Page 528 - Medicine and Surgery

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524 Chapter 15: Overdose, poisoning and addiction

sweating, tachycardia and loss of appetite. Within half an 2 Agitation and hypertension often respond to di-
hour of the last dose of a binge, there is a ‘crash’ when the azepam. Haloperidol and phenothiazines should be
user feels intense cravings, depression and anxiety. After avoided, as they increase the risk of seizures.
a further 1–4 hours, they usually sleep for hours to days, 3 Persisting hypertension should be treated with intra-
intermittently waking up with hunger (‘the munchies’). venous glyceryl trinitrate (GTN), with calcium an-
After a few days, the user becomes low in mood, with tagonists as second line therapy. β-blockers should
lack of motivation, impairment of memory and inter- be avoided (may cause paradoxical hypertension and
mittent anxiety, even suicidal ideation. Long-term users coronary vasoconstriction due to unopposed alpha
may become persistently restless, with anorexia, weight effects).
loss and insomnia. 4 Aspirin, sublingual GTN and diazepam should be
A history should be taken of recent and previous co- giventoall patients who have chest pain. If pain con-
caine use, including methods of administration, use of tinues, intravenous GTN should be commenced and
other drugs, alcohol intake, previous rehabilitation and if despite this, the ECG shows an acute MI, throm-
any problems associated with drug use. A close social bolytic therapy as for a conventional MI should be
history should be taken, as well as a medical history and given, unless there are any contraindications.
examination. 5 Cardiac arrhythmias require specialist advice, for ex-
ample from the National Poisons Information Service
Complications (NPIS).
Physical: Snorting cocaine repeatedly causes damage 6 Cocaine abusers should be referred to a drug reha-

to the nasal mucous membranes with septal perfora- bilitation counsellor or centre. There are no serious
tion, cribiform plate damage and CSF rhinitis. Smok- physical effects from withdrawal so sedatives or a re-
ing can cause granulomas and pulmonary oedema. placement drug are not needed. Propanolol may help
Injecting carries risks of abscesses, infective endo- anxiety (but may exacerbate cocaine-induced hyper-
carditis, HIV and hepatitis infection. Other medical tension or myocardial ischaemia) and antidepressants
complications include hypertension, myocardial in- may be indicated.
farction (MI) due to coronary artery spasm, arrhyth-
mias, seizures, stroke and cardiorespiratory arrest.
Amphetamine abuse
Neuropsychiatric: Anxiety, paranoia, depression and

hallucinations. Definition
Social: The most common reason for a cocaine ad- Amphetamines were originally widely used for medical

dict to present for treatment of dependency is run- reasons such as appetite suppressants and for insom-
ning out of money, as a cocaine or crack binge can nia, but are now recreationally used. Medical use of am-
cost hundreds to thousands of pounds. Other prob- phetamine (and derivatives) is now limited to selected
lems include loss of job and criminal activities such as cases of narcolepsy and attention deficit hyperactivity
stealing, prostitution and drug dealing. disorder.
There are several derivatives of amphetamine, such
Investigations as methamphetamine, which can be smoked, and there-
These depend on the presentation of the individual. Co- fore became popular for their increased speed of on-
caine use can be tested for using a urine screen. Investi- set and intense effect. Amphetamines can be taken
gations may be needed for possible complications such orally, intranasally, smoked or injected. Street names for
as MI, arrhythmias, stroke and infections. amphetamine include ‘speed, whizz, sulphate’, and for
methamphetamine ‘meth, ice’.
Management
Cocaine intoxication: Initial management includes en- Incidence/prevalence
suring a clear airway and ventilation if needed. Amphetamineandderivatives(includingecstasy)arethe
1 Seizures are treated with diazepam or lorazepam. second most common class of illegal drug used after
Phenytoin may be needed. cannabis.