adherence to treatment. They also are at increased risk for suicide. The presence of substance abuse makes diagnosis of both disorders more complicated. For treatment of either disorder to be successful, both must be identified and treated individually. 4. Do certain psychiatric conditions tend to be seen with substance abuse? Yes. Antisocial personality disorder is highly correlated with substance abuse. In one extensive study, 84% of individuals with antisocial personality disorder also had a history of substance abuse. Mood disorders also are commonly associated with substance abuse; in the same study, 32% of individuals with a diagnosis of mood disorder were substance abusers. In addition, specific psychiatric