 Hi everyone and welcome to today's class on stimulus depressants and hallucinogens. You can see in your window that you have the ability to send me a chat message whenever you are ready and wanting to ask a question. If anything comes up and I will try to answer it as we go and I will also hang out after class if you have any other questions. I'm going to kind of fly through this material. I've added a bunch of handouts within the class so you can access some of the stuff that you know I would just be reading to you which is kind of boring anyway. So here we go and I used the wrong slide shot. Anyway the objectives today we're going to define stimulants, depressants and hallucinogens. We'll discuss their mechanisms of actions, symptoms of intoxication, symptoms of withdrawal, short and long-term effects, common street names and then we're going to talk about differential diagnosis. Now a lot of you are familiar with some of the symptoms of intoxication and withdrawal. I think it's really important that we look at differential diagnosis though so we can sort of get an idea in our minds as clinicians. Are we dealing with symptom intoxication or maybe a manic episode? So before we get started a couple little side notes. The method of administration will greatly affect the intensity and duration of onset for various drugs. It doesn't matter whether we're talking stimulants, depressants, yada yada. So oral is your slowest. It's got to go through the gastric system and it takes a lot longer. Inhalation through snorting is a lot faster, smoking is faster, injection is super fast, rectal suppository surprisingly is also super fast and skin patches where it's absorbed directly through the skin is also another relatively fast method of administration. You'll notice with some of the skin patches like the fentanyl patches if somebody gets ahold of those they also may adulterate the patch with other drugs in order to have multiple substances going into their system concurrently. So drugs affect everyone differently based on their size, weight and health, whether the person's used to taking to it, whether other drugs are taken concurrently, the amount taken and the strength of the drug. Now if we're talking illegally produced drugs, you never know what you're going to get, what it's cut with, but it's also important to pay attention to the individual person. I know for myself, I'm a lightweight. What a doctor prescribes to me for pain or for muscle relaxers or anything like that, I take whatever is prescribed and I cut it in half because it is just way too strong for me if I take the full quote adult dose. So we need to pay attention to that with our clients and not minimize if they're only taking a certain amount, they may be more reactive to it. Likewise, if they've developed a tolerance, they may be able to take a lot more. One of the young women I worked with when I was supervising a detox facility, she was maybe 105 pounds soaking wet and she could inject 15 crushed oxys in one sitting. I'm like, oh Lord, half of an oxy and I'm just sitting on the couch drilling. So you can see where tolerance can develop really quickly and she's a lot smaller than me in taking a whole lot more. So just be aware of that. Okay, so what are stimulants? Stimulants are substances that act to excite the central nervous system. Caffeine, amphetamines, cocaine, these are our general stimulant drugs that we're going to talk about. Stimulants increase alertness, attention and energy, as well as elevating blood pressure, heart rate and respiration. Sometimes people use them to counteract the effects of some of the other drugs that they've taken. If they've taken depressants or something that has slowed them down, they may use stimulants in order to kind of wake back up. They're used to treat asthma and other respiratory problems, obesity, neurological disorders, ADHD, narcolepsy, and occasionally depression. So there are medical uses for them, but we do know that they are highly susceptible to abuse. Stimulants enhance norepinephrine and dopamine. Norepinephrine is your wake up chemical and dopamine is your feel good chemical. So you wake up and you feel good. So that sounds like a winner to me. Increases in dopamine can induce a feeling of euphoria when stimulants are taken non-medically. Again, it depends on the person. If you go to Starbucks and you get a tall or whatever it is, brewed coffee, you're going to get so much caffeine that you may feel a buzz. And that's not necessarily, you know, that's food. It's not like you're abusing the coffee. So we'll talk about that a little bit more later. Even medically prescribed levels of stimulants can give somebody the feeling of a buzz. If they're less tolerant to it, and they need to talk with their doctor about that, yada yada. Norepinephrine also increases blood pressure and heart rate, constricts blood vessels, increases blood glucose, and opens up breathing passages. It's your fight or flight, well one of your fight or flight chemicals. It says, let's get ready to go. Let's get that blood pressure up. Let's get the heart pumping and let's make it so we can breathe so we can get through this. Yeah, well that can be good and it can be bad. The increase in norepinephrine or noradrenaline and dopamine happens in four ways in the brain. And I'm going to go over this simply because if you're taking the addictions counselor exam, you may be testing on the mechanism of action. So we are going to talk about it for a minute. They can bind to the presynaptic membrane causing the release of dopamine. So remember you have the presynaptic membrane, the synaptic space, and the postsynaptic. So if it binds to that, basically the opening door and it opens the door up, it causes the release of dopamine into the synaptic space. It can interact with dopamine containing synaptic vesicles releasing free dopamine into the nerve terminal. So again, it can push that dopamine out there into the space basically between the two doorways. It can bind to the MAO's, monoamine oxidase in dopaminergic neurons and prevent the degradation of dopamine leaving free dopamine in the nerve terminal. Basically, it's binding to things to keep the dopamine from breaking down and being reabsorbed. So it's keeping that dopamine in the space longer so more can be sent through the channel. And it can bind to the dopamine reuptake transporter causing it to act in reverse and transport free dopamine out of the nerve terminal. So there are a lot of different ways it's messing with that mechanism of action. Normally, we have a little squirt of dopamine, it sits in the synaptic space, it's absorbed as much as it needs, and then all the excess is sucked back up. We're kind of monkeying with that effect right now. Basically it's making dopamine more available. We know that dopamine is our super reinforcing reward chemical. So when more of that's available, people get a stronger feeling of euphoria. So signs of stimulant intoxication. If somebody comes into your class, maybe you're teaching an IOP class, maybe they're just coming in for an assessment, they're going to feel pretty good. They're going to have increased energy, increased confidence, mental alertness, sexual arousal, possibly itching and scratching, large pupils, large pupils as opposed to our opiates that we'll talk about later where we've got pinpoint pupils. Dry mouth, fast heartbeat and breathing, teeth grinding, reduced appetite and excessive sweating. So if they are chewing on a lollipop or a sucker or, you know, sometimes a tongue depressor or a toothpick, you might want to kind of investigate that. We also have a lot of people who come into treatment who are, you know, they're just a little bit high strung anyway. Maybe they have an anxiety disorder or maybe they're excited to be there, whatever the case may be. We don't want to assume that someone is pumped up on stimulants right away, but it is a good idea to kind of pay attention to some of this stuff and look for signs of intoxication. And it could be that they just pounded back to Red Bulls before they came into group. Whether your facility tolerates that or not is, you know, a policy thing, but it's important for them to realize that just because caffeine is, you know, available at meetings doesn't mean that it is okay to abuse to excess, abuse or use to excess. So stimulant withdrawal, this is fun and I'm being sarcastic. In the four to six days after stimulant use, the following effects may be experienced. Restless sleep and exhaustion, so the norepinephrine and dopamine has gotten all out of whack, which means the serotonin has gotten all out of whack and serotonin helps us sleep, which means circadian rhythms are probably out of whack because we have a lot of people who use stimulants and you know, no surprise, don't sleep. So they may be up for 24 hours, three days a week without sleeping or without sleeping much. So in the four to six days after the body is going, I've got nothing left to give, they're exhausted, but the sleep is restless and unrefreshing. Headaches, dizziness and blurred vision, paranoia, hallucinations and confusion. So they may feel like they're seeing things or hearing things and start to get really paranoid, irritability, mood swings and depression, anxiety and insomnia. So looking at this, these are also symptoms of anxiety when you have restless sleep, exhaustion, headaches, sometimes people, if they go into a little bit of a panic attack, will start to feel like they're getting dizzy and they might start to get a little bit irritable. Again, looking at differential diagnosis, I don't want to assume that every symptom is the result of a drug use. Likewise, I don't want to assume that every symptom is the result of a mental health issue. We need to ferret it out as we get to know people and try to figure out which one is causing which. Obviously, if you're doing urine screens, you're going to have a pretty good idea about any illicit substances they may be taking, but unless you've got a really, really amped up on-site drug panel, you're probably not going to know how much caffeine or nicotine that they've ingested. Methamphetamine, just a little bit of a tidbit here, has a substantially longer half-life than cocaine, which can lead to a more intense and protracted withdrawal. So, withdrawal from methamphetamine is rough. It is really rough. And it can last a lot longer because half-life is the amount of time it takes for the half of the substance to get out of the body. So, for caffeine, you know, just caffeine since we all, well, most of us probably drink it, half-life for caffeine is six hours. So, if you drink a big cup of coffee at noon, it is not going to be fully out of your body until midnight. So, if you have methamphetamine and it takes longer to get out of the system than other stimulants, you know, we're talking more than four to six days. It's going to be more like two weeks that the person may be experiencing symptoms. During this period, chronic methamphetamine users may have episodes of violent behavior, paranoia, anxiety, confusion, and insomnia. It's amazing what happens when the neurotransmitters start to get wonky, especially when we start talking about norepinephrine, which is our fight-or-flight neurochemical. You can see where that might be a problem. Okay. Another one, I felt like it was really important to mention because even if you're not working with drug addicts themselves or if you are and they are trying to work out and get themselves physically healthier, which is great. Don't get me wrong. Turning to supplements that have stimulants in them can be counterproductive to their recovery. The list of, the DOD list of supplements to avoid has 40 supplements on there that have medications that have any, or not medications, but drugs in them that haven't even been studied on humans. So, 11 of them were found to contain beta, beta-methylphenyl ethyl lalamine. Yeah. If you can't pronounce it, probably shouldn't be eaten it. BMPEA. And only three of those supplements actually listed that it had that in it. So if a client comes to you and says, I'm taking this stimulant supplement, but no, it doesn't have any of the bad stuff in it. Since they're not really well-regulated, it's important to educate them that, yeah, it may still. You don't know exactly what's in there. Like I said, the Department of Defense found 40 supplements that actually still had some of these in them and they are not ones that soldiers should be taking. Back to coffee. One of my favorite things. Toxic overdoses or toxic doses of coffee can be anywhere depending on what you're reading from five grams to 10 grams per day for an adult. Now, that's a lot. A gram is a thousand milligrams. So, you know, you're really popping it back. Some people are more sensitive. If you're taking certain medications that are already stimulants, then five grams may be way more than you can actually handle. So, for example, a cup of coffee may have anywhere from 80 to 175 milligrams. We're talking a normal cup. We're not talking, you know, the giant mugs that, you know, Red Bull. Red Bull actually only has 80 milligrams in it and Monster only has 86, but they also have other herbs and things in them that are designed and sugar that are designed to work synergistically with the caffeine to amp people up and they do. I mean, people feel like their heart's going to pound out of their chest sometimes. A Starbucks short, which is a little tiny brewed coffee is 180 milligrams. So, if you get a tall, that's almost 360 milligrams. It's 16 ounces. That's a lot in one sitting. Stacker 2 is a common pre-workout supplement that athletes will take, especially bodybuilders and, you know, people who are weight training that aren't competing where they are regularly drug tested. One capsule of Stacker 2 has 200 milligrams of caffeine, which is the same as one tablet of Viverin. A lot of us, you know, depending on how old you are, if you're, you know, around my age, Viverin was big when we were in college and kind of in high school. Being aware of how much caffeine it has, because you can develop a tolerance to caffeine as well, you can also develop a sensitivity to caffeine and stimulants. So, if someone is taking the take-home message, is if someone is taking over-the-counter stuff, in addition to illicit drugs, in addition to prescription meds, they may be creating a cocktail that is just a recipe for a heart attack. We need to encourage them to be aware of what they're putting in their body. Possible side effects for stimulants include hostility. Have you ever been around somebody who's had too much coffee and they're really amped up, and they're just like, they're sort of freaking out? That's the hostility we're talking about. They may not be able to be patient. They may be feeling that fight or flight, chemical fight or flight reaction that's going on, and they're just like, okay, I got to get it. And anything that stands in their way could be perceived as negative. Paranoia, psychotic symptoms, unsafely elevated body temperature. Stimulants ramp us up. They're also going to elevate our body temperature. We don't really want to cook ourselves from the inside. Irregular heartbeat and heart failure, seizures, and exacerbation of existing anxiety. If you take somebody who is already kind of anxious, has panic attacks, regularly has issues where their heart rate increases, panic attacks, like I said, and you give them stimulants, what do you think is going to happen? They're going to have an exacerbation. It's going to intensify those anxiety symptoms. Coke, I believe, a question came in. Coke, I believe, has about 65 milligrams in it, but you can actually Google caffeine calculator, and there are caffeine calculators online that you can help people use. They can put their drinks and their various things that they eat in them because chocolate has caffeine too. Bummer, and figure out exactly how much caffeine they're ingesting per day. Long-term effects of stimulants, reduced appetite, restless sleep, we're messing with this serotonin and melatonin. We're messing with circadian rhythms, dry mouth and dental problems, reduced immunity. The body's just going, I've got no more to give. It's diverting energy from other places, trouble concentrating, shortness of breath and difficulty breathing, paranoia, depression and suicidal ideation. Now, how does that come from happy chemicals and fight-or-flight response? Well, at a certain point, you run out of gas and you just can't do it anymore, and it starts to sort of have the opposite effect because the person is trying to get dopamine. There's no dopamine left. It's gone through that postsynaptic terminal and their body couldn't make more fast enough. Norepinephrine's out of balance. One of the presentations we did last week talked about dopamine, norepinephrine, GABA and serotonin. They all work in a balance with one another. So when one goes up, some of the others go down and they can actually suppress one another. So the long-term effects of using stimulants or depression and suicidal ideation, what does the person do when they feel depressed and suicidal, when they normally abuse stimulants that make them feel happy and euphoric? Use more stimulants. We know that we're going to have to help people get through this period while their brain sort of recovers. Heart and kidney problems, you're putting an awful, awful tax on them when you're ramping up your system quite that much. Increased risk of stroke because of the increased blood pressure, tolerance, confusion, sexual dysfunction, chest pain and palpitations and seizures and delirium. So as a person develops a tolerance and they use more, they become more susceptible to side effects. Common street names. I'm not going to go through all of these. They are in your handout that's in the class, but there are a lot of different street names. Most of our clients don't expect us to know the street names, which is good because I don't. But if you happen to overhear a conversation while you're walking through the day room or in the lobby or whatever, if you know some of these buzzwords, it can give you a clue as to what's going on and who's selling what to whom. Because we all know it happens and it does even happen on our treatment center properties. No matter how much we try to control it, there are going to be people who try to bring contrapan in. So just being aware. Depressants exert the opposite effect of stimulants. They slow everything down. Depressants do a number of different things. The most prominent of which facilitates GABA, which is our relaxation chemical and inhibition of glutaminergic or monoaminergic, I hate trying to say those, activity. Now, if you remember, if you were in the presentation last week, GABA is actually synthesized from the breakdown of glutamine. So when we're talking about the facilitation of GABA, we're talking about breaking down more glutamine. Glutamine is an excitatory neurotransmitter. So we need to understand that if we're inhibiting that, if we're increasing the breakdown of glutamine in order to make more GABA, which will help people relax, then we're going to start to feel kind of slower. The monoaminergic receptors cover your dopamine noradrenaline and serotonin. So there's noradrenaline, also known as norepinephrine again. So if we're going to inhibit norepinephrine, again, we're going to slow people down some types. Now, stimulants, there's not as many. When you're talking about stimulants, you're talking about like pseudofed as far as over the counter, caffeine, amphetamines, methamphetamines, your ADHD drugs, there aren't as many different categories that stimulants fall in. Your depressants, on the other hand, is a wide range. Your barbiturates and your benzodiazepines are both depressants. Now, barbiturates are not used as much anymore. They're your barbitols. Phenobarbital is one that I've seen a lot in hospice care. It tends to be more prevalent, more easier to get addicted to, more side effects. So people have moved towards using your benzodiazepines. Your benzodiazepines will either end in lamb or Pam, diazepam. So when you're talking about benzos, you're talking about Xanax, Valium, I believe Halcyon, are your trade names. Inhalants, yeah, inhalants are actually depressants. If we have a lot of clients who work in the construction trade, if they're working in construction around paint, gasoline, glue, aerosols of various types, especially in enclosed areas, they may be experiencing sort of secondary effects of inhalants. Encouraging them to understand that so they understand why their mood may be a little bit wonky. Encouraging them to try to avoid being enclosed up rooms where any of this is happening. And please encourage sea level management not to repaint the treatment facility while you have clients in there, if at all possible, because it will have a depressant effect on a lot of your clients. Muscle relaxants, these are also depressants. They're designed to sort of make those muscles, including your heart, slow down, relax a little bit. Your non-benzo hypnotics, like Lunesta and Sonata, and your opiates. So you've got painkillers, you've got sleeping pills, you've got muscle relaxants, you've got random chemical inhalants, benzos, and barbiturates. Oh, interesting little side note. Paints, any of your glitter paints are going to be more psycho reactive than your flat paints. Just be aware. So if you are working with someone who's a paint huffer, if they are using the reflective glittery paints, they're getting a much stronger dose of the chemicals that cause the highs and make the mild and degenerate and all kinds of stuff. 80% of the global opiate supply is used by Americans, and 99% of global hydrocodone is used by Americans. I'm wondering, is that just because our medical system is that much better? You know, something to talk about amongst yourselves. Direct health care costs are 8.7 times higher for opiate abusers, and this comes from the CDC, and the annual cost of opioid abuse in 2001 was 8.6 billion, and in 2007 had skyrocketed to 55.7 billion. And this is for opioid abuse, not for people who are in a pain management clinic seeking medically controlled treatment. These are for people who have crossed over from medical use to abuse. Opiates are a painkiller, a depressant, and an antitussive. I learned that when I was pregnant, it was kind of interesting, at least to me, that codeine is actually a cough syrup or can be used as a cough syrup. I digress. Types of drugs. Your opiates can be natural, synthetic, or semi-synthetic. And whether you're talking about natural, semi-synthetic, or synthetic, they're going to have a similar action. If they are produced in a lab under a controlled setting, then they're going to be more even between batches. So let's talk about drug testing, because drug testing for opiates is really interesting in my very strange mind. They can be detected in the urine for two to four days. Heroin contains acetylcoding. Coding is metabolized into morphine. So both codeine and morphine may be found in the urine after codeine ingestion. So if we're doing an onsite urine test where you have the little rapid test kits and somebody says, I was taking codeine as prescribed by my doctor, but you also see morphine show up. Send it to the lab, because it could just be a byproduct of the metabolite of the codeine. You really need to get a level on what the morphine was. Oxycodone, on the other hand, does not produce a positive response to routine screenings for opiates, which target morphine and or codeine. It produces a different assay. So you either need to have that panel on your cups or you need to need to send it to the lab. So oxycodone, codeine and morphine can show up differently. Heroin, which contains acetylcoding, also may end up showing up with the byproducts of codeine. Take home message for that is if somebody shows up positive and they swear they haven't been using opiates that they weren't prescribed, the adiata, send it to the lab because they may be telling the truth. If patients are taking opiates or benzos for medical purpose, send the urine to the lab and monitor levels. You know, you're not going to know exactly what the level is going to be for any individual person because there's a lot of factors that go into that. But once you get a baseline for patient Amy, then you know it should remain approximately at that baseline. And if it goes up significantly or down significantly, then, you know, we need to have a little treatment talk. Buponorphine can be abused, although it has a ceiling effect. The way they've constructed buponorphine, it can be used, but it only, you can only get a high to a certain point. And then it has that ceiling effect where no matter how much more you take, you're not going to feel any better. Buponorphine needs to have its own test as it produces another unique metabolite. So, you know, you can see why we have these cups that have like 12 panels on them. Suboxone is buponorphine and naloxone. And it's harder but not impossible to abuse. Um, used at excessive amounts. The naloxone will kick in, which is the opiate antagonist and start making someone go into sort of a detox. But Suboxone is heavily traded and heavily used in the black market, if you will. So, now that we know that we have to have all kinds of different urine tests for opiates and they may show up as different things that come out, then actually went in, which is good and important to know in and of itself. Let's talk about the short-term impact. It depends heavily on the dose, the route of administration and previous exposure. I will say here that the recovery, if you will, or the reduction in tolerance to opiates goes away a whole lot faster than the reduction in tolerance than the tolerance to other drugs. So, if someone is clean and maybe they went through a program, they've got 90 days under their belt and they relapse. If they relapse and use the same amount they were using when they went into treatment, they will very likely overdose because their body can't pick that anymore. It's already started to go back to where the average person starts to feel the effects, the sedative effects of the opiates. So, short-term impacts, psychological, euphoria, feeling of well-being, relaxation, sedation, disconnectedness and delirium. I have a lot of patients who are opiate abusers who report they take it because it makes them feel more energetic. It makes them feel better, their uber selves. It's helping them relax and get that feeling of well-being. We need to look at that point if you're taking this drug in order to get this feeling, this relaxation, let's look at what are the underlying mental health symptoms that are going on or feelings that we may need to address or coping skills we may need to look at. Physiological, analgesia, depressed heart rate and respiration, constipation, flushing of the skin, sweating, pupils fixed and constricted and diminished reflexes. Now some of your clients, you'll notice the flushing of the skin and the fixed pupils. They'll try to pull their hat down. They may doze off a little bit during class. They may have a hard time staying awake and be nodding off and they may be sweating when it's not sweatable temperature in your facility. Those are all things to take a look at if you have someone who's abusing opiates and you use a spectra relapse. Side effects, medical complications among opiate abusers specifically when we're talking about depressants, primarily arise from adulterants and non-sterile injecting practices. It may include skin, lung and brain abscesses, collapsed veins, endocarditis which is the inflammation of the lining around the heart, hepatitis and HIV. So there's a lot of bad mojo that happens once you start puncturing veins. Alcohol or other depressants like benzodiazepines and even things like muscle relaxers, antihistamines, over-the-counter stuff that may increase the effects of CNS depressants. So if something normally makes someone drowsy, I mean, without getting real technical, if there are warnings, warning labels on it, then it may make you drowsy. You can pretty well guess that there is some sort of CNS depressant effect. When we combine these things, they work synergistically. It's not 1 plus 1 equals 2. It's like 1 plus 1 equals 7. So people need to be really careful because it's super easy to OD if you start mixing pain medications, antihistamines and the like. Brain changes and brain damage can occur not only from having the neurochemicals out of whack and wonky, but it can also occur because of injecting impurities into the blood system. When people abuse opiates specifically, the brain eventually will stop or reduce the production of its natural painkillers. So people need to be weaned off of opiates and they will feel more pain initially until their body kicks in and goes, oh, I got to do this again. Okay, I got it. Symptoms of intoxication, constricted pupils, agitation, scratching and picking. Now we typically think of scratching and picking being a methamphetamine sort of thing, but a lot of people get very, very itchy when they take opiates. Just kind of bear that in mind when you've got clients coming into your treatment center if they are coming into group and acting differently than normal. Some people are fidgety. I'm fidgety. I don't usually scratch and pick, but I tend to be a little bit fidgety. What is normal for that person and watch to see if it changes over time? Symptoms of withdrawal. Now unlike benzos, opiate withdrawal is generally not life threatening. I don't want to say it's never life threatening, but generally the person they want to die because they feel so awful, but generally it does not cause stroke, heart attack, high blood pressure. Symptoms begin within six to 12 hours of the last dose, last five to 10 days, but it peaks within three days. So the first three days of a detox for someone who is coming down off opiates is miserable and that's not even a strong enough word. They may feel yawning, drug craving, irritability, dysphoria, depression, and flu-like symptoms. Just take the flu if you've ever had it and multiply it times three. That's kind of what they feel like right now. Keeping them hydrated, providing palliative care is a lot of what you can do in a detox situation. Detox issues, tolerance decreases rapidly, so overdosing during relax is easy. This is why having antidotes is important, even in your treatment centers. The biggest focus during opiate withdrawal is to provide palliative care. Try to make them feel better so they can get through it and stay hydrated so they don't develop any secondary symptoms. Fentanyl. Now we have fentanyl by prescription, fentanyl patches, fentanyl lollipops, which I'm not crazy about. Fentanyl is 30 to 50 times stronger than heroin. Overdose rates are super high. The difficulty in getting prescription opioids has led to an increase in demand for heroin. They figured out that heroin is really expensive. Fentanyl is really, really cheap to make. If we make fentanyl and we cut the heroin with it, then we make this super amped up heroin that we can sell for high prices. Unfortunately, a lot of people think they're getting pure heroin and they don't adjust the dosage accordingly and overdose. So, nearly 6% of 12th graders report using narcotics other than heroin for recreational purposes. It's a big trend on the East Coast, and I don't know about the West Coast as much, of going into your parent's medicine cabinet and getting opiates in order to put into it, either take yourself or put into a bowl, and then they have kind of what they call a Skittles party. They just reach in and grab a handful of pills and pop them and see what happens. As far as other medications to help treat symptoms of withdrawal, yes. For opiate withdrawal, some people can use Suboxone in order to taper down. There's a lot of controversy on that. Some people can use methadone in order to taper down. Again, more controversy on that. That will definitely slow down or reduce the intensity of the symptoms. It depends though on A, whether the person can afford it, and B, whether they want to go that route because of the controversy and the risk of getting basically just switching the addiction over. Now, I say that with caution because there are some doctors who will work in an opiate treatment program whose intention is to detox somebody off of the opiates over the course of a year or two in order to make it a slow, gradual process so there is not the physical crisis, which in theory reduces the likelihood of relapse. I did work for one opiate treatment program that the attending physician was adamant, not only about drug screens, about participation in the program, but also about seeking counseling because he realized that it wasn't just about the medication. If we could get people relatively pain free off the opiates, that's great, but we still needed to provide them tools to deal with whatever made them start using in the first place, whether it's mental health or physical health or a combination. Yes, other medications can be prescribed. There are also anti-iomedics that can be prescribed if your person is doing a lot of vomiting or diarrhea, which is why a lot of opiate withdrawal, in my opinion, which you know, what do I know, I think it's better under medically supervised care and not done on an outpatient basis. That way, there are nurses that can attend to these secondary symptoms that are wildly unpleasant. Benzos are your anti-anxieties. They're also system depressants. They're sedatives. They can be hypnotic and anti-anxiety and anxiolytic, anti-convulsant and muscle relaxants. Some athletes are prescribed benzodiazepines after they have a muscle strain in order to prevent muscle spasming and help the muscle recuperate more quickly. I'm trying to keep an eye on our time here. Short-acting and long-acting in your handout, I put a table that shows the different action of your different medications. Everything from Librium, which we know is commonly used in alcohol detox down to Valium and Xanax and Halcyon and some of your longer-acting drugs. Why is this important? Well, if we know that something stays in someone's system for a half-life of 20 hours and they're taking it every four, you can see where it might build up over time. Your benzos enhance the effect of GABA. GABA, you remember, is your common chemical that is synthesized from glutamine. Ingestion of the therapeutic dosages may be detectable for one to three days while extended use over a period of months or years can extend excretion times for up to four to six weeks after cessation of use. If you're working with someone who's on a benzo detox, not only, and I'll say it again later in the presentation, benzo detox can be very life-threatening. I believe up to 30% of people actually have grand mal seizures if they're doing it, not under physician's care. We don't want to encourage people to outpatient detox. So four to six weeks, people may still be excreting some of the benzos from their system, which means they also may be feeling some symptoms. Different tests are required for different benzos. Your alprazolam, which is your Xanax. Lorazepam, remember I said the lambs in the PAMs. Lorazepam is your Ativan. Clonazepam, which is your clonopin, don't share necessarily the same metabolic pathways. Due to individual differences between people and drugs, a standard therapeutic level is often hard to identify. Remember I said earlier, this is true with opiates too. If you want to really figure out if someone's taking it as prescribed, you need to get a baseline for that person and then monitor that. But be aware that our patients are very crafty and resourceful and they may try to accentuate the effect of the benzos by using other CNS depressants that wouldn't be picked up on the urine screen. Some of them are like cava, valerian, passionflower, antihistamines, those sorts of things that you wouldn't necessarily pick up on a urine screen, but they can greatly intensify the effect of the benza. Short-term impact, drowsy blurred vision, poor coordination, amnesia, hostility. It's amazing how all these drugs that people abuse can produce hostility. Anyway, disturbing dreams, reduced inhibition, and impaired judgment. Important side note, short-term effect of benzos in the elderly is confusion, the appearance of dementia, and potentially benzodiazepine overdose. And I will get to the question on the detox in just a second. Benzos do not leave the liver of the person or are not metabolized as quickly and leave the liver of the elderly person nearly as quickly as the non-elderly. So it is very easy for people who are elderly to start to have pretty significant cognitive and physical symptoms. Combining with other depressants has an exponential additive effect, roofenol is a benzodiazepine. Benzodiazepine used for three months or more was associated with an increased risk of Alzheimer's disease up to 51 percent, which, whoops, I guess I took that slide out. The American Society of Geriatric Medicine is actually recommended now that people who are elderly not be prescribed anti-anxiety medications, not be prescribed benzodiazepine specifically because of their long half-life and the risk of causing Alzheimer's-like symptoms and dementia. So now using over-the-counter products to clean your system before a drug screen, there are a lot of different products that can be used. And yes, the smoke shops can carry them. A lot of our clients will order them offline. In addition, they can find things like the Wisinator, which is a physical representation, if you will, of the male anatomy in order to pass a drug test, so you can load that up with clean urine. But they will also push water in order to flush it out of their system, which can be noted even if they try to take creatinine supplements. You'll see that their levels are all out of whack if you send it to the if you send it to the lab in order to go through the mass spec. So yes, there are a lot of different remedies out there, if you will, to help people pass a drug test. Will it help? Well, for your standard on-site P and a cup test, yeah, it will because it may get the metabolite low enough. So if you suspect that or even if you don't, best practice for urine screening really is to randomly and periodically send the urine off to the lab for a full mass spec to make sure you know what you're dealing with and see if the person is diluting. Benzo withdrawal, sleep disturbance, irritability, anxiety, panic attacks, difficulty in concentration, dry heaves and nausea, muscular pain, stiffness, seizures, and psychosis. Your symptoms for Benzos appear around the end of the half-life period. Now, if when you look at your chart that's in the handout, for many of these drugs, that may be 20 hours. If you don't start seeing detox symptoms at four hours, that's why you need to look at the half-life period. The rebound anxiety and insomnia peak within a couple of days. But if you take somebody who already had anxiety and then they've been abusing Benzos, the rebound anxiety is going to be almost unbearable. So be aware of this. It may be, it may really freak them out. I've seen people have back-to-back panic attacks almost consistently for a couple of days because their rebound anxiety was so bad. And there are ways to handle that if you're attending, chooses to. Withdrawal symptoms can last for two to four weeks. And protracted withdrawal is not uncommon and heavy and or long-term users. Where they go through, they have these withdrawal symptoms, they start feeling better and then one morning they wake up and it feels like somebody hit them with a truck. Based on the information that we have, given that most, sorry, responding to a question, would Benzos make symptoms worse in Alzheimer's clients? Since Benzos produced symptoms of dementia and can produce Alzheimer's symptoms in the elderly and since the majority of patients who get Alzheimer's are elderly, my answer to that question would be yes. If you've got someone who has Alzheimer's, they're probably elderly and giving them Benzos is probably going to exacerbate what symptomatology they currently have. According to the DSM-5, a grand mal seizure may occur in as many as 20 to 30% of individuals undergoing untreated, emphasis on untreated withdrawal from benzodiazepines. Remazacon is a competitive antagonist that can reverse the sedative and overdose effects of Benzos, but not of alcohol and other sedatives. So when we're talking about our depressants, if we're specifically talking about Benzos, there is a remedy, if you will, just like there is for opiate overdose. And quite honestly, I hadn't even heard of it until I started doing this presentation, which tells you that it's not one of the more common things to keep around in detox facilities. Benzos and the most frequently used class of drugs for anxiety disorders, 12.9%. And on the quizzes, I do not test you on your percentages because, you know, that's information that you can find anywhere, but it's not relevant to clinical care. Other depressants, GHB, acts on your GABA receptors too. Some athletes use GHB to elevate human growth hormone. It's also used as a date break drug. Hey, you know, not exactly sure how the two of those go together, but it is important to understand that some athletes may test positive for GHB. Non-benzosleep medications, such as Ambien-Lunesta and Sonata have a different chemical structure, but act on some of the same brain receptors as Benzos. And your barbitols are also used to reduce anxiety and help with insomnia. Our clients, if you work with patients with co-occurring disorders, our clients are likely to abuse these two categories of medications, so they're probably not going to be prescribed them legitimately. Inhalants, and I'm going to fly through some of these so we get out of here close to on time. Anything around the house, especially anything with the petroleum base or that's in an aerosol, can be huffed. Like I said, if it has the glitter stuff to it, it's probably got more of a punch than the flat. And markers, and that includes our dry erase markers that we used when we write on whiteboards. Herbs and supplements, valerian, melatonin, passion flower, and GABA supplements can all intensify other depressants. Muscle relaxants like flexoril, atypical antipsychotics, cerakill, trazadone, medications that our patients are regularly prescribed. If they're taking trazadone for their mental health and then they pull a muscle and they go to a different doctor and get flexoril, and oh hey, they take melatonin every night anyway to help them sleep, you know, they may actually put themselves into a respiratory distress. It's so important to encourage our clients to let us know all the OTC stuff they take, including vitamins, just so we can help them understand the interaction. We're not judging, we're informing. Depressants street names, a lot of them. If you go to the DEA website, you can find the most current information on the different depressants street names, and there's a link to that in your classroom. Hallucinogens, I've got five minutes. They cause hallucinations. They can be found in some plants or can be man-made. They can either cause hallucinations or dissociation, sort of an out-of-body experience. It acts on serotonin and glutamate systems, which regulate your mood, your sensory perception, sleep, hunger, temperature again, sexual behavior again, muscle control, pain perception, and learning and memory. So PCP is usually sold as a liquid or powder, can be snorted, smoked, injected or swallowed. Other dissociatives are ketamine, which is a common veterinary medication. It's odorless and tasteless and has amnesia-inducing dissociative properties, which it has been used to facilitate sexual assault. Dextromethorphan is a new one, well, new ER, if you will, that the youth are using now, especially taking it rectally. They get the extra strength, dextromethorphan, and then they take it rectally, which gives them a dissociative high. And then salvia divinorum, also known as diviner sage. This is not the same as the salvia that you've got in your garden, unless you specifically ordered those seeds. The salvia in the garden is salvia splendens, and the hummingbirds just love it, but it does not have the same effects as salvia divinorum. LSD goes by a lot of different names. It's a potent mood and perception alterer, clear, white, odorless, water soluble. I know when I went to the big thing that we did in high school before graduation, a lot of people were taking LSD and having really bad trips, so it is used a whole lot in recreation among college and high school students. Paodi comes from a spineless cactus, and part of the crown or the button is either chewed or brewed into a tea. Short and long-term impact. Again, this is in your handout. The biggest thing we want to look at is the hallucinations, the dissociation, and the potential for psychosis with the hallucinogens. Repeated use of PCP can result in long-term effects that may continue for a year or more, but when we start talking about hallucinogen persisting perceptual disorder, those people who have flashbacks years after taking the substance, that's a whole different ball game, and they still don't know exactly what causes that, but they pretty much have ruled out the there was a little bit left in my brain hypothesis. So stimulants range from caffeine to methamphetamine and amp up the system. Opiates, benzos, barbiturates, alcohol, and inhalants are all depressants. Combination of depressants will have an exponential effect. We need to evaluate patients for exposure to all CNS depressants intentional and incidental, and I mean like cough medicine and pain medicine in addition to psychotropic medicine that we don't think of like your atypical antipsychotics, we don't think of those necessarily as depressants, so we need to be aware of that. There are a whole host of hallucinogens from LSD to PCP, peyote, ketamine, and dextromethorphan. Obviously dextromethorphan is sold OTC, and recent research indicated that persistent perceptual disorder is not due to traces of the drug being freed up, but it is due to some sort of alteration in the brain chemistry. They still don't know what yet. So I made it under the wire with one minute, and I am more than happy to stick around and answer questions. You can log into the classroom now and take your quiz if you have time to do that, otherwise you have access to take the quiz for a while longer, about a week I think. My personal chat page is purechat.me-cue-tv-x. If you have questions that come up after the session and you know after we've actually closed out for the day and you want to you know shoot them to me, you can get me through my personal chat page, or you can send a support request to support at allceuse.com. Whatever is easier for you. Okay everyone, have a wonderful rest of your afternoon, and I will see you Thursday maybe.