Drug Dependence and Drug Abuse Chapter Notes | Forensic Medicine and Toxicology (FMT) - NEET PG PDF Download

Introduction

Hallucinogens, stimulants, and organic solvents are key substances associated with dependence and abuse, explored in detail in this section.

Hallucinogens (Psychedelics)

Hallucinogens, often inaccurately referred to, encompass drugs that induce visual distortions, altered perceptions, and sensations such as synesthesia, depersonalization, and derealization. A more precise description of these substances is illusionogenic, psychedelic, or mysticomimetic. Historically used by Indigenous tribes, these drugs are now a concern due to their misuse among the youth.

Classic Hallucinogens:

• LSD (lysergic acid diethylamide)
• Morning glory seeds
• Psilocybin
• DMT (dimethyltryptamine)
• Mescaline
• Peyote
• Nutmeg

These substances hold medicolegal significance and warrant further exploration.

Other Hallucinogens:

• In addition to classic hallucinogens, there are numerous other natural and synthetic hallucinogens encountered less frequently.
• Clinicians should not presume that all hallucinations arise from drug abuse or psychiatric conditions, as various standard therapeutic agents can also produce hallucinogenic effects at usual or moderate doses.

Therapeutic Agents with Hallucinogenic Effects:

• Amantadine
• Anticholinergic drugs
• Carbamazepine
• Cephalexin
• Chlordiazepoxide
• Chloroquine
• Clonidine
• Dextromethorphan
• Dapsone
• Digoxin
• Diphenhydramine
• Disulfiram
• Ephedrine
• Griseofulvin
• Indomethacin
• Isoniazid
• Levodopa
• Lorazepam
• Methyldopa
• Methylprednisolone
• Minocycline
• Morphine
• Nalidixic acid
• Pentazocine
• Phenothiazines
• Piperazine
• Procainamide
• Procaine penicillin G
• Propoxyphene
• Propranolol
• Streptokinase
• Tricyclic antidepressants

LSD: The Potent Hallucinogen

LSD, or Lysergic Acid Diethylamide, is the most powerful and commonly misused hallucinogen. It was first synthesized by Stoll and Hofmann in 1938 at Sandoz Laboratories in Switzerland while they were exploring pharmacologically active derivatives of a fungus called ergot, which grows on cereal grains, particularly rye.

Street Names for LSD:

• Acid
• Blotter acid
• Blue caps
• Brown caps
• Crackers
• Green caps
• Orange wedges
• Paisley caps
• Pink dots
• Purple Owsleys
• White lightning
• Yellow caps
• 25

Characteristics of LSD:

• LSD is tasteless and odorless, making it highly potent even in small quantities.
• It is often found illegally on sugar cubes, as well as in various colored and shaped pills and ampoules.

Mescaline

• Mescaline is derived from peyote plants.
• It is typically found in the form of a crystalline powder.
• Users can consume it by mixing with water or in capsule form.
• In terms of potency, mescaline is less strong than LSD, but its effects are similar to those of peyote.

Peyote

• Peyote is obtained from a specific variety of cactus.
• The active compounds are located in the button-shaped part of the cactus.
• These buttons are processed into balls and stored in capsules for consumption.
• Alternatively, they can be prepared by brewing in hot tea.
• Like mescaline, peyote is also less potent than LSD.

How Hallucinogens Affect the Mind

• Hallucinogens can be harmful to mental health and may cause various issues, including:
• Anxiety
• Panic
• Depressive and paranoid reactions
• Changes in mood and confusion
• Difficulty in distinguishing between reality and fantasy
• Decreased motivation for normal activities such as studying, working, or contributing to society.

Signs and Symptoms

• Unusual behavior, laughter, rapid emotional shifts, and suspicion
• Possible nausea and vomiting, especially with peyote
• Physical examination may show dilated pupils and tremors
• Bad trips. negative experiences from LSD, often involving intense anxiety or paranoia.
• LSD disrupts the mind's ability to filter information, leading to altered perceptions and effects such as:
• Seeing colors and hearing sounds in unusual ways
• A complete disruption of the senses of time, space, and distance
• Entering a dream-like state with a loss of awareness of body boundaries
• Experiencing various fantasies and hallucinations, along with conflicting emotions like depression and elation.

Complications of Bad Trip

• While these experiences may eventually subside, they can trigger 'flashbacks' of altered states for several months.
• These flashbacks can persist for up to two years, potentially necessitating long-term therapy for complete recovery.

Hangover or Aftereffects

• Patients may occasionally experience the following aftereffects:
• Insomnia
• Headache
• Vertigo
• Psychotic reactions

Effects of Prolonged Consumption

• Prolonged use of hallucinogens can result in:
• Potential brain damage
• Chromosomal damage in peripheral blood smears, particularly with LSD

Fatal Dose

Hallucinogens are potent substances, and the quantity required to produce their effects is relatively small. This makes it uncommon for individuals to consume a lethal dose, resulting in very few fatalities associated with these drugs.

Treatment

• Long-term treatment is crucial because the ‘flashback’ effects from hallucinogens can persist for an extended period.
• Psychotherapy has been shown to be an effective option for treating individuals affected by hallucinogens.
• The use of tranquilizers can help alleviate the “flashback” effects associated with hallucinogen use.

Medicolegal Importance of Hallucinogens

• Hallucinogens have the potential to be habit-forming, but addiction is less common compared to other substances.
• Some individuals may experience problematic use of hallucinogens.
• These substances can pose psychosocial risks, potentially leading to psychotic or depressive reactions, especially with drugs like LSD, along with “flashback” experiences.
• There have been instances of suicide attempts or homicides following hallucinogen use in cases of drug misadventure.
• The use of hallucinogens can impair an individual’s ability to operate vehicles or machinery safely.

Stimulants

Amphetamines are primarily classified as central nervous system (CNS) stimulants.

Effects of Amphetamines

• Flushed face
• Excessive sweating
• Increased excitement
• Restlessness
• Insomnia
• Tremors
• Ventricular tachycardia (rapid heart rate)
• Hypertension (high blood pressure)
• Delirium
• Hallucinations
• Convulsions
• Deep unconsciousness

Toxic psychosis can occur with long-term use of amphetamines.

The fatal dose of amphetamines can vary significantly based on individual factors, but it is generally estimated to be between 120 to 200 mg.

The fatal period for amphetamine overdose can extend up to five days.

Treatment for Amphetamine Overdose

• Gastric lavage (stomach pumping)
• Sedation with chlorpromazine
• Cardiorespiratory resuscitation (CPR)
• General supportive measures (monitoring and stabilizing vital signs)
• Administering haloperidol 5-10 mg IV slowly to address CNS effects

Accidental overdoses of amphetamines can lead to addiction issues. However, amphetamines are also used for:

• Appetite suppression
• Mood elevation
• Treatment of narcolepsy (a sleep disorder)

Organic Solvent

• Organic solvents are volatile substances that can have psychotropic and hallucinogenic effects when inhaled. Examples include toluene, gasoline, xylene, benzene, methylene, ethylene chloride, fluorocarbons, carbon tetrachloride, butane, and propane.
• Solvent abuse involves inhaling these substances intentionally, often through methods like using a plastic bag or soaking a cloth in the solvent.

Risks and Effects

• Inhalation of organic solvents can lead to vagal inhibition, ventricular fibrillation, cardiac arrest, asphyxia, and direct toxicity to the brain and heart.
• Organic solvents such as carbon tetrachloride can cause serious health issues, including hepatotoxicity and nephrotoxicity.
• Inhalation of carbon tetrachloride can result in symptoms like eye and throat irritation, headache, nausea, vomiting, mental confusion, loss of consciousness, arrhythmia, slow respirations, and convulsions.
• Ingestion of carbon tetrachloride may lead to dizziness, headache, nausea, vomiting, colic, tremors, convulsions, and coma.
• The fatal dose for adults is typically between 2 and 4 ml, while for children, it is about 1 ml.
• The fatal period is usually 1 to 2 days.

Management

• In cases of inhalation, it is important to remove the patient from the source, administer oxygen, provide artificial respiration, perform gastric lavage, administer a saline purgative, and treat for hepatic and renal damage.
• N-acetylcysteine may be given in severe cases.

Causes of Poisoning

• Poisoning can occur due to accidental ingestion, solvent abuse, or overdose.

Drug Dependence

The World Health Organisation Expert Committee on Addiction Producing Drugs has introduced the term “ drug dependence. to replace two previous terms: (i) drug addiction and (ii) drug habituation.

This change was made because the distinction between these terms is often unclear in practice.

Even though “drug dependence” is now widely accepted, the older term “ drug addiction. is still frequently used to describe individuals who are dependent on addictive substances.

This situation has created a need to define these terms separately.

Definitions

• Drug dependence: A condition where an individual relies on drugs to function normally.
• Drug addiction: A chronic disorder characterised by compulsive drug seeking and use.
• Drug habituation: A less severe form of substance use, where a person becomes accustomed to a drug without developing dependence.
• Drug dependence refers to a condition, both mental and physical, characterized by a strong compulsion to use a drug.
• This compulsion can manifest continuously or intermittently.
• Individuals may use drugs either to experience their effects or to alleviate the discomfort of withdrawal.

Drug Addiction

• Drug addiction, commonly known as substance use disorder, involves harmful patterns of periodic or chronic intoxication that adversely affect the individual and society.
• This condition results from the repeated use of various substances, including:
  • Opium and its derivatives
  • Pethidine
  • Cannabis
  • Heroin
  • Alcohol
  • Barbiturates
  • Cocaine
  • LSD
  • Amphetamines
  • Chloral hydrates

Drug Habituation

Drug habituation is when a person becomes psychologically or emotionally dependent on a substance, like caffeine or nicotine, due to its regular use.

Drug Abuse

Drug abuse is the improper use of drugs, whether they are meant for therapy or not. This can be harmful, even if addiction is not present.

Etiology of Drug Dependence

• Drug dependence is often seen in adolescents and adults.
• It is more common among individuals who engage in risk-taking, rebellious behavior, truancy, and sexual promiscuity.
• People may use drugs to achieve effects such as euphoria, enhanced understanding and creativity, better relaxation, improved stress coping, increased sexual performance, experiencing sexual pleasure without intercourse, and enhanced religious meditation.
• Drug dependence is frequently observed in individuals with psychological disorders such as psychoneurosis, psychopathic states, and severe psychoses.
• Prolonged use of therapeutic drugs can lead to medical addiction, such as to analgesics and sedatives.

Consequences of Drug Dependence

• Daily drug use necessitates financial expenditure, leading to economic hardship.
• Some individuals may resort to thefts, forgery, and similar activities to acquire funds.
• Prostitution may become a means of survival for certain individuals.
• Fundamental needs such as food, personal hygiene, and clothing are frequently overlooked, resulting in an addict appearing dishevelled, unkempt, unshaven, and dirty.

Mechanism of Drug Addiction

The mechanisms underlying drug addiction are complex and not entirely understood. However, significant advancements have been made in comprehending its neurobiological basis.

Signs and Symptoms of Drug Addiction

• Irresistible craving to continue using the drug.
• Development of tolerance, leading to the need for higher doses.
• Physical dependence on the drug.
• Compulsive behavior to obtain the drug, including illegal methods.
• Withdrawal symptoms when the drug is not taken.

Withdrawal Symptoms (Abstinence Syndrome)

• Withdrawal symptoms typically emerge within 6 to 48 hours after stopping drug use.
• Common characteristics include:
  • Restlessness
  • Feelings of anxiety

Differentiating characteristics of drug addiction and drug habituation

​Although these distinctions are presented in tables, it remains challenging to identify when habit formation transitions into addiction, rendering both concepts equivalent to drug dependence, as defined by the WHO.

Symptoms such as vague abdominal and limb pain, diarrhea, and increased libido may persist for varying durations, influenced by the type of drug, dosage, length of addiction, and abruptness of withdrawal.

Treatment of Addiction

• Institutional treatment is advised for individuals struggling with addiction.
• Surveillance measures should be put in place to prevent the further supply of drugs.
• Progressive tapering involves gradually reducing the drug dosage in stages for safe withdrawal.
• Administering small doses of sedatives, such as barbiturates, helps to manage withdrawal symptoms.
• Encouraging participation in physical and mental activities supports the recovery process.
• Providing psychotherapy and encouragement is crucial for mental health support.
• Improving overall health through nutritious food is essential for recovery.
• Implementing symptomatic measures to address specific withdrawal symptoms is also important.

Mechanism of Drug Habituation

• Drug habituation, like drug addiction, is not fully understood. However, it is known that:
• Drug habituation is common among individuals who have a tendency to imitate others.
• It can be transmitted from one person to another.

Signs and Symptoms of Drug Habituation

• A person who is habituated to drugs is referred to as a drug habitué and exhibits the following symptoms:
• A desire to continue taking the drugs, although this desire is not overwhelming.
• Minimal or no tolerance to the drug.
• As a result, there is little or no tendency to increase the dosage.
• Some degree of psychic dependence, but no physical dependence.
• A negative impact primarily on the individual, although it can also affect society.
• Absence of withdrawal symptoms.