Chapter 6

Substance Abuse
Substance Abuse

• Substance abuse is the self-administration of a drug in a way that

one’s culture or society views as abnormal and not acceptable.
• Throughout history, individuals have consumed both natural and
prescription drugs to increase physical or mental performance,
achieve a relaxed feeling, change a psychological state, or simply
fit in with the crowd.
• Substance abuse has tremendous economic, social, and public
health impacts on society.
Substance Abuse

• Substances from a wide variety of chemical classes are abused and

can be taken through different routes.
• Abused substances have in common an ability to affect the
nervous system, particularly the brain.
• Some agents such as opium, marijuana, cocaine, nicotine, caffeine,
and alcohol are obtained from natural sources.
• Others agents are synthetic or designer drugs created in illegal
laboratories solely for making money in illegal drug trafficking.
Substance Abuse
• Although the public often connects substance abuse with illegal drugs,
this is not necessarily the case:
• Alcohol and nicotine are the two most commonly abused drugs.
• Legal prescription medications such as methylphenidate (Ritalin) and
meperidine (Demerol) are abused by some.
• Volatile inhalants found in common household products such as
aerosols and paint thinners are often abused as “huffing.”
• Frequently abused illegal substances include marijuana, opioids (which
are narcotic analgesics), sedatives, and hallucinogens such as lysergic
acid diethylamide (LSD) and methamphetamine. Phencyclidine (PCP),
although once used more widely, is less prevalent in today’s society.
Substance Abuse
• Several drugs once used therapeutically are now deemed illegal because of
their high potential for abuse.
• Cocaine was once widely used as a local anesthetic, but today nearly all
cocaine use and its purchase are illegal.
• LSD is now illegal, although it was used in psychotherapy in the 1940s and
1950s.
• Phencyclidine was popular in the early 1960s as an anesthetic but was taken
off the market in 1965 because patients reported hallucinations, delusions,
and anxiety after recovering from anesthesia.
• Use of amphetamines, which were once prescribed for bronchodilation, was
stopped in the 1980s after psychotic episodes were reported. Some
commonly abused substances are summarized in Table 6.1.
Substance Abuse

• Addiction, the progressive and chronic abuse of a substance, is an

overwhelming feeling that drives someone to use a drug
repeatedly despite serious health and social consequences.
• It is impossible to predict accurately whether a person will become
an addict. Scientists have used psychological profiles and
investigated genetic links to attempt to predict a person’s addictive
tendency, but no firm connections have been found. Addiction
depends on multiple, complex, and interacting variables.
Substance Abuse
These variables fall into the following categories:

• Agent or drug of abuse. Cost, availability, dose, method of administration (e.g., oral,
intravenous, inhalation), speed of onset or duration of effect, and length of drug use

• User factors Genetic factors (e.g., metabolic enzymes, natural tolerance), tendency
toward risk-taking behaviour, prior experiences with drugs, disease that may require
a scheduled drug

• Environment Social/community norms (behaviour accepted within a community), role

models, peer influences, educational opportunities
Substance Abuse

Addiction may begin with a real need for pharmacotherapy.

For example, narcotic analgesics may be prescribed for pain, or
sedatives for a sleep disorder.
Pain relief or being able to fall asleep may cause the patient to want
to repeat these positive experiences.
Substance Abuse
It is a common misunderstanding, even among some health care
professionals, that the therapeutic use of scheduled drugs creates
addiction in a large number of patients.
In fact, prescription drugs rarely cause addiction when used as
prescribed.
The risk of addiction to prescription medications is mostly a function of
the dose and the length of therapy.
For this reason, medications having a potential for abuse are usually
prescribed at the lowest effective dose for the shortest time necessary to
treat the medical problems.
Substance Abuse

Whether a substance is addictive relates to how easily an individual

can stop taking it repeatedly.
When a person has an overwhelming desire to take a drug and
cannot stop, it is referred to as substance dependence.
Substance dependence is classified into two categories: physical
dependence and psychological dependence.
Substance Abuse
Physical dependence is an altered physical condition caused by the nervous
system adapting to repeated substance use.
Over time, the body’s cells are tricked into believing that it is normal for the
substance to be continually present.
With physical dependence, uncomfortable symptoms, known as withdrawal
syndrome, occur when use of the agent is stopped.
Opioids such as morphine and heroin may produce physical dependence
rather quickly with repeated doses, particularly when taken intravenously.
Alcohol, sedatives, some stimulants, and nicotine are other examples of
substances that may easily produce physical dependence with repeated use.
Substance Abuse

The patient should check with his or her health care provider about
combining alcohol with medications (prescription or OTC drugs).
Alcohol is considered a CNS depressant, so it should never be
combined with other CNS depressants.
Substance Abuse

In contrast to physical dependence, psychological dependence

causes no apparent signs of physical discomfort after use of the
agent is stopped.
The person, however, will have an intense craving and display an
overwhelming desire to continue using the substance, even if there
are obvious negative economic, physical, or social consequences.
The intense craving may be associated with the individual’s home
environment or social contacts.
Substance Abuse
Strong psychological cravings for a substance may continue for months or
even years and is often responsible for relapses (return to the original
drug-seeking behaviour) during substance abuse therapy.
Psychological dependence usually occurs only after relatively high doses
of the substance have been used for a long time, such as with marijuana
and antianxiety drugs.
However, psychological dependence may develop quickly, even after
only one use, as with “crack” cocaine—a potent, inexpensive form of the
drug.
Substance Abuse

Once an individual becomes physically dependent and use of the

substance is stopped, withdrawal syndrome will occur.
Symptoms of withdrawal syndrome may be severe for patients who
are physically dependent on alcohol and sedatives.
Helping a patient withdraw from these agents is best done in a
substance abuse treatment facility.
Examples of withdrawal symptoms related to different abused
substances are listed in Table 6.2.
Substance Abuse
• Prescription drugs may be used to reduce the severity of withdrawal
symptoms.
• For example, alcohol withdrawal can be treated with a benzodiazepine
such as diazepam, and opioid withdrawal can be treated with
methadone.
• Symptoms of nicotine withdrawal may be relieved by nicotine
replacement therapy in the form of patches or chewing gum and the
use of bupropion (Zyban).
• No specific pharmacological treatments are indicated for withdrawal
from CNS stimulants, hallucinogens, marijuana, or inhalants.
Substance Abuse
• With chronic substance abuse, patients will often associate their conditions
and surroundings—including social contacts with other users—with use of the
drug.
• Users tend to return to drug-seeking behaviour when they interact with other
substance abusers.
• Counsellors often encourage patients to stop associating with past social
contacts or having relationships with other substance abusers to lessen the
possibility of relapse.
• With the assistance of self-help groups such as Alcoholics Anonymous, some
patients are able to move to a drug-free lifestyle by making friends with new
people who are drug free and alcohol free.
Substance Abuse
• Tolerance is a biological condition that occurs when the body adapts to a substance
after it is repeatedly administered.
• Over time, higher doses of the agent are needed to produce the initial effect.
• For example, at the start of pharmacotherapy, a patient may find that 2 mg of a
sedative is effective in inducing sleep.
• After taking the medication for several months, the patient notices that he or she
needs to take 4 mg or perhaps 6 mg to fall asleep.
• Development of drug tolerance is common for substances that affect the nervous
system.
• Tolerance should be thought of as a natural consequence of continued drug use and
not be considered evidence of addiction or substance abuse.
Substance Abuse
• Tolerance does not develop at the same rate for all actions of a drug.
• For example, patients usually develop tolerance to the nausea and
vomiting produced by narcotic analgesics after only a few doses.
• Tolerance to the mood-altering effects of these drugs and to their ability
to reduce pain develops more slowly but eventually may be complete.
• Tolerance never develops to the drug’s ability to constrict the pupils.
Patients often put up with the annoying side effects of drugs, such as the
sleepiness caused by antihistamines, if they know that tolerance to these
effects will develop quickly.
Substance Abuse
• Once tolerance develops to one substance, it often also occurs with the
use of closely related drugs. This reaction is known as cross-tolerance.
For example, a heroin addict will be tolerant to the analgesic effects of
other opioids such as morphine or meperidine. Patients who have
developed tolerance to alcohol will show tolerance to other CNS
depressants such as barbiturates, benzodiazepines, and some general
anesthetics. This is important to know because doses of related
medications may need to be adjusted so that the patient receives the
maximum therapeutic benefit.
Substance Abuse
• The terms immunity and resistance are often confused with tolerance.
• These terms more correctly refer to the immune system and infections,
and they should not be used to mean tolerance.
• For example, microorganisms become resistant to the effects of an
antibiotic; they do not become tolerant.
• Patients become tolerant to the effects of pain relievers; they do not
become resistant. It is not acceptable to say that patients are immune to
drug therapy.
Substance Abuse

• CNS depressants form a group of drugs that cause patients to feel

sedated or relaxed.
• Drugs in this group include barbiturates, nonbarbiturate sedative–
hypnotics, benzodiazepines, alcohol, and opioids.
• Although the majority of these substances are legal, they are
controlled because of their abuse potential.
Sedatives and Sedative–Hypnotics

• Sedatives, sometimes referred to as tranquilizers, are prescribed

mostly for sleep disorders and some forms of epilepsy. The two
primary classes of sedatives are the barbiturates, used in the
treatment of epilepsy, and the nonbarbiturate sedative–hypnotics.
Their actions, indications, safety profiles, and addictive potential
are roughly the same. Physical dependence, psychological
dependence, and tolerance develop when these agents are taken
for long periods at high doses.
Sedatives and Sedative–Hypnotics

• Patients sometimes abuse these drugs by taking more doses than

prescribed or by sharing their medication with friends.
• These drugs are frequently combined with other drugs of abuse
such as CNS stimulators or alcohol.
• People with addiction often alternate between amphetamines,
which keep them awake for several days, and barbiturates, which
help them relax and fall asleep.
Sedatives and Sedative–Hypnotics
• Many sedatives have a long duration of action. The effects may last an entire
day, depending on the specific drug. Patients may appear dull or apathetic,
with slurred speech and lack of motor coordination. The medical use of
barbiturates and nonbarbiturate sedative–hypnotics has noticeably declined
over the past 20 years.

• Overdoses of barbiturates and nonbarbiturate sedative–hypnotics are

extremely dangerous. These drugs suppress the respiratory centres in the
brain, and the user may stop breathing or fall into a coma. Death may result
from barbiturate overdose. Withdrawal symptoms from these drugs are similar
to those of alcohol and may be life threatening.
Benzodiazepines

• Benzodiazepines are another group of CNS depressants that have

the potential for abuse. They are one of the most widely prescribed
classes of drugs and have largely replaced the barbiturates for
treating certain disorders. The primary indication for their use is
anxiety; thus, they are called anxiolytic drugs; they are also used as
muscle relaxants.
Benzodiazepines
• Although benzodiazepines are the most frequently prescribed drug class,
benzodiazepine abuse varies, depending on the individual. Those who do
abuse benzodiazepines may appear carefree, detached, sleepy, or
disoriented.
• Death as a result of overdose is rare, even with high doses, unless
benzodiazepines are used in combination with other CNS depressants.
• Abusers may combine these agents with alcohol, cocaine, or heroin to
increase their drug experience. If combined with other agents, death resulting
from overdose is very likely. Benzodiazepine withdrawal syndrome, by itself, is
less severe than barbiturate or alcohol withdrawal syndrome.
Opioids
• Opioids are prescribed for severe pain, persistent cough, and diarrhea.
• The opioid class includes opium, morphine, and codeine, which are
processed from natural substances found in the unripe seeds of the
poppy plant, as well as synthetic drugs such as hydromorphone,
oxycodone, fentanyl, methadone, and heroin.
• Fentanyl, in patch form, is becoming a common drug of abuse in
Canada. Reduce the misuse and abuse of fentanyl patches by asking
patients to return used patches to the pharmacy for proper disposal.
Opioids

• The effects of oral opioids begin within 30 minutes of intake and

may last over a day. Parenteral forms produce immediate effects,
including the brief, intense rush of euphoria (feeling of pleasure)
sought by heroin addicts.
• Individuals experience a range of CNS effects, from extreme
pleasure to slowed body activities and extreme sedation. Signs
include constricted pupils, an increase in the ability to withstand
pain, and respiratory depression.
Opioids

• Addiction to opioids can occur rapidly, and withdrawal can

produce intense symptoms.
• Although extremely unpleasant, withdrawal from opioids is not
necessarily life threatening.
• Methadone, a long-acting, synthetic opioid analgesic (narcotic), is
sometimes used to treat opioid addiction.
• When taken, it acts as an agonist at the mu-receptor, thereby
exerting its pain-killing abilities.
Opioids

• Although methadone has addictive properties of its own, it does

not produce the same degree of euphoria as that of other opioids,
and its effects are longer lasting.
• Heroin addicts may be switched to methadone to prevent
unpleasant withdrawal symptoms. Because methadone is taken
orally, the serious risks associated with intravenous drug use, such
as hepatitis and acquired immunodeficiency syndrome (AIDS), are
eliminated.
Opioids

• Patients sometimes remain on methadone maintenance for the rest

of their lives. Withdrawal from methadone is more prolonged than
that from heroin or morphine, but the symptoms are less intense.
• Doses are slowly titrated upward to avoid severe toxicity and
respiratory depression. Methadone is also indicated for the
management of acute pain.
Ethyl Alcohol

• Ethyl alcohol, known simply as “alcohol,” is one of the most widely

abused drugs.
• Alcohol is a legal substance for adults and is available as beer,
wine, and liquor.
• The economic, social, and health consequences of alcohol abuse
are staggering. In contrast to the many negative consequences
associated with long-term abuse of alcohol, drinking small
quantities of alcohol on a daily basis has been found to reduce the
risk of stroke and heart attack.
Ethyl Alcohol

• Alcohol is classified as a CNS depressant because it slows the

actions of the region of the brain responsible for alertness and
wakefulness.
• Alcohol easily crosses the blood–brain barrier, and its effects can
be noticed within 5 to 30 minutes.
• The effects of alcohol are directly related to the amount consumed
within a certain time frame and include relaxation, sedation,
memory impairment, loss of motor coordination, impaired
judgment, and decreased inhibition.
Ethyl Alcohol
• Alcohol intoxication occurs when muscle coordination is lost and mental
function is affected. It results in a characteristic odor to the breath and
increased blood flow in certain areas of the skin, causing a flushed face,
pink cheeks, or red nose. Although these symptoms are easily
recognized, the pharmacy technician must be aware that other
substances and disorders may cause similar effects.
• For example, many antianxiety agents, sedatives, and antidepressants
can cause drowsiness, memory difficulties, and loss of motor
coordination. Certain mouthwashes, medicines, and other substances
containing alcohol can give the breath an “alcoholic” smell.
Ethyl Alcohol
• The presence of food in the stomach will slow the absorption of alcohol,
thus delaying the onset of drug action. Alcohol metabolism, or
detoxification of alcohol by the liver, occurs at a slow, constant rate,
which is not affected by the presence of food.
• The average rate is about 15 mL per hour—equal to one alcoholic
beverage per hour. If consumed at a higher rate, alcohol will accumulate
in blood and produce greater effects on the brain. An overdose of
alcohol produces vomiting, severe hypotension, respiratory failure, and
coma. Alcohol poisoning often results in death.
Ethyl Alcohol

• Chronic alcohol consumption produces both psychological and

physiological dependence and results in a large number of
adverse health effects.
• The organ most affected by chronic alcohol abuse is the liver.
Alcoholism is a common cause of cirrhosis, a harmful and often
fatal failure of the liver to perform its vital functions. Liver failure
causes abnormalities in blood clotting and nutritional deficiencies
and sensitizes the patient to the effects of all medications
metabolized by the liver.
Ethyl Alcohol

• Alcohol withdrawal syndrome is severe and may be life

threatening. The use of antiseizure medications for treating severe
alcohol withdrawal symptoms is discussed in Chapter 12. Long-
term treatment for alcohol abuse includes behavioural counselling
and participation in self-help groups such as Alcoholics
Anonymous. Disulfiram (Antabuse) may be given to discourage
relapses. Disulfiram inhibits acetaldehyde dehydrogenase, the
enzyme that metabolizes alcohol.
Ethyl Alcohol

• If alcohol is consumed while taking disulfiram, the patient becomes

violently ill within 5 to 10 minutes, with headache, shortness of
breath, nausea or vomiting, and other unpleasant symptoms.
• Disulfiram is effective only in highly motivated patients because the
success of pharmacotherapy is entirely dependent on patient
compliance.
• Alcohol sensitivity can continue for up to two weeks after disulfiram
has been discontinued.
Cannabinoids

• Cannabinoids are substances obtained from the hemp plant

Cannabis sativa, which grows in tropical climates.
• Cannabinoid agents are usually smoked and include marijuana,
hashish, and hash oil.
• Although more than 61 cannabinoid chemicals have been
identified, the ingredient responsible for most of the psychoactive
properties is delta-9- tetrahydrocannabinol (THC).
Cannabinoids

• Marijuana (street names “grass,” “pot,” “weed,” “reefer,” or “dope”)

is a natural product obtained from C. sativa. It is one of the most
commonly used illegal drugs in Canada. Use of marijuana slows
motor activity, decreases coordination, and causes disconnected
thoughts, paranoia, and euphoria. It increases thirst and craving for
food, particularly chocolate and other candies. One hallmark
symptom of marijuana use is red or bloodshot eyes, caused by
dilation of blood vessels. THC accumulates in the gonads
(reproductive glands).
Cannabinoids

• When inhaled, marijuana produces effects that occur within

minutes and last up to 24 hours. Because marijuana smoke is
inhaled more deeply and held within the lungs for a longer time
than cigarette smoke, marijuana smoke introduces four times more
tar into the lungs compared with tobacco smoke. Smoking
marijuana on a daily basis may increase the risk of lung cancer and
other respiratory disorders. Chronic use is associated with lack of
motivation and loss of productivity.
Cannabinoids

• Unlike many abused substances, marijuana produces little physical

dependence or tolerance. Withdrawal symptoms are mild, if they
are experienced at all. Metabolites of THC, however, remain in the
body for months to years, allowing laboratory specialists to
determine easily whether someone has used marijuana. For several
days after use, THC can also be detected in urine. Despite
numerous attempts by scientists and clinicians to demonstrate
therapeutic applications for marijuana, results on the medical use
of marijuana have been controversial.
Hallucinogens

• Hallucinogens consist of an assorted class of chemicals that have in

common the ability to produce an altered, dreamlike state of
consciousness.
• Sometimes called psychedelics, the prototype substance for this
class is LSD.
• None of the hallucinogens has any medical use.
Hallucinogens

• Almost all drugs of abuse cause predictable symptoms in every

user. Effects from hallucinogens, however, are highly variable and
depend on the mood and expectations of the user and the
surrounding environment in which the substance is used.
• Two patients taking the same agent will report completely different
symptoms, and the same patient may report different symptoms
with each use.
Hallucinogens

• Those who take LSD or psilocybin may experience symptoms such

as laughter, visions, religious revelations, or deep personal insights.
Common occurrences are hallucinations and afterimages (images
that are projected onto people as they move). Users also report
unusually bright lights and vivid colors. Some users hear voices;
others report smells. Many experience a profound sense of truth
and deep-directed thoughts. Unpleasant experiences can be
terrifying and may include anxiety, panic attacks, confusion, severe
depression, or paranoia.
Hallucinogens

• LSD (street names “acid,” “the beast,” “blotter acid,” “California

sunshine”) is made from a fungus that grows on rye and other
grains. LSD is almost always used in the oral form. It can be
manufactured in capsules, tablets, or liquids. A common and
inexpensive method for distributing LSD is to place drops of the
drug on small pieces of paper that often contain images of cartoon
characters or graphics related to the drug culture. After drying, the
paper containing the LSD is swallowed to produce the drug’s
effects.
Hallucinogens

• LSD is distributed throughout the body immediately after use. Its

effects are experienced within an hour and may last six to 12 hours.
It affects the central and autonomic nervous systems, increasing
blood pressure, elevating body temperature, dilating pupils, and
increasing heart rate. Repeated use may cause memory loss and
inability to reason.
Hallucinogens

• In extreme cases, patients may develop psychoses. One unusual

adverse effect is flashbacks, in which the user experiences the
effects of the drug again—sometimes weeks, months, or years after
the drug was initially taken.
• With hallucinogens, although users may experience tolerance, they
have little or no dependence.
Stimulants

• Stimulants include a family of drugs with the ability to increase the

activity of the CNS. Some are available by prescription for use in
the treatment of narcolepsy (a sleep disorder in which people fall
asleep unexpectedly), obesity, and attention deficit disorder (ADD)
(or attention deficit hyperactivity disorder [ADHD]).
• As drugs of abuse, CNS stimulants are taken to produce a sense of
exhilaration, improve mental and physical performance, reduce
appetite, prolong wakefulness, or simply “get high.” Stimulants
include amphetamines, cocaine, methylphenidate, and caffeine.
Stimulants

• CNS stimulants have effects similar to norepinephrine, a

neurotransmitter. Norepinephrine activates neurons in the part of
the brain that controls awareness and wakefulness, called the
reticular formation. High doses of amphetamines give the user a
feeling of self-confidence, euphoria, alertness, and empowerment.
Long-term use, however, often causes feelings of restlessness,
anxiety, and fits of rage, especially when the user is coming down
from a drug high.
Stimulants

• Most CNS stimulants affect cardiovascular and respiratory activities,

raising blood pressure and increasing respiration rate.
• Other symptoms include dilated pupils, sweating, and tremors.
• Overdoses of some stimulants lead to seizures and cardiac arrest.
Stimulants

• Amphetamines and dextroamphetamines were once widely

prescribed for depression, obesity, drowsiness, and congestion. In
the 1960s, the health care profession realized that the risk for
amphetamine dependence outweighed the drug’s therapeutic
usefulness.
• Because of the development of safer medications, the current
therapeutic uses of these drugs are extremely limited. Most
substance abusers get these agents from illegal laboratories, which
can easily produce amphetamines and make tremendous profits.
Stimulants
• Dextroamphetamine (Dexedrine) may be used to treat narcolepsy and for
short-term weight loss when all other attempts to lose weight have been
exhausted.
• Methamphetamine (street name “ice” or “crank”) is often used as a
recreational drug by those who want the “rush” it provides. It usually is
administered in powder or crystal form, but it may also be smoked.
• Methylphenidate (Ritalin) is a CNS stimulant, which is widely prescribed for
children diagnosed with ADD/ADHD. Ritalin has a calming effect on children
who are inattentive or hyperactive. It stimulates the alertness centre in the
brain and allows the child to focus on tasks for longer periods.
Stimulants

• In adults, Ritalin usually produces the same effects as those of

cocaine and amphetamines and is sometimes abused by
adolescents and adults seeking euphoria.
• The tablets are crushed and used intranasally or dissolved in liquid
and injected intravenously.
• Ritalin is also sometimes mixed with heroin (street name
“speedball”).
Stimulants
• Cocaine is a natural substance obtained from leaves of the coca plant,
which grows in the Andes Mountain region of South America. The plant
has been used by Andean cultures since 2500 bce.
• Natives of this region chew the coca leaves or make tea with the dried
leaves. Because it is taken orally, its absorption is slow, and the leaves
contain only 1% cocaine, users do not experience the ill effects caused
by pure chemical extracts from the plant. In the Andean culture, use of
coca leaves is not considered substance abuse because it is part of that
society’s culture.
Stimulants

• Cocaine produces effects similar to those of the amphetamines,

although its effects are usually more rapid and intense. It is one of
the most commonly abused illegal drugs in Canada.
• Methods of ingestion include snorting, smoking, and injecting. In
smaller doses, cocaine produces feelings of intense euphoria,
decreased hunger, analgesia, illusions of physical strength, and
increased sensory perception.
Stimulants
• Larger doses will magnify these effects and also cause rapid heartbeat,
sweating, dilation of the pupils, and elevated body temperature.
• After the euphoria diminishes, the user often feels irritable, depressed,
and distrustful and usually has insomnia. Some users report a sensation
of insects crawling under their skin.
• Users who snort cocaine develop a chronic runny nose, a crusty redness
around the nostrils, and deterioration of the nasal cartilage. Overdose
can cause dysrhythmias, convulsions, stroke, or death as a result of
respiratory arrest. Symptoms of withdrawal from amphetamines and
cocaine are much less intense than those from alcohol or barbiturates.
Stimulants

• Caffeine is a natural substance found in the seeds, leaves, or fruits

of more than 63 plant species throughout the world. Significant
amounts of caffeine are consumed in chocolate, coffee, tea, and
soft drinks.
• Sometimes caffeine is added to OTC pain relievers to help relieve
migraines and other conditions. Caffeine travels to almost all parts
of the body after ingestion, and several hours are needed for the
body to metabolize and eliminate the drug. Caffeine has a
pronounced diuretic effect.
Stimulants
• Caffeine is considered a CNS stimulant because it produces increased mental
alertness, restlessness, nervousness, irritability, and insomnia.
• The physical effects of caffeine include bronchodilation, increased blood
pressure, increased production of stomach acid, and changes in blood
glucose levels.
• Repeated use of caffeine may result in physical dependence and tolerance.
Although water is the beverage consumed most frequently and in the greatest
quantity by adults in Canada, for many of them, coffee ranks second. Largely
as a result of drinking coffee, more than 20% of men and 15% of women aged
31 to 70 years exceed the recommended maximum of 400 milligrams of
caffeine per day.
Nicotine

• Nicotine is sometimes considered a CNS stimulant because of its

ability to increase alertness. However, its actions and long-term
consequences place it into a class by itself.
• Nicotine is unique among abused substances in that it is legal,
strongly addictive, and highly carcinogenic.
• Furthermore, “second-hand smoke” can cause harmful effects in
those in the immediate area of the smoker. Smokers often do not
consider tobacco use to be substance abuse.
Nicotine

• The most common method by which nicotine enters the body is

through the inhalation of use of tobacco can cause harmful effects
from a cigarette, pipe, or cigar.
• Tobacco smoke contains more than 1000 chemicals, many of which
are carcinogens.
• The primary addictive substance in cigarette smoke is nicotine. The
effects of inhaled nicotine may last from 30 minutes to several
hours.
Nicotine

• Nicotine affects many body systems, including the nervous,

cardiovascular, and endocrine systems.
• Nicotine stimulates the CNS directly, causing increased alertness
and ability to focus, feelings of relaxation, and lightheadedness.
• The cardiovascular effects of nicotine include accelerated heart
rate and increased blood pressure, caused by the activation of the
nicotinic receptors located within the autonomic nervous system.
Nicotine

• The cardiovascular effects of nicotine can be serious in patients

taking oral contraceptives. The risk of a fatal heart attack is five
times greater in smokers than in nonsmokers.
• Muscular tremors may occur with moderate doses of nicotine, and
convulsions may result from taking very high doses. Nicotine
affects the endocrine system by increasing the basal metabolic
rate, leading to weight loss. Nicotine also reduces appetite.
Chronic use may lead to bronchitis, emphysema, and lung cancer.
Nicotine
• Both psychological and physical dependence occur relatively
quickly with nicotine. Once started on tobacco, patients tend to
continue their drug use for many years despite overwhelming
medical evidence that their quality of life may be adversely
affected and their life span shortened.
• Discontinuation results in agitation, weight gain, anxiety, headache,
and an extreme craving for the drug. Although nicotine
replacement therapy (e.g., patches, chewing gum) and bupropion
assist patients in dealing with the unpleasant withdrawal
symptoms, only 25% of smokers who attempt to stop smoking
remain tobacco-free one year later.
Performance-Enhancing Products

• Some drugs are also taken to enhance physical performance in

sports. This would include anabolic steroids that build muscle
mass. The side effects of their use include steroid rage, shrunken
testicles, acne, and liver damage.
• CNS stimulants such as pseudoephedrine can also boost physical
performance and are banned in sports. Therefore, the use of
common cough and cold remedies, which contain
pseudoephedrine, need to be closely monitored in athletics.
Healthcare Providers

• Most health care providers report that they have encountered

coworkers with perceived alcohol or substance abuse problems.
• For example, compared with nurses in other specialties, critical
care nurses are especially likely to use cocaine and marijuana.
Among nurses, alcohol is the most commonly abused substance;
prescription drugs come second.
Healthcare Providers
• The reasons for these problems seem to be increasing tension as a
result of the demands of the health care profession; social environments
among medical professionals that promote self-reliance and
independence; difficulty sleeping, in particular among workers with
rotating shifts; and, in general, fatigue.
• Warning signs of substance abuse are overworking habits (e.g., arriving
early and staying late for many days on end), high performance followed
by deteriorating performance, isolation from other working staff, and
unexplained or complicated variables related to the health care worker’s
professional or social life.
Healthcare Providers

• The obvious signs may be frequent mood swings, irritability, or

tearful outbursts followed by depression.
• Signs of substance abuse may be smell of alcohol on the breath
covered up by mints or mouthwash, frequent absence from the
pharmacy to visit the restroom, or patients complaining of not
receiving the proper amount of medication or receiving their dose.
Patients may complain about feeling pain despite having received
seemingly adequate or repeated dosing of pain medication.
Healthcare Providers

• There are organizations and groups of organizations that focus

chiefly on addiction in health care professionals as well as
psychiatric disorders among health care workers.
• The focus should not be on disciplinary action alone but also on
monitoring and support services. Some agencies have adopted
alternative disciplinary and peer assistance programs to ensure
that both patients and health care providers receive proper
assistance.
Chapter Review Core Concepts Summary

• 6.1 Abused substances belong to many different chemical classes.

• Abused substances come from different chemical classes. Some
abused substances such as alcohol and nicotine are available
without a prescription. Others such as barbiturates,
benzodiazepines, and most opioids have legitimate medical uses.
Still others such as LSD and heroin are illegal, no longer having any
medical applications.
Chapter Review Core Concepts Summary

• 6.2 Addiction depends on multiple, complex, and interacting

variables.
• Addiction is an overwhelming feeling that causes someone to
continue taking drugs. Although ideas have changed about
addiction over the years, health care providers now recognize it as
being related to drug factors, genetic factors, and environmental
factors.
Chapter Review Core Concepts Summary

• 6.3 Substance dependence is classified as physical dependence or

psychological dependence.
• Dependence is an overwhelming need to take a drug on a
continual basis. Physical dependence occurs when the patient
exhibits signs of withdrawal after the drug is discontinued.
Psychological dependence is an intense craving for the drug.
Chapter Review Core Concepts Summary

• 6.4 Withdrawal results when an abused substance is no longer

available to the body.
• When an abused drug is discontinued, patients may experience
uncomfortable physical symptoms known as withdrawal syndrome.
Symptoms vary, depending on the specific drug of abuse, and
range from mild to life threatening.
Chapter Review Core Concepts Summary

• 6.5 Tolerance occurs when higher and higher doses of a drug are
needed to achieve the initial response.
• Tolerance occurs over time when patients adapt to continued drug
use and require higher doses to produce the same effect. Cross-
tolerance or tolerance resulting from prior exposure to a related
drug also results in higher doses needed to produce the same
effect.
Chapter Review Core Concepts Summary

• 6.6 Central nervous system (CNS) depressants decrease the activity

of the CNS.
• Substances that make patients feel relaxed and sleepy and work by
generally slowing neuronal activity in the brain include sedatives,
opioids, and ethyl alcohol. Examples of sedatives are barbiturates
and benzodiazepines. Because of their abuse potential, many of
these substances are controlled. Ethyl alcohol is a legal substance.
Chapter Review Core Concepts Summary

• 6.7 Marijuana produces little physical dependence or tolerance.

• The most commonly abused illegal substance in Canada is
marijuana. Marijuana produces less physical dependence than
most other drugs and produces less tolerance. The medical value
of this drug remains controversial and unproven. The risks of using
this substance are lung cancer, respiratory problems, and lack of
motivation.
Chapter Review Core Concepts Summary

• 6.8 Hallucinogens cause an altered state of thought and

perception similar to that found in dreams.
• Hallucinogens, also called psychedelics, have the ability to
produce altered states of consciousness and dreams. They include
LSD, mescaline, MDMA (Ecstasy), DOM (STP), MDA (love drug), and
ketamine (an anesthetic).
Chapter Review Core Concepts Summary

• 6.9 CNS stimulants increase the activity of the CNS.

• Amphetamines, methylphenidate, cocaine, and caffeine increase
alertness by stimulating the CNS. Some substances are available by
prescription and are used for treating narcolepsy, obesity, and
attention deficit disorder. Caffeine is available in many consumer
products, including chocolate, coffee, tea, soft drinks, and coffee
ice cream. Cocaine is among the most commonly abused
substances in North America.
Chapter Review Core Concepts Summary

• 6.10 Nicotine is powerful and highly addictive.

• Nicotine is a legal substance that is unique, carcinogenic, and
highly addictive. The most common method of its entry into the
body is through inhalation of smoke from a cigarette, pipe, or
cigar. The important effects of inhaled nicotine include stimulation
of the CNS and increased cardiovascular effects.
Chapter Review Core Concepts Summary
• 6.11 Health care providers strive to remain free of impairment caused
by alcohol and drug addiction.
• The reasons for health care providers having problems with alcohol or
drug abuse seem to be related to the demands of the health profession,
including self- reliant social and professional environments, rotating
working shifts, and fatigue. Signs of impairment are frequent mood
swings, irritability or depressive symptoms, smell of alcohol on the
breath, frequent absences from the unit, or patients not receiving
proper medications. There are support groups and organizations to
assist with substance abuse and related issues faced by health care
workers.
Case Study
• For over six years, Jane Furlong and Philip Blanchard have been
colleagues at the local hospital pharmacy department. Although Jane
does not consider Philip a close friend, she does think of him as
competent and committed. Generally, they work the same schedule,
attend many of the same meetings, and have chatted informally at
departmental and hospital social events. Over the past few months,
however, Jane has heard various staff members remarking how stressed
and disorganized Philip seems to be after his return to work after
surgery and how often his work does not get completed. He has started
staying late and often prefers to work alone. There have also been some
recent discrepancies in the narcotics count.
Case Study
• Today, Jane is at work early and is first in the department. She notices
that Philip is also at work and sees him leaving the narcotics area, which
is not his responsibility. When she greets Philip, he seems startled and
surprised to see Jane. Jane asks him how he is doing and notices Philip
quickly putting his hands into his pockets. He dismisses her abruptly and
says he will be back in the department in a few minutes. As he passes
Jane, she notices that Philip has constricted pupils and is sweating. In
the next half hour, the rest of the staff arrive in the department, but
Philip has yet to return.
Case Study
• Why might you suspect Philip has a substance abuse problem?

• Why are health care professionals at a high risk for substance abuse?

• What should Jane do?

• What would Jane do if she were a pharmacy technician student and

Philip was her preceptor?