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CAPÍTULO XVII De las bajas de alumnos

Withdrawal Symptoms

Te sudden stopping of opioids after prolonged use or

intake of opioid antagonists like naltrexone can produce

withdrawal

withdrawal symptomssymptoms. . Te Te short-term short-term use use of of opioidsopioids

decreases the activity of noradre

decreases the activity of noradrenergic neurons and thenergic neurons and the

long-term use results in compensatory hyperactivity.

When opioids

When opioids are suddenly are suddenly stopped, there stopped, there are symptomsare symptoms

of rebound noradrenergic hyperactivity. Tis hypothe-

sis also explains the mechanism of action of clonidine

(alpha-2 adrenergic receptor agonist, which decreases

norepinephrine release) in management of opioid with-

drawal.

Te withdrawal withdrawal symptoms symptoms usually usually appear appear aroundaround

6–8 hours

6–8 hoursQQ_{after the last dose, peak during the second}_{after the last dose, peak during the second}

or third day and subside during the next 7–10 days. Te

withdrawal from

withdrawal from opioids opioids produces produces aaﬂu-like syndromeﬂu-like syndromeQQ

with

with the the following following symptomssymptoms..

1.LacrimationLacrimationQQ_,_,_rhinorrhea_rhinorrheaQQ_{, sweating,}_{, sweating,}_diarrhea_diarrheaQQ

2. Ya Yawning wning and and piloerectionpiloerectionQQ

3.Pupillary dilationPupillary dilationQQ

4. M

4. Muscle cramps and generalized bodyauscle cramps and generalized bodyacheche

5.InsomniaInsomniaQQ_{, anxiety, hypertension and tachycardia}_{, anxiety, hypertension and tachycardia}

6. N

6. Nausea, vomiting and anorexia.ausea, vomiting and anorexia.

Treatment

A.DetoxiﬁcationDetoxiﬁcation: In this stage, the main focus is on: In this stage, the main focus is on

the manage

the management of withdrawal symptoms. Tement of withdrawal symptoms. Te

medications used are usually long acting opioids like

methadone

methadoneQQ _or_or _{buprenorphine}_{buprenorphine}_{. Both medications,}_{. Both medications,}

in view of their agonist action at opioid receptors,

suppress the withdrawal symptoms. Other opioids

like dextropropoxyphene can also be used. Usually

detoxiﬁcation medicines are required for 2-3 weeks.

Another method

Another method is use ofis use ofclonidineclonidineQQ_{for detoxiﬁcation.}_{for detoxiﬁcation.}

However, clonidine provides considerably less reduction

in symptoms in comparison to buprenorphine or metha-

done. Clonidine is thus mostly used as an adjunct to

methadone or buprenorphine during detoxiﬁcation.

Accelerated

Accelerated detoxiﬁcationdetoxiﬁcation: In this method, initially low: In this method, initially low

doses of naltrexone is given to patient. Naltrexone being

an opioid antagonist, produces severe withdrawal symp-

toms. After that, clonidine is used to control the symp-

toms. Tis method reduces the detoxiﬁcation period to

4-5 days.

B.Maintenance treatment Maintenance treatment : It follows the detoxiﬁcation: It follows the detoxiﬁcation

and the aim is to prevent the relapse. Tere are two

diﬀerent pharmacological approaches for mainte-

nance phase.

•

• Opioid substitution therapy Opioid substitution therapy : In this method, the: In this method, the

illicit, parenterally administered and short acting

opioids (like heroin) are

opioids (like heroin) are replaced by medically safe,replaced by medically safe,

orally taken and long acting opioids. Te long act-

ing opioids such as

ing opioids such asmethadonemethadone, buprenorphine are, buprenorphine are

mostly used. Levo alpha acetylmethadol was also

used in past, however it has since been stopped as

it is known to cause torsades de pointes.

Tese

Tese orally orally used used opioids opioids are are given given at at govern-govern-

ment approved centres. Tough the patient conti-

nues to remain depen

nues to remain dependent, however he is protecteddent, however he is protected

from medical consequence of parenteral opioids

(like HBV, HIV infection) and does not need to

indulge in cri

indulge in criminal activities to fund the illicit opi-minal activities to fund the illicit opi-

oid use.

•

• Opioid antagonist treatment Opioid antagonist treatment :: NaltrexoneNaltrexoneQQ_{can be}_{can be}

given to the patient after detoxiﬁcation is complete.

Te rationale is that naltrexone will block the opi-

oid receptors and any opioid use would fail to pro-

duce the euphoric response and hence would not

be repeated.

• Nonpharmacological approaches like cognitive

behavioral therapy, narcotic anonymous (12 step

self help groups), family therapy and group therapy

are also useful.

C.Overdose treatment Overdose treatment : Te opioids are lethal in over-: Te opioids are lethal in over-

dose. Te drug of choice for treatment of opioid over-

dose is i.v.

dose is i.v.naloxonenaloxoneQQ_{(short acting opioid antagonist).}_{(short acting opioid antagonist).}

CANNABIS

Cannabis is derived from the hemp plant,

Cannabis is derived from the hemp plant, cannabiscannabis sativa

sativa. Te plant has several varieties named after the. Te plant has several varieties named after the

regions where it is found (e.g. cannabis sativa indica in

India, cannabis sativa americana in USA). Cannabis is

India, cannabis sativa americana in USA). Cannabis is thethe

most commonly used illegal drug

most commonly used illegal drug QQ_{in the world and in}_{in the world and in}

India. Te street names include joints, marijuana, grass,

pot, weed, etc.

Te active active ingredient, ingredient, which which is is responsible responsible for for thethe

psychoactive eﬀects of cannabis is

psychoactive eﬀects of cannabis is dd-9 tetrahydrocan--9 tetrahydrocan-

nabinol (HC)

nabinol (HC)QQ_{. Te various preparations of cannabis}_{. Te various preparations of cannabis}

includes.

Table 2:

Table 2: THC concentration in various cannabis preparations. THC concentration in various cannabis preparations.

C Caannnnaabbiis s pprreeppaarraattiioonn TTHHC C ccoonntteennt t ((%%)) B Bhhaanng (g (ddeerriivveed fd frroom m ddrriieed ld leeaavveess)) 11 Ga Gannjja (a (ddeerriivveed fd frroom im innﬂﬂoorreesscceennccee)) 11––22

Hashish/Charas (derived from resinous

exudates) exudates) 8–14 8–14 Ha Hash sh oioil (l (lilipipid sd sololububle le plplanant et extxtraractct)) 1515–4–400

Te cannabis can be ingested orally or is more com-

monly smoked. It is unsuitable for

monly smoked. It is unsuitable for intravenous use becauseintravenous use because

of poor solubility in water and risk of anaphylaxis due to

undissolved particulate matter.

Intoxication

It is characterized by euphoria, subjective sense of

slowing of time, sense of ﬂoating in air,

slowing of time, sense of ﬂoating in air, reddening ofreddening of

conjunctiva

conjunctivaQQ_{(due to dilatation of conjunctival blood}_{(due to dilatation of conjunctival blood}

vessels),

vessels), increased appetiteincreased appetite and dryness of mouth. and dryness of mouth.

Other symptoms include depersonalization, derealiza-

tion,

tion,synesthesiasynesthesiaQQ_{(cross over of sensory perceptions. For}_{(cross over of sensory perceptions. For}

example, patient may report that he is

example, patient may report that he is “seeing” music and“seeing” music and

“hearing” lights).

Sometimes,

Sometimes, after after consumption consumption of of cannabis, cannabis, the the per-per-

son might feel restless, fearful, extremely anxious (similar

to panic attack) and may feel that he is about to go crazy.

Tis unpleasant experience is known as

Tis unpleasant experience is known as“bad trip”“bad trip”QQ_._.

Withdrawal Symptoms

It was earlier believed that cannabis doesn’t cause physi-

cal dependence and produces no withdrawal symptoms,

however recent studies have shown that there are mild

withdrawal symptoms

withdrawal symptoms within within 1-2 1-2 weeks weeks of of cessation andcessation and

include insomnia, anxiety, decreased appetite, irritability,

etc.

In document REGLAMENTO GENERAL JULIO 2012 (página 45-48)