Street Drug Guide Fall 2019 by ckohknox

STREET DRUGS GUIDE

First impressions: ABCs word art from first day of class

Created by pharmacy students in PHPR 48600 Beyond ecstasy Compiled by Cynthia P. Koh-Knox Sharp, PharmD, RPh Purdue University College of Pharmacy Fall 2019

Topic (Author) Page Amanita, psilocybin, peyote (Shannon Purcell) ....................................................................................... 3 Anabolic steroids (Yaw Appiagyei) ........................................................................................................... 5 Anesthetics (Emma Baker) ....................................................................................................................... 7 Ayahuasca (Krystapher Belton)................................................................................................................ 9 Barbiturates (David Bergsma) ................................................................................................................ 11 Bath salts (Elizabeth Besenhofer) .......................................................................................................... 13 Benzodiazepines (Megan Brelage)......................................................................................................... 15 Bromo-dragonfly (D'Asia Bullock) .......................................................................................................... 17 Caffeine and energy drinks (Katelyn Buchanan Butler) ......................................................................... 19 CBD/THC (Sienna Cooper) ...................................................................................................................... 21 Cocaine (Jordan Crew) ........................................................................................................................... 23 Dextromethorphan (Jessica Czajkowski) ............................................................................................... 25 Diamorphine (Madilyn Eberle)............................................................................................................... 27 Diuretics/laxatives (Noah Fawcett)........................................................................................................ 29 Drug deterrent opioids (Christian Fink) ................................................................................................. 31 Drug tests (Remington Griswold)........................................................................................................... 33 Electronic cigarettes (Emily Hall) ........................................................................................................... 35 Ethyl alcohol (Will Harris) ...................................................................................................................... 37 Fentanyl and carfentanil (Stephanie Hendricks).................................................................................... 39 Flakka (Blake Hill) ................................................................................................................................... 41 Flumazenil and naloxone (Matthew Hornfeck) ..................................................................................... 43 Gabapentin/pregabalin (Emily Johnson) ............................................................................................... 45 Gamma hydroxybutyrate (GHB) (Emily Klimek) .................................................................................... 47 Hashish (Jacob Kohley) .......................................................................................................................... 49 Heroin/opium (Alison Kwak) .................................................................................................................. 51 Ibogaine (Sharon Lee) ............................................................................................................................ 53 Inhalants (Moises Martinez) .................................................................................................................. 55 K-2 Spice (Donovan McDuffy) ................................................................................................................ 57 Khat (Maggie Miedema) ........................................................................................................................ 59 Kratom (Madison Modany) .................................................................................................................... 61 Krokodil (Thu Ngo) ................................................................................................................................. 63 Loperamide (Robert Sears) .................................................................................................................... 65 Lysergic acid diethylamide (LSD) (Crystal Nnaji) .................................................................................... 67 MAT agents (buprenorphine and naltrexone (Michael Nolan) ............................................................. 69 MDMA (Javier Aguirre) .......................................................................................................................... 71 Methamphetamine (Olivia Park) ........................................................................................................... 73 Naloxone (Matthew Hornfeck) .............................................................................................................. 43 Nicotine (Alexis Rini) .............................................................................................................................. 75 Nightshade (Emily Sajda) ....................................................................................................................... 77 Opioids Rx analgesics (Matthew Shotts)................................................................................................ 79 Phencyclidine (PCP) (Nicholas Sethman) ............................................................................................... 81 Pseudoephedrine (Jeremy Shen) ........................................................................................................... 83 Rohypnol (Brandon Short) ..................................................................................................................... 85 Rx anorectics (Hailey Stoker) ................................................................................................................. 87 Rx muscle relaxants (Joseph Stoker) ...................................................................................................... 89 Salvia divinorum (Sarah Tucker) ............................................................................................................ 91 Sedatives (Christina Wilder)................................................................................................................... 93 Sildenafil (Christen Wilhight) ................................................................................................................. 95 Stimulants (Spencer Tebbe) ................................................................................................................... 97

Amanita, Psilocybin, Peyote Shannon Purcell Student Pharmacist Fall 2019 History of Use Hallucinogenic mushrooms have been used as far back as 5,000 B.C. The Aztec people used these mushrooms in rituals and ceremonies. In 1521 the Europeans defeated the Aztecs and forbid the use of sacred mushrooms. During the 60’s mushrooms were part of the psychedelic movement and were used as part of spiritual traditions, therapeutically and recreationally. Possession of psilocybin was made illegal in the United States in 1968 and was added to the Controlled Substances Act in 1970. Medicinal and therapeutic uses were studied until 1977 but stopped due to strict governmental controls.1

Slang terms • Amanita: fly agaric mushroom.2 • Psilocybin: shrooms, magic mushrooms, sacred mushrooms, teonanàcatl3 • Peyote: peyote, buttons, mescalito4

Peyote

Amanita

Psilocybin

https://www.erowid.org/plants/p eyote/peyote.shtml.

https://www2.palomar.edu/users/ warmstrong/amanita.htm

https://www.erowid.org/plants/m ushrooms/mushrooms.shtml.

Pharmacology/drug effects Amanita, psilocybin and peyote all have psychedelic and hallucinogenic effects. Amanita contains ibotenic acid, a psychoactive toxin that is a glutaminergic NMDA receptor agonist and produces CNS excitatory effects. Muscimol, an ibotenic acid derivative, is a GABA receptor agonist and produces CNS depressive effects. Overall, there is a decreased level of dopamine in the brain, increased serotonin levels and impaired motor function.6 Psilocybin alters serotonin concentration in the CNS by acting as a serotonin transporter inhibitor and a 5-HT2A receptor agonist. This may alter the processing, transmission and perception of external stimuli.5 Peyote has affinity for the 5-HT2A receptor and has similar effects to those of psilocybin.7

Drug interactions/Toxicology No well documented drug interactions were found. Possible toxic effects are mostly associated with hallucinogenic effects. These include panic, psychosis, paranoia, frightening hallucinations, increased blood pressure, breathing rate and body temperature. Another toxic effect associated with but not directly caused by these mushrooms is the possibility that someone consumes a mushroom that is poisonous thinking it is one with psychedelic effects.8

•

• • • •

Monitoring/Drug Screens No specific monitoring parameters were found; monitor for toxic effects Not included in most panel drug tests Can be detected in blood Quest Diagnostics and NMS Labs offer urine tests for psilocybin and its metabolite psilocin; however, the drug may be cleared from a person’s system in less than a day.12

Laws Amanita o Un-scheduled o Legal to possess, cultivate, distribute without a license or prescription o If it is sold as a supplement or for consumption it is regulated by the government9 Psilocybin o Made Schedule 1 by the Controlled Substance Act o Illegal to cultivate or possess o Can be used for scientific research with special license from DEA10 Peyote o Schedule 1 under the Controlled Substance Act, making it illegal for recreational use o Legal for the Native American Church to use peyote in religious ceremonies11

Professional Opinion Mushrooms with psychedelic and halluci nogenic effects can have various toxic side effects and the use of these mushrooms may lead to an overdose or accidental consumption of poisonous mushrooms that could leado tdeath. Additionally, these mushrooms do not seem to have any significant therapeutic benefit. One of the main effects of these mushrooms is increasing serotonin. There are medications approved by the FDA and associated wit h fewer risks than mushrooms that have this same effect. However, mushrooms such as peyote have a place in some religious and spiritual ceremonies. In these situations, use of the mushrooms should be monitored due to possible toxic effects. ~ S. Purcell

References 1. The Vaults of Erowid. Psilocybe Mushroom History. Available at: https://www.erowid.org/plants/mushrooms/mushrooms_h istory.shtml. Accessed October 26, 2019. 2. Wayne’s Word. Old & New World Hallucinogenic Mushrooms. Available at: https://www2.palomar.edu/users/warmstrong/amanita.ht m. Accessed October 26, 2019. 3. The Vaults of Erowid. Psilocybin Mushrooms. Available at: https://www.erowid.org/plants/mushrooms/mushrooms.s html. Accessed October 26, 2019. 4. The Vaults of Erowid. Peyote. Available at: https://www.erowid.org/plants/peyote/peyote.shtml. Accessed October 26, 2019. 5. Psilocybin. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com. Accessed October 26, 2019. 6. Isoxazoles. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com. Accessed October 26, 2019. 7. Peyote. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com. Accessed October 26, 2019. 8. Drugs.com. Psilocybin (Magic Mushrooms). Available at: https://www.drugs.com/illicit/psilocybin.html. Accessed October 26, 2019. 9. 9. The Vaults of Erowid. Psychoactive Amanitas Legal Status. Available at: https://erowid.org/plants/amanitas/amanitas_law.shtml. Accessed October 26, 2019. 10. Drug Policy Alliance. Are psilocybin mushrooms illegal? Available at: http://www.drugpolicy.org/drug-facts/arepsilocybin-mushrooms-illegal. Accessed October 26, 2019. 11. Addiction Resource. Is Peyote Legal? Historical and Current Peyote Legal Status. Available at: https://addictionresource.com/drugs/peyote/peyote-legalstatus/. Accessed October 26, 2019. 12. Very Well Mind. How long Does Psilocybin Stay in Your System? Available at: https://www.verywellmind.com/how-long-doespsilocybin-stay-in-your-system-80319. Accessed October 26, 2019.

YAW APPIAGYEI Student Pharmacist Fall 2019

ANABOLIC STEROIDS

HISTORY

AKA ‘ROIDS’ or ‘JUICE’

Testosterone was first made in Germany in 1935 and was used for depression treatment. Professional athletes began abusing steroids during the 1954 Olympics and later extended to the public in the 1980S. In 1990, congress then passed a law to challenge the increase availability and use of steroids by making it a controlled substance and later on banning its sale as an over the counter drug in 2004. They also increased the penalties for possessing, selling and making anabolic steroids making steroids legal. Steroids are still legal over the counter in other countries such as Canada and Mexico and this serves as a way steroid get into the US despite all the regulation.

Example: Nandrolone

PHARMACOLOGY Anabolic steroids are synthetic substances similar to androgenic hormones such as testosterone. Steroids enhance tissue building by stimulating receptors in muscle cells to activate specific genes for protein production. They also inhibit protein degradation by affecting the rate of degrading enzyme.

DRUG EFFECTS There is potential for abuse of anabolic steroids due to their testosterone like effects making the abuse high in people trying to build muscle. They increase tissue binding in the body. Since steroids are used at very high doses to increase muscle and tissue production, there is an increased stimulation of receptors. In the long run, anabolic steroids can cause many complications to the liver and the kidneys

LAWS In 1990, congress passed a law that made steroids a controlled drug as to control how steroids were used. In 2004, congress started the Anabolic steroid act of 2004 that banned the over the counter sale of anabolic steroids and increased the penalties for making, selling or possessing anabolic steroids.

DRUG INTERACTION Anabolic steroids have interactions with drugs such as bupropion, warfarin, acenocoumarol, anisindione, glimepiride, phenindione, phenprocoumon.

Professional opinion MONITORING/Toxicology Anabolic steroids should be used with caution due to their effects on the body. Use of anabolic steroids in high doses can lead to negative mental effects such as paranoia, irritability, and impaired judgment. Anabolic steroids need to be monitored because Long term use can lead to Liver and kidney damage. They also cause an increased risk of stroke and heart attacks due to heart enlargements and cholesterol changes.

Steroids have a legitimate need in in the healthcare system to treat people with hormonal issues. steroids should not be highly restricted because they prevent people who need them from having access without a prescription. Making them illegal defines the abuse therefore increasing the potential to actually abuse the drugs. Alternate formulation changes and reduction of access to large doses of steroids could or even making them behind the counter would go a long way in controlling anabolic steroid use. ~ Y. Appiagyei

References 1. 2. 3. 4. 5. 6.

National Institute of drug abuse. Steroids and other appearance and performance enhancing drugs. (APEDs). Available at: Steroids and Other Appearance and Performance Enhancing Drugs (APEDs). Accessed October 29, 2019. Nandrolone. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 29, 2019. National Institute of drug abuse. Anabolic Steroids. Available at: https://www.drugabuse.gov/publications/drugfacts/anabolic-steroids. Accessed October 29, 2019 WebMD. Anabolic steroids. Available at: https://www.webmd.com/men/anabolic-steroids#1-3. Accessed October 29, 2019. Streetdrugs. Anabolic steroids. Available at: https://streetdrugs.org/605-2/. Accessed October 29, 2019. Encyclopedia of sports medicine and science. anabolic-androgenic steroids: Mechanism of Action and Effects on Performance. Available at: https://www.sportsci.org/encyc/anabster/anabster.html. Accessed October 29, 2019.

Emma Baker ` Student Pharmacist Fall 2019

Slang Terms •

•

Anesthetics

•

Pharmacology/Drug Effects •

•

Phencyclidine: a hallucinogen; a glutamatergic NMDA receptor blocker that binds to sites in the brain’s cortex and limbic structures—effecting dopamine, norepinephrine and serotonin release and reuptake Ketamine: a dissociative anesthetic; distorts perception of sight, sound, and produces feelings of detachment from the environment and self. Propofol: short acting, causes global CNS depression; complex actions on the nervous system

Phencyclidine/PCP o PCP o the peace pills o ozone o rocket fuel o love boat o superweed Ketamine o K o Special K o cat Valium o vitamin V Propofol (Diprivan) o “milk of anesthesia”

Background/History •

•

Phencyclidine: Was originally developed in the 1950s as a general anesthetic for surgery and later utilized by veterinarians as an animal tranquilizer. PCP entered the street scene in the 1960s in San Francisco. Ketamine: In 1970, the FDA approved ketamine for human use as a general anesthetic. The first evidence of illicit abuse of the drug was on the West Coast in the 1970s. Propofol: Originally developed in the UK following research into sedatives, but first anesthetic properties were reported in January 1973. Received FDA approval in October 1989 for therapeutic uses.

Common Uses/Known Uses •

•

Phencyclidine o Used for its mind-altering/ psychedelic effects. o Can be snorted, swallowed, or smoked (most common). o Pharmaceutical-grade PCP is still being manufactured and used in veterinary medicine. Ketamine o In social situations, used intranasally and orally to receive rapid effects; used IV in hospitals/under professional care. o Currently used as an anesthetic for humans and animals o Much ketamine sold on the street have been diverted from veterinary offices o Can be added to drinks to facilitate sexual assault Propofol o anesthesia: loss of consciousness, acting as a general anesthesia in a major surgery o Off label: ▪ Treatment of postoperative nausea and vomiting ▪ Epilepticus o Mostly abused by health care staff Propofol and Michael Jackson o Michael Jackson wanted to use as a sleep aid. o Jackson’s personal doctor, Conrad Murray MD, states that he only gave him 50mg doses, then lowered it to 25 mg to wean him off o Those doses were not lethal, but when mixed with benzodiazepines, like Valium, it could result in respiratory arrest, which is what most likely happened.

Professional Opinion

Drug interactions/ Toxicology •

Certain anesthetics, approved by the FDA, are critical for performing safe and effective surgeries under professional care. Any other use should be discouraged due to potential for abuse. -Emma Baker

• •

Monitoring/ Drug Screens •

•

Phencyclidine: can be found in urine 4-6 hours after use and remains there for 7-14 days, depending on the user. Ketamine: Rapidly metabolized by the body and is difficult to detect through urine or blood; is undetectable by 48 hours after ingestion Propofol: During monitored anesthesia care (MAC) sedation, attention must be given to the cardiorespiratory effects

Phencyclidine: apraclonidine ophthalmic, brexanolone, brimonidine ophthalmic, brimonidine topical, esketamine, flibanserin, ioflupane I 123 Ketamine: epinephrine, fentanyl, doxapram, norepinephrine, memantine, phenylephrine, selegiline, and over 171 other drugs. Propofol: There is no antagonist or reversal medication for propofol toxicity. There is a total of 120 drugs that interact including Ativan, fentanyl, diluadid, morphine, valium, Xanax, and versed.

Laws • •

•

Phencyclidine o Became illegal in 1978; Scheduled II substance Ketamine o Schedule III substance o Illegal to abuse Propofol o not scheduled under the Controlled Substances Act

Sources: American Addiction Centers Editorial Staff. PCP Facts, History and Statistics: Dangers and Legality. DrugAbuse.com. https://drugabuse.com/pcp/history-statistics/. Published June 12, 2019. Accessed October 29, 2019. Chidambaran V, Costandi A, D'Mello A. Propofol: a review of its role in pediatric anesthesia and sedation. CNS drugs. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4554966/. Published July 2015. Accessed October 29, 2019. Doheny K. Propofol Linked to Michael Jackson's Death. WebMD. https://www.webmd.com/pain-management/news/20090824/propofol-linked-to-michael-jacksons-death#1. Published August 24, 2009. Accessed October 29, 2019. Ketamine (Ketalar): Side Effects, Dosages, Treatment, Interactions, Warnings. RxList. https://www.rxlist.com/consumer_ketamine/drugs-condition.htm. Published April 14, 2017. Accessed October 29, 2019. NIDA. Hallucinogens and Dissociative Drugs. National Institute on Drug Abuse website. https://www.drugabuse.gov/publications/research-reports/hallucinogens-dissociative-drugs. February 1, 2015. Accessed October 29, 2019. Phencyclidine Drug Interactions. Drugs.com. https://www.drugs.com/drug-interactions/phencyclidine.html#list. Accessed October 29, 2019. Wehrwein P. Propofol: the drug that killed Michael Jackson. Harvard Health Blog. https://www.health.harvard.edu/blog/propofol-the-drug-that-killed-michael-jackson-201111073772. Published November 7, 2011. Accessed October 29, 2019. Vial and syringe photo: https://www.health.harvard.edu/media/content/images/anesthesia-doctor-needle-shot.jpg Propofol photo: https://www.drugaddictiontreatment.com/wp-content/uploads/2013/01/propofol.jpg

Ayahuasca

Pharmacology

Other names: Appane, Ayahoasca, Caapi, Chacrona, Chacruna, Chaliponga, Daime, Hoasca, Jagube, Jurema, Kawa, Mariri, Natem, Ooasca, Queen, Rainha, Soulvine, Yagé, Yajé.

Krystapher Belton Student Pharmacist Fall 2019

https://erowid.org/plants/show_image.php 1

History Ayahuasca is a term for the Banisterioopsis Caapi vine and for the hallucinogenic brew made from the plant and a DMTcontaining plant called Psychotria viridis. The word ayahuasca means “vine of the souls” and is common in South America

First western record of the psychoactive effects of B. caapi was in Brazil in 1852. Several reports were done on ayahuasca in the mid-1800s, leading to a popularization of the drug in the West. By the late 20th century, many north americans and Europeans traveled to South America to try ayahuasca in a “traditional”setting. Nowadays ayahuasca brews are sold by street vendors all throughout South America

DRUG EFFECTS Onset of drug effects usually begin around 20-60 minutes after indigestion, depending on how much and how recent it was eaten. The drug’s peak effects last for about 2-6 hours, with lingering effects lasting for 1-8 hours depending on the size of the dose. During the period of peak effects, the person experiences euphoria, visual and auditory hallucination, paranoia, mind-altering psychedelic effects, fear, diarrhea and vomiting. The effects experienced vary with people either having the euphoria and enlightenment or fear and anxiety. There is also some evidence of ayahuasca use for depression, addiction, suicide prevention, anxiety, impulse control, insomnia, pain and cancer.

Ayahuasca the plant contains Bcarboline alkaloids, chiefly harmine, harmaline and tetrahydroharmine. The brew also contains N.N-dimethyltryptamine (DMT), a psychedelic 5-HT agonist. B-carbolines reversibly inhibit monoamine-oxidase (MAO), which prevent oxidative deamination of DMT and allows it to be absorbed into the central nervous system. The metabolism and excretion of DMT and B-carbolines has not been thoroughly studied in humans. Instead other analytical methods have been used such as high-performance liquid chromatography, to evaluate the metabolism and disposition of ayahuasca alkaloids in humans. Results showed that less than 1% of DMT was excreted unchanged. DMT was recovered as indole-3acetic acid (~50%), DMT-N-oxide (10%) and other MAOindependent compounds.

Toxic/Adverse Effects: •

Law The plant parts of ayahuasca are not federally controlled in the US, but the DMT in it is Schedule I in many nations like the US. Therefore ayahuasca is illegal. Harmala alkaloids are Schedule III in Canada and the plant analogues are illegal in France. Ayahuasca has been legal in Brazil for religious purposes since the late 1980s.

Drug Testing

Drug Interactions • •

• • • • •

Flu-like symptoms (i.e. N/V/D, body aches, sweats/chills,etc.) Fear and paranoia Disequilibrium Feeling of loosing ones mind Feeling that you’re dying Overwhelming feelings

Prozac- can lead to coma or death Ampetamines-can lead to hypertensive crisis

The best way to test for ayahuasca would be to test for DMT. DMT is metabolized by the body very quickly and the usually hallucinogenic blood and urine analysis only finds trace amounts of DMT. Results are difficult to confirm.

Professional Opinion

https://erowid.org/chemicals/s how_image. 1

Ayahuasca is a recreational drug used widely around the world for its hallucinogenic and euphoric effects. Studies are still being conducted on its pharmacology, toxic effects and benefits. Possible benefits that are being investigated include treating depression, anxiety, drug and alcohol addiction, insomnia and other problems. Ayahuasca is not believed to have any physical or psychological dependence, and has not shown withdrawal effects. ~ K. Belton

References: Riba J, Mcllhenny EH, Valle M et al. Metabolism and disposition of N,N-dimethyltryptamine and harmala alkaloids after oral administration of ayahuasca. PubMed 2012; 4(7-8):610-6. DOI: 10.1002/dta.1344. WebMD. Ayahuasca. Available at: https://www.webmd.com/vitamins-supplements/ingredientmono-1550ayahuasca.aspx?activeIngredientId=1550&activeIngredientName=ayahuasca Erowid. Ayahuasca. Available at: https://erowid.org/chemicals/ayahuasca/ayahuasca.shtml Savinelli A, Halpern JH. MAOI Contraindications. MAPS 1995;6(1):58. Very Well Mind. How long Does DMT Stay in Your System?. Available at: https://www.verywellmind.com/how-longdoes-dmt-stay-in-your-system-80239.

David Bergsma Student Pharmacist Fall 2019 Central Nervous System Depressants “Downers, Barbs, Bluebirds”

Background of Abuse Barbiturates were first used in the early 1900s to treat anxiety, seizure disorders, and insomnia. They started to become popular recreational drugs in the 1960s, and people would use them to treat the unwanted side effects of illicit drugs. Since the 1970s, barbiturate use/abuse has been on the decline, because a much safer group of drugs called Benzodiazepines has been introduced that works very similarly. Addiction to barbiturates is uncommon today, although barbiturate use among teenagers may be increased compared with the early 1990s.

https://www.webmd.com/drugs/2/drug-8689/ phenobarbital-oral/details https://www.1800petmeds.com/Phenobarbital+Tablets-prod11828.html

Pharmacology Barbiturates increase the activity of gamma-aminobutyric acid (GABA) in the brain. GABA is a chemical that inhibits activity in the

Drug Effects

brain. Specifically, barbiturates modulate the GABA receptor by

Physical effects: Small doses produce calmness

binding to the allosteric site and

and relax the muscles. Large doses can cause

increasing the duration of channel

slurred speech, poor judgement, and staggering.

opening. These drugs have a very

These drugs slow down the heartbeat, breathing,

long half life, meaning that they

and reflexes. Abruptly stopping regular use of

accumulate in the body and have a

these drugs can cause seizures.

high risk for overdose. Unlike

Psychological Effects: Barbiturates induce a

benzodiazepines, the drug that has

feeling of tranquility, euphoria, and temporary

come to replace them, the CNS

relief of anxiety. Prolonged use induces

effects of barbiturates don’t slow

tolerance, and withdrawal symptoms include

down at very high doses. Extreme

insomnia, restlessness, and anxiety.

doses can cause coma and death.

Monitoring

Laws Currently most of the widely used barbiturates are Scheduled drugs, although they fall into different categories depending on their potential for abuse.

If a patient has overdosed on a Barbiturate, the following should be monitored while waiting for the drug to be eliminated from the body: •

Temperature

•

Pulse

Schedule III: butabarbital

•

Breathing

Schedule IV: phenobarbital, mephobarbital

•

Blood pressure

Schedule II: amobarbital, secobarbital

Professional Opinion Barbiturates can be somewhat effective for treating anxiety and sleep disorders, but with the availability of Benzodiazepines there’s really no justification for their use. The addictive properties of barbiturates coupled with their dangerous side effects and risk of death when overdosed make Barbiturates a very niche medication with few uses in practice. - D. Bergsma

Interactions/ Toxicology Barbiturates are CYP3A4 inducers and may decrease the concentration of any drug metabolized by this enzyme. They should also be avoided if a patient Is taking an opioid painkiller, as they can decrease serum concentrations of those drugs. Alcohol should be avoided, because barbiturates can increase its CNS depressant effects. Toxic effects include convulsions and unconsciousness.

REFERENCES 1. Anderson, L.. CSA Schedules. Available at: https://www.drugs.com/csa-schedule.html. Accessed on October 30, 2019. 2. Fookes, C. Barbiturates. Available at: https://www.drugs.com/drug-class/barbiturates.html. Accessed on October 30, 2019. 3. George Mason University. Barbiturates. Available at: http://www.gmu.edu/resources/facstaff/facultyfacts/1-2/barb.html. Accessed October 30, 2019. 4. National Institute of Drug Abuse. Prescription CNS Depressants. Available at: https://www.drugabuse.gov/publications/ drugfacts/prescription-cns-depressants. Accessed on October 30, 2019. 5. Phenobarbital. Drug Facts and Comparisons. Facts and Comparisons eAnswers. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: https://fco.factsandcomparisons.com/lco/action/doc/retrieve/docid/fc_dfc/5549383 . Accessed October 30, 2019. 6. WebMD. Barbiturate Abuse. Available at: https://www.webmd.com/mental-health/addiction/barbiturate-abuse#1. Accessed on October 30, 2019.

From: https://www.google.com/url?sa=i&source=i mages&cd=&ved=2ahUKEwiCntKrlLrlAhXkh

BATH SALTS Elizabeth Besenhofer Fall 2019 HISTORY

From:

https://www.rightstep.com/rehabblog/bath-salt-drugs-really-bathsalts-learn-difference/

Bath Salts were first synthesized in France in the late 1920’s. They were first made to be used in medical practice, but never were because of the harsh side effects including dependence. The Soviet Union first started to abuse these drugs in the 1930’s and 40’s because they were being used as antidepressants and people began to become addicted. Spread of the abused products reached America in the 1990’s. In 2007 the drug got even more popular because it started to be able to be purchased online. In 2012 the US made the two main bath salt ingredients illegal, but drug makers quickly made new substances that are still sold today and are even sold openly as “Glass Cleaner”.

SLANG The chemical name for bath salts is substituted cathinones. Bath Salts are sold under many different “brand” names. These names include: Bliss, Blue, Silk, Cloud Nine, Drone, Energy-1, Ivory Wave, Red Dove, Snow Leopard, Stardust, Vanilla Sky, White Dove, White Knight, and White Lightning.

PHARMACOLOGY From: https://www.healthstreet.net/product/bath-salts/

The true pharmacology of synthetic cathinones is still largely unknown, but they do act similarly to amphetamines, cocaine, and MDMA. 3,4-methylenedioxypyrovalerone is the most common substance in bath salts and affects the brain like cocaine but 10 times more powerful. The effects of bath salts are paranoia, hallucinations, friendliness, increased sex drive, panic attacks, and excited delirium. Synthetic cathinones also increase heart rate and blood pressure causing chest pain. The is a serious side effect especially in patients using them with cardiovascular problems. Snorting or injecting the drug results in worse outcomes, but death is seen in all formulations.

REFERENCES

Anderson L. Drugs.com. Bath Salts Drug. Available at: https://www.drugs.com/illicit/bathsalts.html. Accessed October 26, 2019. Drug Free. Bath Salts. Available at: https://drugfree.org/drug/bath-salts/. Accessed October 26, 2019. Drug Free World. Bath Salts: A Short History. Available at: https://www.drugfreeworld.org/drugfact s/synthetic/bath-saltshistory.html#targetText=Abuse%20of%20t hese%20drugs%20started,key%20ingredie nt%20was%20made%20illegal. Accessed October 26, 2019. Moran J, Seely K. AACC. Bath Salts. Available at: https://www.aacc.org/publications/cln/ articles/2014/march/bath-salts. Accessed October 26, 2019. National Institute on Drug Abuse. Synthetic Cathinones. Available at: https://www.drugabuse.gov/publications /drugfacts/synthetic-cathinones-bathsalts. Accessed October 26, 2019.

TOXICOLOGY/DRUG INTERACTIONS During an overdose on bath salts the bath salts are stimulating the central nervous system stimulation and to treat the symptoms of this a patient may need IV benzodiazepines and/or antipsychotics and even restraints. The rest of care for an overdose patient is just supporting the symptoms with hydration, cardiac care, and electrolytes. During an overdose, rhabdomyolysis also may occur and should be monitored.

LAW In 2012, Barack Obama signed a law making mephedrone, methylone, and MDVP, the main chemicals used in bath salts, a schedule I controlled substance. This means that it is illegal to sell bath salts and it cannot be used for medicinal purposes and it means that any future drugs that mimic the effect of bath salts. It is also illegal to have bath salts in your possession.

MONITORING/TESTING Testing for bath salts is a challenge as they cannot be detected using normal standardized drug tests. Bath Salts can be detected using liquid chromatography/tandem mass spectrometry, gas chromatography/mass spectrometry, and liquid chromatography/timeof-flight mass spectrometry by research laboratories. These are complicated tests though and drug makers keep changing the chemicals in the drug which further increases the difficulty to test for these drugs.

PROFESSIONAL OPIONION In my professional opinion, bath salts are a very dangerous and addictive substance. These substances are especially dangerous because they are synthetic human-made chemicals that are not regulated and the specific ingredients in them are changed often. This leaves a lot of room for error and tampering in the drug which can add on to the negative effects of the drug or add more negative effects to the drug. These drugs should be illegal and monitored because of their danger and addictive nature. Patients who are addicted to this substance should receive help by cognitive/behavioral therapy to address the addiction and by medical professionals to treat the adverse effects of the drug/help with the withdrawal of the drug. ~ E. Besenhofer

Benzodiazepines Alprazolam (Xanax) Clonazepam (Klonopin) Diazepam (Valium) Lorazepam (Ativan)

Other Common Names: Benzos Downers

Pharmacology and Drug Effects: Benzodiazepines act on the central nervous system, producing sedation, relaxing muscle, and lowering anxiety levels. They inhibit gammaaminobutyric acid which is a neurotransmitter, decreasing brain activity.

www.webmd.com

Megan Brelage Student Pharmacist Fall 2019

History and Background of Use/Abuse: Benzodiazepines have been on the market for over 50 years. They are widely prescribed and heavily used. It was in the 1980â&#x20AC;&#x2122;s where health care providers began to worry about the dependence and abuse of benzodiazepines. Benzodiazepines are physically and psychologically dependent. Many people who abuse them abuse them with other substances. They enhance the feeling of euphoria when taken with alcohol and opioids. There is very little genetic disposition. Common environmental influences are socioeconomic status, unemployment, and peer pressure.

Drug Interactions & Toxicity: Antidepressants and oral contraceptives can result in a build up of drugs in the body and if taken with benzodiazepines will worsen side effects Some antibiotics such as rifampicin and anticonvulsants such as carbamazepine and phenytoin decrease the impact of benzodiazepines Benzodiazepines should never be taken with alcohol or opioids. This interaction is very toxic and could be fatal.

Law:

Professional Opinion:

Benzodiazepines are a scheduled

Benzodiazepines are proven affective for treating anxiety, insomnia, muscle spasms, reducing seizures, and alcohol withdraw. Although these drugs can be fatal if taken with alcohol or opioids and can become addictive, the therapeutic benefit outweighs the risk. However, this medication should be prescribed with caution. Prescribers need to address the patient as a whole and make sure it is appropriate for the patient. ~ M. Brelage

IV controlled drug

Monitoring & Drug Screening: Urine drug screening can be done to see if an individual has any benzodiazepines in his or her system. However, the urine test cannot tell the amount of drug in oneâ&#x20AC;&#x2122;s system.

References: Drug Enforcement Administration. Benzodiazepines. Available at: https://www.deadiversion.usdoj.gov/drug_chem_info/benzo.pdf. Accessed October 20, 2019. Drug Enforcement Administration. Drug Fact Sheet: Benzodiazepines. Available at: https://www.getsmartaboutdrugs.gov/sites/getsmartaboutdrugs.com/files/Benzodiazepines_R.pdf. Accessed October 26, 2019. PubMed. The History of Benzodiazepines. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24007886. Accessed October 20, 2019. WebMD. After Opioids, Benzodiazepines Use Raises Concern. Available at: https://www.webmd.com/mental-health/addiction/news/20190206/after-opioids-benzodiazepine-use-raises-concerns. Accessed October 20, 2019. WedMD. Benzodiazepine Abuse. Available at: https://www.webmd.com/mental-health/addiction/benzodiazepine-abuse#1. Accessed October 20, 2019. (Picture)

Pharmacology:

BROMODRAGONFLY Slang Terms: Fly, BDF, Bromo-DragonFLY, DOBDragonfly, Br-DF

History/background: Bromo-Dragonfly is a synthetic psychedelic that acts as a stimulant reflecting the experience of altered consciousness. In 1998 the drug was first synthesized by Matthew Parker to investigate the structure and activity of the serotonin receptors in the brain for animal studies. This chemical has little to no reports of human use.

http://killtheheroinepidemicnationwide.org/wpcontent/uploads/2017/08/c3Pww.jpg

D'ASIA BULLOCK Student Pharmacist

Fall 2019

There is limited information regarding the metabolism of the drug within the human body. Bromo-Dragonfly is classified as a non-selective 5-HT2 receptor agonist that acts on the serotonin receptor. The binding of this drug to the receptor will effect the consumers mood, sensory perception, body temperature, muscle control, and sexual behavior. Bromo-DragonFLY has an onset of 20-90minutes, peaks within a few hours, effects plateau for 6-12 hours after ingestion and then gradually wear off. Total duration of action is typically 12-24 hours, but can last up to three days.

Drug Effects: Positive effects according to consumers: High energy levels Ego-softening Decreased appetite Hallucinations Negative effects according to consumers: Short-term memory loss and confusion Muscle tension Sleep disturbances Nausea

Drug Interactions Cannabis Ketamine Stimulants Lithium

MONITORING/DRUG SCREENINGS There is a test available that detects a minimum of 1.0ng/mL Bromo-Dragonfly using liquid chromatography-tandem mass spectrometry. Urine sample tests that require secondary procedures to confirm potentially positive tests are also available.

LAWS

Toxicology http://2.bp.blogspot.com/xqluiwT8t2g/TzFzFLhKFAI/AAAAAAAAA_8/Oq5OTrbqLAc/s320/D%2B Fly%2BB.JPG

REFERENCES: 1 Erowid. Bromo-Dragonfly. Available at: https://erowid.org/chemicals/bromo_dragonfly/. Accessed October 27, 2019. 2. Detox, Briarwood. Briarwood Detox Center. Designer Drugs you Need to Know About. Available at: https://www.briarwooddetox.com/blog/3-designer-drugs/. Accessed October 27, 2019. 3. TestCountry. What you Should Know About Bromo-DragonFLY. Available at: https://testcountry.com/pages/all-you-need-to-knowabout-lsd-acid. Accessed October 27, 2019. 4. Promo Choice. Bromo-DragonFLY. Available at: https://promochoices.blogspot.com/2018/05/bromo-dragonfly.html. Accessed October 27, 2019. 5. ADDICTIONLINK.FL. Bromo-DragonFLY. Available at: https://paihdelinkki.fi/en/info-bank/articles/drugs-and-otherintoxicants/bromo-dragonfly. Accessed October 27, 2019.

Bromo-Dragonfly is dosed in mcg, which increases the chances of an overdose occurring. Elevated of the drug in the body can cause the consumer to experience any of the following: vasoconstriction leading to tissue necrosis in extremeties, heart problems, flushing, hallucinations, paranoia, seizures, and death.

Bromo-Dragonfly is not regulated in the United States, and is not approved for human consumption. The drug can be considered as a controlled substance (2C-B analog) meaning that "sales of Bromo-Dragonfly for human consumption or possession with the intent to ingest could be procecuted under the Federal Analogue Act." Bromo-Dragonfly is considered illegal in the following European countries: Finland, Sweden, Norway, and Denmark.

PROFESSIONAL OPINION As a student pharmacist, I do not recommend the use of Bromo-DragonFLY. There is a limited amount of research regarding the usage of the drug. Researches have not been able to determine the metabolism and toxicity effects of this drug in humans. The inability to predict the effects of the drug may be the reason for the notably large fatalities associated with human consumption of Bromo-Dragonfly. The lack of reliable information on the potency of the drug increases the harm in human consumption, and with that being said I do not recommend the use of Bromo-Dragonfly. - D'Asia Bullock

Caffeine & Energy Drinks

Katelyn (Buchanan) Butler Fall 2019

Pharmacology1,2

Slang terms: “go-go juice,” “liquid energy”, coffee, tea, “java,” “cuppa joe” [stimulant]

Caffeine is a xanthine alkaloid, that readily crosses the blood-brain barrier to elicit its effects.

Drug Effects2

Caffeine’s primary

When taken orally, caffeine takes 15-45 minutes mechanism involves the to reach its peak effect, and lasts 2 to 4 hours. https://marquettewire.org/3919444/tribun blockage of adenosine e/tribune-news/coffee-deemed-healthierPositive effects of caffeine include decreased alternative-to-energy-drinks/ receptors and boredom and depression, increased alertness and physical stamina, and increased performance on phosphodiesterase (PDE) repetitive tasks. enzymes. Blocking the Negative effects include increased anxiety and adenosine receptors nervousness at high doses (especially with energy indirectly affects the drinks), increased jaw tension, increased heart rate, release of respiration, basal metabolic rate, GI reflexes, and norepinephrine, withdrawal symptoms with cessation of use.

History3,4

https://caffeineandyou.wor dpress.com/historyandback ground/

Caffeine has been a part of our global history for thousands of years. The exact origin of caffeine is unknown; however, folk stories suggest it originated in Ethiopia with the discovery of cocoa beans. Caffeine was first extracted into its purest form in the 1820s by a German scientist named Friedrich Ferdinand Runge. Energy drinks originated in Japan to replace the use of amphetamines when laws were passed to curb their use in the 1950s. In 1962, the first commercial energy drink was introduced by Taisho as “Lipovitan D,” a legal, energizing tonic sold in minibar-sized bottles. By the 1980s, energy drinks increased in popularity by Japanese executives trying to “get ahead,” which pushed manufacturers to expand their market. In the 1990s and early 2000s, formulations such as Red Bull, Monster, and Rockstar began to take over the market.

dopamine, acetylcholine, serotonin, glutamate, and GABA, thus promoting stimulatory effects. Inhibiting PDE increases intracellular cAMP, which promotes the availability of fuels for the body. When orally administered, caffeine is absorbed in the stomach and small intestine. Caffeine is renally excreted unchanged in the urine.

Professional Opinion In moderation, caffeine can be an effective stimulant with little/minor harmful effects. Drinking a cup of coffee or tea a day is not likely to elicit many negative effects. On the other hand, energy drinks have negative effects due to their high caffeine concentration and contents of other harmful additives. Because of this, energy drinks should be consumed in low quantities with much caution. Although the abuse potential of caffeine is relatively low, caffeine can be addictive and can still elicit negative effects at high doses. ~ K. Butler

Drug Interactions/Toxicology2,6 Caffeine’s contraindications include patients with stomach ulcers, generalized anxiety or panic disorder, and pregnancy. Drug interactions with caffeine include CYP1A2 substrates (i.e. tobacco), other phosphodiesterase inhibitors (i.e. riociguat), CNS stimulants, and amphetamines. High doses (250-750 mg) can cause insomnia, anxiety, tension, nausea, headache, and irregular heartbeat. Very high doses (750 mg-1 g) can cause toxic symptoms, such as nausea, vomiting, tremor, seizures, and irregular heartbeat. The lethal dose for humans is estimated between 3-20 g.

https://caffeineandyou.wordpre ss.com/historyandbackground/

Laws2 Caffeine is legal in every country around the world. In the US, the FDA limits caffeine content to 72 mg per 12 ounce serving. Energy drinks are not limited to this rule, because they are allowed as “dietary supplements” rather than food.

Monitoring/Drug Screens5 Currently, no there is no information on tests or screens for abuse. For monitoring in clinical practice, caffeine and it’s metabolites can be measured in the urine.

References: 1. DrugBank. Caffeine. Available at: https://www.drugbank.ca/drugs/DB00201. Accessed October 27, 2019. 2. The Vaults of Erowid. Caffeine. Available at: https://www.erowid.org/chemicals/caffeine. Accessed October 3, 2019. 3. Caffeine: The Good, the Bad, and the Maybe. History and Background. Available at: https://caffeineandyou.wordpress.com/historyandbackground/. Accessed October 3, 2019. 4. Engber D. Who made that energy drink?. The New York Times Magazine. December 6, 2013. https://www.nytimes.com/2013/12/08/magazine/who-made-that-energy-drink.html. Accessed October 3, 2019. 5. Rybak ME, Sternberg MR, Pao CI, Ahluwalia N, Pfeiffer CM. Urine excretion of caffeine and select caffeine metabolites is common in the US population and associated with caffeine intake. J Nutr. 2015;145(4):766774. DOI:10.3945/jn.114.205475 6. Caffeine. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 27, 2019.

SIENA COOPER | BSPS STUDENT| Fall 2019

CBD/THC CANNABIDIOL (CBD) TETRAHYDROCANNABINOL (THC)

STREET NAMES Weed – Pot – Hash – Bud – Reefer – Mary Jane – Ganja – Dope – Kush – Green – Hash – Grass – Herb – Haze

HISTORY AND BACKGROUND Derived from hemp (cannabis plants that contain less than 0.3 percent THC) or from marijuana plants (cannabis plants with higher concentrations of THC). CBD was first isolated in 1940.THC was later isolated in 1964 by the chemist Raphael Mechoulam. THC and CBD are very similar in structure and differ most in their effects when consumed. CBD is non-psychotropic and hence does not illicit the characteristic “high” associated with consumption of THC. THC is a psychotropic compound and is the only known cannabis-derived compound to illicit a “high”.

https://www.britannica.com/story/why-ismarijuana-illegal-in-the-us

TOXICITY CBD is well-tolerated, even in large doses. Any side effects associated CBD use are likely the result of drug-to-drug interactions between CBD and other medications. CBD can affect the availability of many medications. THC can case negative side effects but is not currently known to be life-threatening at any dose.

EFFECTS OF USE The typical effects of THC consumption are general feelings of euphoria, relaxation, and changes in perception. Other common effects are increased heart rate, loss of coordination, increased appetite, dizziness, drowsiness, dry mouth, red eyes, slowed reactions, impaired judgement, temporary memory loss, anxiety, sweats, paranoia, nausea and many others. CBD is thought to decrease anxiety, insomnia, seizures, and inflammatory and neuropathic pain. CBD causes no euphoria or “high”. https://www.vpr.org/post/marijuanaseffects-developing-brain#stream/0

https://www.washington.edu/news/2019/10/28/teenmarijuana-use-may-have-next-generation-effects/

LAWS CBD products are legal in Indiana as of March 2018, as long as the product contains less than 0.3% THC. THC remains illegal in Indiana, even in medicinal cases. Indiana has some of the most stringent laws on marijuana possession, the most common method of obtaining THC. Possessing 30g or under will land you a Class A misdemeanour, but any more than that is a Class D Felony.

DRUG TESTING The DAST is a two-part urine immunoassay that identifies THC or THC metabolites. The cut-off test sensitivity is 50 nanograms per millilitre (ng/ml). THC can remain in the system for up to one month.

PHARMACOLOGY CB1 is a G protein-coupled cannabinoid receptor located primarily in the central and peripheral nervous system with a particularly high abundance in the brain. As part of the endocannabinoid system it is activated by the endogenous neurotransmitters, anandamide and 2-arachidonoylglycerol, as well as other naturally occurring compounds including the phytocannabinoids found in cannabis. As a potent partial agonist of CB1, THC stimulates the CB1 receptor leading to the psychotropic effects experienced when consuming cannabis. CBD on the other hand, is classified as a negative allosteric modulator of CB1, meaning it effectively alters the shape of the CB1 receptor. This change makes it more difficult for CB1 agonists, like THC and other endogenous CB1 agonists, to stimulate the receptor. The fact that CBD does not bind to, or stimulate, CB1 is also the reason it does not produce the psychotropic effects associated with THC. REFERENCES Analytical Cannabis. (2019). CBD vs THC â&#x20AC;&#x201C; What are the Main Differences?. [online] Available at: https://www.analyticalcannabis.com/articles/cbd-vs-thc-what-are-themain-differences-297486 [Accessed 30 Oct. 2019]. Healthline. (2019). Whatâ&#x20AC;&#x2122;s the Difference Between CBD and THC?. [online] Available at: https://www.healthline.com/health/cbd-vsthc#medical-benefits [Accessed 30 Oct. 2019]. Peter Grinspoon, M. (2019). Cannabidiol (CBD) Harvard Health Blog. Available at: https://www.health.harvard.edu/blog/cannabidiol-cbd-whatwe-know-and-what-we-dont-2018082414476 [Accessed 30 Oct. 2019]. Urmc.rochester.edu. (2019). Cannabinoid Screen and Confirmation (Urine) - Health Encyclopedia - University of Rochester Medical Center. [online] Available at: https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid =167&contentid=cannabinoid_screen_urine [Accessed 30 Oct. 2019]

https://www.projectcbd.org/cbd-101/what-is-cbd

https://www.webmd.com/a-to-z-guides/medical-marij

PROFESSIONAL OPINION CBD in many forms, such as oils, can be useful in the treatments of pain caused by neuropathy, difficulty sleeping, anxiety, and many other ailments. Although more research needs to be done on the mechanisms and dosing for the use of CBD in medicine, there are no concerns for abuse or addiction at this time. THC is the abusable isotype of this product and causes many desirable effects such as euphoria and relaxation. However, it can prove dangerous in social situations, such as automobile operation. Though THC is becoming decriminalized in the US, it is not currently recommended for treatments. CBD has greater potential to be used medicinally without risk of abuse in conjunction with whole-patient management care. ~ S. Cooper

Jordan Crew Fall 2019

Cocaine (Coke, snow, blow, crack, rock) Long before the modern concept of cocaine use came about, leaves of the coca plant where chewed by the indigenous peoples of the Andes region. After a brief period of popularity through medical products and Coca-Cola, cocaine was banned and remained an unpopular (but still present) choice for recreational drug users in America until the 70’s, when it began to regain popularity during the disco era. American pop culture glamorized cocaine use, and it became associated with luxury, leading to its peak in 1983, when 10.4 million Americans tried cocaine for the first time. Around this time, crack, a freebased form of cocaine hydrochloride, became popular in poorer urban areas due to its low price. In response, the War on Drugs was launched by the Reagan government, specifically against crack cocaine. Due to the socioeconomic factors surrounding cocaine vs. crack usage, Reagan-era policies caused disproportionate punishment of addicts belonging to racial minorities. Cocaine use began to decline after the 80’s; however, recently, it seems to be increasing in popularity again, as addicts seek to avoid drug policies targeting the opioid crisis.

Pharmacology and drug effects. Cocaine is a CNS stimulant. Cocaine mediates this stimulation by blocking reuptake of dopamine, norepinephrine, and serotonin in neurons in the CNS. This causes stimulation of the CNS and sympathetic nervous system, which causes the characteristic euphoria associated with cocaine. Certain cocaine users will process cocaine further using alkaline materials to form large crystals of freebased cocaine, commonly called crack. This form is often smoked instead of snorted, and is generally cheaper than the powdered form, although they have similar effects on the body Other effects associated with cocaine use include increased alertness, increased heart rate, increased body temperature, paranoia, seizures, and death, among others. The cardiac effects are what mediate many of the incidents that cause death in acute cocaine overdose. Long-term effects of regular cocaine use include loss of sense of smell and nasal damage (if snorting cocaine powder), lung damage (if smoking cocaine), and an increased risk of strokes.

Toxicology and interactions with other drugs Large doses of cocaine cause cardiotoxicity and respiratory failure through failure of the vital medullary centers to function correctly. High doses can also result in seizures and hyperthermia. Ultimately, death can result from respiratory failure, myocardial infarction, stroke, cerebral bleeding, and heart failure. Combining with alcohol increases cardiotoxic effects, like blood pressure and heart rate; this combination can also cause hepatotoxicity. Heroin and cocaine are frequently used together in a combination called a “speedball”; this combination is complex because cocaine is a stimulant and heroin is a depressant. Combined use is associated with increased potency of cocaine’s cardiovascular toxicity. Some drug addicts use both cocaine and methamphetamine. Both cocaine and methamphetamine are stimulants, and their combination leads to increased cardiovascular toxicity.

Laws Cocaine is a schedule II drug; it has approved medical uses, but it cannot be dispensed as a prescription. In a hospital setting, cocaine may be used as a topical anesthetic during surgeries. Outside of that, use of cocaine is unapproved and illegal.

Drug screening and monitoring Cocaine can be detected using urinalysis and hair samples. For medical purposes, monitoring includes signs of systemic intoxication and local anesthesia.

Professional opinion Cocaine’s use as a topical anesthetic is appropriate as long as it is tightly regulated within a medical institution. Use of cocaine for recreational purposes is strongly cautioned against because of the strong risk of addiction, which can lead to chronic abuse and bodily damage. ~ J. Crew

● ● ● ● ● ● ●

Cocaine. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 30, 2019. MedlinePlus. Cocaine. Available at: https://medlineplus.gov/cocaine.html#cat_92. Accessed October 30, 2019. National Institute on Drug Abuse. Cocaine. Available at: https://www.drugabuse.gov/drugs-abuse/commonly-abused-drugs-charts#cocaine. Accessed October 30, 2019. Recovery.org. The History of Cocaine Around the World and in the U.S. Available at: https://www.recovery.org/cocaines/history/. Accessed October 30, 2019. Sobic EL. Cocaine and amphetamine combined. BMJ 2004;328(7452):1365. Streetdrugs. Cocaine. Available at: https://streetdrugs.org/cocaine/. Accessed October 30, 2019. WebMD. What Is Cocaine?. Available at: https://www.webmd.com/mental-health/addiction/cocaine-use-and-its-effects#1. Accessed October 30, 2019.

DEXTROMETHORPHAN Fall 2019

JESSICA CZAJKOWSKI

HISTORY/BACKGROUND https://americanaddictioncenters.org/ dextromethorphan-dxm/abuse

SLANG

Dextromethorphan was approved in the 1950s by the FDA as an OTC cough suppressant to substitute codeine, which was abused. However, abuse of dextromethorphan also started in the 1960s. Since the 1990s, there has been an increase in the amount of teens abusing it for the euphoria and hallucinations.

Orange Crush Poor Manâ&#x20AC;&#x2122;s PCP Red Devils/Hots Robo Skittles Velvet Syrup https://www.12keysrehab.com/help-center/dxm-addiction/

PHARMACOLOGY The cough suppression is accomplished by acting on the medulla oblongata in the brain. However, it is also a potent Ď&#x192;1 receptor agonist, which causes it hallucinogenic affects when taken at high doses. Additionally, it is a non-selective serotonin reuptake inhibitor. This causes an increase in serotonin in the brain, resulting in euphoria. However, there is a risk of serotonin syndrome. Since the structure is a derivative of morphine, there is a chance of developing an addiction. However, there is no analgesic effects. Thus, it binds to opioid receptors. As a result, the many drug targets within the body increases the potential for harmful drug interactions.

https://en.wikipedia.org/wiki/ Dextromethorphan

DRUG INTERACTIONS

LAWS

MOA inhibitors and grapefruit juice increase the risk of serotonin syndrome. Due to the many potential binding sites , there are many drug interactions that include 36 serious, 38 moderate, and 24 mild.

Dextromethorphan is restricted in most states to those 18 years of age and older to prevent drug abuse in children and adolescents.

TOXICOLOGY Mild to moderate overdoses cause dextromethorphan to bind to the PCP binding site on NMDA receptors. This results in CNS effects including dysphoria, ataxia, and alteration of muscle reflexes. High doses result in severe toxicity caused from binding to opioid receptors and inhibition of serotonin re-uptake. This causes sedation, serotonin syndrome, psychosis, delirium, seizures, coma, hypotension, and respiratory depression.

DRUG SCREENS Due to the many binding sites on receptors, it can cause a false positive for PCP and opioids. However, it is not usually tested for it alone. http://www.selanochiropractic.com/drug-screening.html

MY PROFESSIONAL OPINION Dextromethorphan is an effective OTC cough suppressant, but should be regulated. Due to the easy access for teenagers and adolescents, I believe that restricting the sale of dextromethorphan should be continued. This will decrease the likelihood of obtaining the drug for the intention of drug use. Parents should be educated on the potential for abuse and limit access at home. ~ J. Czajkowski -Addiction Resource. Dextromethorphan Mechanism of Action: How does DXM Work? Available at: www.addictionresource.com/drugs/dxm/usage-moa/. Accessed October 22, 2019. -Consumer Healthcare Products Association. What is DXM? Available at: www.stopmedicineabuse.org/what-is-dxm/. Accessed October 20, 2019. -Dextromethorphan. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: www.micromedexsolutions.com. Accessed October 15, 2019. -MedicCast. History, Statistics, and Preparations of Dextromethorphan. Available at: www.mediccast.com/blog/episode-transcriptsdextromethorphan/history-statistics-and-preparationsof-dextromethorphan/. Accessed October 27, 2019. -Neerman MF, Uzoegqu CL. Is dextromethorphan a concern for causing a false positive during a urine drug screening? Laboratory Medicine 2010;41(8): 457-60. DOI: 10.1309/ LMC384VVWIPJFXCZ

Madilyn Eberle Student

Diamorphine

Pharmacist Fall 2019

(Diacetylmorphine) Street Name: Heroin

History/Background: Heroin is derived from the opium poppy, a flower commonly grown in Mexico, Asia, and South America. It is administered via injection, inhalation (snorting or sniffing), or smoking and is commonly found as a white or brown powder. Since its illegalization in the United States in 1924, heroin use fluctuated within the 1900s. Some individuals claimed that films such as Pulp Fiction â&#x20AC;&#x153;glamorizedâ&#x20AC;? its use. However, from the years 2007 to 2012, the use of heroin doubled. This can be attributed to an increase in painkiller opioid prescriptions such as OxyContin and Vicodin, which are also produced by the poppy plant. Since Heroin is a cheaper, more potent opioid, the usage of this drug has greatly increased in most recent years.

https://www.newscientist.com/article/2172947heroin-users-brains-hint-at-a-new-treatmentfor-narcolepsy/

Slang Terms: Dope, Junk, Smack, H, Brown Sugar, Horse

Pharmacology/Drug Effects: Following administration, Heroin rapidly crosses the blood brain barrier where it is converted back to morphine by enzymes and binds to opioid receptors. These receptors are prevalent along the brain stem which controls automatic functions such as blood pressure and respiration, as well as areas of the brain associated with the pain and reward pathways. This results in the user feeling a sense of euphoria and analgesia. With its binding to opioid receptors, heroin will slow the heart rate and breathing and block pain receptors. Additionally, common side effects observed with this drug include: nausea and vomiting, dry mouth, warm flushing of the skin, and heaviness of the limbs.

Major Drug Interactions: Buprenorphine, Hydromorphone, Fentanyl, Methadone, Morphine, Hydrocodone, Oxycodone, Roxicodone, Tramadol

Toxicology: Due to Heroinâ&#x20AC;&#x2122;s highly addictive properties, it can lead to tolerance within individuals. Tolerance leads to higher and more frequent doses of the drug in order to achieve the original effects. If an individual attempts to fight this addiction, severe withdraw symptoms may occur. Restlessness, severe body pain, sleep disturbances, diarrhea, vomiting, cold flashes, jitters, and cravings commonly occur. The side effects previously listed are also prevalent. As a result of Heroin binding to opioid receptors, the suppression of breathing and a decreased heart rate can decrease the overall flow of oxygen to the brain resulting in hypoxia. Hypoxia can result in coma and even death.

Laws: Heroin is a schedule I drug in the United States, meaning it has no acceptable medical purpose and has extremely high potential for abuse. Overall, it is an illicit, highly addictive opioid drug.

Monitoring/Drug Screens: The United States tests for Heroin in both standard drug tests and extended drug tests. Heroin can only be detected in the urine as its metabolite, morphine, for 1-4 days. There are additional methods to screen as well such as GC/MS, HPLC, and sweat patches.

Professional Opinion: With the opioid epidemic that is currently present within the United States, it is understandable that individuals with an opioid addiction are seeking alternative options that are cheaper and more potent. However, heroin usage is extremely dangerous, highly addictive, and can lead to an increase in the spread of infectious disease. I do not believe Heroin has a place in treatment or therapy. Overall, I am very appreciative of resources such as naloxone and rehabilitation facilities that are helping to fight the opioid epidemic. -Madi Eberle

References: 1. The Vaults of Erowid. Heroin. Available at: https://www.erowid.org/chemicals/heroin/heroin.shtml. Accessed October 10, 2019. 2. WebMD. Heroin: What You Need to Know. Available at: https://www.webmd.com/mental-health/addiction/heroin-use#1. Accessed October 10, 2019. 3. Street Drugs. Heroin. Available at: https://streetdrugs.org/heroin/. Accessed October 11, 2019. 4. National Institute on Drug Abuse. Heroin. Available at: https://www.drugabuse.gov/publications/drugfacts/heroin. Accessed October 11, 2019. 5. U.S. National Library of Medicine. Heroin. Available at: https://pubchem.ncbi.nlm.nih.gov/compound/Heroin#section=Absor ption-Distribution-and-Excretion. Accessed October 11, 2019.

Diuretics/Laxatives NOAH F AWC E T T - S TUDENT PHARMAC I S T

Fall 2019

PHARMACOLOGY (DIURETICS) Diuretics: The term "diuretic" is a blanket word used to classify any drug that causes an increase in urine formation/passage. A 2008 study found furosemide and hydrochlorothiazide to be the most frequently abused diuretics. Their mechanisms of actions are below: Furosemide: Inhibits sodium, potassium, and chloride reabsorption by inhibiting the NKCC2 transporter in the ascending loop of Henle. Increased concentration of electrolytes in the urine pulls water into the tubules and creates more urine. Hydrochlorothiazide: Inhibits sodium reabsorption in the distal convoluted tubule. Increased sodium in the tubules pulls water in and increases urine volume.

PHARMACOLOGY (LAXATIVES)

HISTORY/BACKGROUND

Most laxatives are available over the counter and work relatively quickly. The most common agents are bisacodyl, polyethylene glycol (PEG), and docusate sodium. Their mechanisms are below: Bisacodyl: stimulates nerve endings in the walls of the GI tract to force contractions PEG: passes through the GI tract unabsorbed, pulls water into the stool via osmosis and softens stool Docusate: Lowers surface tension of stool, allowing water to flow into the stool and soften it

RISKS OF INAPPROPRIATE USE Abuse of both laxatives and diuretics can create electrolyte abnormalities and induce dehydration in users. Consequences of electrolyte abnormalities include mental status changes, EKG changes, and even death

SLANG TERMS

DIURETIC ABUSE - Diuretics can be abused by athletes in an effort to quickly lose weight to meet match criteria (boxing/wrestling) - Diuretics can be abused by those who wish to lose weight or appear thinner - Diuretics can be abused by illicit drug users in an attempt to pass an upcoming urine drug screen

LAXATIVE ABUSE - Laxatives are sometimes used by those with eating disorders who believe taking laxatives after a binge will prevent absorptionÂ of food/calories eaten - Laxatives can be used in an attempt to lose weight https://www.mcguffmedical.com/content/images/ thumbs/0002315_furosemide-20mg-100-tab_550.jpeg

www.mcguffmedical.com/ content/images/thumbs/ 0003636_hydrochlorothiazi de-hct_550.jpeg

Diuretics: Loops, HCTZ (hydrochlorothiazide), water pills Laxatives: stool softener, gut stimulants, brand names (Miralax, Colace, Dulcolax, etc.)

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DRUG INTERACTIONS -Diuretics: - Can further reduce blood pressure alongside anti-hypertensive agents such as ACE Inhibitors, Angiotensin II Receptor Blockers, Calcium Channel Blockers, and Beta Blockers - Diuretic effect of drugs can be diminished when administered alongside NSAIDs - HCTZ can enhance increase in blood sugar seen with corticosteroids - Alcohol and diuretics can cause a profound lowering of blood pressure Laxatives: - Antacids (calcium carbonate, aluminum hydroxide, etc.) can decrease the effect of laxatives - Bulk forming laxatives can decrease absorption of many drugs - PEG can decrease serum concentration of digoxin

MONITORING/DRUG SCREENS Diuretics: - Used to dilute samples for urine drug screens. This is an especially effective way to "beat" a drug test. Abusers call this method "flushing." Samples that appear diluted are often marked as positive by drug testers and result in a failed test - Diuretics can alter electrolytes, specifically sodium, potassium, magnesium, and phosphorus Laxatives: - Laxatives would not appear on a routine drug test - Can cause changes in weight or appearance. Dehydration caused by laxatives would present with sunken eyes, reduced skin turgor, and dry mucous membranes - Like diuretics, changes in electrolyte concentration can be seen clinically

LAWS Diuretics are available via prescription only. They are often prescribed for patients with hypertension, congestive heart failure, or peripheral edema. The World Anti-Doping Agency (WADA) considers diuretics to be banned substances. Athletes found with diuretics in their system are subject to penalties in their respective sport. Laxatives are most often available over the counter. There is very little data regarding laxative abuse. There are no existing laws that limit the purchase of laxatives (unlike other products such as - pseudoephedrine). Also, there are no FDA warning labels or statements regarding abuse of laxatives (unlike antidiarrheals such as loperamide).

PROFESSIONAL OPINION DIURETICS Athlete abuse of diuretics is not a large issue anymore. The WADA can catch and punish those who are abusing. However, abuse by the general population is largely undetectable. Diuretics are widely prescribed and are effective treatments in a wide a variety of c onditions. They are not controlled substances and should remain un scheduled due to their vital role in management of many common chronic diseases (CHF, HTN, etc.). While diuretic abuse is concerning, it is often times not life threatening. In my opinion, those with eating disorders should be routinely monitored and educated about the risks of diuretic abuse.

LAXATIVE ABUSE Similar to diuretic abuse, the main intervention needed to reduce laxative abuse is education. Those with eating disorders should be educated about the risks of abuse and the facts about mechanisms of action. Since these agents often won't cause large changes in weight they are not abused frequently. Laxatives are a great over the counter product available to patients who need them. No scheduling or additional laws are needed regarding laxatives. Pharmacists in the community setting should routinely use SCHOLAR questions and provide patient centered counseling to all patients purchasing laxatives over the counter. ~ N. Fawcett

REFERENCES: 1.) Cadwallader AB, de la Torre X, Tieri A, Botrè F. The abuse of diuretics as performance-enhancing drugs and masking agents in sport doping: pharmacology, toxicology and analysis. Br J Pharmacol. 2010;161(1):1–16. doi:10.1111/j. 1476-5381.2010.00789.x 2.) DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 10e New York, NY: McGraw-Hill; 2017. 3.) Francisco LL, Ferris TF. The Use and Abuse of Diuretics. Arch Intern Med. 1982;142(1):28–32. doi:10.1001/archinte.1982.00340140030008 4.) Furosemide. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com. Accessed October 28, 2019. 5.) Hydrochlorothiazide. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com. Accessed October 28, 2019. 6.) Mundell, E. (2019). Opioid Crisis Leads FDA To Restrict Imodium. [online] WebMD. Available at: https://www.webmd.com/digestive-disorders/news/20180130/opioid-crisis-leads-fda-to-restrict-imodium Accessed October 28, 2019. 7.) National Eating Disorders Association. (2019). Laxative Abuse. [online] Available at: https://www.nationaleatingdisorders.org/learn/general-information/laxative-abuse. Accessed October 28, 2019. 8.) Polyethylene Glycol-Electrolyte Solution. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com. Accessed October 28, 2019.

CHRISTIAN FINK STUDENT PHARMACIST FALL 2019

DRUG DETERRENT PIOIDS Opioid formulations less susceptible to abuse Also know as

ABUSE DETERRENTS

Routes of Abuse Crushing

Snorting

Injecting

https://chronicpaintc.com/why-choose-abuse-deterrent-opioids/

Why manipulate? "Dose dumping" effect: delivery of more rapid concentration of drug to brain to increase euphoria

Abuse Deterrent Technologies 1. Physical or chemical barriers: prevents crushing or dissolving 2. Drug agonist/antagonist combination: interferes with euphoria 3. Aversion: unpleasant effect, e.g. nasal irritant

FDA approved abuse deterrent opioids OxyContin (Oxycodone ER) (first opioid deterrent approved in 2010) Xtampza ER (Oxycodone ER) RoxyBond (Oxycodone IR) Hysingla ER (Hydrocodone ER) Vantrela ER (Hydrocodone ER) MorphaBond ER (Morphine ER) Arymo ER (Morphine ER) Embeda (Morphine + Naltrexone ER)

These drugs are primarily crush/extractionÂ resistant. If the drug is able to be crushed into a fine powder and is dissolved in a solvent, a thick gel will form and solidify in a needle, preventing IV injection.

Drug Overdose

"LEADING CAUSE OF INJURY-RELATED DEATH IN THE UNITED STATES." -CENTERS FOR DISEASE CONTROL AND PREVENTION Guidelines for Evaluation 1. Guidance for Industry: Abuse-Deterrent Opioids – Evaluation and Labeling Makes recommendations for studies, how they should be performed and evaluated, and what labeling claims can be made based on the results

2. General Principles for Evaluating the Abuse Deterrence of Generic Solid Oral Opioid Drug Products Studies that should be conducted to show the generic formulation is no less abuse-deterrent than the brand name product

Benefits? Prevention of overdose Prevention of bloodborne infections (HIV, Hepatitis C) Prevention of nasal perforation and/or necrosis

Problems?

Cost Drugs can still be abused Lack of insurance coverage

Professional Opinion Drug deterrents are a great start to combating the opioid crisis. Although these drugs cannot prevent abuse or addiction, they have the potential to reduce the frequency of abuse. Because opioids will continue to be prescribed for various reasons, creating drug deterrents cannot hurt and will instead aid in the reduction of opioid abuse. -C. Fink

References 1. Food and Drug Administration. Abuse-deterrent opioids analgesics. Available at: https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-andproviders/abuse-deterrent-opioid-analgesics. Accessed October 28, 2019. 2. American Society of Anesthesiologists. Abuse-deterrent opioid formulations. Available at: https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2667599. Accessed October 28, 2019. 3. Adler JA, Mallick-Searle T. An overview of abuse-deterrent opioids and recommendations for practical patient care. J Multidiscip Healthc 2018;11:323–332. DOI:10.2147/JMDH.S166915 4. American Pharmacists Assocation. FDA approves more abuse-deterrent opioids, but questions remain about their value. Available at: https://www.pharmacytoday.org/article/S10420991(17)30238-4/fulltext. Accessed October 28, 2019. 5. Centers for Disease Control and Prevention. Opioid overdose. Available at: https://www.cdc.gov/drugoverdose/index.html. Accessed October 28, 2019. 6. All graphics from Canva.com

Remington Griswold

Student Pharmacist Fall 2019

Drug Tests AKA: Drug Screen, Pee Test, Tox Screen, Urinalysis

https://americandrugtest.com/5-panel-urine-dip-carddrug-test-clia-waived-25-box-free-shipping/

Pharmacology/How a Drug Test Works Usually a drug test is separated into two different laboratory test to detect use. The initial immunoassay test which has a higher chance at producing false positives and the confirmatory gas chromatography-mass spectrometry (GC-MS) test. The initial immunoassay test works by using a test strip that contains antibodies that will bind to the parent drug or that drugâ&#x20AC;&#x2122;s metabolites. When the test strip is inserted into the urine it will bind to the drug or metabolites producing color meaning a positive result. However, this test is prone to cross reaction or false-positive results. In the case the an immunoassay test has a positive result, a confirmatory GC-MS test is preformed in order to clarify the results. The GC-MS test breaks down a sample into ionized fragments and separates them based on their mass-charge ratio. Doing this allows the test to identify a specific drug instead of a broad class.

History of Drug Test Drugs have been around since before the United States of America was even established. The Native Americans that lived here hundreds of years ago used drugs but it wasnâ&#x20AC;&#x2122;t until the 1960s when drugs became a nation wide topic being discussed everywhere on the news. During the Vietnam era drug use became a normality amongst the younger generation. In the 1970s, the US government decided to take action against the growing drug use and their solution was workplace drug testing, but this idea did not really take off until 1986. Drug test started to gain popularity after a 1981 Marine Corps jet crashed into its aircraft carrier and led to the death of 14 crew members and injuring 48 more. After the crew members tested positive for marijuana use the armed forces started a no tolerance policy they severely reduced the number of positive drug test. Seeing the effect drug testing had in the military President Ronald Reagan started the Drug-Free Workplace Program which allowed drug testing for pre-employment and on reasonable suspicion and these practices are still done today.

Laws

Types of Drug Screens

The Drug Free Workplace Act created by President Ronald Reagan was passed into law in 1988 and it states that â&#x20AC;&#x153; it is illegal for employees to manufacture, distribute, dispense or have in possession prohibited controlled substances" . This means that even in states that have medical or recreational marijuana use you can be fired or prohibited from getting a job for using marijuana since it is a control substance on the federal level. In recent years, states have started to pass laws prohibiting the discrimination of marijuana drug use in their state. The Drug Free Workplace Act allows employers to drug test employees for pre-employment or for reasonable suspicion of drug use.

There are 4 main types of drug screens that can test for more recent drug use or drug use years in the past: Urine test, Saliva test, Blood test, and Hair follicle test Saliva drug test are for more recent use and Hair follicle test can test for drug use years in the past There are also drug test that test for different drugs. There are single panel drug test and multipaneled (usually 5-10 panel) drug test that can test for a multitude of drugs.

Drug Interactions There are drugs that can lead to false positives on a drug test and some of them are shown in the image below

Professional Opinion Drug tests have come along way since first used and implemented. The use of confirmatory GC-MS test should always be used to confirm a positive result due to the higher accuracy of this test. The GC-MS test is still not perfect though and lead to false positives in rare circumstances, because of this new and better drug testing methods need to be researched and created to make sure all positive results are accurate. ~ R. Griswold https://www.mdedge.com/psychiatry/article/103088/urine-drug-screens-when-mighttest-result-be-false-positive

References: 1. Drug Testing FAQs. Drugs.com. https://www.drugs.com/article/drug-testing.html. Published September 7, 2019. Accessed October 30, 2019. 2. Midwest New Media. Workplace Fairness. Drug Testing. https://www.workplacefairness.org/drug-testing-workplace. Accessed October 30, 2019. 3. Pawlowski J, Ellingrod VL. Urine drug screens: When might a test result be false-positive? MDedge Psychiatry. https:// www.mdedge.com/psychiatry/article/103088/urine-drug-screens-when-might-test-result-be-false-positive. Published December 11, 2018. Accessed October 30, 2019. 4. Screening ND. A History of Drug Testing in the United States. National Drug Screening. https://www.nationaldrugscreening.com/ show-blog.php?id=357. Published February 14, 2014. Accessed October 30, 2019.

Electronic Cigarettes

https://www.cdc.gov/tobacco/basic_information/e-cigarettes/pdfs/Electronic-CigarettesInfographic-508.pdf

A Brief Overview of the Health Effects and Risks of Smoking and Vaping Nicotine Products Emily Hall Fall 2019

Slang Terminology

October 30

▪ ▪ ▪ ▪ ▪ ▪

Pharmacology

▪

e-cig mods vapes (vape pens) e-hookahs (hookah pens) tank systems electronic nicotine delivery systems JUULpods

Nicotine containing products are highly addictive and can be harmful to the developing brain, as well as to pregnant women. Smoking nicotine products causes an increase in plaque buildup within the arteries which can raise BP and increase risk of a MI or stroke.

How Did E-Cigs Come About? E-cigarettes came into existence due to a societal need for nicotine-containing products that cause reduced-harm in comparison to rolled-paper cigarettes. The thought it that ecigarettes do not contain tobacco, increasing the safety of its users by reducing the risk of cancer and other deadly diseases. ▪ ▪ ▪ ▪ ▪

https://www.heart.org/en/healthy-living/healthy-lifestyle/ quit-smoking-tobacco/the-101-on-e-cigarettes-infographic

1965 – Herbert A. Gilbert is credited with creating the first relatively modern e-cigarette 1986 – The Favor Cigarette was created as an alternative nicotine-containing product 2003 – Chinese pharmacist, Hon Lik, created the first e-cigarette that became commercially successful 2008 – WHO declares e-cigarettes are not legitimate smoking cessation aids Today – E-cigs come in all shapes and sizes, even being confused for small USB devices.

Professional Opinion The origin of the “electronic cigarette”, is one of good intentions. These devices were founded by smokers attempting to make their own bad habits a little bit safer. The unfortunate aspect of this invention is that, although e-cigarettes do not contain some of the same carcinogenic components of rolledpaper cigarettes, they still contain many dangerous chemicals including nicotine. Overall, it is not suggested that patients use these devices as a smoking cessation aid, nor should teenagers or adolescence be able to purchase or use “vaping” products. Nicotine is a very addictive substance, and research is beginning to show that more and more young adults and children are being exposed to these products. A device that was once meant for aiding in smoking cessation, is now becoming a threat to the safety of our youngest generations. Without more research on the specific chemicals used in e-cigarettes and vapes, it is highly recommended that everyone, especially teenagers and pregnant women, avoid the use of these devices. ~ E. Hall

References: 1. WebMD. Smoking Cessation. Available at: https://www.webmd.com/smoking-cessation/ taking-nicotine-test#2. Accessed October 26, 2019. 2. Public Health Law Center. U.S. ECigarette Regulation – 50 State Review (2019). Available at: https://www.public healthlawcenter.org/resources/us-ecigarette-regulations-50-state-review. Accessed October 27, 2019. 3. Drugs. Nicotine Drug Interactions. https://www.drugs.com/druginteractions/nicotine-index.html? filter=2. Accessed October 28, 2019. 4. CASAA. A Historical Timeline of Electronic Cigarettes. Available at: http://www.casaa.org/historicaltimeline-of-electronic-cigarettes/. Accessed: October 28, 2019. 5. National Institute on Drug Abuse. Electronic Cigarettes. Available at: https://www.drugabuse.gov/publications/drugfa cts/electronic-cigarettes-e-cigarettes. Accessed October 28, 2019. 6. CDC. Chapter 1. Available at: https://www. cdcgov/tobacco/data_statistics/sgr/e-cigarettes /pdfs/2016_SGR_Chap_1_508.pdf. Accessed October 29, 2019.

Drug Interactions Most e-cigarettes contain nicotine which can interact with many medications and worsen the smoker’s concurrent disease states. Interactions include, but are not limited to caffeine, bupropion, ergotamine, varenicline, hydroxyprogesterone and telotristat. Nicotine can negatively impact a patient’s CVD and pheochromocytoma.

https://www.cdc.gov/vitalsigns/ecigarette-ads/infographic.html

https://www.cdc.gov/tobacco/basic_information/ecigarettes/pdfs/Electronic-Cigarettes-Infographic-508.pdf

Laws In the US, many states restrict youth access to e-cigs. Minimum legal sales age ranges from 18-21. States have specific definitions and regulations placed on e-cigs (i.e. IL taxes e-cigs at a 15% rate of wholesale price). Each year more laws are put into place by the government to try and protect citizens from the dangers of e-cigs.

Drug Screening Drug tests can be used to test for nicotine, using blood and urine samples. The test measures the amount of cotinine, a byproduct of nicotine metabolism, in the body, lasting up to 10 days after smoking. This test is used for employment, smoking cessation programs, life and health insurance policies, among other reasons.

Ethyl-alcohol Street Name: Alcohol

Common Slang terms: Booze, liquor History/Background: Alcohol is produced from fermenting grains, fruits, or other plant based products in yeast.1 Distilled products with higher alcohol concentration are produced in much the same way, but then are subsequently distilled to increase ethanol concentration. There is evidence of alcohol consumption dating back to 7000 B.C. in China, showing its long history of use.2 Alcoholism became “widespread” in Britain when the production of grain alcohols was encouraged by their government. This led to changes in the way alcohol was viewed, and in 1920 the US passed the Prohibition, essentially outlawing alcohol in the country. This was ended in 1933. Today, alcohol is among the most commonly used intoxicating substances in the world. In 2017, more than 87% of adults over the age of 26 report having used alcohol in their lives.3 Additionally, it does have potential to be addictive to its users. However, it is not widely viewed as a “drug.” This is likely because alcohol is used for religious and social purposes in various cultures around the world, and is legal in nearly all parts of the world.1 Will Harris, Student Pharmacist Fall 2019

https://www.webmd.com/food-recipes/rm-quiz-alcohol-myths-facts

Pharmacology of Alcohol: Alcohol is a solution administered through the oral route. It is rapidly absorbed into the bloodstream where it can exert its effects on the central nervous system.1 In the brain, alcohol disrupts the communication signals and effect how the brain can work. The half-life of alcohol varies greatly based on several factors listed such as enzyme induction and tolerance. Alcohol’s Effects on the Body: The effects of alcohol on the body result in depression of the central nervous system and slight hypnotic effects. Inhibition of cognition, motor function, and reflex responses also occur. These effects are dependent blood alcohol concentration (BAC), expressed as a percent of grams of alcohol per deciliter of blood. BAC is dependent on several factors such as size, weight, and sex of the user, the amount used at one time, and the rate of consumption. Short term adverse effects are related to BAC and they include nausea, vomiting, memory loss, impaired motor reflexes, poor judgement, and more. Long term complications of alcohol are generally related to prolonged use, and can include damage to your heart, liver, esophagus, pancreas, and immune system. Long term alcohol use can also lead to cancers and malabsorption.

Drug Interactions: Alcohol has 455 known drug interactions, with at least 31 being considered “highly clinically significant.”4 Some major drugs and classes include opioids, due to increased central nervous system depression, and acetaminophen, due to increased liver toxicity. Toxicology: There are many toxic effects associated with recurrent alcohol use. Alcohol interferes with brain cell signaling, causes numerous heart defects, cirrhosis of the liver, pancreatitis, suppression of the immune system, and some types of cancer.5 There are also a number of immediate toxic effects that are dose dependent, or based upon the concentration of alcohol in the blood. A BAC of 0.08 gram% will put a person at risk for impaired judgement and reduced inhibitions.6 A BAC of 0.15 gram% can manifest as slurred speech, impaired balance, nausea, and vomiting. Finally, a BAC >0.30 g% will likely result in coma or death. Alcohol use during maternity can lead to harmful effects on a fetus or nursing child. Laws: In the United States, alcohol is limited in its sale and use by the Federal Government. People must be 21 years of age or older to purchase and consume alcoholic beverages. Additionally, due to its intoxicating effects, a person may not drive while their BAC is above 0.08 g%. Breaking this law could result in arrest, jail time, and suspension of driving privileges.

https://www.verywellmind.com/thmb/ocA8DsFXShQonflixc3lP0lKWmE=/ 1500x1000/filters:no_upscale():max_bytes(150000):strip_icc()/if-you-geta-dui-67215_FINAL-5be992db46e0fb00510b72ca.png

Monitoring: The most common method of monitoring for alcohol use is field testing done on drivers by police officers to test for intoxication. A person’s BAC can be determined by a breathalyzer due to alcohol excretion through lungs. Additionally, balance and coordination tests can be done if necessary to test for impairment. Professional Opinion: As a pharmacy student studying the effects of drugs on the body, it is apparent that alcohol mostly exhibits negative effects on the body. However, these effects are dose and duration dependent. Drinking alcohol in moderation on occasion is most likely not harmful to the body in the long term. It is recommended that men consume 2 or less alcoholic beverages per day and women drink 1 or less per day. This level of consumption will not cause intoxication or long term defects associated with alcohol use, however this does not apply in pregnancy or nursing mothers. In those situations, alcohol should be avoided. ~ W. Harris Reference: 1. The Vaults of Erowid. Facts About Alcohol. Available at: https://www.erowid.org/chemicals/alcohol/alcohol_in fo2.shtml. Accessed October 14, 2019. 2. Foundation for a Drug Free World. Alcohol: A short history. Available at: https://www.drugfreeworld.org/drugfacts/alcohol/ashort-history.html. Accessed October 16, 2019. 3. NIDA. Alcohol. Available at: https://www.drugabuse.gov/drugs-abuse/alcohol. Accessed October 16, 2019. 4. Drugs.com. Alcohol (contained in alcoholic beverages) (ethanol) drug interactions. Available at: https://www.drugs.com/druginteractions/ethanol,alcohol-contained-in-alcoholicbeverages.html. Accessed October 23, 2019. 5. National Institutes of Health. Alcohol’s effects on the body. Available at: https://www.niaaa.nih.gov/alcohols-effects-body. Accessed October 23, 2019. 6. Government of South Australia. Blood alcohol concentration (BAC) and the effects of alcohol. Available at: https://www.sahealth.sa.gov.au/wps/wcm/connect/p ublic+content/sa+health+internet/health+topics/healt h+conditions+prevention+and+treatment/alcohol/bloo d+alcohol+concentration+bac+general+information. Accessed October 20, 2019.

Stephanie Hendricks Student Pharmacist, Purdue University C

Fall 2019

Fentanyl Duragesic B R A N D

Carfentanil B R A N D

Actiq

History/Background

Fentanyl â&#x20AC;&#x201C; the drug that killed Mac Miller, Prince and Tom Petty, was first synthesized in 1960 by Dr. Paul Janssen. It is a synthetic opioid used for the indication of severe pain and is available in

Wildin

the form of intravenous, patches, intranasal and tablets. Fentanyl is 80-100 times more potent than morphine.

Carfentanil â&#x20AC;&#x201C; first synthesized in 1974 by Janssen

Slang Terms

Drop Dead

Pharmaceutica (included Paul Janssen) and is considered to be one of the most potent opioids known. It is an analogue of the popular synthetic opioid fentanyl.

Pharmacology/Drug Effects

China White

Serial Killer

Fentanyl, an opioid agonist, interacts with the opioid mu-receptor which is located in the human brain, spinal cord and other tissues. Pharmacological effects include analgesia, anxiolysis, euphoria, respiratory depression and constipation. Carfentanil is a structural analog of fentanyl. It is short acting, fast onset and is 10,000 times more potent than morphine, whereas fentanyl is 100 times more potent than morphine.

Drug Interactions There are 225 major drug interactions, 287 moderate drug interactions and 3 minor drug interactions. Importantly, Fentanyl and carfentanil should not be mixed with alcohol or other CNS depressants Monitoring https://reason.com/2018/07/20/thankdrug-warriors-for-the-escalating-d/

Respiratory depression and sedation, renal and hepatic impairment, use with CYP3A4 inhibitors or inducers, worsened seizure control

Professional Opinion Drug Screens Fentanyl is effective in the management of pain; however, the potential for abuse is incredibly high. The number of overdose deaths that occur due to heroin laced with fentanyl is astronomical. In the picture above, it illustrates the amount of heroin, fentanyl and carfentanil it takes to overdose. In my professional opinion, carfentanil has no purpose of use in human medicine (but perhaps in vet med with larger animals) and fentanyl should be used as a last resort for pain management or not at all. ~ S. Hendricks

A Fentanyl drug test is not included in the standard 5-panel drug test primarily used by employers. In order to screen for Fentanyl, a specialized drug test that includes fentanyl must be ordered from the testing vendor in order to have fentanyl included. Other drug testing panels that include fentanyl are: healthcare professional panels, urine/hair/blood test.

Laws Since 2017, the DEA has issued a law regarding Fentanyl to only be used in an emergency basis. The DEA has found enough evidence that this drug is, “extremely deadly and serves no real medical purpose” (FHE Health). However, fentanyl remains a Schedule II drug to date. Possession is a Federal Felony.

References: Sullum, Jacob. “Thank Drug Warriors for the Escalating Death Toll From Superpotent Synthetic Opioids.” Reason.com, Reason, 20 July 2018, reason.com/2018/07/20/thank-drug-warriors-for-theescalating-d/. Screening, National Drug. “Fentanyl Drug Test.” National Drug Screening, 25 June 2019, www.nationaldrugscreening.com/fentanyl-drug-test.php.

Fun fact! Carfentinal is so potent that it is used to sedate

elephants!

“DEA Attacks Fentanyl Crisis With Stricter Laws.” FHE Health – Addiction & Mental Health Care, 14 June 2018, fherehab.com/news/new-fentanyl-law/. “Fentanyl Disease Interactions.” Drugs.com, www.drugs.com/disease-interactions/fentanyl.html. Fentanyl. Drug Facts and Comparisons. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.factsandcomparisons.com. Accessed September 24, 2019. Fentanyl. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed September 24, 2019..

Blake Hill, Student Pharmacist Fall 2019

Flakka

Compound: alpha-Pyrrolidinopentiophenone (alpha-PVP) Street names: gravel, flocka, crystal love, snow blow, vanilla sky Photo (above): https://en.wikipedia.org/wiki/Alpha-Pyrrolidinopentiophenone Photo (left): https://www.marylandaddictionrecovery.com/what-is-flakka

History and Background • • • •

Alpha-PVP first discovered in 1963 First patented as a product in 1967 o Used as a CNS stimulant and pressor agent Alpha-PVP first seen in the United States in 2013 The United States Federal Government placed Flakka in Schedule I of the Controlled Substances Act in 2014 In 2014, there were 2,720 cases of alpha-PVP in crime labs across the country

•

What is it, how does it work, and what are its effects? • • • • • •

Flakka is a synthetic drug similar to cathinone, a stimulant found in the Khat plant native to East Africa and southern Arabia It is similar to the active ingredient found in commonly abused “bath salts” Alpha-PVP is a potent dopamine and norepinephrine reuptake inhibitor The drug can be swallowed, smoked, snorted, or injected Use of this drug results in an “excited delirium”, hallucinations, paranoia, psychotic delusions, psychosis, and seizures Alpha-PVP also has serious, life-threatening adverse effects such as arterial hypertension, vasoconstriction, arrythmias, myocardial infarction, and myocarditis

What does the law say about alpha-PVP? •

The Drug Enforcement Administration (DEA) made alpha-PVP a schedule I controlled substance on January 28, 2014 and banned the substance effective February 27, 2014.

Schedule I Controlled Substances

Penalties for Possession

“Drugs, substances, or chemicals … with no currently accepted medical use and a high potential for abuse.” dea.gov/drug-scheduling

pngfly.com/png-or3f6q/download.html

Possession of a schedule I controlled substance is a felony. Possession of paraphernalia is a misdemeanor for the first offense but is a felony if the person has a prior drug related offense.

Drug Interactions and Toxicology • • •

An important note for designer drugs: because these drugs constantly change, evolve, and are replaced by the newest designer drugs, it is difficult to pinpoint specific interactions. Therefore, there is little to no data available to reflect drug-drug interactions with alpha-PVP. One of the major commonly used substances with bath-salts like substances is alcohol – mixing the two can result in increased euphoria from alpha-PVP and other bath-salts like substances. There are many toxicities associated with Flakka use such as: o Violent behavior o Vomiting o Dizziness o Depression o Many serious cardiac toxicities (mentioned above) pinclipart.com/downpngs/ixmxTJ_drug-interactions-clipart

Monitoring and Drug Screens • •

Alpha-PVP is detectable in the urine and can be measured using a specialized urinalysis The urine sample must be wrapped in foil and protected from light due to light sensitivity

My Professional Opinion

To Whom It May Concern…

Because Flakka is a substance made solely for abuse with no medical benefit and a large list of adverse effects and potentially dangerous side effects, I support its current listing as a schedule I controlled substance. However, as is common with designer drugs, when one substance becomes too difficult to come by or too “high profile”, the right person can simply tweak the chemical and change it to a new product that doesn’t fall under current federal scheduling. So, though I fully understand that scheduling a drug of this type is only a temporary setback until a new drug is developed to replace it, I appreciate the efforts made by the DEA to control access to a substance. ~ B. Hill

References 1. 2. 3. 4. 5. 6. 7.

Cordant Health Solutions. Flakka. Available at: https://cordantsolutions.com/resources/flakka/. Accessed October 29, 2019. Cunha JP, Davis CP. MedicineNet. Flakka. Available at: https://www.medicinenet.com/flakka/article.htm#flakka_vs_bath_salts. Accessed October 29, 2019. Hokemeyer P. Maryland Addiction Recovery Center. What is Flakka? Available at: https://www.marylandaddictionrecovery.com/what-is-flakka. Accessed October 29, 2019. A Rhonda. On The Wagon. Everything you wanted to know about Flakka. Available at: https://www.onthewagon.org/flakka/. Accessed October 29, 2019. Dsouza A, Pereira L, Levounis P. MDedge Psychiatry. ‘Flakka’: A low-cost, dangerous high. Available at: https://www.mdedge.com/psychiatry/article/144927/addiction-medicine/flakka-low-cost-dangerous-high. Accessed October 29, 2019. National Institute on Drug Abuse. Commonly Abused Drug Charts. Available at: https://www.drugabuse.gov/drugsabuse/commonly-abused-drugs-charts#synthetic-cathinones-bath-salts-. Accessed October 29, 2019. Linebaugh M. CriminalDefense Lawyer. Possession of a Controlled Substance in Indiana. Available at: https://www.criminaldefenselawyer.com/resources/criminal-defense/drug-charges/possession-controlled-substanceindiana. Accessed October 29, 2019.

Flumazenil and Naloxone

Matt Hornfeck Student Pharmacist Fall 2019

https://drugfreeva.org/sink-orswim/drug-facts/prescriptiondrugs/naloxone/

http://www.doctoralerts .com/flumazenil/

History and Background

Terminology

Flumazenil

FDA-approved on December 20, 1991 for benzodiazepine overdose / reversal of postoperative sedation

Brand name: Romazicon â

No reports of abuse – Not a controlled substance

Brand name(s): Narcan â (intranasal), Evzio â (intramuscular auto-injection)

Naloxone Injection was FDA-approved in April of 1971 for reversal of opioid overdose. On November 18, 2015, an intranasal spray formulation of Naloxone was approved by the FDA.

Naloxone

All formulations of naloxone are commonly referred to as “narcan”

No abuse potential – Not a controlled substance

Pharmacology and Drug Effects Flumazenil is a benzodiazepine receptor antagonist. It inhibits the activity and reverses the binding of benzodiazepines and other substances that bind to the benzodiazepine receptor sites on GABA/benzodiazepine receptor complexes in the CNS. This results in complete or partial reversal of the sedative effects resulting from normal binding to this receptor in 1-2 minutes, with the peak effect being seen in 10 minutes Naloxone is a pure opioid receptor antagonist. It competes for and displaces opioids at opioid receptor sites in the brain. Through this, naloxone quickly restores breathing that has stopped due to an opioid overdose. The intranasal formulation has an onset of action of 8-13 minutes, while subcutaneous or intramuscular injections take 2-5 minutes until onset.

save lives in the case of an overdose and should therefore be readily accessible to the community. Flumazenil must be used with a little more caution and should only be considered in benzodiazepine naïve populations due to adverse effects. Naloxone, on the other hand, should always be used in the case of a suspected opioid overdose.

M. Hornfeck

Adverse Events (Toxicology)

Laws / Regulation

Flumazenil: FDA boxed warning for seizures, especially in patients with benzodiazepine tolerance or dependency

Flumazenil: No legislation

Naloxone: Upon administration, overdose victims could experience opioid withdrawal symptoms (headaches, nausea, vomiting, tremors, sweating, increased heart rate, and blood pressure changes) Will have no effect if no opioids are present in the body

Monitoring Flumazenil: Monitor victim for return of sedation, respiratory depression, and symptoms of withdrawal for 2 hours Naloxone: Monitor respiratory rate, heart rate, blood pressure, temperature, and level of consciousness Overdose is not an issue with either drug

https://www.saveliveskenosha.o rg/narcan-empowering-ourcommunity-in-the-fightagainst-opioid-overdoses/

Professional Opinion: Both flumazenil and naloxone can be used to

Naloxone: Laws are expanding to ensure naloxone’s use in clinical practice. The Center for Disease Control’s 2016 guidelines recommend co-prescription of naloxone with all opioid prescriptions Many pharmacists have gained prescribing powers or have collaborative practice agreements that give them the ability to prescribe naloxone, and in some states it is now even considered a nonprescription medication In Indiana, anyone is able to obtain a prescription if they know someone at risk of an opioid overdose

Drug Interactions Flumazenil: None Naloxone: Methylnaltrexone, naldemedine, and naloxegol

References: 1. 2. 3. 4. 5. 6. 7.

National Institute on Drug Abuse. Naloxone. Available at https://www.drugabuse.gov/publications/drugfacts/naloxone. Accessed October 24, 2019. Shoar NS and Saadabadi A. National Center for Biotechnology Information. Flumazenil. Available at https://www.ncbi.nlm.nih.gov/books/NBK470180/. Accessed October 24, 2019. Flumazenil Injection. Drug Facts and Comparisons. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at http://factsandcomparisons.com. Accessed October 25, 2019. Naloxone Hydrochloride Intranasal. Drug Facts and Comparisons. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at http://factsandcomparisons.com. Accessed October 24, 2019. Drugs.com. Narcan Approval History. Available at: https://www.drugs.com/history/narcan.html. Accessed October 24, 2019. Desimone II EM, Tilleman JA, Kaku KA, Erickson CT. Expanding access to naloxone. US Pharm 2018;43(3):16-20. State of Indiana. Overdose Prevention (Aaron’s Law). Available at: https://www.in.gov/dol/2907.htm. Accessed October 24, 2019.

Slang Terms

History/Background Gabapentin was first discovered by Gerhard Satzinger; it was produced by the pharmaceutical company Parke-Davis (now owned by Pfizer) as a possible drug for the treatment of epilepsy in 1974. Gabapentin was initially approved for the treatment of partial seizures in 1993. Gabapentin was subsequently approved for the treatment of neuropathic pain in the US and the UK in 2002. In 2004, pregabalin (similar to gabapentin â&#x20AC;&#x201C; but more efficiently absorbed) was released by Pfizer. Both gabapentin and pregabalin are FDA-approved for the treatment of post-herpetic neuralgia (PHN) and as a partial seizure adjunct. Pregabalin is also FDA-indicated for the treatment of fibromyalgia, renal impairment, and neuropathic pain associated with diabetic peripheral neuropathy. Since gabapentin and pregabalin can result in euphoria and feelings of relaxation and calmness, abuse of these drugs became more common as their popularity increased. In 2010, pregabalin was classified as a new recreational psychoactive substance by EU agencies.

o o

Gabapentin o Gabbies, Morontin

Pregabalin o Gabbies, Budweisers, and Bud Light

Gabapentin

https://www.drugs.com/gabapentin.html

Pharmacology/drug effects o

o o

Both gabapentin and pregabalin are structurally similar to GABA; they bind with high affinity to the alpha-2-delta protein subunit of voltage-gated calcium channels in the CNS. This binding to calcium channels causes a reduced calcium influx through the gated channels and a reduced release of neurotransmitters in the CNS. The release of neurotransmitters such as dopamine, glutamate, norepinephrine, and serotonin is inhibited. The exact mechanisms of gabapentin and pregabalin are uncertain. The absorption properties for gabapentin and pregabalin differ. Pregabalin is rapidly absorbed and reaches peak blood concentrations within one hour. Gabapentin is slowly absorbed and reaches peak concentrations 3-4 hours after ingestion. Gabapentin is only absorbed in the small intestine, whereas pregabalin is absorbed throughout the small intestine and continuing to the ascending colon. Neither drug is metabolized or bound to plasma proteins. Both drugs are eliminated via renal excretion. Both gabapentin and pregabalin can cause headache, blurred vision, increased appetite, dry mouth, poor coordination, memory problems, constipation, shortness of breath, weight gain, and red, itchy eyes. These drugs are abused due to their ability to produce euphoria, dissociation, relaxation, sedation, and occasionally psychedelic effects. Gabapentin and pregabalin may be used in combination with other substances such as alcohol, cannabis, SSRIs, amphetamines, or others. Pregabalin (schedule V controlled substance) is classified as having a higher risk for abuse.

Pregabalin

Emily Johnson

Gabapentin/Pregabalin Fall 2019

http://www.bbc.com/news/uk-northern-ireland-47766520

Drug Interactions/Toxicology o

Orlistat (results in reduced effectiveness), calcifediol (results in altered serum levels of calcifediol) o Both are major interactions for gabapentin and pregabalin Overdose of these drugs is rare. Toxic effects are similar to adverse effects observed at appropriate doses. For pregabalin, the most common adverse effects include dizziness and somnolence, ataxia, tremor, amnesia, speech disturbances, euphoria, and nervousness. Gabapentin has similar adverse effects; some others for gabapentin include movement disorders, GI upset, nystagmus, hypotension, and hypertension. There is no antidote available for either drug in the case of overdose.

Monitoring/drug screens o o

Gabapentin o Monitoring: periodic renal function, evidence of suicidality (suicidal thoughts, depression) Pregabalin o Monitoring: signs and symptoms of suicidality, pain intensity/seizure frequency, degree of sedation, weight gain/edema, symptoms of myopathy, renal function, symptoms of ocular disturbance Gabapentin/pregabalin are unlikely to be detected in a basic drug test since drug tests are only designed to detect illicit substances. Testing for gabapentin/pregabalin requires products specifically designed for their detection (gabapentin drug test urine dip card – detects gabapentin use within two days after last ingestion, pregabalin urine test – detects pregabalin in urine 2-4 days after last intake).

https://ndclist.com/ndc/0071-1027

References 1. 2.

Laws o

o o

Pregabalin is classified as a schedule V controlled substance in Indiana. Gabapentin is not yet classified as such in Indiana, although a growing number of states (e.g. Kentucky, Michigan) have made it a schedule V controlled substance. Schedule V drugs are less likely to be abused than other drugs or schedule IV substances. Illegal possession of a schedule V controlled substance is classified as a Class D felony in Indiana.

Professional Opinion o Gabapentin and pregabalin are both

FDA-indicated and relatively effective for post-herpetic neuralgia and as a partial seizure adjunct. Additionally, pregabalin is effective for the treatment of fibromyalgia and neuropathic pain. Although these drugs have abuse potential, it is quite low as reflected by pregabalin’s classification as a schedule V drug. Abuse of these drugs will result in less physical dependence /psychological dependence than other drugs or schedule IV substances. However, caution should still be exercised by health care providers who prescribe or fill these drugs for patients since patients have become addicted. ~ E. Johnson

Wesche D, Bockbrader H. A Pharmacokinetic comparison of pregabalin and gabapentin. The Journal of Pain 2005;6:S29. Gabapentin. Drugs Facts and Comparisons. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.factsandcomparisons.com. Accessed October 19, 2019. 3. Pregabalin. Drugs Facts and Comparisons. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.factsandcomparisons.com. Accessed October 19, 2019. 4. Gabapentin. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 19, 2019. 5. Pregabalin. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 19, 2019. 6. Nova Recovery Center. Gabapentin Addiction, Withdrawal, and Treatment. Available at: https://novarecoverycenter.com/drugs/gabapentin/. Accessed October 19, 2019. 7. Confirm Biosciences. Gabapentin. Available at: https://www.confirmbiosciences.com/knowledge/drug-facts/gabapentin/. Accessed October 19, 2019. 8. Practical Pain Management. Special Report: The Abuse Potential of Gabapentin & Pregabalin. Available at: https://www.practicalpainmanagement.com/treatments/pharmacological/non-opioids/special-report-abuse-potentialgabapentin-pregabalin. Accessed October 19, 2019. 9. Drugs.ie. Pregabalin. Available at: https://www.drugs.ie/pregabalin. Accessed October 19, 2019. 10. State of Indiana. 5 Scheduled Drug Categories Defined. Available at: https://www.in.gov/isdh/27380.htm. Accessed October 19, 2019. 11. Crane L. Chemistry World. Gabapentin. Available at: https://www.chemistryworld.com/podcasts/gabapentin/1017577.article. Accessed October 19, 2019. 12.

Emily Klimek, Student Pharmacist Fall 2019

History and Background of Abuse: GHB is a CNS sedative that was used to treat sleep disorders The FDA banned the use of GHB in the early 1990’s due to the associated dangers of it. On July 17th, 2002, a sodium salt form of GHB, Xyrem, (Sodium Oxybate) was approved to be used for a narcolepsy. Xyrem is a Schedule-3 Controlled Substance, and requires specific patient enrollment. GHB is abused by teenagers and young adults in party scenes like bars and night clubs, and often placed in alcoholic beverages. GHB is a liquid that has no smell or color associated with it. Therefore, GHB can easily be placed into alcoholic beverages prior to sexual assaults. Victims of GHB placed into their drinks become sedative and therefore can’t resist sexual assault. GHB is documented to also have amnesia effects on the brain.

Gamma hydroxybutyrate (GHB) Slang Terms: “Date Rape” Drug / “Liquid E” / “Gamma –OH”

Photo Credits: https://thedrugclassroom.com/video/ghb/

Pharmacology and Drug Effects:

v GHB works as an agonist in receptors in the brain. GHB binds to the GHB receptor, and acts as a weak agonist to the inhibitory GABAB Receptor in our brain. In high concentrations, GHB activates the GABAB receptors and exerts a sedative effect. v GHB has sedative effects on the body which include, euphoria, drowsiness, anxiety, and hallucinations. v At high concentrations, GHB can cause the body to become unconscious and experience seizures.

Drug Interactions: Professional Opinion: The use of Xyrem (Sodium Oxybate), the sodium salt of GHB, can be used legally as an effective sedative for narcolepsy. Although, one can argue that there are different medications on the market for the treatment of narcolepsy. When prescribed Xyrem, patients have to be enrolled in a patient accessed program. This similar form to GHB can be abused due to its odorless and clear component, would not be recommended for patients. ~ E. Klimek Drug Screenings and Monitoring: GHB has a short half-life of 30 minutes, and it can be excreted through the urine within an hour. At this rate, the drug can be broken down completely in a few hours. It is important to complete urine screenings as soon as possible if suspected of GHB abuse. It is very difficult to be detected in a drug screen. Law: Xyrem (Sodium oxybate) is a Schedule-3 Controlled drug when it is prescribed and used legally in patient restricted access program. If Xyrem is abused and used as a recreational drug, it is considered a schedule-1 illegal drug. GHB is a Schedule-1 Controlled drug under the Date-Rape Drug Prohibition Act of 2000.

Alcohol

Selective Sedative Hypnotics

•In combination can increase drowsiness

•Sodium oxybate contraindicated with GHB use

CNS Depressants •Fentanyl, Benzodiazepines, tramadol •In combination can increase drowsiness

Toxicology of Gamma Hydroxybutyrate:

Low dose of GHB side effects are unprediatable due to patient variability

Dose related side effects include: CNS depression, amnesia, hypotonia (10mg/kg), dizziness, drowsiness, and euphoria

References: 1) 2)

4) 5)

6) 7)

Street Drugs. Publishers Group West, LLC. GHB. Available at: https://streetdrugs.org/ghb/. Accessed October 4, 2019. Drug Rehab. Amy Keller. How Long Does GHB Stay in Your System. Available at: https://www.drugrehab.com/addiction/drugs/ghb/length-in-system/. Accessed October 4,2019. WebMD. Gamma-Hydroxybutyrate. Available at: https://www.webmd.com/vitamins/ai/ingredientmono-950/gammahydroxybutyrate. Accessed October 4, 2019. Drug Bank. Canadian Institutes of Health Research. Gamma-Hydroxybutyric Acid. Available at: https://www.drugbank.ca/drugs/DB01440. Accessed October 4, 2019. DEA. GHB- Gamma-Hydroxybutyic Acid. Available at: https://www.dea.gov/factsheets/ghb-gamma-hydroxybutyric-acid. Accessed October 4, 2019. Sodium Oxybate Oral. Drug Facts and Comparisons. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc. Philadelphia, PA. Available at: http://factsandcomparisons.com. Accessed October 9, 2019. Sodium Oxybate. Drug Interactions. Micromedex 2.0. Truven Health Analytics, Inc. Greenwood Village, CO. Available at: http://www.micromedexsolutions.com Accessed October 4, 2019

FALL 2019

Hashish Jacob Kohley | Student Pharmacist

https://ktar.com/story/2593289/arizona-supreme-court-rules-hashish-ok-for-medical-marijuana-patients/

Pharmacology

Street Names

Active component: THC Hash, gangster, keesh, THC attaches to cannabinoid receptors in

shish, finger, brick

the brain and activates neurons. It can work in the hippocampus and can cause impaired thinking or interfere with a person's ability to learn and perform complicated tasks. THC can also activate the brains reward pathway causing an increased release of dopamine from neurons and thus resulting in a "high".

Drug Effects Hashish is the most potent grade of marijuana. It is known as an intoxicant, as it leads to euphoria and exaggeration of sensations. The acute psychosis associated with this drug includes hallucinations, delusions, and a loss of sense of personal identity.

History Hashish was first introduced by a French psychiatrist who wanted to utilize the drug in order to understand mental illness. His group of friends reported the drug to be all-powerful and had reports of hallucinations. When first introduced in England, the drug was said to help with pain, muscle spasms, migraines, convulsions, and swollen tonsils.

Drug Interactions/ Toxicology

Laws In Indiana, CBD products with less than 0.3% THC is legal. All other marijuana with greater THC concentration is

Major Interactions

illegal. Hashish has a higher THC concentration than marijuana, thus all hashish is illegal in the state of

Medications that cause drowsiness such as

Indiana. The laws of the United States

barbiturates, benzodiazepines, and CNS depressants

says that all hashish and marijuana

should be used with caution as hashish may increase

possession is illegal.

drowsiness. Hashish may also decrease the

Monitoring/

effectiveness of theophylline. THC is also metabolized by CYP2C9 and CYP3A4, so people taking hashish should avoid drugs that alter the concenterations of these enzymes.

Drug Screens THC metabolites can be detected in a person's body long after the effects of the drug has worn off. Active THC can be detected in the blood for a few hours. Metabolites can be detected in the urine from about 2 weeks to 3 months depending on how often the person has used hashish. Daily use could also be detected in the hair for up to 3 months. Typically, a urine drug screening is used to test for THC.

https://greenrushdaily.com/culture/hash/

Professional Opinion In my opinion, hashish use should continue to be illegal as the high THC concentration comes with greater risks. I see benefits in medical marijuana, however, I feel that hashish is too potent and if marijuana is not legalized then hashish definitely should not be. The euphoria produced by hashish is very addictive

and there are also many drug interactions to be aware of. ~ J. Kohley

References 1. Encyclopedia.com. Hashish. Available at: https://www.encyclopedia.com/medicine/drugs/pharmacology/hashish. Accessed October 18, 2019. 2. National Institute on Drug Abuse. How does marijuana produce its effects. Available at: https://www.drugabuse.gov/ publications/researchreports/marijuana/how-does-marijuana-produce-its-effects. Accessed October 18, 2019. 3. Infoplease. Hashish. Available at: https://www.infoplease.com/encyclopedia/medicine/drug/pharmacology/hashish Accessed October 18, 2019. 4. WebMD. Cannabis. Available at: s://www.webmd.com/vitamins/ai/ingredientmono-947/cannabis. Accessed October 20, 2019. 5. Pharmacy Times. Drug interations with marijuana. Available at: https://www.pharmacytimes.com/publications/issue/2014/december2014/druginteractions-with-marijuana. Accessed October 20, 2019. 6. NORML. Indiana laws and penalties. Available at:https://norml.org/laws/item/indiana-penalties-2. Accessed October 20, 2019.

FALL 2019

HEROIN/OPIUM Alison Kwak, Student Pharmacist

https://www.yahoo.com/news/mexicos-poppy-war-mexican-army-slideshow-wp-172436968.html

SLANG TERMS Heroin: Black tar Brown sugar Mud Opium: Aunti Big O Dopium

HISTORY/BACKGROUND Opium was the first opioid and is derived from the sap of opium poppies. The cultivation of opium can be traced back to as far as 3400 BC in the ancient civilization of Mesopotamia. Opium's use as a therapeutic agent by physicians in the U.S. began in the 18th century. Towards the end of the 18th century, physicians began recognizing its addictive quality. In 1874, heroin was synthesized from morphine by an English chemist. In 1898, it started becoming commercially produced by Bayer. Heroin was used in place of morphine due to morphine abuse. However, it was discovered that heroin was also highly addictive.

PHARMACOLOGY/DRUG EFFECTS Opium is an agonist for opioid receptors in the brain. They cause a reduction in neuronal excitability and inhibit the release of pain neurotransmitters. Therefore, opium reduces the intensity of pain. It also causes sedation, euphoria, dysphoria and respiratory depression. Heroin binds to and activates mu-opioid receptors. This leads to the release of dopamine, causing a sensation of pleasure. The initial sensation of pleasure is accompanied by a warm flushing of the skin, dry mouth and a heavy feeling of the extremities.

DRUG INTERACTIONS/TOXICOLOGY Other opioids, alcohol, drugs for sleep or anxiety, muscle relaxants and antihistamines may increase the risk of severe side effects when taken in combination with heroin or opium. Most heroin overdoses are caused by a combination of drugs. The drugs most commonly associated with heroin overdoses are depressant drugs such as alcohol or benzodiazepines.

LAWS Heroin is a Schedule I drug under the Controlled Substances Act. A first time possession charge results in a prison sentence up to 1 year and a minimum fine of $1,000. A second time possession charge results in a 15 day2 year prison sentence and a minimum fine of $2,500. Any subsequent possession charges result in a 90 day-3 year prison sentence and a minimum fine of $5,000. https://www.rt.com/usa/389885-police-find-500mn-heroin-field/

MONITORING/DRUG SCREENS 6-AM is a metabolite that the body produces after heroin use. Therefore, 6-AM testing can detect heroin use. 6-AM is only excreted for 2-8 hours after heroin use, which makes the window for this test very narrow. In a typical urine drug screen, morphine may be the only drug detected in a heroin user. Gas chromatography-mass spectrometry can provide more sensitive and specific results. Heroin can be detected 2-4 days since last use.

PROFESSIONAL OPINION Heroin and opium are drugs that may give the user a temporary feeling of euphoria, however the long-term effects can be devastating. Long-term use can lead to collapsed veins, insomnia, abscesses, mental disorders and many other issues. I think that it is never too late to seek help for substance use. There are many resources within every community that are available to those who need it. ~ A. Kwak

References: 1. Methoide. Origin and History. Available at: https://methoide.fcm.arizona.edu/infocenter/index.cfm?stid=174. Accessed October 15, 2019. 2. DrugBank. Opium. Available at: https://www.drugbank.ca/drugs/DB11130. Accessed October 15, 2019. 3. National Institute on Drug Abuse. Heroin. Available at: https://www.drugabuse.gov/sites/default/files/heroinrrs_11_14.pdf. Accessed October 15, 2019. 4. WebMD. Opium. Available at: https://www.webmd.com/drugs/2/drug-93960/opium-tincture-oral/details. Accessed October 15, 2019. 5. LegalMatch. Heroin State and Federal Penalties. Available at: https://www.legalmatch.com/law-library/article/heroin-state-and-federalpenalties.html. Accessed October 15, 2019. 6. Truescreen. Drug Testing for Heroin. Available at: https://www.truescreen.com/resource-center/occupational-health-screening/drugtesting-for-heroin/. Accessed October 15, 2019.

MOISES MARTINEZ, STUDENT PHARMACIST, FALL 2019

INHALANTS

Slang terms: Bold (nitrates), Laughing gas (nitrous oxide), Poppers (amyl nitrite and butyl nitrite), Rush (nitrites), Snappers (amyl nitrite), Whippets (fluorinated hydrocarbons)

Background The history of inhaling fumes from chemical vapors has been recorded in religious and ritualistic practices of many different societies including Egypt, Babylonia, China, Greece, and others. In the 1800s, nitrous oxide, ether, and chloroform were used as inhalants for recreational intoxication. These were used medicinally as anesthetics at the time. Nitrous oxide was even used as a vapor substitution for alcohol during prohibition. Presently, common inhalants include glue, air duster, paint thinners, acetone, lighter fluid, spray paint, and many others.

Pharmacology The majority of behavioral effects from inhalants appear to be caused by changes in receptor and/or ion channel activity for GABAA, glycine and 5HT3 receptor activation, and NMDA receptor inhibition, although nonspecific interactions can also arise at high concentrations. Recent studies examining the effects of toluene exposure suggest there are long-term alterations in the function of NMDA and GABAA receptors. Over long -term use, after just 4 days of regular exposure, NMDA receptors become upregulated and GABAA receptors become downregulated. These findings show that regular use of toxic inhalants would cause a hyperexcitability/hyperglutamatergic state during withdrawal following chronic exposure, a situation that similarly occurs during withdrawal from alcohol.

Effects Acute Exposure

https:// w alants/si ww.galaxrecov ery gns-sym ptoms-w .com/addictio n/inh ithdraw als/

Sudden sniffing death, dizziness, slurred speech, euphoria, lethargy, slowed reflexes, slowed thinking, tremors, blurred vision, stupor or coma, generalized muscle weakness, and involuntary eye movement

Prolonged Exposure

Long-Term Abuse

Latent confusion, paranoia, anxiety, social withdrawal, memory loss, seizures, loss of coordination

significant learning and memory impairments, diminished brain activity, neurological dysfunction

Laws

In Indiana, inhaling toxic fumes or vapors from any legal or illegal products with the intent of become intoxicated or causing an altered condition is a Class B Misdemeanor.

Monitoring and Screening

The clinical screening tests for inhalant use are the Volatile Solvent Screening Inventory (VSSI) and Comprehensive Solvent Assessment Interview (CSAI). The VSSI assesses past-year and lifetime frequency of use of inhalant chemicals and products, medical history, demographic characteristics, current psychiatric symptoms, suicidal thoughts and attempts, trauma history, temperamental traits such as impulsivity, and the frequency and nature of antisocial behavior in the prior year. The CSAI assesses reasons for many similar characteristics.

Drug Testing There are currently no biological tests in clinical to detect the presence of inhalants. Studies suggest that immunoassays/bioassays for hippuric acid, o-cresol levels, and benzylmercapturic acid may eventually be used as urinary markers of toluene abuse.

https://www.therecoveryvillage.com/inhalant-addiction/

Toxicity

Major interactions are dependent on the exact chemical nature of the product and differ depending on what is inhaled. In general, all inhalants affect medications which target voluntary and involuntary muscle control. Recurrent inhalant intoxication can lead to Parkinsonism, impaired cognition due to encephalopathy, cerebral atrophy, and loss of muscle strength and coordination due to damage to the cerebellum (cerebellar ataxia). References American Addiction Centers. (2019). Huffing Canned Air or Dust-Off: Side Effects, Signs, and More. [online] Available at: https://americanaddictioncenters.org/inhalantabuse/side-effects [Accessed 30 Oct. 2019]. Findlaw. (2019). Indiana Code Title 35. Criminal Law and Procedure ยง 35-46-6-2 | FindLaw. [online] Available at: https://codes.findlaw.com/in/title-35-criminal-lawand-procedure/in-code-sect-35-46-6-2.html [Accessed 30 Oct. 2019]. Foundation for a Drug-Free World. (2019). History of Inhalants - Nitrous Oxide, Chloroform & Anesthetics - Drug-Free World. [online] Available at: https://www.drugfreeworld.org/drugfacts/inhalants/a-short-history.html [Accessed 30 Oct. 2019]. Matthew O. Howard, M. (2019). Inhalant Use and Inhalant Use Disorders in the United States. [online] PubMed Central (PMC). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3188822/ [Accessed 30 Oct. 2019]. NIDA for Teens. (2019). Inhalants. [online] Available at: https://teens.drugabuse.gov/drug-facts/inhalants [Accessed 30 Oct. 2019].

Professional Opinion

In my professional opinion, I believe that inhaling vapors chemicals or toxic products is only medically indicated and safe for use in anesthesia when supervised by a medical professional. Other, unregulated use of these inhalants is not only dangerous, but it can cause death instantaneously. The law should discourage the use of inhalants as strictly as possible, and education on the risks of use should be prioritized ~ M. Martinez https://www.drugfreeworld.org/drugfacts/inhalants.html

https://cbsnews1.cbsistatic.com/hub/i/ 2015/05/08/6477c7a4-1ec6-49e8-9ecba27de2e244f7/ap100215039023.jpg

PHPR

486

https://cdn.cnn.com/ cnnnext/dam/assets/ 180816181830-01-k2synthetic-weed-supertease.jpg

K-2 SPICE Donovan McDuffy Second Year Professional Pharmacy Student Fall 2019

Slang Terms: Spice, K2, Blaze, Red X Dawn, Bliss, Black Mamba, Bombay Blue, Fake Weed,

Genie, Serenity, Zoh, Demon, Spike, Crazy Clown, Paradise, Smoke, Skunk, etc.

History/background of use/abuse: Spice is something known as a synthetic cannabinoid.

Synthetic cannabinoids are man-made mind-altering chemicals that are either sprayed on dried, shredded plant material so they can be smoked or sold as liquids to be vaporized and inhaled in e-cigarettes and other devices. Cannabinoids were discovered in the 80s starting with two banned compounds founded by Pfizer for analgesic properties and had cannabis type effects. In 1988, Hebrew University in Israel founded two more compounds found to have anti-inflammatory and anesthetic properties and were 100 to 800 times more potent than natural THC but produced no cannabis type effects. A Clemson University researcher created another compound for experimental purposes and it is believed this was copied to make Spice. In 2004, the brand â&#x20AC;&#x153;Spiceâ&#x20AC;? was released and gained popularity in 2006 particularly in Europe but soon spread throughout the world reaching the US and Canada in 2009. For years it was untraceable in urine test until 2011.

Pharmacology/Drug effects: Spice is a hallucinogen and is listed in the same class of marijuana. It is at least 5 times more potent than some of the strongest marijuana and this is due to there being no regulations. These cannabinoids act by binding to two types of nerve receptors (CB1 and CB2) which are linked to the proteins that regulate neurotransmitters. The cannabinoids activate these receptors and supposedly bind better and longer than natural THC giving a longer high.

LAW Synthetic cannabinoids have no accepted medical use and currently 26 substances are listed as Schedule I substances either through legislation or regulatory action. Other substances that match the Controlled Substances Act’s definition for “cannabimimetic agents” are also Schedule I. There are also many synthetic cannabinoid substances sold as “incense”, “potpurri” and other products that are not controlled substances. These are confiscated through the Controlled Substance Analogue Enforcement Act which allows non-controlled drugs to be treated as Schedule I.

Adverse Effects:

Anxiety Panic Attacks Heart Palpitations Respiratory Complications Aggression Mood Swings Altered Perception Paranoia

Monitoring/Drug Screens:

Toxicities

Urine Screen Test (NarcoCheck®)

Toxins are unknown due to no regulation of this drug.

Drug Interactions: ‣ CYP2C9 Inhibitors ‣ CYP1A2 Inhibitors

https:// media.narcocheck.com/ 65-thickbox_default/k2spice-syntheticcannabinoids-test.jpg

My Opinion: My professional opinion would be trying to get spice off the streets as fast as possible. The data collected including thousands of hospitalizations annually are not good for the communities or users. People are altering this drug constantly causing different harms and side effects and the thought that it is being sold disguised as other products is very concerning. ~ D. McDuffy

https://encryptedtbn0.gstatic.com/images? q=tbn:ANd9GcR87L8fTYBGH3Y WlJEd30XabAYN7CyaTiWLwolzlYgoUigryMOCA&s

References: ‣ NIDA. Synthetic Cannabinoids (K2/Spice). National Institute on Drug Abuse website. https:// www.drugabuse.gov/drugs-abuse/syntheticcannabinoids-k2spice. April 7, 2016. Accessed October 25, 2019. ‣ NarcoCheck. Urine Drug Tests. K2/SPice urine test (synthetic cannbinoids). https://www.narcocheck.com/ en/urine-drug-tests/k2-spice-synthetic-cannabinoidstest.html. Acccessed October 25, 2019 ‣ Tai S, Fantegrossi WE. Pharmacological and Toxicological Effects of Synthetic Cannabinoids and Their Metabolites. Curr Top Behav Neurosci. 2017;32:249–262. doi:10.1007/7854_2016_60 ‣ Spice and K-2. Hunterdon Drug Awareness Program. https://www.hdap.org/spice-k2. Accessed October 25, 2019. ‣ Spice/ K2, Synthetic Marijuana. DEA. https:// www.dea.gov/factsheets/spice-k2-synthetic-marijuana. Accessed October 25, 2019. ‣ Partnership for a Drug-Free New Jersey. Drug Free NJ K2 Spice. http://drugfreenj.org/drug-encyclopedia/k2spice/. Accessed October 25, 2019.

Pharmacology Cathinone and cathine are the stimulants found in khat that make someone feel high. They do this by increasing levels of dopamine and stimulating release of norepinephrine. Use and effects of khat been compared to amphetamines. Wrapped bundles of khat

Slang terms for khat include Abyssinian Tea, African Salad, Catha, Chat, Kat, Miraa, Oat, Qat, Quaadka.

So how does this affect the body? It can cause manic behavior, increased energy, hallucinations, paranoia, nightmares, increased heart rate and blood pressure, insomnia, euphoria, and gastric problems, with chronic use linked to depression.

History of Khat Catha edulis Forsk, also known as khat, is a shrub found in East Africa and Southern Arabia. It has been used for centuries for its stimulant like properties and as part of cultural tradition. Khat can be chewed (similar to tobacco), made into tea, smoked, or sprinkled onto food and has addictive properties. In Somalia and Yemen, khat is often chewed socially, like meeting a friend for coffee in the US. Use of khat is spreading as people from these countries immigrate elsewhere.

KHAT

Maggie Miedema Student Pharmacist Fall 2019

Drug interactions and toxicology Chewing khat interferes with the absorption of amoxicillin and ampicillin. Khatâ&#x20AC;&#x2122;s stimulant effects are enhanced by nicotine and caffeine. Toxic effects of khat include oral and gastric cancers, cerebral hemorrhage, severe headache, myocardial infarction, ulcers, hypertension, and low-birth-weight infants.

Khat leaves 1. 2. 3. 4. 5. 6. 7.

Laws Cathinone is a Schedule I drug in the US making khat use illegal, however the khat plant itself is not controlled Drug Screening There are tests that can detect cathinone (an active ingredient in khat) in urine with gas chromatographic-mass spectrometric procedures. However, this method is not widely used because khat use is relatively uncommon in the US and it is more expensive than a standard urine drug test.

Khat. Drug Facts and Comparisons. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.factsandcomparisons.com. Accessed October 26, 2019. Paul BD, Cole KA. Cathinone (Khat) and methcathinone (CAT) in urine specimens: a gas chromatographic-mass spectrometric detection procedure. J Anal Toxicol 2001;25(7):525-30. National Institute on Drug Abuse. Commonly Abused Drugs Charts. Available at: https://www.drugabuse.gov/drugs-abuse/commonlyabused-drugs-charts#khat. Accessed October 26, 2019. National Institute on Drug Abuse for Teens. Letâ&#x20AC;&#x2122;s Talk About Khat. Available at: https://teens.drugabuse.gov/blog/post/lets-talk-aboutkhat. Accessed October 26, 2019. AfricaMetro. Khat in the Horn of Africa-A Scourge or Blessing? Available at: http://www.africametro.com/business/khat-horn-africascourge-blessing. Accessed October 27, 2019. Talking Drugs. Khat use in the UK. Available at: https://www.talkingdrugs.org/khat-use-in-the-uk. Accessed October 26, 2019. United States Drug Enforcement Administration. Khat. Available at: https://www.dea.gov/factsheets/khat. Accessed October 26, 2019.

Professional opinion Khat is normally used recreationally and socially in certain countries, such as Yemen and Somalia. It has addictive properties and in terms of stimulant activity appears to fall between coffee and amphetamines. It is not widely used in the US and Europe except by those immigrating from East Africa and Southern Arabia as it is illegal and difficult to obtain in aforementioned areas. ~Maggie Miedema~

REFERENCES

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HISTORY/BACKGROUND:

Krokodil (desomorphine) Thu Ngo

Fall 2019

SLANG TERMS: • Crocodil • Crocodile

PHARMACOLOGY/DRUG EFFECTS: Krokodil has a faster onset and shorter duration than morphine. It also causes less nausea and respiratory depression. The street method of manufacturing results in many impurities and therefore causes many problems when injected. Krokodil is notorious for causing severe tissue damage, gangrene, and damage to veins. It can also increase the spread of HIV through needle use. Consequences of using this drug can include limb amputation, impaired cognitive function, liver and kidney damage, or even death.

Krokodil is a synthetic opiate analogue that was invented in 1932 in the US. Despite its origin, there is no accepted use in the US. It is a much more potent derivative of morphine. When it was used in Switzerland, it was sold under the brand name Permonid. Abuse of this drug first was seen internationally in 2002. Now this drug is used in Russia, especially when the heroine supply becomes scarce or expensive. Russia has a large opiate addiction problem and has an estimated number of one million users. This high number of users could be due to krokodil’s lower price compared to heroin. Codeine (one of the ingredients of krokodil) is available in Russia as over the counter which allows it to be more cheaply manufactured. Krokodil use is now spreading to other European countries. Russia is now trying to find methods to prevent use of this drug.

The name “krokodil” (crocodil) comes from the scale-like and green appearance of the skin of its users. http://drugspoisonsandvenoms.blogspot.com/2016/

DRUG INTERACTIONS/TOXICOLOGY: Studies show that desomorphine is 3x more toxic than morphine Krokodil has the same drug interactions as other opioids

MONITORING/DRUG SCREENS:

PROFESSIONAL OPINION:

Although this drug is not used clinically in the US, users should still monitor for any tissue death in order to prevent any need of amputation. Given the potency of this drug, users should also monitor for overdose if at all possible.

LAWS: Krokodil is classified as a Schedule I substance of the Controlled Substances Act. This means that the drug has high abuse potential and no currently accepted medical use.

The risks of this drug outweigh any benefit that it might have and therefore should not be used clinically. It should continue to not be used in the United States. In other countries where abuse of krokodil is prevalent, codeine should be prescription only to increase the difficulty of making this drug. ~ T. Ngo

References: 1. Khatri M. 12 Illegal street drugs: krokodil, molly, flakka, and more. Available at: https://www.webmd.com/mental-health/addiction/street-drugs-risks#3. Accessed on October 27, 2019. 2. Addiction medicine FYI â&#x20AC;&#x153;krokodilâ&#x20AC;?. Office of Alcholism and Substance Abuse Services. Available at: https://www.oasas.ny.gov/AdMed/FYI/Krokodil.cfm. Accessed on October 27, 2019. 3. Desomorphine. Drug Enforcement Administration. Available at: https://www.deadiversion.usdoj.gov/drug_chem_info/desomorphine.pdf. Accessed on October 27, 2019. 4. Krokodil Drug Facts. Drugs.com. Available at: https://www.drugs.com/illicit/krokodil.html. Accessed on Octobet 27, 2019. 5. Drug Scheduling. Dea. Available at: https://www.dea.gov/drug-scheduling. Accessed on October 27, 2019.

Street term:

Imodium Robert Sears, Student pharmacist

Background and Abuse Loperamide is an opioid used to treat acute diarrhea at therapeutic doses. It has very poor penetration into the brain, however when taken in large amounts, it can produce a euphoric feeling like other opioids. It is sometimes misused to lessen opioid cravings and withdrawal symptoms. Pharmacology and Drug Effects Loperamide binds to opioid receptors on the circular and longitudinal intestinal muscles to inhibit peristalsis and prolong transit time, reduce fecal volume, increase fecal viscosity, and diminishes fluid and electrolyte loss. Loperamide can produce a euphoric feeling at higher than therapeutic doses. However, this can increase the severity of side effects, such as dizziness, drowsiness, and severe cardiac adverse reactions.

Drug Interactions and Toxicology Loperamide is contraindicated in patients younger than 2 years of age. P-glycoprotein/ABCB1 Inducers will decrease the effects of loperamide. P-glycoprotein/ABCB1 inhibitors will increase the effects of loperamide. QTc-prolonging agents will increase the cardiac adverse effects. Other antidiarrheals and opioids will increase the constipating effects of loperamide. In case of an overdose, naloxone can be used as an antidote.

Fall 2019

Laws Loperamide is not scheduled as a controlled substance by the FDA. However, the FDA has encouraged drug manufacturers that sell loperamide as an OTC to limit each package to 48 mg to prevent abuse and overdoses.

Monitoring and Drug Screens Patients with hepatic impairment who are taking loperamide need to be monitored for signs of CNS toxicity. On a drug test, loperamide will not produce a positive result for the presence of opioids. Professional Opinion Loperamide is one of few antidiarrheal medications that is available to purchase without a prescription. It can be an effective and safe treatment option when used as directed. Because it is not a scheduled medication by the FDA, it is likely there is research that demonstrates loperamide has low potential for abuse. However, there have been cases where people have abused loperamide or showed signs of addiction. Patients with a history of opioid addiction have the greatest risk of loperamide abuse or addiction. ~ R. Sears References 1. Center for Drug Evaluation and Research. FDA limits pachaging for anti-diarrhea. U.S. Food and Drug Administration. https:// www.fda.gov/drugs/drug-safety-and-availability/fda-limits-packaging-anti-diarrhea-medicine-loperamide-imodium-encourage-safeuse. Accessed October 23, 2019. 2. Loperamide. Drug Facts and Comparisons. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.factsandcomparisons.com. Accessed October 23, 2019. 3. Loperamide. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http:// www.micromedexsolutions.com. Accessed October 23, 2019 4. National Institute on Drug Abuse. Over-the-Counter Medicines. NIDA. https://www.drugabuse.gov/publications/drugfacts/overcounter-medicines. Accessed October 22, 2019. 5. Varghese SP, Kumari P, Wijegunaratne H, et al. Loperamide addiction: atypical opioid use disorder treated with buprenorphine/ naloxone. Prim Care Companion CNS Disord. 2019;21(4):19l02446. 6. What Is Loperamide?: Loperamide Abuse and Abuse Potential. The Recovery Village. https://www.therecoveryvillage.com/ loperamide-abuse/. Published May 10, 2019. Accessed October 22, 2019. 7. Loperamide. https://www.aliem.com/wp-content/uploads/2016/08/Loperamide-Pills.jpg. 8. Naloxone. http://3.bp.blogspot.com/-n-4nM4RC96c/UMeMW1wK4lI/AAAAAAAAHTY/HUsFOpvhX-U/s1600/naloxone++from+savalife+dot+com.jpg. 9. Pill. https://upload.wikimedia.org/wikipedia/commons/thumb/2/2b/Pill.svg/640px-Pill.svg.png. 10. Pill bottle. http://media.istockphoto.com/vectors/pill-bottle-vector-id459644605?k=6&m=459644605&s=612x612&w=0&h=03phRmhWrZoW0bELGyrw_opSHjZXZZSBitBPZzVDmc=.

Pharmacology | Drug effects

Lysergic Acid Diethylamide LSD is a psychedelic that works by binding to

https://www.drugsbanks.com/lsd/

History | Background of Use | Abuse LSD is a hallucinogen that was first discovered in 1938 by the Swiss chemist Albert Hofmann in Sandoz Pharmaceuticals – now Novartis. Its synthesis was to obtain a respiratory and circulatory stimulant— an analeptic. A few years later Hoffman accidentally ingested the drug and discovered its psychedelic properties. In 1947 the drug was commercialized for various psychiatric uses under the brand name Delysid. The drug was widely used for psychotherapy in the 1950s and 1960s. It was later discovered that LDS has no clinical applications and was scheduled class 1 in the United states in 1971. This means they have very high abuse potential and no associated clinical benefit.

serotonin receptors in the brain, specifically the 5-HT2A receptor. It’s mechanism of action is not exactly understood. LSD is a white crystalline odorless compound. The crystals are usually formulated into a blotting paper, the paper is then divided into small single-dose squares. The drug also comes in tablet and capsule form, but the blotting paper is most common. The drug is so potent that only a dose of 0.02mg is enough to elicit a response. The drug is

(Delysid) Street names: ACID, Window pane, Blotter, Trips, Dots, Battery acid, loony toons, Doses.

Crystal Nnaji

usually ingested as a blotting paper placed on the tongue and is rapidly absorbed. The onset of action occurs within 20 - 60 mins of ingestion and the total duration of action lasts about 6 -12 hours. The hallucinogen produces different effects on different areas of the body. Physically it can

Student pharmacist Fall 2019

increase the body temperature, cause pupil dilation and increase heart rate. Psychologically it can cause visual illusions, also known as “trips”; this is presented as an array of colors like what’s seen in a kaleidoscope. Some people experience “good trips” and some experience “bad trips”, it varies depending on how much is used and how the brain responds to it.

Photo by © DEA

http://www.emcdda.europa.eu/publications/drug-profiles/lsd#physical

Professional Opinion Lysergic Acid Diethylamide currently has no clinical benefit and it should not be recommended as treatment for patients with psychiatric disorders including depression, anxiety, drug dependence and psychosis. The abuse potential of this drug is very high. Although overdose with this drug is uncommon and the effects are not fatal, there have been reports of behavioral fatalities and suicides associated with LSD use. Serious caution should be taken by law enforcement, in the seizing, handling, and regulation of this drug. Very little amounts of the drug, sometimes not visible to the human eye can elicit a response. ~ C. Nnaji

Drug Interaction | Toxicology LSD is a teratogenic agent although the cause

References: 1.

is not clear, and findings are inconsistent. The chronic or frequent use of LSD may result in “flashbacks” or hallucinogen persisting perception disorder (HPPD). HPPD is the development of symptoms while not under the influence of LSD, it includes irritability, agitation, visual hallucinations, confusion and delusions. LSD overdoses are not common but can result in fatality, comatose states, and

hyperthermia.

Laws LSD is a schedule I substance under the Controlled Substances Act. Possession of LSD is considered a misdemeanor and there are penalties associated based on number of offenses. First offences include a fine up to $5,000, up to two years in prison, or both. Second offenses are considered felonies and can incur a fine of up to $5,000, up to five years in prison, or both.

Monitoring | Drug Screens

Lee MA, Shlain B, eds. Acid Dreams, The Complete Social History of LSD: The CIA, The Sixties and Beyond. 1st ed. New York. NY: Grove Press; 1992. The Vaults of Erowid. LSD Effects by Erowid. Available at https://www.erowid.org/chemica ls/lsd/lsd_effects.shtml. Accessed October 27, 2019. Lysergic Acid Diethylamide. LexiTox. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at http://online.lexi.com. Accessed October 27, 2019 Drugsbank. LSD (Lysergic Acid Diethylamide): Uses, Hazards, Effects, FAQs. Available at https://www.drugsbanks.com/ls d/. Accessed on October 27, 2019. Lysergic Acid Diethylamide. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at:

https://www.micromedexsolut ions.com. Accessed October 27, 2019

Diagnosis is based on patient’s history, physical exam, and clinical suspicion. Urine toxicology screens may not detect the presence of LSD. In patients with altered mental status, https://www.dazeddigital.com/artsandculture/artic le/28785/1/your-guide-to-a-safe-acid-trip

a neurological exam and head CT can be used. Monitor patient’s total creatinine kinase levels and renal function in severe agitation. These patients may also need cardiac monitoring. https://www.esquire.com/lifestyle/health/a26 621431/what-is-acid/

Buprenorphine

Michael Nolan

and Naltrexone:

Student Pharmacist

. asd

Fall 2019

Agents for MAT

https://www.samhsa.gov/medication-assisted-treatment

Background of Use and Abuse Buprenorphine and naltrexone are both agents used to treat opioid use disorder (OUD) in medication-assisted treatment (MAT). Buprenorphine was approved by the Food and Drug Administration (FDA) in 2002 and was the first drug used to treat OUD that was allowed to be prescribed and dispensed by physician offices. Buprenorphine acts like an opioid in the body but has a much weaker effect, use of buprenorphine in OUD allows for the prevention as well as lessening of withdrawal symptoms. Buprenorphine comes in multiple products that include buccal films and sublingual tablets. Buprenorphine has also been abused as it offers opioid effects, although it is usually abused by people who have not yet built a tolerance to opioids. Naloxone is always combined with buprenorphine to prevent this abuse from occurring as it will inhibit the opioid effects if the tablet or film were crushed to be snorted or melted for injection. Naltrexone can also be prescribed and administered by physician offices and can be found as a pill or an injection. Naltrexone is used to treat OUD, as well as alcoholism, only once the patient has gone through withdrawal as it works to block the effects of opioids and can suppress cravings. There has been no history of abuse or addiction to naltrexone.

Slang Terms: Buprenorphine: Buse, Oranges, Sobos, Stops, Strips, Sub, Subs Naltrexone does not have any street names.

Drug Effects Buprenorphine is an opioid receptor partial agonist, which means that it causes the same effects as an opioid, such as euphoria, respiratory depression, constipation, nausea, muscle cramps, and even cravings, but to a weaker extent. The opioid effects of buprenorphine increase as the dose increases until a ceiling is hit. Once this ceiling is hit more of the drug will not cause a stronger high. Naltrexone on the other hand, is an opioid antagonist. This means that it inhibits the actions of the opioid receptor and will actual stop the effects of opioids. Naltrexone also causes diarrhea, vomiting, headache, nervousness, sleep problems, and muscle pain. Also, naltrexone can decrease an addicts tolerance to opioids.

Laws Toxicology and Interactions Buprenorphine can cause severe respiratory and CNS depression in pediatric patients that may result in death. High doses of buprenorphine in adults can cause hepatitis and acute renal failure as well as opiate withdrawal but has not been shown to cause severe CNS or respiratory depression. Buprenorphine interacts with a total of 596 drugs including opioids, amphetamines and benzodiazepines. Naltrexone has not been shown to have any toxic effects. Interactions are limited to opioid agonists and antagonists.

Buprenorphine is a schedule III drug and can only be acquired with a prescription from a provider that is registered with the DEA. Prescriptions for schedule three drugs can only be transferred once and expire after 6 months. First time offenders caught selling schedule III drugs can face up to $500,000 in fines and 10 years in prison depending on the state. Naltrexone is a legend drug which means it can only be acquired with a prescription and the prescription expires after 1 year.

Drug Screens

https://www.narcononnewliferetreat.org/l

Buprenorphine will not be detected by a standard opioid drug test. Patients taking buprenorphine for OUD are drug tested regularly to ensure that they are taking the drug and not selling and to ensure that they are not taking other illicit drugs.

Professional Opinion Buprenorphine and naltrexone have been proven to aid in the treatment of OUD through the application of MAT. Although buprenorphine does have potential for abuse, it is safer than other opioids and is effective in the treatment of opioid withdrawal. Naltrexone also has a favorable safety profile and has significant benefit in preventing and treating relapse. Lastly, it is important that providers and physicians alike fully consider the risks and benefits before prescribing and dispensing these drugs and ensure the patient receives the proper counseling and non-pharmacologic treatment for their addiction. ~ M. Nolan

References 1. 2. 3. 4. 5. 6. 7.

US Department of Health and Human Services. Buprenorphine. Available at: http://guides.lib.purdue.edu/c.php?g=352750&p=2377852. Accessed October 25, 2019. US Department of Health and Human Services. Naltrexone. Available at: https://www.samhsa.gov/medication-assistedtreatment/treatment/naltrexone. Accessed October 25, 2019. Addiction Center. Drug Street Names. Available at: https://www.addictioncenter.com/drugs/drug-street-names/. Accessed October 25, 2019. Buprenorphine. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 25, 2019. Naltrexone. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 25, 2019. The Recovery Village. Drug Schedules: Controlled Substances and US Drug Laws. Available at: https://www.therecoveryvillage.com/drugaddiction/drug-schedules/#gref. Accessed October 25, 2019. Ali Safawi. Workit Health. Yes, Suboxone Might Show Up On a Drug Test. It Depends on Who Is Testing. Available at: https://www.workithealth.com/blog/suboxone-drug-tests. Accessed October 25, 2019.

MDMA 3,4-methylenedioxymethamphetamine Javier Aguirre, Student Pharmacist, Fall 2019

Slang Terms: Ecstasy, molly, Adam, beans, candy, clarity, dancing shoes, disco biscuits, E, egg rolls, happy pills, Lover’s speed, Malcolm X, Scooby snacks, Vitamin E, Vitamin X, XTC

Background/History: First developed in 1912 by a German pharmaceutical company, MDMA was intended to be a parent compound used to make medications that would control bleeding. This drug has not undergone formal clinical trials or approval from the FDA for human use. Psychiatrists thought is was useful for helping patients communicate and obtain insights about their problems. In the late 1970’s and early 1980’s, MDMA became more widely available in the streets and by 1985 the DEA declared an emergency ban on the drug, giving it the title of Schedule I.

Pharmacology/Mechanism of Action: MDMA is primarily an indirect serotonergic agonist. This will increase serotonin released to the synapse. The process starts when MDMA is transported to the nerve terminal to increase serotonin secretion through transportermediated exhance. MDMA affects serotonin storage in the vesicles and increases the amount of serotonin ready to be released, leading to greatly increased levels available to leave the synapse. MDMA can also increase dopamine and NE, mediated through a manner similar to increased serotonin release. Lastly, MDMA can also inhibit monoamine oxidase, increasing monoamine extracellular levels

Ecstasy. (n.d.). Retrieved from https://www.talktofrank.com/drug/ecstasy.

Drug Interactions:

Monitoring/ Drug Screens:

MDMA may interfere with serotonin reuptake inhibitors such as Paxil, Zoloft, and Prozac. MDMA is broken down by CYP2D6 therefore other drugs broken down by this enzyme will have decreased metabolism and prolonged effects (ie. Ritonivar for HIV, codeine and other opiate derivatives)

MDMA urine screening test can be used however it is very sensitive and may show a positive due to a small amount of MDMA in the body. Itâ&#x20AC;&#x2122;s also possible to be positive even if the person doesnâ&#x20AC;&#x2122;t use MDMA which may be the result of other prescribed/ OTC medications. Blood screenings in lab may be used if test is uncertain.

Laws:

Admin. (2014, March 14). Is Pure MDMA Safer Than Other Drugs? Retrieved from https://brigantinemunicipalalliance.org/news/is-pure-mdma-safer-than-other-drugs/.

Toxicities in Health Conditions: MDMA produces an increased heart rate of around 30 bpm and it also significantly increases blood pressure meaning this drug can lead to severe heart complications in people with preexisting heart conditions. Users prone to seizures can have an increased risk of seizures while on MDMA. In psychiatric disorders, MDMA can exacerbate symptoms such as depression. Heatstroke susceptibility is also more prominent in the use of this drug.

MDMA is a Schedule I drug. Possession, the supplying others, producing, importing, and exporting of MDMA. Possession of 5+ grams can be 5-40 years of imprisonment.. Possession of MDMA that results in a death or serious injury because of the drug can give a prison term of 20+ years and a fine of 2-5 million dollars

My Professional Opinion: MDMA is a dangerous drug that can rapidly increase dopamine, NE and serotonin in the body causing a variety of physiological effects. These effects include having increased energy, pleasure, and distorted time perception and senses. Typically used as a party drug, I would not recommend this drug be legalized due to the abuse and extreme effects of the drug. ~ J. Aguirre References:

MDMA Drug Screen (Urine). (n.d.). Retrieved from https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=167&contentid=mdma_drug_screen_urine. MDMA Contraindications. (n.d.). Retrieved from https://dancesafe.org/drug-information/mdma-contraindications/. Pharmacology of MDMA (ecstasy). (n.d.). Retrieved from https://www1.health.gov.au/internet/publications/publishing.nsf/Content/drugtreat-pubsmodpsy-toc~drugtreat-pubs-modpsy-2~drugtreat-pubs-modpsy-2-3~drugtreat-pubs-modpsy-2-3-pmdm. Ecstasy. (n.d.). Retrieved from https://www.crchealth.com/find-a-treatment-center/california-treatment-information/popularly-abused-drugs/ecstasy/. MDMA Laws and Penalties (Ecstasy/Molly). (2015, June 30). Retrieved from https://www.eldenlawgroup.net/mdma-laws-and-penalties-ecstasymolly/.

Olivia Park, Student Pharmacist Fall 2019

Methamphetamine Common brand name: Desoxyn Street name: meth, crystal

History/Background Methamphetamine, a strong stimulant, was first synthesized by Japanese scientist A. Ogata in 1919.1 Its use was originally intended to improve the performance of soldiers by making them alert during World War II.1,10 “In post-war US, methamphetamine was medically approved to treat depressions and additionally, was prescribed as a weight loss aid.”10 Although there are current FDAapproved indications of methamphetamine for ADHD and obesity, it has become a very popular drug of choice for recreational use since then.10 There are two reason why methamphetamine is used by many drug addicts. First, methamphetamine is chemically synthesized unlike cocaine and heroin which are derived from plants. Second, it can easily be made in small laboratories with inexpensive over-the-counter cold medication containing pseudophedrine.4 Therefore, its easy manufacturing method and common ingredients make it available to the hands of many drug addicts.

Street terms: “Methamphetamine takes the form of a white, odorless, bitter-tasting crystalline powder.”4 Based on how it looks, methamphetamine is called by different names such as “meth, crystal, chalk, and ice”.4 Also, by knowing that methamphetamine can make users rapidly alert, it also has other street names like “speed, biker’s coffee, stove top, trash, crank, or shabu”.7

https://www.drugabuse.gov/publications/researchreports/methamphetamine/what-methamphetamine

https://www.webmd.com/drugs/2/drug-9124/desoxynoral/details

Pharmacology/Drug effects Methamphetamine stimulates the central nervous system (CNS) by altering the release and re-uptake of different neurotransmitters such as dopamine, serotonin, and norepinephrine. The mechanism of action by which it alters neurotransmitters is to increase monoamine levels mainly through inhibiting the monoamine transporters, reducing the dopamine transporters at the synapse, and inhibiting the monoamine oxidase activity.2 -As soon as methamphetamine is injected and smoked, increasing dopamine levels affects the pleasure reward pathway and initiates the feelings of pleasure that persist for several minutes. In contrast to injecting and smoking, swallowing does not result an immediate euphoric effects.2

Drug interactions/Toxicology Concomitant use of methamphetamine and several medications may cause life-threatening drug interactions in patients. The possible lists of these medications are: drugs that increase the serum concentration of monoamine (isocarboxazie, linezolid, phenelzine, procarbazine, selegiline), drugs that increase serotonin level (St. John’s Wort, SSRIs, SNRIs), and drugs that could raise heart rate or blood pressure (cough-and-cold products, diet aids, or NSAIDs).9 Consuming methamphetamine may cause different symptoms including “insomnia, acute anxiety, agitation, and psychotic or violent behavior”.3 Persistent users can develop more severe symptoms like “poor personal hygiene and body sores called “crank bugs”, unhealthy complexion, and tactile hallucination”.3 They also may develop “cracked teeth because of clenching behavior” during the time being high on methamphetamine.3 Chronic methamphetamine use can trigger physical and psychological dependence and increased tolerance. Because an instant euphoric effect is diminished quickly, the users are often at the risk of overdose to reach the consistent “high”.3 Moreover, “Methamphetamine’s sympathomimetic effect permits peripheral actions by increasing blood pressure, decreasing bronchodilation, and stimulating respiratory activity.”5

Monitoring/drug screens Among many negative health consequences depicted in the toxicology section above, patients should be monitored for sudden, large changes in blood pressure or heart rate.5 According to the American Academy of Pediatrics, “the routine use of electrocardiograms is not recommended in most children due to a risk of sudden cardiac death.” 5 Also, patients should be monitored for the development of severe mental and behavioral symptoms that may be considered as signs of dependency.3

Professional opinion Based on the negative health consequences in methamphetamine users, it is clear that the risks outweigh the benefit. However, 0.7 percent of US population who ages 12 or older were found to use methamphetamine in 2018, according to National Survey of Drug Use and Health. 6 Although the current regulation has prevented the spread and availability of methamphetamine to some extent, the number still shows there are many potential people who abuse methamphetamine in US population. Also, methamphetamine should be recommended to only those who are legally prescribed for FDA-approved indication. There should be more effective ways to control the recreational or self use of methamphetamine in order to protect them from lifethreatening events. ~ O. Park

Laws

Historically, methamphetamine abuse has been prevalent in the United States. Due to its highly addictive property, it is currently regulated under the Comprehensive Drug Abuse Prevention and the Controlled Substances Act and classified as a Schedule II drug, the most restrictive classification for a prescription drug that cannot be refilled.4,8 Such actions as drug manufacturing, distribution, sales, and possession of methamphetamine are considered as felony and the penalties are varied in each state jurisdiction.8 According to an amendment to the Patriot Act, “the pharmacies control the purchase of common over the counter medications that have been used to make crystal meth and even require the purchaser’s legal identification to keep on file to the amount of the purchased medications.” 8

Reference 1.Erowid. Methamphetamine Timeline. Available at: https://www.erowid.org/chemicals/meth/meth_timeline.php. Accessed October 21, 2019. 2. University of Arizona. Methamphetamine Pharmacology. Available at: https://methoide.fcm.arizona.edu/infocenter/index.cfm?stid=166. Accessed October 19, 2019. 3. Yasaei R, Saadabadi A. Methamphetamine. StatPearls Publishing 2019 4. Publishers Group West. Streetdrugs. Available at: https://streetdrugs.org/methamphetamine/. Accessed October 20, 2019. 5. Micromedex. Methamphetamine. Available at: https://www-micromedexsolutionscom.ezproxy.lib.purdue.edu/micromedex2/librarian/PFDefaultActionId/evidencexpert.DoIntegratedSearch?navitem=topHome&isToolPage=true#. Accessed October 20, 2019. 6. National Institute on Drug Abuse. Methamphetamine. Available at: https://www.drugabuse.gov/drugs-abuse/methamphetamine. Accessed October 21, 2019. 7. United States Drug Enforcement Administration. Methamphetamine. Available at: https://www.dea.gov/factsheets/methamphetamine. Accessed October 19, 2019. 8. National Legal Professional Association. Crystal Meth Laws. Available at: http://nlpa.com/latest-news/crystal-meth-laws/. Accessed October 21, 2019. 9. WebMD. Crystal Meth: What You Should Know. Available at: https://www.webmd.com/mental-health/addiction/crystal-meth-what-you-should_know#1. Accessed October 20, 2019. 10. American Addiction Centers Resource. Methamphetamine History and Statistics. Available at: https://drugabuse.com/methamphetamine/history-statistics/. Accessed October 22, 2019. 11. WebMD. Desoxyn image. Available at: https://www.webmd.com/drugs/2/drug-9124/desoxyn-oral/details. Accessed October 29, 2019. 12. National Institute on Drug Abuse. What is methamphetamine?. Available at: https://www.drugabuse.gov/publications/research-reports/methamphetamine/whatmethamphetamine. Accessed October 29, 2019.

ALEXIS RINI, STUDENT PHARMACIST (FALL 2019)

NICOTINE Background/History In 1556 the first tobacco was brought to france, then in 1809 nicotine is observed as the acive product in tobacco juice. In 1856 the first cigarette factory opens in england. It wasnâ&#x20AC;&#x2122;t until https://www.rd.com/health/how-much-nicotine-is-in-one1900 that japan decides to ban the use cigarette/ of cigaretted by anyone under the age of 20. The US federal trade comission releases its first tar and nicotine report PHARMACOLOGY/DRUG EFFECTS in 1967, which leads to nicotine gum being approved by the FDA for Nicotine is a naturally occurring alkaloid. It binds stereo-selectively to the perscription use in the United States in nicotine-cholinergic receptors in the adrenal medulla, at the neuromuscular 1984. Then in 1996 president Clinton junctions, and in the brain. There are two types of CNS effects that are announces an anti-smoking porgram believed to contribute to the addictive properties of nicotine. There is a which granted the FDA jurisdiction to stimulating effect that occurs in the cortex, and a reward effect occurs in the regulate cigarettes. limbic system. At low doses the stimulant effect is higher, while at high doses the reward effect is higher. The reward effect is triggered by the Slang Terms indirect release of dopamine that nicotine causes. Dopamine is a brain Cigarettes: Smokes, Cigs, or Butts chemical that affects emotions, movements, and sensations of pleasure and pain. Overall nicotine will cause an increase in heart rate, breathing Smokless: Chew, Dip, Spit Tobacco, or activity, and blood pressure. Snuff

https://en.wikipedia.org/wiki /Nicotine

http://mylungsmylife .org

LAWS

MONITORING/ DRUG SCREENS

In Indiana it is illegal for anyone under the age of 18 to buy nicotine products. This includes cigarettes, e-cigarettes, and smokeless tobacco. Venders also need a permit in order to sell these products.

Nicotine can be screened for in urine, hair, saliva, and blood test. Each one varies in the time frame that they are able to detect, and the sensitivity. All of these test for the nicotine metabolite cotinine. The detection period for all of them ranges from 2-10 days. The most sensitive test being saliva testing, being able to detect as low of concentrations as 1ng/ml of cotinine.

DRUG INTERACTIONS/TOXICOLOGY Nicotine may enhance the tachycardic effect of Adenosine. Along with this Cimetidine may increase the serum concentration of nicotine, and varenicline may enhance the toxic effect of nicotine. The signs and symptoms of nicotine toxicity are severe headache, dizziness, confusion, abdominal pain, rapid, weak, irregular pulse, and nausea/vomiting.

https://theravape.net/products/juul-starter-kit

MY PROFESSIONAL OPINION In my professional opinion, nicotine is a very addictive drug. That being said, I also think that nicotine can serve a purpose in the healthcare field. Nicotine replacement therapy is used to help people who have a nicotine addiction move away from the more harmful nicotine delivery systems (cigarettes, chewing tobacco, e-cigarettes). Although these patients are still receiving nicotine, it is helping them to slowly reduce their nicotine intake and move towards living a nicotine free life. ~ A. Rini

WORKS CITED 1. Nicotine. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 26, 2019. 2. The Vaults of Erowid. Nicotine Drug Testing. Available at: http://www.erowid.org/chemicals/nicotine/nicotine_testing.shtml. Accessed October 26, 2019. 3. The Endowment for Human Development. Facts on Drugs: Nicotine. Available at: http://www.ehd.org/health_tobacco_17.php#chapter2. Accessed October 26, 2019. 4. Medical News Today. Everything you need to know about nicotine. Available at: http://www.medicalnewstoday.com. Accessed October 26, 2019. 5. Public Health Law Center. E-Cigarette Regulations-Indiana. Available at: http://www.publichealthlawcenter.org. Accessed October 26,b2019. 2

LAW

NIGHTSHADE Emily Sajda • Student Pharmacist • Fall 2019

BACKGROUND Nightshade sometimes called deadly nightshade is from a plant with high toxicities. It was once used to enlarge pupils by women who dropped small amounts into their eyes when that was the standard of beauty. Scopolamine is a derivative from nightshade and is believed to be used to blow into the face of victims causing them to become incapable of forming memories during the time they are under its influence. Now large doses are used to produce vivid hallucinations recreationally.

Nightshade is not federally regulated and is not approved for human consumption. In the United States all parts of the nightshade plant are legal to grow, buy, and distribute without a prescription or license.

SLANG TERMS -

Atropa Belladonna Devil’s Cherries Scopolamine

PHARMACOLOGY Nightshade is a neurotoxin affecting the central nervous system. Primary effects after consumption last for three to four hours, but hallucinations can last up to three to four days. Some negative effects are present for several days. Scopolamine and hyoscyamine are responsible for producing the psychoactive effect. Hyoscyamine is a Depressant and sedative at low doses. https://www.erowid.org/plants/show_image.php?i=belladonna/atropa_b elladonna11.jpg

https://www.erowid.org/plants/show_ima ge.php?i=belladonna/atropa_belladonn a6.jpg

DRUG EFFECTS •

• • • • • • • •

Hallucinations o Said to begin enjoyable then turn frightening Tachycardia Dry mouth Blurred vision Mydriasis Confusion Seizures Death Additional anticholinergic effects

MONITORING Patients should be monitored for signs and symptoms of anticholinergic toxicities such as dry mouth and dilated pupils.

Drug SCREENS Currently, there is no information on drug screens for nightshade use.

PROFESSIONAL OPINION In my opinion, the recreational uses of nightshade are not clinically beneficial in any way. The risks involved in the anticholinergic action of nightshade puts users in an unsafe situation. There are many severe interactions with anticholinergic drugs that individuals using nightshade may be unaware of. The potency is very strong as well which may be hard to judge and use to the average individual leading to death. ~ E. Sajda ~ E. Sajda

https://en.wikipedia.org/wiki/Atropa_belladonna

DRUG INTERACTIONS -

Other anticholinergic medications

Antihistamines

Phenothiazines

Tricyclic antidepressants

https://www.erowid.org/plants/show_image.php?i=belladonna/atropa_belladonna8.jpg

References: - Independent. 10 of the most dangerous street drugs in the world. Available at: https://www.independent.co.uk/news. Accessed October 26, 2019. - Mother Earth Living. Deadly Nightshade: The Wicked Belladonna. Available at: https://www.motherearthliving.com/natural-health/deadly-nightshade-the-wickedbelladonna. Accessed October 26, 2019. - Nightshade. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 25, 2019. - The Vaults of Erowid. Belladonna. Available at: 2 https://www.erowid.org/plants/belladonna/belladonna.shtml. Accessed October 25, 2019.

https://hawaiipharm.com/components/com_mijoshop/o pencart/image/cache/data/1/belladonn a-autoxauto.jpg

Slang Terms

Pharmacology

Street naming often depends on specific brand/generic being sold, but here are a few examples: Cody, Schoolboy, Loads, Monkey, Demmies, Apache, Goodfella, Friend, Jackpot, TNT, Oxy, Perks, Juice, Dillies

Opioid drugs are agonists of the opioid receptor. This means that these drug molecules bind receptors in the brain, spine, and other tissue throughout the body and activate them. The end result is reduced pain signaling to the central nervous system.

Opioids (Rx Analgesics) Matthew Shotts â&#x20AC;&#x201C; Fall 2019

History of Use/Abuse 1898: Heroin is commercially distributed for pain by Bayer 1924: Anti-Heroin Act in the US bans production and sale of heroin 1970: Controlled Substances Act is created. Heroin becomes schedule I while other opiates like morphine, oxycodone, and methadone become schedule II 1995: OxyContin (long-acting oxycodone) is created and marketed as a safe/less addictive painkiller 2007: US government files charges against Purdue Pharma for this false marketing campaign 2015: DEA completes 15-month sting operation that resulted in 280 arrests involving doctors and pharmacists who dispensed high volumes of opioids 2016: CDC releases pain management guidelines that require doctors to switch many patients from opioids to OTC painkillers

Drug Interactions/Toxicology

Laws

Common adverse effects of opioids include constipation, nausea, dizziness, headache, and urinary retention. More serious events that may occur include circulatory depression, cardiac arrest, shock, anaphylaxis, coma, seizure, dyspnea, respiratory depression, and drug dependence/withdrawal symptoms. Many drug interactions exist with opioids. Most involve either risk of serotonin syndrome (safinamide, CNS depressants, etc.) or increased risk of neurological/respiratory depression (alcohol, cyclosporine, cimetidine, etc.)

Specific laws vary by state, but opioids are federally classified as schedule II-controlled substances. In Indiana, this kind of medication requires a prescription which cannot be transferred between pharmacies or given over the phone. The doctorâ&#x20AC;&#x2122;s DEA number must be on the prescription as well. In addition, most pharmacies only allow for a 7 day fill the first time the patient is uses an opioid.

Monitoring/Drug Screens

Professional Opinion

Monitoring parameters for patients using opioids include pain relief, signs of addiction/misuse, signs of respiratory depression and sedation, signs of hypotension, worsened seizures, and exacerbations of biliary tract disease The most common drug screen for opioids involves a urine test. Other methods include blood, hair, saliva, and sweat samples.

It is no secret that there is an ongoing opioid crisis in the United States. We are currently working on, and have already developed, many less addictive pain medications. These include OTC medications and partial opioid agonists. While research is further developed, healthcare professionals should be careful to only prescribe/dispense full opioid agonists when they are completely necessary for severe pain. Patients should also be careful to take these medications only as prescribed because of their high risk for abuse and addiction. ~ M. Shotts

References Asam.org. (2019). Opioids: Brand names, generic names & street names. [online] Available at: https://www.asam.org/docs/default-source/education-docs/opioid-names_generic-brandstreet_it-matttrs_8-28-17.pdf?sfvrsn=7b0640c2_2 [Accessed 29 Oct. 2019]. BBC News. (2018). What are opioids and what are the risks?. [online] Available at: https://www.bbc.com/news/health-43462975 [Accessed 29 Oct. 2019]. Columnhealth.com. (2019). Timeline of the Opioid Crisis. [online] Available at: https://columnhealth.com/blog_posts/timeline-of-the-opioid-crisis/ [Accessed 29 Oct. 2019]. Labtestsonline.org. (2019). Opioid Testing | Lab Tests Online. [online] Available at: https://labtestsonline.org/tests/opioid-testing [Accessed 29 Oct. 2019]. Morphine. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 29, 2019. WebMD. (2019). How do opioid (narcotic) pain medications work?. [online] Available at: https://www.webmd.com/pain-management/qa/how-do-opioid-narcotic-pain-medications-work [Accessed 29 Oct. 2019].

Information Technology Solutions

Monitoring/ Drug Screens PCP can be detected with a urine test for 1-7 days when only used once or twice but frequent users of high doses can be detected with a urine text for up to four weeks. The most common sample taken is a hair follicle as it may be the most accurate up to three months.

Pharmacology/Drug Effects PCP is considered a hallucinogen but is undert the caterogy of a dissociative drug that can cause users to feel dissociated from their physical form or environment. Approximately 10% of PCP is eliminated intact through urine. It is stored in fatty tissue and muscle for many weeks. The half-life for PCP is 7-46 hours and as it metabolizes, it turns into hydroxylate. Up to 97% will be fully excreted within 7 days but cumulative properites may accrue for up to several weeks.

Drug Interactions/Toxicology

History/Background Originally created in the 1950s as an anesthetic for surgery. No longer in use due to the serious side effects it can cause Abuse primarily happened during late 1970s but was never hugely popular Common names include Angel Dust, Hog, Love Boat, Peace Pill, Ozone, and Rocket Fuel

“Make a Word Cloud.” WordItOut, worditout.com/wordcloud/create.

Can cause the user to feel “superhuman” strength, mainly from the inability to feel pain due to the numbing effect that PCP has on extremities. It has many psychological side effects such as paranoia, confusion, or amnesia. PCP also has general sedative effects so it would interact heavily with other CNS depressants like benzodiazepines of alcohol that could lead to coma or death – Toxic to the body if done in large doses by means of coma, intense fever, stroke, or respiratory failure in while death can result

Laws PCP is considered to be a Schedule II controlled substance but is charged under state laws. Federal prosecution may be faced if a person is found manufacturing, transporting, or selling this drug with conviction leading to a maximum of 20 years to life in prison with a large multimillion dollar fine.

I would not ever condone the use of this drug at this time. I feel that there are no true benefits found clinically with Phencyclidine that cannot be done better, with less side effects, with current anesthetics on formulary in hospitals. In regard to its use for general public, I also see no benefit that would draw anybody in, even in comparison to other illicit street drugs with less chance for adverse effects. ~ N. Sethman

Deeney, Jeff. “PCP: The New Rise of a Drug That Turns Teens Crazy.” The Daily Beast, The Daily Beast Company, 22 Apr. 2011, www.thedailybeast.com/pcp-the-new-rise-of-a-drug-that-turns-teens-crazy.

“Phencyclidine.” Wikipedia, Wikimedia Foundation, 24 Oct. 2019, en.wikipedia.org/wiki/Phencyclidine.

“PCP.” Streetdrugs, streetdrugs.org/pcp/. “PCP - Vaults of Erowid.” Erowid PCP (Phencyclidine) Vault, erowid.org/chemicals/pcp/.

National Institute on Drug Abuse. “Hallucinogens.” NIDA, www.drugabuse.gov/publications/drugfacts/hallucinogens. England, Deborah C. “PCP Possession and Penalties.” Www.criminaldefenselawyer.com, Nolo, 1 Oct. 2013, www.criminaldefenselawyer.com/resources/pcp-possession-andpenalties.htm. “Drug Tests: Articles on PCP.” The Good Drugs Guide, www.thegooddrugsguide.com/pcp/drugtests.htm.

Pseudoephedrine (SudafedTM) Street names: Chalk, Crank, Speed, Meth Nasal Decongestant, Behind-The-Counter

Pharmacology:

Drug History / Laws PSE is a drug found in a variety of over-the-counter and prescription products, and can be illegally used to make methamphetamine. Methamphetamine is a potent and addictive stimulant that is illegal for use in the United States.

Pseudoephedrine (PSE) is a non-specific

Major Drug Interactions - Monoamine Oxidase Inhibitors - Dihydroergotamine - Methyldopa - Drugs that increase blood pressure (i.e. Sympathomimetics)

Crystal Methamphetamine, https://www.drugabuse.gov/

adrenergic receptor agonist. It acts as a nasal decongestant by stimulating vascular smooth

Congress limited the sale of products containing PSE to â&#x20AC;&#x153;behind the counterâ&#x20AC;? with the Combat

muscles, leading to constriction of arterioles in the nasal mucosa. This ultimately leads to reduced blood flow to the congested area. PSE displaces norepinephrine from storage vesicles, causing them to be released into neuron synapses where they can activate alpha-adrenergic receptors. This leads to dilation in the bronchial tube in addition to reducing inflammation of the nasal passages.

Methamphetamine Epidemic Act of 2005, or CMEA. The act sets daily and 30-day period limits on how much PSE product a customer may purchase, requires

Toxic Effects and Antidote

customers to present photo ID at the point of

pressure, increased heart rate, insomnia, anxiety,

purchase, and requires sellers to maintain logs of sales and customer information. Currently, a

nervousness and restlessness. Serious side effects include atrial fibrillation, myocardial infarction, and ventricular premature beats.

prescription is required to dispense PSE in the states of Oregon and Mississippi. Drug Effects PSE may be abused due to its stimulant properties, however it is more commonly abused after conversion to methamphetamine, which has high abuse potential. It causes a variety of stimulant side effects, including increased wakefulness, decreased appetite, rapid or unusual heartbeat, increased body temperature, and increased blood pressure.

https://www.healthline.com/health/allergies/sudafed

- Guanethidine

Common side effects include increased blood

In general, the antidote used for side effects of agitation or seizures caused by PSE are benzodiazepines. For other symptoms, supportive care such as IV fluids and oxygen or mechanical ventilation should be provided as appropriate. Blood pressure and heart rate should also be monitored in a clinical setting.

Jeremy Shen Student Pharmacist Fall 2019

Jeremy Shen

Drug Testing A drug test called an amphetamine assay is commonly

Clinical trials have shown that PSE is safe and effective as a

used to detect amphetamines and illicit analogues.

nasal decongestant when over-the-counter options do not

However, PSE (as well as several other

help relieve congestion. However, the abuse potential of PSE

decongestants, stimulants, and anorexiants) are known to lead to false-positives on amphetamine assays in drug-tests, which makes amphetamine assays a difficult test to interpret.

Student Pharmacist

Professional Opinion

Fall 2019

References:

remains high, as it can be converted illegally to methamphetamine. The prevalence of this diversion is what

Addiction Center. Drug Street Names. Available at: https:// www.addictioncenter.com/drugs/drug-street-names/#. Accessed October 8, 2019.

Centers for Disease Control and Prevention. Pseudoephedrine: Legal Efforts To Make It a Prescription-Only Drug. https:// www.cdc.gov/phlp/docs/pseudo-brief112013.pdf. Accessed October 8, 2019.

Moeller, Karen E. et al. Urine Drug Screening: Practical Guide for Clinicians. Mayo Clinic Proceedings, Volume 83, Issue 1, 66 - 76. Accessed October 8th, 2019.

National Center for Biotechnology Information. PubChem Compound Database; CID=7028, https://pubchem.ncbi.nlm.nih.gov/ compound/7028. September 21, 2019.

National Institute on Drug Abuse. Methamphetamine. Available at https://www.drugabuse.gov/publications/drugfacts/ methamphetamine. Accessed October 8, 2019.

Pseudoephedrine Hydrochloride. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http:// www.micromedexsolutions.com. Accessed October 8, 2019.

U.S. Food and Drug Administration. "Legal Requirements for the Sale and Purchase of Drug Products Containing Pseudoephedrine, Ephedrine, and Phenylpropanolamine." Accessed October 8, 2019.

led to the creation of CMEA and other subsequent restrictions on pseudoephedrine sales. PSE has continued to be stigmatized since CMEA was enacted,

As required by CMEA, PSE sales are monitored as all

yet it remains as the only viable option for many patients as

sales must be linked to a valid driverâ&#x20AC;&#x2122;s license, and

an effective nasal decongestant. It is my opinion that the

limits are set on how much PSE customers may

restrictions on PSE sales are more likely to restrict ordinary

purchase daily and monthly.

patients than it is to stop those seeking to divert PSE. While the legislation surrounding PSE sales are not particularly likely to change soon, it is important for prescribers and pharmacists to discuss other potential options with patients

with nasal decongestion if PSE is not an option. ~ J. Shen

https://www.sudafed.com/products/sudafed-sinus-congestion-24-hour? upcean=300819600270

https://pharmacyforme.org/2018/12/05/5-ways-pharmacistshelp-people-live-healthier/

Brandon Short Student Pharmacist

Rohypnol

Fall 2019

(flunitrazepam) Street Names: Roofies, Forget Me Pill, La Rocha, Mexican Valium

https://www.dea.gov/factsheets/rohpynol

PHARMACOLOGY Drug Effects USERS OFTEN DESCRIBE ITS EFFECTS AS “PARALYZING.” MOST COMMON EFFECTS ARE LOSS OF MUSCLE CONTROL, CONFUSION, DROWSINESS, AND AMNESIA. POTENTIAL FOR ABUSE STEMS FROM THE LOW COST ($0.50-5) PER PILL. SINCE THE DRUG IS MANUFACTURED FOR USE IN SOME COUNTRIES WHERE IT IS LEGAL, THE DRUG SEEMS SAFER BECAUSE IT IS NORMALLY SOLD IN ITS ORIGINAL PACKAGING. THIS GIVES USERS THE IDEA THAT THIS IS A SAFE DRUG.

History and Law Rohypnol was first introduced in 1975 by Hoffman-La Roche. Rohypnol is legal in over 20 countries today throughout Europe and Latin America as a sleeping agent. In 1984, the DEA placed this as a Schedule IV drug. However, the penalties associated with Rohypnol are equivalent of Schedule I substances like heroin and ecstasy.

- Rohypnol is benzodiazepine derivative. This drug binds nonspecifically to benzodiazepine receptors BNZ1, mediating sleep, and BNZ2, which affects muscle relaxation, anticonvulsant activity, motor coordination, and memory. -Benzodiazepines are also thought to be coupled with GABAA receptors enhancing the effects of GABA. Binding of inhibitory neurotransmitter GABA to the site opens the chloride channel, resulting in a hyperpolarized cell membrane that prevents further excitation of the cell. -Rohypnol is absorbed in the gut and enters the bloodstream as quickly as 15 minutes. The metabolites are excreted mainly by the kidneys.

Abuse History

Drug Interactions • Alcohol • Ecstasy Rohypnol increases higher risk of overdose when taken together.

Professional Opinion Although Rohypnol can be very effective in treatment of insomnia, the potential for abuse and misuse outweighs the potential positive effects. There are many other agents that are proven to work for insomnia that have far less potential to be misused. Although this drug is does not prove to be overly addictive, it does appear to be misused heavily as a date-rape drug. This should remain an illegal drug in the United States and should be highly regulated in other countries where it is legal. ~ B. Short

https://www.addictioncenter.com/be nzodiazepenes/rohypnol/

Drug Testing URINE TEST CAN DETECT ROHYPNOL IN THE BODY. THIS TEST NEED TO BE DONE 24-72 HOURS AFTER USE.

Toxic Effects

Rohypnol is most commonly known as a date-rape drug. Due to the drug being odorless, colorless, and easily dissolvable in liquid it is slipped into drinks of unsuspecting people which incapacitates them. Rohypnol is also used in a trend known as speedballing. This is when it is taken with ecstasy to induce a stronger effect. It is also used with marijuana, cocaine, or heroin to produce a floating affect.

Overdose of this drug could result in becoming incapacitated and can lead to a halt in breathing.

References: 1. DEA. Rohypnol. Available at: https://www.dea.gov/factsheets/rohypnol. Accessed October 25, 2019. 2. Drugs.com. Rohypnol: Effects, Hazards & Methods of Abuse. Available at: https://www.drugs.com/illicit/rohypnol.html. Accessed October 25, 2019. 3. Foundation for a Drug-Free World. Rohypnol. Available at: https://www.drugfreeworld.org/drugfacts/prescription/rohypnol.html. Accessed October 25, 2019. 4. Michael’s House Treatment Centers. Origins of Rohypnol. Available at: https://www.michealshouse.com/blog/origins-of-rohypnol/. Accessed October 25, 2019. 5. Ramapo College of New Jersey. Date Rape Drugs: XTC, Rohypnol, Ketamine. Available at: https://www.ramapo.edu/aod/date-rape-drugs-xtc-rohypnol-ketamine/. Accessed October 25, 2019.

Common Slang Terms9:

Rx Anorectics Hailey Stoker Student Pharmacist Fall 2019

-ice -crank -crystal -fire -chalk -glass -speed -go fast

https://www.northpointwashington.com/blog /prescription-crystal-meth-common-desoxynabuse/

Desoxyn is a form of methamphetamine, and thus carries many of the methamphetamine trade names when being illegally purchased.

History and Background:

https://drugabuse.com/desoxyn/

Pharmacology/Drug Effects: In short, this medication assists in management of obesity when used in conjunction with proper diet. This drug has potential abuse as it results in feeling “high” due to an increase in dopamine levels.6 A study specifically reviewing the anorectic dexfenfluramine showed that the drug releases 5hydroxytryptamine (5-HT) from nerve terminals and inhibits its reuptake, which has a significant effect on satiation.2 More recent studies of phentermine show that it is an indirect-acting sympathomimetic drug which releases noradrenaline from the presynaptic vessels in the lateral hypothalamus. This increase in the synaptic cleft results in stimulation of 2-adrenergic receptors. This, along with some highly debated effects, results in a fight-or-flight response, leading to a reduction in hunger.3 The exact mechanism of action is highly debated still, but this is a generally accepted description.

In November of 1943, Abbott Laboratories submitted a drug application for the drug desoxyephedrine (Desoxyn) to the FDA. This drug, an amphetamine, was not originally meant to be used for weight loss. One year later, a new form of desoxyephedrine, known as Hydrin, was released to the public with the added approval of an adjunct treatment of obesity. This did not last long, however, as the FDA soon decided that the use of Hydrin for adjunct treatment of obesity was inappropriate and “irrational”. 1 To the surprise of many, studies showed the efficacy of desoxyephedrine for weight loss, leading to FDA approval of Desoxyn and Hydrin in 1957 as adjunct treatment of obesity alongside dietary management. By 1960, five more drugs, referred to as “amphetamine congeners” were approved by the FDA as adjunct treatment for obesity management.1 There has been a lot of controversy surrounding these medications, but they remain on the market due to their high efficacy in conjunction with diet to manage obesity.

Drug Interactions:

Toxicology:

-monoamine oxidase inhibitors4 -antihypertensive drugs (to a â&#x20AC;&#x153;clinically insignificantâ&#x20AC;? amount)4

There are many possible side effects relating to an acute overdose including restlessness, tremors, hyperreflexia, rapid respiration, confusion, assertiveness, hallucinations and panic state followed by fatigue, and depression. Some side effects of the cardiovascular system include reports of tachycardia, arrhythmia, hypertension, hypotension, and circulatory collapse. In the GI tract, there are symptoms of nausea, vomiting, diarrhea and abdominal cramps.3 On the other hand, chronic overdosing is apparently marked by dermatoses, insomnia, irritability, hyperactivity and personality changes. In severe cases, it can even result in a schizophrenia-like psychosis.3

https://www.ashwoodrecovery.com/b log/desoxyn-legal-methamphetamineprobably-havent-heard/

https://www.cheatsheet.com/healthfitness/when-you-shouldnt-weighyourself.html/

Laws, Monitoring, and Drug Screening: Anorectics are class II, III, IV, or V. All are controlled substances, however.5, 7 Possession of these medications without a prescription is classified as a class A misdemeanor in the state if Indiana.8 The use of anorectics is often misread as amphetamines use on a drug screening as some of these medications contain some methamphetamine or are derivatives of it.6 Desoxyn in particular is a C-II as it is a form of methamphetamine which is thought to have high abuse potential.

As stated above, there are many possible side effects relating to overdosing of these medications.

Professional Opinion: These medications have legitimate efficacy in patients who have been unable to lose weight in the past with diet and exercise, and thus have a place in drug therapy. These drugs are not first line medications for weight loss (or ADHD) due to the potential for abuse, and those patients who end up on anorectics have a need for them. Due to their status as controlled substances, there is a stigma surround the use of these medications and their abuse. This is a stigma which should be broken, as controlled does not necessarily mean that the use of it will lead to drug abuse. ~ H. Stoker

References: 1. Colman E. ACP. Anorectics on trial: A half century of federal regulation of prescription appetite suppressants. Available at: https://annals.org/aim/fullarticle/718716/anorectics-trial-half-century-federal-regulationprescription-appetite-suppressants. Accessed October 30, 2019. 2. Samanin R, Garattini S. Neurochemical mechanism of action of anorectic drugs. Pharmacol Toxicol. 1993;73(2):63-8. DOI:10.1111/j.1600-0773.1993.tb01537.x. 3. DrugBank. Phentermine. Available at: https://www.drugbank.ca/drugs/DB00191. Accessed October 30, 2019. 4. Craddock D. Anorectic drugs: Use in general practice. Drugs. 2012;11(5):378-93. DOI:10.2165/00003495197611050-00002. 5. Anderson L. Drugs.com. Weight loss and diet pills: Options to know. Available at: https://www.drugs.com/article/prescription-weight-loss-drugs.html. Accessed October 30, 2019. 6. Mayo Clinic Laboratories. Amphetamines confirmation, random, urine. Available at: https://www1.mayocliniclabs.com/test-catalog/Clinical+and+Interpretive/8257. Accessed October 30, 2019. 7. DrugAbuse.com. Desoxyn abuse. Available at: https://drugabuse.com/desoxyn/. Accessed October 30, 2019. 8. LawServer. Indiana code 35-48-4-7. Available at: https://www.lawserver.com/law/state/indiana/incode/indiana_code_35-48-4-7. Accessed October 30, 2019. 9. Recovery.org. Find the best residential Desoxyn recovery center. Available at: https://www.recovery.org/prescription-drug/find-the-best-residential-desoxyn-recovery-center/. Accessed October 30, 2019.

Rx Muscle Relaxants Joseph Stoker Fall 2019 History:

Slang Terms6:

The first documented history of the use of muscle relaxants drugs dates back to the 16th century when European explorers encountered natives of the Amazon Basin in South America who used poison tipped arrows to cause death by skeletal muscle paralysis. The poison used in these arrows (known as curare) started some of the earliest pharmacological studies. By 1943, neuromuscular blocking drugs became established as muscle relaxants in the practice of anesthesia and surgery.1 As with nearly all drugs, muscle relaxers have potential for abuse. Generally, abuse with muscle relaxers is observed in high frequency in the overall population of the world, but usually when these drugs are abused they are abused in conjunction with other central nervous system depressants, such as narcotics or alcohol%. The abuse that is seen with muscle relaxers is generally because of its ability to produce sedative effects, dizziness, and drowsiness. With long term use these drugs may also cause dependency.2

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Pharmacology: Acetylcholine then diffuses across the synaptic cleft. It may be hydrolyzed by acetylcholine esterase (AchE) or bind to the nicotinic receptors located on the motor end plate. The binding of two acetylcholine molecules results in a conformational change in the receptor that opens the sodium-potassium channel of the nicotinic receptor. This allows Na+ and Ca2+ ions to enter the cell and K+ ions to leave the cell, causing a depolarization of the end plate, resulting in muscle contraction.4 Normal end plate function can be blocked by two mechanisms. Nondepolarizing agents, such as tubocurarine, block the agonist, acetylcholine, from binding to nicotinic receptors and activating them, thereby preventing depolarization. Alternatively, depolarizing agents, such as succinylcholine, are nicotinic receptor agonists which mimic Ach, block muscle contraction by depolarizing to such an extent that it desensitizes the receptor and it can no longer initiate an action potential and cause muscle contraction.1 Both of these classes of neuromuscular blocking drugs are structurally similar to acetylcholine, the endogenous ligand, in many cases containing two acetylcholine molecules linked end-to-end by a rigid carbon ring system, as in pancuronium (a nondepolarizing agent).1

Monitoring/Drug Screens: Most muscle relaxant drugs are not controlled substances which are generally tested for via drug screen. Most screens are looking for marijuana, amphetamines, benzodiazepines, opioids (both opium derived and thebaine derived, so morphine, codeine, hydrocodone, oxycodone, hydromorphone, oxymorphone etc.) barbiturates, PCP. mescaline, LSD, MDMA or Ecstasy, cocaine, etc.1

Drug Interactions/Toxicology: Lincosamides acts by having a direct effect on muscle. Administration of Tetracycline chelates calcium. Metronidazole can potentiate the effects of NDMBs. Other drug classes that interact with muscle relaxants include anticonvulsants, various antiarrhythmics, and inhaled anesthetics. 5

https://www.rxlist.com/flexeril-drug.htm

https://www.northpointrecovery.com/blog/flexeril-high-musclerelaxer-creating-dependency/

Laws: Depending on the perceived abuse potential of some of these medications, some are controlled, and some are prescription only, but generally speaking most muscle relaxants are not controlled. Sometimes Valium is used as a muscle relaxant like other benzodiazepines, and these would be considered controlled.5

Professional Opinion: Various drugs are used as muscle relaxants which are generally safe for the public to use therapeutically. Muscle relaxants are important for people who experience injury to muscles particularly in the back, but are used for a variety of types of muscle spasms. ~ J. Stoker

References: 1. Miller RD. Skeletal muscle relaxants. Basic Clin Pharmacol. 1998;13(7):434â&#x20AC;&#x201C;49. DOI:16.1842374/sj.bjp.0729985. 2. Bowman WC. Neuromuscular block. Br J Pharmacol. 2006;147(S277â&#x20AC;&#x201C;86). DOI:10.1038/sj.bjp.0706404.

3. eMedExpert. Comparison of Skelaxin, Flexeril, and Soma. Available at: https://www.emedexpert.com/compare/muscle-relaxers.shtml. Accessed on October 30,2019. 4. Craig CR, Stitzel RE, eds. Modern Pharmacology with clinical applications. 6th ed. MD: Lippincott Williams & Wilkins. 2003 5. Open Anesthesia. Muscle relaxants: Drug interactions. Available at: https://www.openanesthesia.org/muscle-relaxants-drug-interactions/. Accessed on October 30, 2019. 6. North Point Washington. 25 dangerous drugs and their street names. Available at: https://www.northpointwashington.com/blog/25-dangerous-drugs-and-their-street-names/. Accessed on: October 30, 2019.

Salvia divinorum Street names: Magic Mint, Sage of the Seers, Diviner’s Sage, Salvia, Sally-D, Maria Pastora Sarah Tucker, Student Pharmacist

Fall 2019

Salvia divinorum is a member of the mint family. The plant is native to Oaxaca, Mexico. It has been used by the Mazatec people for religious ceremonies and https://mindfuel.co.nz/products/diviners-sagehealing rituals for salvia-divinorum-live-clone-organic centuries. The herb came into public perception in the mid 2000s when it became popular for teens to record themselves using the drug and post videos of their trip online. Teen stars such as Miley Cyrus helped to make this trend more popular. Easy access, legal status, and short duration of action can make it an appealing choice for youth wishing to experiment. Use among teens seems to be declining since its peak popularity in the 2000s, with less than 1% of teenagers reporting having used the substance in the NIDA Monitoring the Future Survey of 2018.

So what does it do? The psychoactive component of salvia divinorum, salvinorin A, has a hallucinogenic effect. Salvinorin A is an agonist of kappa opioid receptors on nerve cells. Unlike other hallucinogens like LSD and psilocybin, it does not affect serotonin receptors. Users will likely notice visual distortions and hallucinations, cartoon like imagery, dissociation from reality and self, synesthesia (a distortion of the senses that allows people to “hear” colors or “smell” sounds), and feelings of giddiness or uncontrollable laughter. Many users will also experience slurred speech, impaired coordination, emotional swings, and potentially anxiety or fear. Time to onset and duration of psychological effects vary greatly depending on method of ingestion.

SMOKE

CHEW

DRINK

Smoking has the fastest onset but shortest duration. Salvia starts working in under a minute when inhaled in this fashion.

The juice released from chewing fresh leaves is absorbed through the gums. Effects can be seen within 10-15 minutes.

Fresh leaves can be ground up and made into a drink. This method has the most sustained duration of action.

Laws and Regulations Salvia divinorum and salvinorin A are not federally controlled substances. There currently are not any laws restricting or criminalizing the use of salvia divinorum at the federal level, though the DEA does list it as a drug of concern. In some states, its sale and possession is limited to people above a certain age limit. In others, it is illegal to manufacture or sell salvinorin A, but the plant itself is legal. In some states, there are no regulations at all.

Toxicology No serious health risks have been proven, but studies in rats have shown negative effects on learning and memory which may transfer to humans. No toxicity was shown in a two week toxicology study in mice. The addiction potential of salvia divinorum has not yet been proven, though it is plausible to think the potential for addiction increases with continuous use.

Professional opinion https://www.tatanka.nl/ product/salvia-divinorumleaf-10-gram

Salvia divinorum and salvinorin A extract are widely available online and can also be found in smoke shops in areas where they are are legal. It is legal to grow salvia divinorum in multiple states throughout the US. Testing for salvinorin A is not included in many drug screens. Though there are tests that can detect it, they are not common and often very expensive.

Salvinorin A is considered to be the most potent naturally occurring hallucinogen. It does not seem to have any major negative health impacts on users, although impairment caused by its ingestion could pose a threat to the health of users or the public if one were to try to drive or operate machinery under its influence. Like all hallucinogens, it is not recommended for use in people with or at risk of developing psychological disorders like schizophrenia, as its use could precipitate development of such conditions. Studies are currently underway to see if salvinorin A could be useful in treating conditions like Alzheimerâ&#x20AC;&#x2122;s and addiction. ~ S. Tucker

REFERENCES WebMD. Salvia FAQ. Available at: https://www.webmd.com/parenting/features/salvia-faq#1. Accessed October 28, 2019. StreetDrugs. Salvia. Available at: https://streetdrugs.org/salvia. Accessed October 27, 2019. Drug Enforcement Administration. Salvia Divinorum and Salvinorin A. Available at: https:// www.deadiversion.usdoj.gov/drug_chem_info/salvia_d.pdf#search=salvia. Accessed October 28, 2019. American Addiction Centers. Available at: https://www.deadiversion.usdoj.gov/drug_chem_info/ salvia_d.pdf#search=salvia. Accessed October 29, 2019. Barbara Poncelet. Verywell Mind. What to Know About Salvia Divinorum Use. Available at: https:// www.verywellmind.com/salvia-divinorum-a-legal-trip-3200920. Accessed October 30, 2019.

Barbiturates, benzodiazepines, sleeping medications Christina Wilder, Student Pharmacist, FALL 2019

Image extracted from: https://www.shopmedvet.com/category/SD-Sedatives

MOST ABUSED

HISTORY/BACKGROUND  An estimated 20% of adolescents reported lifetime medical or nonmedical use of prescription sedatives  Sedatives are prescribed widely for insomnia or anxiety and are controlled substances due to their potential for misuse and abuse  Frequently used at date rape drugs  Barbituates are chemical derivatives of barbituric acid Agents that act as a central nervous system depressant and are used for a variety of treatments Barbituric acid was first synthesized in 1864 and marketed by Bayer in 1903 Have mostly been replaced in medical practice by benzodiazepines Significantly higher risk for addiction and overdose than barbituates Lack an overdose antidote Also used for general anesthesia, epilepsy, migraines, cluster headaches, euthanasia, capital punishment, and assisted suicide  Benzodiazepines are a class of psychoactive agents and were globally the most prescribed medications in 1977 Chlordiazepoxide was the first benzodiazepine and was available in 1960 Generally viewed as safe and effective for short-term use Commonly misused and taken in combination with other drugs Considered less toxic than barbiturates  “Z-drugs” are nonbenzodiazepine drugs with effects similar to benzodiazepines and are used to treat sleep problems  Sedatives are commonly abused for providing feelings of relaxed contentment and euphoria

 Barbiturates (phenobarbital/Nembtal®)  Benzodiazepines (alprazolam/Xanax®, chlorodiazepoxide/Librium®, diazepam/Valium®, lorazepam/Ativan®, triazolam/Halicon®)  Sleep medications or “Z-drugs” (eszopiclone/Lunesta®, zaleplon/Sonata®, zolpidem/Ambien®)

SLANG NAMES  Barbiturates: barbs, phennies, red birds, reds, tooies, yellow jackets, yellows  Benzodiazepines: candy, downers, sleeping pills, tranks, benzos  Sleeping medications: forget-me pill, Mexican valium, R2, roche, roofies, roofinol, rope, rophies

PHARMACOLOGY The most commonly prescribed sedatives are benzodiazepines. They are similar to alcohol in that they facilitate the inhibitory effects of gammaaminobutyric acid (GABA) at the GABA-A receptor complex. Barbiturates act as positive allosteric modulators and, at higher doses, as agonists of GABA receptors. They produce their pharmacological effects by increasing the duration of chloride ion channel opening at the GABAA whereas benzodiazepines increase the frequency of the chloride ion channel opening at the GABAA receptor. The direct gating or opening of the chloride ion channel is the reason for the increased toxicity of barbiturates compared to benzodiazepines in overdose.

Background image extracted from: https://www.aboutlawsuits.com/prescription-drug-murder-study-82927/

DRUG EFFECTS  Short-term health effects of these classes: drowsiness, slurred speech, poor concentration, confusion, dizziness, problems with movement and memory, lowered blood pressure, slowed breathing  Side effects may include depression, anxiety, aggression, restlessness, hallucinations, and loss of personality  Long-term health effects are unknown  Sedatives reduce heart rate and breathing, and in overdoses, to the point that death may occur  A person can quickly develop tolerance to sedatives

DRUG INTERACTIONS/TOXICOLOGY  When combined with alcohol or opiates, further slows heart rate and breathing, leading to possible death  Some overdoses can be treated with flumazenil, a reversal agent, along with supportive care  Sedative withdrawal syndrome is treated by tapering the sedative and may require hospitalization

MONITORING/DRUG SCREENS  Drug testing cannot determine how often a substance is used and cannot separate habitual users from casual users  Drug testing is not inclusive of all substances, but it can identify barbiturates and benzodiazepines  Drug tests do not have 100% accuracy

LAWS  It is a felony in the United States to use medication prescribed for another person  Many prescription sedatives are controlled drugs (class 3 through 5)  Prescriptions are limited to 5 refills PROFESSIONAL OPINION Sedatives can be used appropriately but are frequently abused and have strong potential for addiction. There are currently no FDAapproved medications to treat addiction to prescription sedatives. A better approach to combat addiction to sedatives is to lower the dose over time with the help of a health care provider. More research needs to be done to see how efficacious behavioral therapies are to treat addiction to sedatives. ~ C. Wilder Resources López-Muñoz F, Ucha-Udabe R, Alamo C. The history of barbiturates a century after their clinical introduction. Neuropsychiatr Dis Treat 2005:1(4):329-343. McCabe SE, Veliz P, Boyd CJ, Schulenberg JE. Medical and nonmedical use of prescription sedatives and anxiolytics: Adolescents' use and substance use disorder symptoms in adulthood. Addict Behav. 2017;65:296–301. DOI:10.1016/j.addbeh.2016.08.021 Merck Manual for Professionals: Drug Testing. https://www.merckmanuals.com/home/specialsubjects/recreational-drugs-and-intoxicants/drugtesting. Published March 1, 2018. Accessed October 28, 2019. Narconon: The Effects of Drug Abuse. https://www.narconon.org/drug-abuse/effects-ofsedatives.html. Accessed October 28, 2019. National Institute on Drug Abuse. https://www.drugabuse.gov/drugs-abuse/ commonly-abused-drugs-charts#CNSdepressants. Published July 1, 2019. Accessed October 28, 2019. National institute on Drug Abuse for Teens. https://teens.drugabuse.gov/drug-facts/prescriptiondepressant-medications. Published May 1, 2019. Accessed October 28, 2019. Weaver MF. Prescription Sedative Misuse and Abuse. Yale J Biol Med. 2015;88(3):247–256. Published 2015 Sep 3.

Background image extracted from: https://www.northpointrecovery.com/images/drugs/sedatives.jpg

Monitoring and Drug Screening

Monitor blood pressure, pulse, and pulmonary edema. Sildenafil is not a controlled substance nor is it an illicit drug. Majority of tests do not check for its presence in the blood or urine.

Sildenafil (Viagra) Christen Wilhight Student Pharmacist

Professional Opinion "Overall Viagra is an effective medication for erectile dysfunction. It works on a wide variety of patient populations' chronic conditions. It’s onset of action is quick, has a duration of action of about 12 hours, and it is also approved for pulmonary hypertension. There are some common side effects such as facial flushing, headache, and dizziness but these are generally tolerated. Priapism is a rare occurrence. The risk here, along with any other prescription drug that is being obtained without a prescription; abuse has the potential for contraindicated medical conditions and drug-drug interactions occurring without appropriate counsel. The abuse has also lead to risky sexual behavior of not using a condom, increasing the risk of HIV, STD and Hepatitis." - Christen Wilhight, Student Pharmacist

References: Urban Thesaurus. Viagra. Available at: https://urbanthesaurus.org/synonyms/viagra. Accessed on October 28, 2019. Drugs.com. Viagra: How a Little Blue Pill Changed the World. Available at: https://www.drugs.com/slideshow/viagra-little-blue-pill-1043. Accessed on October 28, 2019. Sildenafil. Dosing and Administration. Micromedex Solutions. Truven health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 38, 2019. Sildenafil. Medication Safety. Micromedex Solutions. Truven health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 38, 2019. Everyday Health. Recreational Viagra? Why It’s Not a Good Idea. Available at: https://www.everydayhealth.com/mens health/recreational-viagra-why-its-not-good-idea/. Accessed on: October 28, 2019. Krenzelok EP. Sildenafil: clinical toxicology profile. J Toxicol Clin Toxicol. 2000;38(6):645-51. Sildenafil [package insert]. Manhattan, NY. Pfizer Laboratories Div Pfizer Inc; 1998. Medical News Today. Uses and risks of Viagra. Available at: https://www.medicalnewstoday.com/articles/232912.php#9 Accessed on October 28,2019. Drugstore365. Does Viagra show up on a drug test? Available at: https://drugstore365.net/does-viagra-show-up-on-a-drug-test/. Accessed on October 28, 2019.

Fall 2019

https://www.healthymale.com/sildenafil-citrate-camber/?coupon=radio49

Mechanism of Action

History and Law Sildenafil (Viagra) is a well-known and widely used prescription in the US. It is often called “the little blue pill.” Viagra was the first phosphodiesterase 5 inhibitor (also known as PDE5) indicated to treat erectile dysfunction (ED). As men age, ED becomes a more common sexual problem. About 30 million men in the US and 100 million men the world suffer from this sexual problem. Viagra’s original plan for use was not to treat erectile dysfunction. This discovery was an unplanned event. Sildenafil was made and developed by Pfizer Drug Company and was originally indicated to treat hypertension (high blood pressure) and angina pectoris (chest pain caused by heart disease). It wasn’t until heart clinical trials, where there was a discovery that Viagra was effective in inducing erections, more effective than treating angina. Pfizer soon realized that ED was a medical need that had yet to be treated and saw this as an opportunity for financial gain. Sildenafil is not a controlled substance and there is a maximum fine of $10,000 for all felony sentences levied by the Indiana courts due to the drug trafficking of Sildenafil.

Slang Terms Blue bomber, Blue thunder, Blue steel, Blue pill, Blue diamond, Pleasure tabs, Vitamin V, Blue man, Little blue pill, Blue Love, Woody pills, Blue vitamin, Soldier pills, Magic Potion, Philter

Mechanism of erection: release of nitric oxide (NO) in the corpus cavernosa of the penis during sexual stimulation. NO activates guanylate cyclase leading to increased levels of cGMP, smooth muscle relaxation, and an inflow of blood. Sildenafil stimulates the effect of NO by inhibiting PDE5. PDE5 degrades cGMP. Inhibition of PDE5 stimulates muscle relaxation and inflow of blood. https://www.google.com/search?q=sildenafil&sxsrf=ACYBGNT9XKOKNpnX0p4KfttFpGie95HIw:1572406337038&source=lnms&tbm=isch&sa=X&v ed=0ahUKEwicnqWJhsPlAhUIiqwKHdD7CX0Q_AUIFCgD&biw=1440&bih=7 89#imgrc=e-rI6oyoDMkyYM:

Use and Abuse The indicated use for Sildenafil (Viagra) is for erectile dysfunction and pulmonary arterial hypertension. Non-FDA uses included: sexual dysfunction, disease states associated with erectile or sexual dysfunction, and druginduced impotence. Even men who do not suffer from ED want to improve their sexual game. Men believe it will enhance their sexual and athletic performance. Men are buying Viagra from internet drugstores or getting it from their friends and family. This is centered around cost and convenience, the stigma around ED, and finding time to actually go see a doctor. Buying Viagra from an unreliable source can be very dangerous. About 80% of these drugs sold on these sites are fake or contaminated. Some men mix Viagra with other illicit drugs and use it recreationally. Other men, who don’t even have ED, use Viagra so often that they are now addicted and rely on it to get an erection.

Drug Interactions and Adverse Effects Sildenafil has over 53 drug-drug interactions – most common ones are to nitrates and nitrites that can produce hypotension. This can then lead to decreased coronary perfusion and myocardial infarction. Sildenafil has drugfood interactions with grapefruit juice and pomelo juice. Sildenafil also has a moderately severe interaction with pregnancy and a major reaction with lactation. Adverse Effects: headache, flushing, difficulty sleeping, dyspepsia, abnormal vision, nasal congestion, back pain, myalgia, nausea, dizziness, fainting, rash, erection that is painful and lasts longer than 4 hours, worsening or shortness of breath, and chest pain Viagra Overdose: vomiting, blurred and distorted vision, papilledema, prolonged priapism, optic neuropathy, tachycardia, blindness, diarrhea, rhabdomyolysis

2.18

STIMULANTS Spencer Tebbe Fall 2019

HISTORY The first amphetamines were synthesized in 1887 but were not actually put into use until the 1930’s when they were prescribed for nasal congestion. Amphetamine was then used as a cure-all drug, as advertisements claimed it could cure anything from alcoholism to obesity. It wasn’t until the late 1950s that amphetamines were restricted and can only be obtained through a prescription.

SLANG o Addy o A-Train

https://www.google.com/url?sa=i&source=images&cd=&ved=2ahUKEwigq9_k_sTlAhVFd6wKHeo2Dp 8QjRx6BAgBEAQ&url=https%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3DifutqKQ6KQE&psig =AOvVaw0TsCb8yPY80aw83HbpdsXT&ust=1572559498481401

PHARMACOLOGY Amphetamine works primarily by increasing the activity of the neurotransmitters, dopamine and norepinephrine, in the brain. It does this by mimicking these neurotransmitters in the synapses, competing for reuptake by the cells, allowing neurotransmitters to stay active in the synapse much longer to activate a response.

EFFECTS Amphetamine’s major abuse potential is due to its stimulatory effects. These include feeling more alert, euphoria, rise in motivation, and desire to get work done. Other effects not linked to abuse caused by amphetamine include increased blood pressure, headache, insomnia, loss of appetite, nausea, and diarrhea.

o Study Buddies o Amps o Lid Poppers o Smarties o Zing

https://www.healthyplace.com/sel f-help/adhd/what-happens-whenyou-stop-taking-adderall

https://www.medicalnewstoday.co m/articles/325646.php

LAW

DRUG INTERACTIONS

Amphetamine is a schedule II drug no matter the formulation. It can come as an instant release pill, an extended release capsule, as a prodrug, and in pills with other release mechanisms. In Indiana, it is considered a felony to be in possession of amphetamine without a prescription, and can be punishable up to a class A felony depending on the amount and intentions.

Amphetamine has many drug interactions as it acts in the central nervous system and is metabolized by the P450 system. It is a stimulatory drug, so you should avoid using depressants such as alcohol and benzodiazepines as the effects they could cause together can be very toxic. Antidepressants are another drug class that should be avoided as they act on the same neurotransmitter receptors and can counter amphetamineâ&#x20AC;&#x2122;s effects.

MONITORING/ PROFESSIONAL OPINION Amphetamine is a great drug for helping those with DRUG ADHD and narcolepsy stay alert and attentive. Because of how well this drug actually works, it has been overSCREENS Amphetamine can be tested for in the urine and will test positive for 1-3 days after use depending on the frequency. This test can be done at home or in a professional laboratory.

prescribed and has flooded the streets with people abusing it who do not actually need it. Doctors and pharmacists need to fully assess patients before prescribing this medication so that all of the pros and cons can be pondered before a script is given. ~ S. Tebbe

1. 2.

RESOURCES

3. 4.

Adderall Amphetamine Urine Drug Test. (n.d.). Available at https://requestatest.com/adderall-amphetamine-urine-drug-test. Accessed October 30, 2019. Amphetamine. Drug Facts and Comparisons. Facts & Comparisons e Answers. Wolters Kluwer Health, Inc. Philadelphia, PA. Available at http://factsandcomparisons.com. Accessed October 30, 2019. Linebaugh, M. May 1, 2012. Possession of a Controlled Substance in Indiana. Available at https://www.criminaldefenselawyer.com/resources/criminaldefense/drug-charges/possession-controlled-substance-indiana What Are Stimulants? â&#x20AC;&#x201C; History of Amphetamines. Available at https://science.jrank.org/pages/clo337q5pw/What-Are-Stimulants-HISTORYAMPHETAMINES.html. Accessed October 30, 2019