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Contents:
  1. Spravato (esketamine)
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Since cocaine is such a short-acting drug, treatment of acute intoxication is rarely necessary except in instances of acute psychotic reaction. Although amphetamines are frequently withdrawn abruptly from long-term users, gradual tapering over several days can be more effective. There is currently no accepted treatment of cocaine withdrawal. There are numerous uncontrolled reports in the literature, but no drug has proved to be effective in controlled studies.

There is currently debate regarding the presence of a cocaine withdrawal syndrome. During this period, the user often attempts to resume use of stimulants. Supportive psychological therapy is required to prevent relapse to drug use. The depression that sometimes results from stimulant withdrawal gradually clears over several days.

If marked depression persists longer than 1 week, patients should be evaluated carefully to determine if they are self-medicating an underlying depression, which should then be treated properly. Hallucinogen abuse dropped off precipitously in the middle and late s and remained at low levels during the s. In the past few years, there has been a slight increase in hallucinogen use on college campuses.

However, this is nowhere near the level of use during the late s and early s. Table 8 presents the clinical features of hallucinogens. The quality of the LSD-induced psychedelic state, or "trip," is influenced by the mood and environment of the user at the time of induction set and setting.

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A bad trip can be caused by fear, anxiety, or anger at the time the drug is taken. It may be difficult at times to distinguish between a bad trip and an acute psychotic reaction, but with careful observation this distinction can be made. Use of hallucinogens is always in the differential of any patient presenting with new-onset psychosis.

Reactions to hallucinogenic drugs are cyclical, showing periods of lucidity alternating with periods of intense reaction to the drug. Monitoring the frequency of these cycles can be helpful; if the cycles are frequent, the patient is probably in the early part of a trip and the syndrome has not yet peaked. If the cycles are occurring less often, the syndrome has most likely peaked and is beginning to clear. If this information can be ascertained, the physician should tell the patient what is happening, thereby increasing the patient's confidence in treatment.

When treating a bad trip, it is important to make physical contact with the patient, for example, by holding the patient's hands. This may be the only way that contact can be made with someone who is having severe hallucinations, but be careful about the patient reacting suddenly or violently to your touch.

The physician should continually reassure the patient that adequate medical care is being administered. As in treating any drug overdose, if verbal contact can be made, ascertain what was taken, how much was taken, and how long ago it was taken. In treating a patient in a psychedelic state, this information will provide some idea of the trip's prior and future duration. Also, try to make contact with the patient during lucid intervals and maintain this contact into the intense periods of drug reaction. Efforts to make contact with the patient during an intense period are generally a waste of time.

The area in which treatment takes place should be quiet away from large groups of people , have soft lighting, and possibly a source of music to help distract the person. Deep, slow breathing may be helpful as an alternative distraction, if a suitably calming or engrossing environment is not available. It may be necessary for someone to demonstrate such breathing and pace the patient. Phencyclidine has achieved great popularity as a street drug. It is identified by various street names such as "PCP," "peep," "hog," "angel dust," and "crystal.

Phencyclidine is also frequently sold in mixtures with other drugs. The drug can be taken orally or IV, smoked, or inhaled. In low-dose intoxication, the patient presents with nystagmus, confusion, ataxia, and sensory impairment.


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Phencyclidine is the only drug of abuse that causes a characteristic vertical nystagmus however, it can cause horizontal or rotatory nystagmus as well , which helps to identify it as the cause when a patient presents with intoxication by an unknown drug. When it is taken in moderate doses, the patient presents a catatoniclike picture, staring blankly and not responding to any stimuli; the eyes remain open, even when the patient is in a comatose state.

In high doses, the drug produces seizures and severe hypertension. The hypertension should be treated vigorously because it may cause hypertensive encephalopathy or intracerebral bleeding. This drug causes a dissociative phenomenon and individuals using it exhibit dangerous behaviors and can be violent. The effects of phencyclidine may last for several days.

While the patient is recovering from the intoxication, levels of consciousness may fluctuate fairly rapidly. The patient may also appear psychotic. The most effective treatment of phencyclidine intoxication is to enhance its urinary excretion by acidifying the urine with ammonium chloride or ascorbic acid.

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The urine pH should be monitored and kept around 5. Once this pH is reached, the patient should be administered a diuretic to enhance excretion. The urinary sample should be checked for presence of phencyclidine to ensure that it is being excreted. Urine acidification should only be performed after it is determined that the patient does not have myoglobinuria indicating rhabdomyolysis to prevent the development of acute renal failure.

Some practitioners believe that the benefits of urine acidification are outweighed by the risks, especially in patients with hepatic or renal impairment. For psychotic behavior, the patient should be treated with haloperidol. It was once believed that volatiles were only abused by adolescents who sniff airplane glue. Although this problem persists, especially in indigent areas, new types of volatile abuse have emerged.

Factory workers exposed to solvents in industrial processes will sometimes take these home for use in the evening and over weekends. Amyl nitrate "poppers" and butyl nitrite vials "Rush" have become popular. Nitrous oxide is also abused.

The most severe consequence from abuse of these substances is hypoxia or anoxia, which may cause death. Many of the solvents are similar to general anesthetics and sensitize the myocardium to catecholamines: fatal arrhythmias have been reported secondary to solvent abuse. Treatment of short-term effects of these drugs is simply removal of the person from the drug and clearing the drug through the respiratory system.

The chronic complications of abuse usually clear if the person can be kept free of drugs. Many substance-abusing patients recognize the risks and costs associated with drug use, especially if they have experienced an acute toxicity or withdrawal reaction as described earlier. However, they are still attracted to addictive behavior for a variety of reasons despite the risks. They want to continue drinking or abusing drugs, but they also do not want to, and they are not exactly sure what to do about their situation. This is known as ambivalence, and it is a normal and common component of many psychological problems.


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  • Some patients are unable to admit the substance abuse problem to themselves and try to conceal it from family, friends, and physicians; this is the mechanism of denial. The patient cannot see the relationship between substance abuse and its consequences; instead, the patient rationalizes, intellectualizes, minimizes, or covers up the consequences with reasons why they are not serious. Ambivalence and denial are common components of most chronic diseases. The job of a physician who recognizes drug addiction is to help the patient resolve this ambivalence or denial.

    This allows the substance-abusing patient to make a decision to stop using drugs and move along the path toward change. The process of helping the substance-abusing patient come to a decision can be accomplished through motivational interviewing. Motivation can be described as a state of readiness or eagerness to change.

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    It may fluctuate from one situation to another. The substance-abusing patient is ambivalent about changing behavior from abusing drugs, seeking treatment, and remaining abstinent. The physician's goal is to increase the patient's intrinsic motivation, so that change arises from within rather than being imposed from without. Motivational interviewing is a particular way to help people recognize and do something about their present and potential problems.

    It is useful with people who are reluctant to change and helps resolve ambivalence to get a patient moving along the path to change. In a substance-abusing patient, the path to change means accepting treatment and beginning to work at a program of recovery from substance abuse. A patient-centered interpersonal relationship between physician and patient provides an ideal atmosphere for change.

    Substance-abusing patients are allowed to explore their experiences openly to reach resolution of their own problems, while the physician acts as facilitator.

    To do this, the physician must express empathy, which means understanding the patient's feelings and perspectives without judging, criticizing, or blaming. Aggressive confrontational tactics have been shown to predict treatment failure; empathy is the opposite of hostile confrontation. It is important to avoid arguing, since someone who is ambivalent about changing behavior will almost always take the side of defending the behavior when confronted by a physician or therapist who aggressively argues that they must change the behavior.

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    Instead, the physician should listen to the patient and elicit statements from the patient that indicate willingness to change. Some patients will not be ready to change their addictive behavior and will still be ambivalent about it.