PHPR 48600 Beyond ecstasy - Street drugs guide 2018

STREET DRUGS GUIDE

First impressions: ABCs word art from first day of class

Created by pharmacy students in PHPR 48600 Beyond ecstasy Compiled by Cynthia P. Koh-Knox, PharmD, RPh Purdue University College of Pharmacy Fall 2018

Table of contents Street drug Page 2C-B (Michelle Lesniewski) .......................................................................................................... 1 3,4-methylenedioxy pyrovalerone (3,4-MDPV) (Emily Letsinger) ............................................... 3 Acetaminophen (Allacyn Arnold) ................................................................................................. 5 Alcohol (Joel Garcia) .................................................................................................................... 7 Alpha methyltryptamine (Julia Bass) ........................................................................................... 9 Amanita muscaria (Jonathan Berry) .......................................................................................... 11 Amphetamine (Claire Brady) ..................................................................................................... 13 Anabolic steroids (Eric Brenneman) .......................................................................................... 15 Ayuhuasca (Skye Castenada) ..................................................................................................... 17 Barbiturates (Matthew Chellino) ............................................................................................... 19 Bath salts (Alicia Cheng) ............................................................................................................. 21 Benzodiazepines (Derek Chui) ................................................................................................... 23 Bromo-dragonfly (Emily Coffer) ................................................................................................. 25 Buprenorphine (Claire Corvari) .................................................................................................. 27 Caffeine/Energy drinks (Christine Cunningham) ....................................................................... 29 Cannabidiol (Albert Dinh) .......................................................................................................... 31 Cannabinol (Brandon Do) .......................................................................................................... 33 Carisoprodil (Alana Dorfstatter)) ............................................................................................... 35 Cocaine (Helen Fagan) ............................................................................................................... 37 Dextromethorphan (Erin Flynn) ................................................................................................. 39 Dehydroepiandrosterone (Claire Fellers) .................................................................................. 41 Diacetylmorphine (Sara Foreman) ............................................................................................. 43 Diphenhydramine (Luke Fosbrink) ............................................................................................. 45 Diuretics (Merideth Fritz)........................................................................................................... 47 Drug tests to detect use (Jessica Zhao)...................................................................................... 49 Drug test deterrents (Trenton Myers) ....................................................................................... 51 Fentanyl (Seth Garries) .............................................................................................................. 53 Flakka (Paige Gilk) ...................................................................................................................... 55 Gabapentin (Aubrey Glazik) ....................................................................................................... 57 Gamma hydroxybutyrate (Moses Haile) .................................................................................... 59 Hashish (Sarah Harding) ............................................................................................................. 61 Heroin (Ishmum Hasan) ............................................................................................................. 63 Hydrocodone (Sharae Hightower) ............................................................................................. 65 Hydromorphone (Hannah Howell) ............................................................................................ 67 Ibogaine (Taylor Jones) .............................................................................................................. 69 Inhalants (Josh Joveski) .............................................................................................................. 71 Insulin (Karen Kandhola) ............................................................................................................ 73 i

Street drug Page Ketamine (Roza Karamacoski) ................................................................................................... 75 Khat (Fatima Khan)..................................................................................................................... 77 Kratom (Koste Kocoski) .............................................................................................................. 79 Krokodil (Peter Kokkinias) .......................................................................................................... 81 Laxatives (Morgan Kuenning) .................................................................................................... 83 Loperamide (Sarah Lamon) ........................................................................................................ 85 Lysergic acid diethylamide (Emily Lee) ...................................................................................... 87 MDMA (Daniel Lin) ..................................................................................................................... 89 Mescaline (Elise Mann) .............................................................................................................. 91 Methadone (Joshua Martin) ...................................................................................................... 93 Methamphetamine (Jennifer Nguyen) ...................................................................................... 95 Methaqualone (Jeff Otis) ........................................................................................................... 97 Morning glory (Naa Adokaley Pappoe) ...................................................................................... 99 Muscle relaxers (Maria Tordi) .................................................................................................. 101 Naloxone (Toria Piper) ............................................................................................................. 103 Naltrexone (Elizabeth Portteus) .............................................................................................. 105 Nicotine (Leilanie Rivera Fores) ............................................................................................... 107 Nightshade (Ross Robinson) .................................................................................................... 109 Nitrous oxide (Jessica Sarna) ................................................................................................... 111 Opium (Maria Shelley) ............................................................................................................. 113 OTC analgesics (Amanda Schoettmer) ..................................................................................... 115 Oxycodone (Chelsea Shi).......................................................................................................... 117 Phencyclidine (Rebecca Silvola) ............................................................................................... 119 Pseudoephedrine (Wyatt Simpson) ......................................................................................... 121 Psilocybin (Dominic Snemis) ................................................................................................... 123 Quetiapine (Kristina Stoncius) ................................................................................................. 125 Rohypnol (Jessica Stone).......................................................................................................... 127 Rx Anorectics (Kiley Strakus) .................................................................................................... 129 Rx depressants (Michaela Todd) .............................................................................................. 131 Rx Stimulants for ADHD (Grace Whitham) .............................................................................. 133 Rx Sleep drugs (Madeline Verbeke) ......................................................................................... 135 Salvia divornum (Emily Woods) ............................................................................................... 137 Scopolamine (Austin Wooten) ................................................................................................. 139 Sildenafil (Xuping Yan) ............................................................................................................. 141 Spice/K2 (Hannah Karam) ........................................................................................................ 143 Tetrahydocannibinol (Ryan Yoo).............................................................................................. 145 Tramadol (Grace Yun) .............................................................................................................. 147 Tramadol (Zach Zajac) .............................................................................................................. 149 Yohimbe (May Zhang) .............................................................................................................. 151 ii

2C-B Michelle Lesniewski Student Pharmacist Fall 2018 Reprinted from Exploring Your Mind, 20183

History

Slang Terms • • • • • • • • • •

1974: Created in California by Alexander Shulgin

Venus Pink Cocaine To see bee Nexus Erox “The Elite Drug” Toonies Bromo Spectrum

1985: Used as a legal alternative to Ecstasy and marketed as an aphrodisiac in Germany 1990: Used to treat impotency and fragility in the United States.

Early 1990’s: Used by Shamans in South Africa 1994: Illegal in the United States (Schedule 1) 2001: Categorized as a Schedule II drug at UN Convention 2004: Increased in popularity in Latin America 2018: Produced primarily in Columbia

Pharmacology 4-bromo-2,5-dimethoxyphenethylamine •

Reprinted from The Drug Classroom, 20154

• • • • • •

Works by blocking or minimally activating 5-HT2A at the serotonin receptor. Also, increases dopamine concentration in the brain.

Dosage Forms: Powder, tablet, capsule Dosing: 2mg-50mg Routes of Administration: Oral or intranasal Duration of Action: 3-8 hours Metabolized by liver hepatocytes Categorized as an entactogen, hallucinogen, stimulant, and psychedelic.

1

Drug Interactions/Toxicology Drug Interactions

Contraindications

• • • • • •

• • • •

Alcohol MAOIs Tramadol Mescaline Amphetamines Cocaine

Seizure disorders Heart problems Schizophrenia History of mental illness

Side Effects • • • • • • •

Irritability Severe headache N/V/D Dilated pupils Hallucinations Hypertension Sweating

Monitoring ➢ Monitor vital signs (heart rate, temperature, blood pressure) ➢ Monitor for changes in mental status ➢ Monitor serum electrolytes and renal function

Drug Screens ➢ Difficult to detect on standard drug test assays ➢ Use of 2C-B could trigger a false positive for amphetamine use ➢ Detection requires use of gas (or liquid) chromatography/mass spectroscopy.

Law As a Schedule 1 drug in the United States, it is illegal to manufacture, possess, or distribute this substance.

Professional Opinion There is not enough information available on this drug to warrant its use as a therapeutic substance. It shows promise as an aphrodisiac and in anger management treatment, but more studies are needed on its safety and efficacy before it should be recommended for use therapeutically. ~Michelle Lesniewski

References 1.

The Essential Guide to 2C-B. The Third Wave. https://thethirdwave.co/2c-b/. Accessed October 9, 2018.

2.

2C-B: Dangers and Addiction Potential. San Diego Addiction Treatment Center. https://sdtreatmentcenter.com/syntheticdrugs/2c-b/. Accessed October 9, 2018.

3.

Tucibi (2CB): The Elite Drug. Exploring your mind. https://exploringyourmind.com/tucibi-2cb-the-elite-drug/. Accessed October 9, 2018.

4.

5.

2C-B. The Drug Classroom. https://thedrugclassroom.com/video/2c-b/. Accessed October 9, 2018.

Phenethylamine Designer Drugs-2c Series. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 9, 2018.

2

3,4-MethylenedioxyPyrovalerone

(3,4-MDPV)

Emily Letsinger Student pharmacist

Fall 2018

Also Known As: Bath Salts, Ivory Wave, Plant Fertilizer, Vanilla Sky, and Energy1

History and Background

Pharmacology

3,4-Methylenedioxy-Pyrovalerone was first developed by a team at Boehringer Ingleheim in the 1960s.

Increases extracellular neurotransmitter levels by preventing the uptake of monoamine neurotransmitters like dopamine and norepinephrine through transport inhibition.

It has been reportedly used for chronic fatigue and as an anorectic.

Around 2004 3,4-MDPV was being sold as a designer recreational drug at local gas stations and convenience stores in the United States.

The drug was banned in 2011 and is now a Schedule 1 drug.

Effects are similar to that of cocaine and amphetamine.

Subjective effects include: empathy, stimulation, alertness, and euphoria.

These effects tend to last two to three hours.

Side effects include: tachycardia, hypertension, vasoconstriction, and sweating. These effects tend to last six to eight hours.

3

Toxicology

Monitoring

When tested in mice, it was shown that the dose to reach central nervous system stimulation was 0.20 mg/kg.

Throughout a number of studies 3,4-MDPV has shown to have similar affects to cocaine and methamphetamine but more potent.

Will have drug interactions with any inducer or inhibitor of CYP450.

- Blood Pressure - Heart Rate - Liver Function - Kidney Function - Psychological effects should last three to four hours.

- Side effects can last up to eight hours.

Professional ht Opinion

Laws 3,4-MDPV is a federally schedule 1 drug

“It wasn’t anything to kill them, but enough to get them messed up.”

No currently accepted use for treatment in the United States.

It is a Class B misdemeanor to posses it. https://www.google.com/search?q=bath+salts+the+d rug&rlz=1C1CHBF_enUS718US718&source=lnms &tbm=isch&sa=X&ved=0ahUKEwjx_tCmq4feAhX QhOAKHcwLAYgQ_AUIDigB&biw=1152&bih=6 80#imgrc=scPLFBlI76ONPM:

~ a county coroner commenting on the death of two individuals that had died after ingestion of 3,4-MDPV.

References 1. Wikipedia. Methylenedioxypyrovalerone. Available at: https://en.wikipedia.org/wiki/Methylenedioxypyrovalerone. Accessed October 13, 2018.

2. Caymen Chemical. 3,4-Methylenedioxy Pyrovalerone. Available at: https://www.caymanchem.com/product/10624. Accessed October 13, 2018.

3, Drug Enforcement Administration. 3,4-Methylenedioxypyrovalerone (MDPV). Available at: https://www.deadiversion.usdoj.gov/drug_chem_info/ mdpv.pdf. Accessed October 13, 2018 4. Expert Committee on Drug Dependence. 3,4-Methylenedioxypyrovalerone. Available at: http://www.who.int/medicines/areas/ quality_safety/4_13_Review.pdf. Accessed October 13, 2018.

4

ACETAMINOPHEN Allacyn Arnold | Student Pharmacist | Fall 2018

Focus Bioscience. Available at: https://focusbio.com.au/products/acetaminophen/.

Accessed October 13, 2018.

“ONE OF THE WORLD’S SAFEST PAINKILLERS” Acetaminophen is typically used to treat pain and inflammation. It has been dubbed “one of the world’s safest painkillers” - however, it can have lethal consequences when not taken appropriately.

PHARMACOLOGY The mechanism of pain relief of acetaminophen is not well known. One proposal is that acetaminophen acts similarly to aspirin by inhibiting a COX enzyme, COX-3 ,and consequently stopping prostaglandin formation (a signaling molecule for pain and inflammation).

Side effects: nausea, vomiting, itching, insomnia Metabolized by liver and cytochrome P450 | Excreted renally Common dosage forms: tablet, liquid, geltab, IV, suppository

ALTERNATE NAMES Tylenol® N-(4-hydroxyphenyl) acetamide Paracetamol APAP

HISTORY

1873: First synthesis of acetaminophen by Harmon Northrop Morse 1949: Safety and efficacy of the drug was studied 1953: First acetaminophen combination product was synthesized with butobarbital 1955: Acetaminophen went on sale in US under brand name “Tylenol®” 1963: 500 mg tablets of acetaminophen went on sale in the United Kingdom under trade name “Panadol”

Social Psych Online. Available at: http:// socialpsychonline.com/2016/05/tylenol-pain-psychology -acetaminophen/. Accessed October 13, 2018.

Ancient & Medieval Times: Willow bark, the precursor of aspirin, was the only treatment for fever

5

DRUG INTERACTIONS/TOXICOLOGY:

ACETAMINOPHEN & ALCOHOL: •

•

Tylenol and alcohol should not be mixed!

•

•

Any dose over 4 grams is considered an “overdose”, and 7 grams can be toxic

•

Severe interactions: isoniazid, Prevnar 13, imatinib

Alcohol prevents the breakdown of a toxic

metabolite of acetaminophen,

•

causing toxicity and increasing risk for liver damage

LAWS & SCREENING

Acetaminophen has a narrow therapeutic window with a maximum daily dose of 4 grams/day

Contraindications: active or severe liver disease, liver impairment, hypersensitivity

•

Accidental deaths are rare: 150 in the US each year per a 2013 investigation

•

Timing is essential—25,000 hospitalizations a year can be reduced to 450 deaths with prompt treatment

Acetaminophen alone is available over –the-counter with no restrictions

TREATMENT OF OVERDOSE:

on purchasing. However, Tylenol 3 & 4 are considered C-3 substances because they contain codeine . To

screen for codeine abuse, an opiate test can be used.

• •

main goal: minimize liver injury

1st line: gastrointestinal decontamination and activated charcoal •

2nd line: N-acetylcysteine, IV or orally

“I would recommend acetaminophen as a good drug therapy for patients suffering from pain and/or fever, especially in patients who have poor kidney function. However, symptoms or damage of liver toxicity and overdose such as anorexia, nausea, vomiting, and diaphoresis should be monitored for. Acetaminophen can be easily abused due to a narrow therapeutic range and thus should be used with caution” ~ A. Arnold

References Acetaminophen. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http:// www.micromedexsolutions.com. Accessed October 12, 2018.

Epocrates. Available at: https://online.epocrates.com/diseases/33741/Acetaminophen-overdose/Treatment-Approach. Accessed October 13, 2018.

History Hole. Available at: http://historyhole.com/history-acetaminophen-tylenol/? con=&loc=&utm_source=. Accessed October 13, 2018.

Josh Bloom. American Council on Science and Health. Available at: https://www.acsh.org/ news/2017/09/11/tylenol-far-most-dangerous-drug-ever-made-11711. Accessed October 13, 2018. Midwood Addiction Treatment.

Available at: https://www.midwoodaddictiontreatment.com/tylenol-3-tylenol-4-abuse-addiction/. Accessed October 14, 2018.

New World Encyclopedia. Available at: http://www.newworldencyclopedia.org/entry/Acetaminophen. Accessed October 13, 2018.

Yang J, Cribb R. The Star. Available at: https://www.thestar.com/news/world/2014/02/21/ the_dark_side_of_acetaminophen.html. Accessed October 13, 2018.

6

Alcohol Joel Garcia Student pharmacist

Fall 2018

History/background 6000-4000 BCE: Cultivation of grape vines for making wine was originated in Western Asia.

https://medlineplus.gov/alcohol.html

3000-2000 BCE: Records of beer recipes in Mesopotamian civilization.

1800 BCE: Mass production of beer in northern Syria.

500: Wine reaches China along the Silk Road.

Middle ages: Records of grain alcohol distillation.

1500s: Viticulture spread to South America.

1600s: England and its territories attempt to define drunkenness and make laws regarding alcohol use.

1920: 18th Amendment enforced by United States to prohibit the production and sale of alcohol.

1933: 18th Amendment is repealed by the government.

Slang terms Booze

Wine

Moonshine

Liquid Courage

Liquor

Spirits

Liquid bread

Sauce

Beer

Juice

Draft

Hard stuff

Pharmacology/drug effects Alcohol inhibits the activity of GABA and NMDA receptors which cause CNS depression. Inebriation causes feelings of euphoria, loss of control of body movements, impulsivity, nausea, vomiting, hypertension and tachycardia.

7

Drug interactions/toxicology Chronic alcohol use causes permanent decrease in GABA and NMDA receptor activity. Sudden discontinuation of alcohol causes hyperexcitable state which can cause withdrawals.

Excessive use may cause: coma, respiratory depression, hypoglycemia, and hypothermia.

https://upload.wikimedia.org/wikipedia /commons/e/e8/Ethanol-structure.svg

Drugs that interact with alcohol: Sulfonyureas, acetaminophen, cefmenoxime, tolazoline, moxalactam, furazolidone, acetohexamide, tolazamide, tolbutamide and chlorpropamide.

Laws The sale and consumption of alcohol is legal in the United States, however, the minimum legal age of alcohol consumption is 21 years. The legal limit for driving under the influence is 08% blood alcohol concentration.

Monitoring After excessive consumption, the following parameters should be monitored to assess the individual’s health: Heart rate, respiration rate, temperature, head CT if evidence of trauma, arterial or venous blood gases, serum or urine ketones to avoid alcoholic ketoacidosis.

Drug screens Ethanol concentration can be measured from the blood or from breath via a breathalyzer.

Professional opinion Alcohol should be legal but the age of sale and consumption should remain 21 years due to its abuse potential. ~J. Garcia

References 1. Alcohol. The Vaults of Erowid. https://erowid.org/chemicals/alcohol/alcohol.shtml. Updated July 8, 2018. Accessed October 10, 2018.

2. Alcohol Laws. Indiana State Excise Police. https://www.in.gov/atc/isep/2384.htm. Accessed October 10, 2018 3. DUI &DWI. DMV. https://www.dmv.org/automotive-law/dui.php. Accessed October 10, 2018.

4. Ethanol. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http:// www.micromedexsolutions.com. Accessed October 10, 2018.

8

Facts about Drugs. 2015 Available thttps://cwtchcymru.wordpress.com/2015/06/24/what-is-amt-factsabout-drugs-their-effects/. Accessed October 11, 2018.

AlphaMethyltryptamine Julia Bass Student pharmacist Fall 2018

DRUG EFFECTS

Erowid; 2000 Available at https://www.erowid.org/chemicals/amt/amt_chemistry.shtml.

Accessed October 11, 2018

PHARMACOLOGY Alpha-Methyltryptamine binds moderately with Serotonin 5-HT receptors. This binding inhibits the uptake of monoamines and is a potent inhibitor of monoamine oxidase. This enzyme is critical for the breakdown of the different monoamines, the chemicals important for sensory, emotional, and behavioral functions. This excess in monoamines in the brain lead to side effects such as hallucinations and Euphoria.

Euphoria Psychedelic effect (Hallusionations) Empathy Pupil Dilalation Anxiety Jaw Thightness Emotional Distress Increased Energy Blurred Vision Restlessness Nervousness Irritabliity Insomnia

SLANG NAMES

Sprials

IT-290

3-IT

αMT or AMT

Tachycardia Muscle Tension

Nausea/Voming

BACKGROUND

Early 1960s Alpha-methyltryptamine was developed as an antidepressant under the name Indopan and sold by the pharmaceutical company UpJohn in the Soviet Union

1968 US Bureau of Drug Abuse Control mentiones that Alphamethyltryptamine is available on the streets as a "new" hallucinogen

1997-1998 Alpha-methyltryptamine is available for purchase online through CRSB and in 1998 is available for purchase through chemical research websites

2004 Alphamethyltryptamine is permenantly classified as a Schedule 1 substance

9

Fun Fact AMT is sold at events for $5-20 per tablet

TOXICOLOGY AND DRUG INTERACTIONS Alpha-methyltryptamine has been shown to produce long-lasting serotonergic neurotoxicity at very high doses. There is not much information on the possible drug interactions present with AMT.

LAWS Alpha-methyltryptamine is Schedule I drug in the United States. This means it is illegal to manufacture, buy, possess, or distribute without a DEA license.

MONITORING/ DRUG SCRRENINGÂ Currently, there is no way to detect alphamethyltryptamine in the body without the use of gas chromatography and mass spectrometry.

AMT is not tested for in both the standard and extended drug test. AMT is not structurally similar to any drugs commonly tested for so it should not yield a positive result for another substance.

PROFESSIONAL OPINION Due to the negative side effects that are associated with this substance I would not recomend the use of this drug for self medication or abuse. ~ J. Bass

Fun Fact THe Effects of AMT usually last 8-12 hoursÂ

References Erowid. AMT Vault. Available at: https://www.erowid.org/chemicals/amt/. Accessed October 11, 2018.

Drug Enforcement Administration. Alpha-methyltryptamine. Available at: https://www.deadiversion.usdoj.gov/drug_chem_info/amt.pdf.

Accessed October 11, 2018.

PubChem. Indopan. Available at: https://pubchem.ncbi.nlm.nih.gov/compound/9287#section=Top. Accessed October 11, 2018. DrugBank10 Alpha-methyltryptamine. Available at:https://www.drugbank.ca/drugs/DB01446. Accessed October 11, 2018.

10

Amanita Muscaria

https://en.wikipedia.org/wiki/Amanita_muscaria

Amanita Muscaria History •

4000 B.C. – The Uralic language splits into two branches with both having words designated for amanita.

100 A.D. – miniature statue of amanita is found in Mexico suggesting its use in Central and South America.

1730 – A Swedish prisoner of war in Siberia writes a book about the practice of making tea out of amanita in war camps.

1960-1965 – amanita use appears in the United States urban subcultures but remains rare due to user reports of unpleasant effects.

1978 – A Native American author from the Ojibway people who live near Lake Superior in North America writes about the traditional use of amanita in certain tribes.

•

•

•

•

Slang Terms for Amanita • • • •

Fly agaric Magic Mushrooms Beni Tengutake Panther Mushrooms

https://shamanherbs.com/product/

Pharmacology of Amanita

amanita-muscaria-fly-agaric-mushrooms/

The two active metabolites of amanita, muscimol and ibotenic acid, are what cause the effects seen from amanita.

Muscimol acts similarly to the neurotransmitter GABA in which it binds to the same receptor and acts as an agonist.

Ibotenic acid acts similarly to glutamic acid and acts as an agonist to the NMDA glutamate receptors and metabotropic glutamate receptors.

• • •

• •

•

Different from other psychedelic mushrooms that contain psilocybin.

Provides psychoactive, hallucinogenic, and stimulatory effects.

Dose is entirely dependent on size of plant and which part of the plant is ingested. o More muscimol and ibotenic acid located in the cap of the plant.

No available dosage forms beyond a dried version of the outdoor grown mushroom.

A large fraction of ibotenic acid gets excreted unmetabolized in the urine while muscimol gets metabolized in the liver via transamination.

Duration of amanita is 5-10 hours depending on dose taken.

11

Drug Interactions with Amanita According to multiple searches through WebMD, there are no known studies showing any type of drug interactions with amanita muscaria.

•

•

• •

Toxicology of Amanita General side effects include: nausea, vomiting, muscle twitching, increased salivation, and sweating.

Serious side effects include: delirium, cholinergic crisis, seizures, coma, and even death.

Contraindicated while operating heavy machinery or driving.

Medical contraindications would include seizures/convulsive disorders and schizophrenia or family history of severe mental illness including suicide.

Laws on Amanita Amanita mushrooms, and their active metabolites, are uncontrolled in the United States and most countries. It can be sold for consumption as a food or drug. Sales are regulated by the FDA in the United States. http://wtffunfact.com/post/86405600886/the-super-mariomushrooms-amanita-muscaria

Drug Screening for Amanita Since amanita is legal in the United States, no standard or even extensive drug tests will screen for amanita. The active metabolites, muscimol and ibotenic acid, can be screened for via gas chromatogroaphy

Monitoring for amanita includes: • Serum electrolytes • Blood Glucose • Serum Creatinine • History of trauma via CT scan

PROFESSIONAL OPINION: Due to lack of any clinical evidence showing true therapeutic advantages for using amanita mushrooms, I WOULD NOT support the use of this substance therapeutically. Also, due to the extremely dangerous side effects and possible emergency situations that could be caused by amanita, I would strongly recommend not using this substance recreationally either. ~ J. Berry

References: 1.

The Vaults of Erowid. Amanita Muscaria. https://erowid.org/plants/amanitas/amanitas_history1.shtml Accessed: October 14, 2018.

2.

Wikipedia. Amanita Muscaria. https://en.wikipedia.org/wiki/Amanita_muscaria#Pharmacology Accessed: October 14, 2018.

3.

Science Direct. Muscimol. https://www.sciencedirect.com/science/article/pii/0028390879900091 Accessed: October 14, 2018.

4.

WebMD. AGA. https://www.webmd.com/vitamins/ai/ingredientmono-190/aga Accessed: October 14, 2018.

12

Amphetamine Claire Brady, Student Pharmacist Fall 2018

Slang Speed Jollies Dex

Fast Bennies Uppers Dexies Up hDps://www.google.com/search? q=amphetamine&source=lnms&tbm=isch&sa=X&ved=0ahUK EwiOhdK55O_dAhUDjq0KHV9aCYIQ_AUIDigB&biw=1051&bi h=800#imgrc=AvXkwFNF4ONUkM:

Pharmacology hDps://www.google.com/search? q=amphetamine&source=lnms&tbm=isch&sa=X&ved=0 ahUKEwiOhdK55O_dAhUDjq0KHV9aCYIQ_

C9H13N

Dosage forms: tablet, capsule, ODT, suspension Dose: 5 mg, 7.5 mg, 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg

History

1887: First synthesized 1930: Came to market as Benzedrine as OTC inhaler for congesAon Late 1930s: Newly indicated for narcolepsy and ADHD, amphetamine use grew rapidly during WWII 1971: Amphetamine became scheduled

Non-catecholamine sympathomimeAc amine that acts as a CNS sAmulant by blocking the reuptake of NE and dopamine Onset: 30-60 minutes, immediately if injected or smoked Effects: 4-6 hours IR, 8-12 hours ER Short term effects: increased alertness, aDenEon, energy; increased HR and BP, large pupils, dry mouth Long term effects: irregular heart beat, heart disease, seizures, anxiety Primarily renally excreted.

Metabolized by CYP2D6

13

Drug InteracAons Amphetamine + anEdepressants = increased BP, leading to irregular heart beat, heart failure, and stroke

Amphetamine + alcohol, cannabis, or benzodiazepines = masked eects of drug, leading to potenEal overdose

Concomitant use of MAOIs May lead to hypertensive crisis

TCAs and SSRI/SNRIs may cause serotonin syndrome

Laws Amphetamine is Schedule II with a valid prescripEon

Professional Opinion I believe amphetamine, when used responsibly, is eďŹƒcacious and safe for its FDA indicaAons.

-Claire Brady

Monitoring + Drug Screens

hDps://www.google.com/search? q=amphetamine&source=lnms&tbm=isch&sa=X&ved=0ahUKEwiOhdK55O_dA hUDjq0KHV9aCYIQ_AUIDigB&biw=1051&bih=800#imgrc=GbFnvPrNnNcZFM:

References 1.

2.

3.

4.

Amphetamine. Micromedex SoluEons. Truven Health AnalyEcs, Inc. Ann Arbor, MI. Available at: hDp://www.micromedexsoluEons.com.

Accessed October 6, 2018.

Alcohol and Drug FoundaEon. Amphetamines. Available at: hDps:// adf.org.au/drug-facts/amphetamines/. Accessed September 28, 2018.

NaEonal InsEtute on Drug Abuse. Commonly Abused Drug Charts.

Available at: hDps://www.drugabuse.gov/drugs-abuse/commonlyabused-drugs-charts#prescripEon-sEmulants. Accessed September 28, 2018.

The Vaults of Erwoid. Amphetamine. Available at: hDps:// www.erowid.org/chemicals/amphetamines/ amphetamines_basics.shtml. Accessed September 28, 2018.

Enzyme immunoassay via urine or blood samples is used to detect amphetamine and methamphetamine

Amphetamine can be detected by a standard drug test for 1-4 days

Monitor BP and HR regularly

Monitor growth in pediatric paEents

Monitor for behavior changes 14

Anabolic Steroids Eric Breneman Student pharmacist Fall 2018

Barban, John. JohnBarban. Steroids. Available at: https://johnbarban.com/tag/steroids/page/2.

Accessed 14 October 2018.

Background

Lingo

1930s: Synthetic form of testosterone is developed to aide in growth and development 1940s: Synthetic testosterone used by soldiers during WWII to help put on weight and improve energy 1956: Artificial testosterone is first used by Olympic athletes in competition. Anabolic steroids are soon introduced and commonly used in professional 1975: International Olympic Committee bans use of steroids

        

Juice Gear Roids Stackers Fakes Basement Drugs Bulking up Doping Roid Rage

1988: Anti-Drug Abuse Act becomes first major federal regulation of steroids 1990: Anabolic Steroid Enforcement Act is passed, placing specific anabolic steroids on schedule III of CSA

Pharmacology As a synthetic derivative of testosterone, anabolic steroids bind to the same receptor proteins as the natural hormone.

Once bound, the hormone is transported into the nucleus of a cell and binds to chromatin to produce mRNA to create more protein and code the enzyme that produces the effects of steroids (or testosterone).

Chaiet, Dan. Steroidal. Types of Steroids. Available at: https://www.steroidal.com/types-of-steroids. Accessed 14 October 2018.

15

Side Effects Severe acne Paranoia Irritability Impaired judgment Delusions Kidney problems Liver Damage Gynecomastia Baldness

Contraindications Carcinoma of prostate or breast Pregnancy Nephrosis Hypercalcemia Hepatic dysfunction Hypersensitivity

Law Currently listed as Schedule III controlled substances under the CSA by the Anabolic Steroids Control Act of 1990 Banned substance in many professional and all Olympic sports

Monitoring Obtain liver function tests periodically.

Determine serum lipids ad HDL-cholesterol periodically.

Check hemoglobin and hematocrit for polycythemia.

If taking oxymetholone, check serum iron and iron binding capacity.

In women with disseminated breast carcinoma, check urine and serum calcium levels.

Professional Opinion “Well, when I think of steroids I think of an image. You have the advantage over someone, which is a form of cheating. I guess it wouldn’t be right unless it was legal for everybody. Reason it’s not legal for everybody is because it can hurt people seriously.” – Evander Holyfield

References Center for Substance Abuse Research. Anabolic Steroids. Available at: http://cesar.umd.edu/cesar/drugs/steroids.asp. Accessed 14 October 2018.

Facts and Comparisons. Anabolic Steroids. Available at: https://fco-factsandcomparisonscom.ezproxy.lib.purdue.edu/lco/action/search?q=Anabolic%20Steroids&t=name&va=anabolic# adr-nested. Accessed 14 October 2018.

Merck. Anabolic Steroids. Available at: https://www.merckvetmanual.com/pharmacology/systemic-pharmacotherapeutics-of-themuscular-system/anabolic-steroids. Accessed 14 October 2018.

NIDA. Anabolic Steroids. National Institute on Drug Abuse. Available at: https://www.drugabuse.gov/publications/drugfacts/anabolic-steroids. Accessed 14 October 2018.

16

ayahuasca

Skye Castaneda | Student Pharmacist | Fall 2018

Also known as…

* Yagé * La medicina * Pharma-huasca * Vine * La purga (the purge) Trudo. Ayahuasca: Transformation on Soul Level. Available at: https://www.trudo.net/ayahuasca-english/ayahuasca/. Assessed October 7, 2018.

History and Background: Ayahuasca is a brew made from the Banisteriopsis caapi (B. caapi) vine and the Psychotria viridis (P. viridis) leaf. It was first created and used by the various indigenous tribes of the Brazilian Amazon, dating back to the pre-Columbian era. Its use began to spread throughout South America and eventually was incorporated into several religious and cultural practices as a method of “healing.” The first record of the psychoactive effects of the B. caapi component of ayahuasca was in 1852. It wasn’t until the 1960s that more research and publications focused on the psychedelic effects of ayahuasca. Today, ayahuasca is used as a healing tool in religious ceremonies for mental illnesses (depression, anxiety, schizophrenia etc.) as well as addiction and ADHD.

Pharmacology and Drug Effects: P. viridis contains N,N-dimethyltryptamine (DMT), a chemical that is well-known for causing kaleidoscopic visual hallucinations when ingested. DMT acts on serotonin receptors and is usually broken down quickly by monoamine oxidase (MAO), an enzyme found in the human body.

B. caapi contains MAO inhibitors (MAOIs) that prevent the degradation of the DMT components of P. viridis, allowing for the psychoactive effects of DMT. In fact, DMT is not orally active unless it is ingested with an MAOI. The three major MAOIs found in B. caapi are harmine, tetrahydroharmine (THH) and harmaline.

The psychological effects of ayahuasca typically peak within 1/2 – 1 hour, and last for about 4-6 hours. Since ayahuasca acts on serotonin receptors, it produces a meditative state and feelings of euphoria, explaining its use in “healing” ceremonies. The major, well-known effects of ayahuasca are the colorful, vibrant hallucinations whose strengths/vividness are oftentimes dose-dependent. The “vision” that ayahuasca produces has been compared to entering an alternate reality.

17

Drug Interactions and Toxicology: Ayahuasca should not be used with the following: * Antihypertensives * Vasodilators * Dietary pills *Antipsychotics *Barbiturates * Antihistamines *MAOIs * Alcohol *Amphetamines * SSRIs *Cocaine * Opiates

United States Laws: - Two churches, UDV and Santo Diame, are the only groups in the U.S. with ability to practice using ayahuasca legally - DMT is a schedule I drug - Plants containing DMT, such as P. viridis, are not illegal and are available for purchase - Once a DMT-containing plant is utilized to brew ayahuasca, it is illegal Laws Outside of the U.S.: - Legal in Brazil and Peru, where “Ayahuasca Retreats” are held - In Canada, DMT and harmaline are schedule III drugs. Thus, ayahuasca brews are illegal.

ABC. Ayahuasca Brew. Available at: http://www.abc.net.au/news/2016-04-10/ayahuasca-brew/7294832.

Accessed October 7, 2018.

Monitoring and Drug Screening: - DMT is not included in regular or extensive drug screens

- It is not recommended to take ayahuasca alone and should instead be reserved for ayahuasca retreats to see the maximum therapeutics effect - Things to monitor: changes in blood pressure and side effects of vomiting, tremor, increased heart rate and body temperature fluctuations

Professional Opinion: Personally, I think that ayahuasca can be useful for short-term treatment of mental illnesses such as depression and schizophrenia, given its mechanism of action. However, I believe that more studies should be conducted to assess the efficacy of ayahuasca on long-term treatment. Given that it is a brew of naturallyoccurring chemicals, I believe that more studies are needed to view the risk-benefit profile of the brew. ~ S. Castenada Retreat Guru. Three-Week Ayahuasca Retreat in Peru. Available at: https://retreat.guru/events/12625/three-week-ayahuasca-retreat-in-peru-8211-2550-1.

Accessed October 9, 2018.

References: 1.

The Vaults of Erowid. Ayahuasca. Available at: https://www.erowid.org/chemicals/ayahuasca/ayahuasca.shtml. Accessed October 7, 2018.

2.

The Third Wave. The Essential Guide to Ayahuasca. Available at: https://thethirdwave.co/psychedelics/aya huasca/. Accessed October 7, 2018.

3.

Motherboard. This Is How Ayahuasca Affects the Brain. Available at: https://motherboard.vice.com/en_us/article/ezp57m/ watch4.

5.

how- ayahuasca-affects-the-brain-. Accessed October 7, 2018.

Medicine Hunter. Ayahuasca – Plant Spirit Medicine. Available at: http://www.medicinehunter.com/ayahuasca. Accessed October 7, 2018.

A New Understanding. How the Plants Contained Within an Ayahuasca Brew Amalgamate to Create a Powerful Spiritual Experience.

Available at: http://www.anewunderstanding.org/single-post/2018/01/23/How-the-Plants-Contained-Within-an-Ayahuasca-Brew-Amalgamateto- Create-a-Powerful-Sp iritual-Experience. Accessed October 7, 2018.

18

History Dec 4, 1863—Barbituric acid is discovered by Belgian researcher Adolf von Baeyer. His discovery came on the day of St. Barbara, so he chose the name "barbiturate" as a combination of St. Barbara and "urea".

1903—Barbitone, the first medicinal barbiturate, is synthesized from barbituric acid by German scientists Emil Hermann Fischer and Joseph von Mering. It was marketed under the trade name Veronal.

BARBITURATES

1912—Phenobarbital is introduced under the trade name Luminal as a sedative-hypnotic.

1950s-1960s—Reports increase about side effects and dependence related to barbiturates.

Matthew Chellino Student Pharmacist

Jul 15, 1965—U.S.: Drug Abuse Control Amendment (DACA) prohibits the unregistered possession, manufacture, or sale of barbiturates

Fall 2018 (image: https://www.erowid.org/chemicals/ show_image.php?i=barbiturates/barbiturates1.jpg)

1970—Pentobarbital (II), secobarbital (II), amobarbital (II), butabarbital (III), phenobarbital (IV), and barbital (IV) are all scheduled with the passage of the U.S. Drug Abuse Regulation and Control Act of 1970.

PHARMACOLOGY •

Phenobarbital, Amobarbital, Butalbital, Secobarbital, etc.

•

Can produce all levels of CNS mood alteration from excitation to mild sedation, hypnosis, and deep coma

•

Sufficiently high therapeutic doses can produce anesthesia; overdosage can produce death

•

Effect by stimulating the gamma-aminobutyric acid (GABA) channel in brain neurons, which causes the neurons to depress and become resistant to nerve impulses

•

Depress the sensory cortex, decrease motor activity, alter cerebellar function, and produce drowsiness, sedation, and hypnosis; dose-dependent respiratory depression

•

Administered via tablets, capsules and IV injections

(above image: https://upload.wikimedia.org/wikipedia/commons/thumb/4/49/ Barbituric-acid-structural.svg/440px-Barbituric-acid-structural.svg.png)

Slang Terms

Barbs - Barbies - Downers - Blues - Nembies - Reds - Yellow Jackets - Red Birds 19

Drug Interactions ∗

atazanvir

∗

boceprevir

∗

lurasidone

∗

ranolazine

∗

telapravir

∗

voriconazole

∗

ritonavir

∗

alprazolam

∗

clonazepam

∗

diazepam

∗

zolpidem

Contraindications 

Pregnancy and breastfeeding

∗

Liver function impairment

∗

Patients with respiratory disease where dyspnea or obstruction is present

∗ Dizziness ∗ Sedation ∗ Headache ∗ Abdominal pain

∗ Respiratory depression

Renal impairment

* Reduce heart rate



Previous addiction to sedative/hypnotic group

* Potentially habit

Presence readily detected in urine tests

secobarbital - Schedule III drug: butabarbital - Schedule IV drugs: barbital, phenobarbital

Monitoring Hematopoietic organ systems

forming

Drug Screens

- Schedule II drugs: pentobarbital, amobarbital,

Hepatic system

∗ Nausea/vomiting



U.S. FEDERAL LAW

Renal system

Side Effects

PROFESSIONAL OPINION Based on the nature of these CNS depressants, side effect profile, drug interactions, susceptibility for addiction and abuse, and that there are safer CNS depressants on the market, I would not recommend these drugs unless medically necessary. ~ M. Chellino

Resources Erowid. Barbiturates Timeline. Available at: https://www.erowid.org/chemicals/barbiturates/barbiturates_timeline.php. Accessed October 13, 2018.

Sedatives and Hypnotics, Barbiturates. Drug Facts and Comparisons. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http:// online.factsandcomparisons.com. Accessed October 13, 2018.

Mandal, A. News Medical. Barbiturate Mechanism. Available at: https://www.news-medical.net/health/Barbiturate-Mechanism.aspx. Accessed October 13, 2018.

Ogbru, O. MedicineNet. Barbiturates. Available at: https://www.medicinenet.com/barbiturates-oral/article.htm#what_are_barbiturates?. Accessed October 13, 2018.

Laws. What are Barbiturates? Available at: https://drugs.laws.com/barbiturates. Accessed October 13, 2018.

20

Alicia Cheng Student Pharmacist Fall 2018

Synthetic Cathinones, “Bath Salts,” is a term used to describe a wide variety of designer drugs.

Those drugs gained the name of “bath salts” because they were packaged in a way that looked like true bath salts (like Epsom salts).1 •Bath salts were first syntehsized (artificially created) •Originally researched for potential medical use France • Most drugs failed for medical use due to severe side effects, including dependency 1928 & 19292

• Abuse of these drugs started in the former Soviet Union Soviet Union • Mainly abused for the anti-depressent effects 1930s-1940s

Isreal 2004-2008

2007

• Bath salts were used heavily in Isreal until the key ingredient in bath salts was made illegal

• Bath salt use skyrocked due to their appearance on interenet drug forums

• Two key ingredients in bath salts were made illegal in the U.S. • United States Underground chemists created new variations of bath salts 2012

• Abuse of bathsalts gained popularity in America United States 1990s

Slang3

Pharmacology/Drug Effects4 • • • • • •

Central nervous system stimulant “High” like methamphetamine Euphoria Elevated sex drive Hallucinations Increased concentration

European Monitoring Centre for Drugs and Drug Addiction. Synthetic Cathinones Drug Profile. Available at: http://www.emcdda.europa.eu/ publications/drug-profiles/synthetic-cathinones. Accessed on: October 13, 2018.

21

Toxicology5,6: • • •

Morris, G. Bath Salts Addiction and Recovery Facts. Available at: https:// www.recovery.org/topics/bath-salts-facts/. Accessed on: October 13, 2018.

Contraindications: Unknown Drug interactions: Unknown Side Effects: o Rapid heart rate o Chest pain o High blood pressure o Hyperthermia o Excess sweating o Seizures o Violent behaviors o Paranoia

Laws7: • • • •

Illegal to possess, use or distribute many of the chemicals used to make bath salts o Newly made synthetics that do not contain those chemicals are technically legal Possession is illegal under federal law Possession= up to $1,000 fine and max of one year in jail Manufacturing/sale= serious felony charges

Monitoring/Drug Screens8 • • •

Watch out for all side-effects listed above, all can indicate overdose Standard drug screens do not screen for bath salts, specialized ones are used in cases of suspected use Bath salts can be detected 48-72 hours after use

Professional Opinon9 “The abuse of synthetic stimulant drugs known as “bath salts” has become a major public health threat across the U.S. Unlike traditional cosmetic bath salts, which are made to be added to bath water, toxic bath salt products have no legitimate use for bathing and are produced specifically for recreational drug abusers as legal substitutes for cocaine, ecstasy (MDMA), and amphetamines.” – J. Gerashman (PharmD, CPh) and A. Fass (PharmD) References: 1. NIH. Synthetic Cathinones (“bath salts”). Available at: https://www.drugabuse.gov/publications/drugfacts/synthetic-cathinones-bath-salts. Accessed on: October 13, 2018.

2. Drug-Free World. Bath Salts: A Short History. Available at: https://www.drugfreeworld.org/drugfacts/synthetic/bath-salts-history.html. Accessed on: October 13, 2018.

3. American Addiction Centers. List of Street Names for Drugs. Available at: https://drugabuse.com/library/list-of-street-names-for-drugs/. Accessed on: October 13, 2018.

4. European Monitoring Centre for Drugs and Drug Addiction. Synthetic Cathinones Drug Profile. Available at: http://www.emcdda.europa.eu/ publications/drug-profiles/synthetic-cathinones. Accessed on: October 13, 2018.

5. Drugs.com. Bath Salts Drug. Available at: https://www.drugs.com/illicit/bath-salts.html. Accessed on: October 13, 2018.

6. Morris, G. Bath Salts Addiction and Recovery Facts. Available at: https://www.recovery.org/topics/bath-salts-facts/. Accessed on: October 13, 2018.

7. LegalMatch. Bath Salts Synthetic Drug Laws. Available at: https://www.legalmatch.com/law-library/article/bath-salts-synthetic-drug-laws.html.

Accessed on: October 13, 2018.

8. New Life House. How Long Do Bath Salts Stay in your System? Available at: https://newlifehouse.com/how-long-do-bath-salts-stay-in-your-system/.

Accessed on: October 13, 2018.

22 9. Gershman JA, Fass AD. Synthetic Cathinones (“Bath Salts”): Legal and Health Care Challenges. Pharmacy and Therapeutics. 2012;37(10):571-595.

Benzodiazepines Derek Chiu, 2nd Year Professional Pharmacy Student

Fall 2018

https://www.webmd.com/drugs/2/drug-9824/xanax-oral/details

PHARMACOLOGY/DRUG EFFECTS

HISTORY/BACKGROUND

Benzodiazepines are a class of medications often used to sedate a person to calm anxiety, treat panic disorders and epilepsy, and/or address insomnia.4 Between 1996 and 2013, benzodiazepine prescriptions increased from approximately 8.1 million to 13.5 million prescriptions; that’s a 60% increase in prescriptions.1 Often prescribed with benzodiazepines are opioids.1 Various studies indicate simultaneous use of both opioids and benzodiazepines increase the risk of drug overdose death.1 This problem has become so severe, the CDC issued new guidelines in 2016 involving benzodiazepines and opioids to reduce the amount of drug-related deaths.1 Common benzodiazepines include diazepam (Valium), alprazolam (Xanax), and clonazepam (Klonopin).1 Griffin CE, Kaye AM, Bueno FR, Kaye AD. Benzodiazepine Pharmacology and Central Nervous System–Mediated Effects. The Ochsner Journal. 2013;13(2):214-223.

SLANG TERMS

• Commonly used slang names for benzodiazepines include: Benzos, Blue V, Candy, Downers, Sleeping Pills, Tranks, and Rohypnol.2 • There are more specific slang names for Xanax.

These include Zanies, Zans, Blue Footballs or Blue (for 1 mg blue tablets), Z Bars, Zan Bars, Quad Bars, Totem poles, or Tombstones (2mg barshaped tablets).3

• Benzodiazepines act as positive allosteric modulators on the gamma amino butyric acid (GABA)–A receptor.4 The GABA receptor reduces the excitability of neurons, so it produces calming effects.4 These receptors are located in the cortex and limbic system; as a result, this calming effect affects the brain.4 • The image on the left illustrates the GABA receptor and its various binding sites.

Benzodiazepines bind to alpha and gamma subunits of the receptor and induces a conformational change in the GABA-A receptor.4 This change allows for the influx of chloride, and this hyperpolarization of the cell attributes to GABA’s inhibitory effect throughout the central nervous system.4 • Common side effects of benzodiazepines include: drowsiness, lethargy, and fatigue.4 At higher doses, euphoria can occur.4 It can be noted hostile behavior or erratic behavior may result as well.4

XANAX FACTS

• Alprazolam is the most popular medication in its class.3 • Alprazolam generally comes in 4 different strengths: 0.25 mg (white), 0.5 mg (peach), 1 mg (blue), and 2 mg (white).3 The street price is $5 per 2 mg tablet.3 • Effects are generally felt 20-40 minutes after ingestion.3 Users report these effects may last two to six hours.3

National Institute on Drug Abuse. Benzodiazepines and Opioids. Available at: https://www.drugabuse.gov/drugs-abuse/opioids/benzodiazepines-opioids. Accessed October 13, 2018.

23

DRUG INTERACTIONS/TOXICOLOGY

Benzodiazepines are metabolized in the liver by cytochrome p450. Medications that attenuate (e.g., oral contraceptive pills, antifungals, some antibiotics) or potentiate (e.g., carbamazepine, phenytoin, rifampin) cytochrome p450 will increase or decrease the benzodiazepine elimination halflife, respectively.4

LAWS

Under the Controlled Substances Act, benzodiazepines are classified as schedule IV depressants.5 Flunitrazepam is an exception; it is placed in schedule IV class, but it has schedule I penalties.5

MONITORING/DRUGS SCREENS

Benzodiazepines are measured by a urine test, but it can be measured by a blood test as well; in which case, it is more accurate and harder for the user to hide.6 These tests look for metabolites, and these vary based on each benzodiazepine’s half-life.6 Although most benzodiazepines show up in standard urine tests, alprazolam, clonazepam, temazepam, and triazolam may not be found in these common tests.6

PROFESSIONAL OPINION

Benzodiazepines are beneficial to select patient populations. Like many drugs, its effects are dose-dependent. As a result, people abuse benzodiazepines because it is easy to achieve a euphoric effect. Personally, I believe there should be stricter regulation on prescribing benzodiazepines (ex: changing it from schedule IV to a lower schedule). Although this is highly improbably, perhaps allow for flumazenil (the “Antidote” for benzodiazepine overdose) to be more accessible. ~ D. Chui

REFERENCES

National Institute on Drug Abuse. Overdose Death Rates. Available at: https://www.drugabuse.gov/relatedtopics/trends-statistics/overdose-death-rates. Accessed October 13, 2018

1)National Institute on Drug Abuse. Benzodiazepines and Opioids. Available at: https://www.drugabuse.gov/ drugs- abuse/opioids/benzodiazepines-opioids. Accessed October 13, 2018.

2) Patterson, Eric. DrugAbuse.com. List of Street Names for Drugs. Available at: https://drugabuse.com/library/list-ofstreet-names-for-drugs/#benzodiazepines. Accessed October 13, 2018.

3) Erowid. The Vaults of Erowid. Alprazolam (Xanax) Basics. Available at: https://www.erowid.org/pharms/alprazolam/alprazolam_basics.shtml. Accessed October 13, 2018.

4) Griffin CE, Kaye AM, Bueno FR, Kaye AD. Benzodiazepine Pharmacology and Central Nervous System–Mediated Effects. The Ochsner Journal. 2013;13(2):214-223.

5) Drug Enforcement Administration. Benzodiazepines. Available at: https://www.deadiversion.usdoj.gov/drug_chem_info/benzo.pdf. Accessed October 13, 2018.

6) University of Rochester Medical Center. Benzodiazepines (Urine). Available at: https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=167&contentid=benzodiazepine_urine.

Accessed October 13, 2018.

7) National Institute on Drug Abuse. Overdose Death Rates. Available at: https://www.drugabuse.gov/relatedtopics/trends-statistics/overdose-death-rates. Accessed October 13, 2018.

8) WebMD. Xanax Images. Available at: https://www.webmd.com/drugs/2/drug-9824/xanax-oral/details. Accessed October 14, 2018.

24

Emily Coffer Student Pharmacist Fall 2018 http://www.huiduochemical.com/bromo-dragonfly-3460592.html

Developed by Matthew Parker in David E. Nichols' laboratory at 1998 Purdue University.

2001

2007 2009 2011 2012

2016

Reported recreational use began.

Illegal classification for Bromo-DragonFly in Denmark.

Reported overdose - related death in Copenhagen, DE. Two reported overdose - realted deaths in Oklahoma due to mistakenly taking Bromo-dragonfly instead of the less potenet 2C-E. Deemed illegal in Finland.

Designated as a Schedule III substance in Canada.

• • • • • • • • •

Bromo-DragonFly BDF FLY DOB-Dragonfly Spamfly B-fly Br-DF 3C-Bromo-Dragonfly Bromo-benzodifuranilisopropylamine

Chemical Name: 1-(8-bromobenzo (1,2 – b; 4,5- b) difuran-4-yl)- 2-aminopropane Synthetic phenethylamine analogue with α1-adrenergic receptor agonist and non-selective 5-HT2 serotonin receptor agonist activity. The R-enantiomer is more potent and has a higher affinity for 5-HT2 serotonin receptors than the S-enantiomer. Bromo Dragonfly inhibits the monoamine oxidase isoform, MAO-A, effectively inhibiting the metabolism of monoamine neurotransmitters (e.g. serotonin, adrenaline, noradrenaline) and the drug itself.

http://www.universityprimetime.com/10-legal-drugs-way-scarier-illegal-drug-2/

Drug Class: psychedelic, hallucinogenic, psychotropic Potency in Drug Class: More potent than LSD in rat models3 Dosage Forms: tablet, powder, blotter sheets, liquid Dose: Varies due to batch inconsistencies, usually administered in micrograms Onset of Action: 20 minutes up to six hours Duration of Action: 12 – 24 hours, with after effects felt for up to 36 hours after initial dose 25

Physical: agitation, tonic-clonic (Grand mal) seizures, vasoconstriction, death, visual changes, muscle stiffness, nausea, tissue necrosis of limbs Mental: severe, vivid and often frightening hallucinations, elevated mood, higher energy levels, loss of inhibition, short-term memory loss, confusion, serotonin syndrome Long-term: This drug is fairly new and has not been extensively studied in human models.

Adverse effects from long-term use are not known at this time.

Tramadol: Tramadol lowers the seizure threshold therefore, concomitant use with psychedelics, such as bromo-dragonfly, may trigger seizures, particularly in those who are predisposed.

Stimulants: Stimulants have CNS activity and when combined with psychedelics, over-stimulation of serotonin receptors can lead to feelings of anxiety, panic attacks, thought loops and paranoia.

Lithium: Lithium increases the risk of seizures and psychosis due to a similar mechanism as tramadol.

After ingestion of Bromo-DragonFly, it is important to monitor mental status and vital signs, as changes in either can be indicative of toxicity. If someone is suffering from moderate to severe toxicity (agitation, delirium, seizures, coma, hypotension), monitor sodium, creatinine phosphokinase, and renal function with continuous cardiac monitoring.

Bromo dragonfly can be detected using sophisticated serum techniques such as HP-LC (high performance liquid chromatography), but it currently cannot be identified with simple urine tests.

Currently, it is unscheduled in the U.S but, could be considered a chemical analog to other Schedule I phenethylamine-related compounds under the 1986 Federal Analogue Act. This means that the consumption or possession of Bromo-DragonFly could be prosecuted if the Drug Enforcement Agency (DEA) declares it an analog.

Currently, there are no approved indications for Bromo-DragonFly in human pharmacology; however, due to its agonist activity on 5-HT2 serotonin receptors, it could potentially be used as a treatment for ocular hypertension or glaucoma in humans if administered via topical application to minimize the hallucinogenic side effects. – Paraphrased from M. Coppola3

1.

2.

3.

4.

5.

6.

7.

Parker, M.A., Marona-Lewicka, D., Lucaites, V.L., et al. A novel (benzodifuranyl)aminoalkane with extremely potent activity at the 5HT2A receptor. J Med Chem. 1998;41:5148-49.

Surakka, Veli-Matti. AssictionLink. Bromo-DragonFly. Available at: https://www.paihdelinkki.fi/en/info-bank/articles/drugs-and-otherintoxicants/bromo-dragonfly. Accessed: October 13, 2018.

Coppola M, Mondola R. Bromo-DragonFly: Chemistry, Pharmacology and Toxicology of a Benzodifuran Derivative Producing LSD-Like Effects. J Addict Res Ther 2012;3(122). DOI: 10.4172/2155-6105.1000133.

Hallucinogenic Amphetamines. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed: October 14, 2018.

Bromo-Dragonfly. The Vaults of Erwid. https://www.erowid.org/chemicals/bromo_dragonfly/bromo_dragonfly.shtml. Updated November 15, 2015. Accessed: October 13, 2018.

Wikipedia. Bromo-Dragonfly. Available at: https://en.wikipedia.org/wiki/Bromo-DragonFLY. Accessed: October 13, 2018.

Psychonautwiki. Bromo-Dragonfly. https://psychonautwiki.org/wiki/2C-B. Updated September 7, 2017. Accessed: October 13, 2018.

26

Claire Corvari | Student Pharmacist | Fall 2018

Buprenorphine Subutex

Bupe, Box, Boxes, Sobos, Oranges, Sub, Saboxin

History and Background In 1985, buprenorphine was approved by the FDA for analgesic use as a schedule V medication. In 2002, buprenorphine was approved by the FDA as a medication assisted treatment (MAT) of opioid addiction. It was the first MAT approved that could be dispensed in a physicians office under the Drug Assisted Treatment Act (DATA) of the year 2000.

Image Available At: thedrugclassroom.com/video/buprenorphine-subutex-temgesic/

Image Available At: en.wikipedia.or g/wiki/bupreno rphine

Mechanism of Action Buprenorphine is a mu-receptor partial agonist. It is used in patients who have opioid use disorder. It allows patients to stop taking opiates without experiencing withdrawal effects. Because buprenorphine is a partial mu-receptor agonist, patients will experience some euphoria and analgesic effects, but not to the same extent as an opioid with full mu-receptor activity. It has a limited potential for abuse compared to other opioids due to the “ceiling effect�. After a certain dose of buprenorphine is reached, its physiological effects plateau.

27

Interactions Buprenorphine should not be used in combination with opioids due to risk of serotonin syndrome, withdrawal symptoms, or reduced analgesic effects.

Other Interactions include: • clopidogrel • cyclobenzaprine • naltrexone • alcohol • metoclopramide • Anticholinergics

Monitoring/Drug Screens

Image Available At: www.medicalook.com/reviews/bupr enorphine.html

Cedia™ Buprenorphine II Drugs of Abuse Assay Detects three major metabolites of buprenorphine in the urine, norbuprenorphine, buprenorphine-3-B-glucuronide, and norbuprenorphine-3-β-glucuronide Buprenorphine can also appear on a 12-panel drug test, which tests for opioids, benzodiazepines, methadone, oxycodone, etc.

Professional Opinion

Image Available At: opiateaddictionresource.com/media/images/buprenorphine_IV

Laws Under the Drug Assisted Treatment Act of 2000, buprenorphine can be dispensed by physicians who are qualified to prescribe schedule III, IV, and V medications in their practice. This allows physicians to prescribe buprenorphine to patients with opioid use disorder in a setting other than an opioid treatment program.

Buprenorphine is a beneficial MAT for patients struggling with opioid use disorder. Because it is a partial agonist at the mu-opioid receptor, it provides relief from the withdrawal symptoms that make recovery so difficult for opioid addicts. While there is potential for abuse, the benefits of addiction recovery outweigh the risks of misuse, which are much smaller in comparison to full opioid receptor agonist.

Works Cited 1. The Treatment Center. Drug Slang. Available at: thetreatmentcenter.com/drug-slang/. Accessed October 6 2018.

2. National Alliance of Advocates for Buprenorphine Treatment. What Exactly is Buprenorphine. Available at: naatb.org/faq_answers.cfm?ID=2.

Accessed October 6 2018.

3. RxList.com. Buprenorphine. Available at: https://www.rxlist.com/subutex-drug.htm#description. Accessed October 6 2018.

4. Substance Abuse and Mental Health Services Administration. Buprenorphine. Available at: https://www.samhsa.gov/medication-assistedtreatment/treatment/buprenorphine. Accessed October 6 2018.

5. Subutex [package insert]. North Chesterfield, VA: Indivior Inc. 2018.

6. Buprenorphine. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed Month day, year.

7. The Recovery Village. Does Suboxone Show Up on a 12-Panel Drug Test? Available at: https://www.therecoveryvillage.com/suboxoneaddiction/suboxone-drug-test/#gref. Accessed October 6 2018.

8. Yokell MA, Zaller ND, Green TC, Rich JD. Buprenorphine and Buprenorphine/Naloxone Diversion, Misuse, and Illicit Use: An International Review.

Curr Drug Abuse Rev 2011;(1):28-21.

9. Substance Abuse and Mental Health Services Administration. Buprenorphine Waiver Management. Available at: https://www.samhsa.gov/programscampaigns/medication-assisted-treatment/training-materials-resources/buprenorphine-waiver. Accessed October 6 2018.

28

Slang Terms • • •

Background • •

•

Caffeine is a stimulant that is used daily by many people.

Dirt Java Liquid Energy High octane

Caffeine & Energy Drinks Christine Cunningham Student Pharmacist Fall 2018

The use of caffeine dates back to as early as 600,000 BCE.

• The first coffee tree and

coffee beans were discovered in the Arabian Peninsula around 1100.

•

As of 1995, coffee was the world’s most popular drink.

•

The infamous energy drink has been around for centuries, dating back to the idea that Indian men would drink a mixture before religious ceremonies, political councils, and war.

The first technical energy drink was CocaCola in 1886 as it contained caffeine and cocaine.

•

•

Red Bull was launched in 1987.

Pinterest. Clip Art Cup of Coffee.

Available at: https://www.google.com/search?q=clip +art+cup+of+coffee&rlz=1 C1CHBF_enUS802US802&tbm=isch&sourc e=iu&ictx=1&fir=YsuOtf R6FmAPZM% 253A%252Ci0m68hLrgSKjcM% 252C_&usg=AI4_kTOJP6YGRIMDTSKA3llv9VRcsivHA&sa=X &ved=2ahUKEwi9mIT4q4 LeAhUQUa0KHdcGBLgQ9QEwAHoECAQQB A#imgrc=YsuOtfR6FmAP ZM:. Accessed October 13, 2018.

Pharmacology •

Caffeine works as a stimulant on the central nervous system (CNS).

•

Stimulates the heart, muscles, and centers that control blood pressure.

•

Caffeine is also viewed to have four pharmacological actions: adenosine receptor blockade, phosphodiesterase inhibitor, increases calcium entry into cells, and binds to GABA receptors at the benzodiazepine site.

Rense, Sarah. Esquire. An Energy Drink Claims it can Cure Alzheimer’s, That’s a New One. Available at: https://www.esquire.com/lifestyle/health/a23006613/ energy-drink-claims-cure-alzheimers-lawsuit/. Accessed October 13, .

Velocigraphics. Caffeine Molecule Decal. Available at: https://velocigraphics.myshopify.com/products/caffeinemolecule-decal. Accessed October 13, 2018.

29

29

Further Information

Laws

Toxicology •

•

•

•

•

•

Caffeine does cross the placenta and is not recommended during pregnancy as it can lead to miscarriages or growth retardation.

Caution during breastfeeding as active metabolites of caffeine are present in the breast milk.

Cautioned in patients with GI disease, seizure disorder, and cardiovascular disease.

Caffeine is a major substrate of CYP1A2 and needs to be cautioned with other drugs that undergo or inhibit CYP1A2 metabolism.

•

The safety of caffeine and energy drinks is heavily debated, especially due to the rise of teens consuming these drinks.

•

The FDA claims that caffeine is safe to consume up to 400 mg/ day.

•

Under the law, caffeine is allowed to be added to food and beverages as long as it is listed in the ingredients panel.

•

The quantity of caffeine in food or beverage products does not have to be listed, just the ingredient itself

•

There is no legal requirement that shows the need for ID in order to purchase caffeine products, including energy drinks

Some of the following are drugs that interact with caffeine: atomoxetine, bupropion, ciprofloxacin, clozapine, lithium, and tizanidine.

Most energy drinks are not recommended for children as they lead to neurologic and cardiovascular defects.

Sharefaith. Brewing Tea Bag Clipart. https://www.google.com

Monitoring •

Caffeine is not typically tested for in drug tests as it is not an illegal substance.

•

It can be tested for in the urine and can be detected for up to 2-3 days.

•

A blood test could trace caffeine for up to 24 hours, although this method is not very common.

Professional Opinion I believe that caffeine/energy drinks are drug products that have potential benefits when used in moderation.

However, it worries me that these products are not more strictly regulated and that individuals of all ages have access to them. Therefore, I believe that proper education on caffeine use and when to know if someone is experience harmful side effects is necessary for our generation, especially among college students. Finally, I think that in the world of pharmacy, there should be more regulation on the purchase of caffeinated products/energy drinks in individuals under the age of sixteen. ~ C. Cunningham

References 1.Erowid. Documenting the Complex Relationship Between Humans & Psychoactives. Available at: https:// www.erowid.org. Accessed October 13, 2018.

2. Lile, Samantha. Wall Street Insanity. The History of Energy Drinks: A Look Back. Available at: https:// wallstreetinsanity.com/the-history-of-energy-drinks-alook-back/. Accessed October 13, 2018.

3. Coffee.Org. 20 Slang Terms for Coffee. Available at: https://www.coffee.org/blog/20-slang-terms-for-coffee/.

Accessed October 13, 2018.

4. WebMD. Caffeine. Available at: https:// www.webmd.com/vitamins/ai/ingredientmono- 979/ caffeine. Accessed October 13, 2018.

5. Caffeine. Drug Facts and Comparisons. Facts & Comparisonse Answers. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http:// online.factsandcomparisons.com. Accessed October 13, 2018.

6. Caffeine Informer. Caffeine Intake Safety Laws.

30 Available at: https://www.caffeineinformer.com/caffeinesafety-laws. Accessed October 13, 2018.

30

Albert Dinh

Pharmacology

Student Pharmacist Cannabidiol Fall 2018

CBD has an anticonvulsant effect but does not interact with cannabinoid receptors. It is shown to be effective for improving pain, muscle-tightness, and urination frequency in people with MS. There is not a lot of evidence to suggest effectiveness of this agent.1 There is currently insufficient evidence for bipolar disorder, dystonia, epilepsy, Huntington’s Disease, Insomnia, Parkinson’s disease, and schizophrenia to name a few.1

Success story Eric Lakey from Georgia, lived as an extreme sports enthusiast. Eric got injured via multiple knee and ankles injuries and it eventually resulted in him suffering from major back problems in his 40s.3 https://canabidol.com/cd-oil-drops/

History 1533 – medical benefits of cannabis were studied mid-1950s – cannabidiol was extracted and proven to be a non-psychoactive component Present – legal in all 50 states in the US and FDA has begun review CBD

His MRI showed that he had seven bad disks down his spine, which was causing him to experience severe pain. He received treatments such as radiofrequency ablation to burn his nerves as well as extensive opioid drugs such as hydrocodone and 10mg/500mg acetaminophen. 3 Eric eventually tried CBD, which resulted in severely reduced joint and muscle pain. He was able to wean off his opioid medication and noticed scars from his 20s disappear.3

Slang Terms Cheeba, weed, sticky-icky-icky, Yarndi, zig-zag – cannabis N/A – cannabidiol

Drug effects Patients exposed to this agent may develop rash, weight loss, abdominal discomfort, abdominal pain, decreased appetite, diarrhea, drooling, and excessive salivation.2

https://a1.vaping360.com/wp-content/uploads/2017/11/ health-benefits-of-cannabidiol.png oils-juice/

31

Drug Interactions

Professional opinion

There are severe drug-drug interactions with valproic acid, which may lead to increased risk of hepatocellular injury.

Current knowledge of interactions with pregnant women and lactating women are unclear and should be used with caution.

In my opinion, I believe that the psychoactive derivatives of cannabidiol should be banned. This prevents the potential for abuse and allows for use of its medicinal products therapeutically.

I believe that there is opportunity in using this agent to treat symptoms such as pain, glaucoma, emesis to name a few. ~ A. Dinh

Toxicology Cannabinoids as a class may show acute and long-term cardiovascular effects such as: cardiac labor, systemic vasodilation, and increased blood pressure.

Smoking cannabis has been shown to increase inflammation of large airways, increased airway resistance, and destroy lung tissue eventually leading to bronchitis, emphysema, chronic respiratory inflammation, and impaired respiratory function.5

Laws Cannabidiol is currently legal in all 50 states generally. However, hemp-derived CBD is currently legal. It has no psychoactive effects and thus it is legal in all 50 states.

Marijuana-derived CBD is legal in some state, but not legal in others. This is due to cannabidiol forms to be rich in THC. A total of 46 states have legalized cannabidiol use for medicinal usage. 17 states have specific laws pertaining to THC-levels found in CBD and vary from state to state. These states include: Alabama, Florida, Georgia, Indiana, Iowa, Kentucky, Mississippi, Missouri, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.

Monitoring/drug screens Currently, drug screen tests include delta-9-tetrahydrocannabinol or THC. This is screened in a metabolite form in the urine. It is considered quite accurate.

references 1. WebMd. Available at: https://www.webmd.com/vitamins/ai/ ingr edientmono-1439/cannabidiol.

Accessed October 15, 2018.

2. Cannabidiol. Micromedex Solutions Available at: https://wwwmicromedexsolutionscom.ezproxy.lib.purdue.edu/ micromedex 2/librarian/CS/ECC66B/ ND_PR/evidencex pert/ND_P/ evidencexpert/DUPLICATIONS HIELDSYNC/C89C47/ND_PG/ evidencexp ert/ND_B/evidencexpert/ ND_AppProduct/evidencexpert/ND_T/ evidencexpert/PFAc tionId/ evidencexpert.DoIntegratedSearch ?

SearchTerm=cannabidiol&UserSearchT erm=cannabidiol&SearchFilter=filterNo ne&n avitem=searchALL#. Accessed October 15, 2018.

3. Honey Colony. Available at: https://www.honeycolony.com/ article/6-cbd-success-stories/.

Accessed October 15, 2018 4. Sachs J, McGlade E, Yurgelun-Todd D. Safety and Toxicology of Cannabinoids, Neurotherapeutics. 2015 Oct; 12(4): 735746. doi: 10.1007/s13311-015-0380-8.

5. Medium. Available at: https://medium.com/cbd-origin/is-cbdlegal-legal-status-of-cbd-2018d1b4a0ed42df. Accessed October 15, 2018.

32

Brandon Do, Student Pharmacist

Fall 2018

Cannabinol (CBN) Slang •

CBN

•

Fake THC

•

Cannabis

History/Background End of 19th century

Cannabinol was the first of the phytocannabinoids to be isolated.

1937

Marijuana Tax Act – banning use and sales

1940

R.Adams achieved the first successful chemical synthesis of CBN in the US.

1971 Controlled Substances Act classified Cannabis as a Schedule I. 1972 Schafer Commision declared that Marijuana should not be in Schedule I; President Nixon dismissed recommendations.

1996 California became the first state to approve use of medical Marijuana.

PayPsi. Everything You Need To Know About Cannabinol. https://www.payspi.org/ everything-you-need-know-about-cannabinol/

Pharmacotherapy 6,6,9-trimethyl-3-pentylbenzo[c]chromen-1-ol Cannabinoid is isolated from the Cannabis plant by breaking down from tetrahydrocannabinol (THC) into it’s metabolites. Cannabinol binds to the cannabinoid G-protein couple receptor CB2 which is present on immune cells. Stimulating these Receptors may trigger apoptosis of T-cells, B-cells, macrophages and dendritic cells, and therefore have immunosuppressive and anti-inflammatory effects.

• Comparable to CBD • Immunosuppressant, sedative, pain reliever • Can be ingested or inhaled

Dosing Cannabinol is considered to be the most sedative out of all the cannabinoids. Consumption of 2.5 to 5 mg of CBN has the same level of sedation as diazepam, a known sedative. Unlike THC, CBN lacks the psychoactive effects.

PayPsi. Everything You Need To Know About Cannabinol. https://www.payspi.org/everythingyou-need-know-about-cannabinol/

33

lorem ipsum dolor

issue, date

Drug Interactions/Toxicology Drug Interactions •

Ketoconazole (CYP3A4 inhibitors)

•

Alcohol and benzodiazepines (CNS depressants)

•

Contraindications

Rifampin and carbamazepine (CYP3A4 inducers)

•

As of now there are no contraindications to CBN

•

It is unclear of CBN’s effect on women who are pregnant or breastfeeding (for now, recommend to avoid)

Side Effects •

Somnolence

•

Fatigue

•

Diarrhea

•

Increased appetite

Monitoring/Drug Screens Monitoring ü Affects heart rate and CNS

Drug Screens §

ü Monitor sleeping patterns §

Law

Drug screens don’t test for THC metabolites including CBN Could cause a false positive for THC

As of now CBN is illegal in all states that have banned THC, however unlike THC or CBD, CBN is not classified as a Schedule I drug. It is therefore unclear of the legal status on this drug. With that being said, it can be used in states that have legalized marijuana.

Drug Test. What are Drug Tests? https://www.dixiebotanicals.com/will-fail-drug-test-using-cbd/

Professional Opinion Due to mild side effects, and numerous studies on its benefits on sleep and relaxation, I would recommend this use therapeutically in states that have legalized the use of marijuana. ~ B. Do

References 1. Pertwee RG. Cannabinoid pharmacology: the first 66 years. Br J Pharmacol 2006; 147(Suppl 1): S163–S171. DOI: 10.1038/sj.bjp.0706406.

2. Drug Policy Alliance. How Did Marijuana Become Illegal in the First Place? Available at http://www.drugpolicy.org/blog/how-did-

marijuana-become-illegal-first-place. Accessed October 8, 2018.

3. Steep Hill. Cannabinol (CBN): A Sleeping Synergy. Available at https://www.steephill.com/blogs/34/Cannabinol-(CBD):-A-Sleeping-

Synergy. Accessed October 8, 2018.

4. Wantanbe K, Yamori S, Funahashi T, Kimura T, Yamamoto I. Cytochrome P450 enzymes involved in the metabolism of

tetrahydrocannabinols and cannabinol by human hepatic microsomes. Life Sci 2007; 80(15):1415-9.

5. TheAnswerPage. Medical Marijuana – Medical, Legal, Social and Political Issues. Available at https://www.theanswerpage.com/

multichoice.php?specialty_id=8&topic_id=156. Accessed October 8, 2018.

34

Carisoprodol

Fall 2018

Alana Dorfstatter, Student Pharmacist

HISTORY 1956-­‐ Frank M. Berger of Wallace Laboratories created this drug. A number of meprobamate derivatives were also being studied, but this drug in particular was found to have unique properties.

1959-­‐ Carisoprodol (Soma) was introduced following FDA approval. It is used as a muscle relaxant and pain relief.

1978s A report came out discussing the abuse potential of the drugs and concern about the adverse effects.

1990s 2000ss Claims of the drug being used to boost or alter the effects of opiods, benzodiazepines, cocaine, and alcohol.

2012- It became a schedule 4 drug.

1960s It was investigated in both humans and animals being compared to meprobamate.

PHARMACOLOGY AND DRUG EFFECTS Carisoprodol is a central nervous system depressant. It acts as a sedative and muscle relaxant. It does not act directly on skeletal muscles, however. Carisoprodol disrupts the neuron communication in the spinal cord. This results in altering pain perception and sedation. The exact mechanism of action is unknown as this point in time.

http://portal.sman1baso.sch.id/2018/06/cariso prodol-­‐tablets-­‐usp-­‐350mg.27714_905.php https://en.wikipedia.org/wiki/Carisoprodol

SLANG TERMS • • • •

Soma Coma (soma and codeine) Las Vegas Cocktail (soma and Vicodin) Ds Dance https://www.webmd.com/drugs/2/drugs 8625/ carisoprodols oral/details 35

DRUG EFFECTS/TOXICOLOGY Taking large doses of carisoprodol can lead to coma, respiratory depression, amnesia, and even death. Some reports have also stated seizures, agitation, and movement disorders. Drug interactions include CNS depressants such as alcohol, benzodiazepines, opioids, and tricyclic antidepressants. More drug interactions include CYP2C19 inhibitors and inducers.

These include omeprazole, fluvoxamine, rifampin, and St. John’s Wort.

http://www.blackgirldangerous .com/2013/09/no-­‐more-­‐allies/

Monitoring & Drug Screens

Laws

http://westerlaw.org/index.php/2017/05/25/he--significance---of---employee---law---posters/

Carisoprodol became a schedule 4 controlled substance on December 12, 2011. A pharmacy may only fill a prescription if all of these requirements are made: legitimate medical purpose, DEAs registered physician, prescription contains all the information required by state/federal laws, and the number of refills is five or less. A schedule 4 controlled substance may not be refilled more than six months after the prescription issue date.

While taking this medication, patients and physicians should monitor a patient’s relief of discomfort associated with skeletal conditions that indicate efficacy. Patients and physicians should also be aware of the many drug interactions and side effects, so they can be avoided. This medication does not show up in drug screens and is not looked for in drug tests. Only for specific drug tests that are looking for this medication is when it will show up.

References Professional Opinion I believe that carisoprodol can be used if used appropriately and for the correct purpose of certain patients However, it does have the potential to be abused, so I think that it is a good thing it is a controlled substance to try to redcuce that potential.

-­‐A. Dorfstatter

1.Drug Bank. OMx Personal Health Analytics, Inc. Carisoprodol.

Available at: https://www.oasas.ny.gov/admed/fyi/soma.cfm.

Accessed October 9, 2018.

2. Soma [package insert]. Somerset, NJ: Meda Pharmaceuticals Inc; 2009.

3.Drug Enforcement Administration. U.S. Department of Justice.

Carisoprodol. Available at: https://www.deadiversion.usdoj.gov/drug_chem_info/carisoprodol/ ind ex.html. Accessed October 10, 2018.

4. Carisoprodol. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com.

Accessed October 10, 2018.

36

Cocaine Helen Fagan Student Pharmacist Fall 2018 https://luxury.rehabs.com/cocaine-addiction/shooting/

History •

Comes from leaf of Erythroxylon bush

•

Isolated in 1860 and began to be used as anesthetic

•

Crack-cocaine use became prominent in 1980s, made cocaine a popular drug due to high regulation of amphetamines

https://drugabuse.com/library/is-cocaine-addictive/

Slang Terms •

Blow

•

Coke

•

Crack

•

Toot

•

Base

Pharmacology •

Blocks neurotransmitter up-take

•

Constant stimulation leads to euphoric feeling

•

Anesthetic effect comes from blocking ion channels, which blocks electrical signal 37

Drug Interactions/Toxicology •

Interactions: hydrocodone, amphetamines, hydromorphone, codeine, alcohol

•

Side effects: Tachycardia, dilated pupils, nausea, elevated blood pressure, tremors

•

Contraindications: Lactation, dihydroergotamine

Drug Screens •

Urine or saliva may be tested

•

Urine test able to detect cocaine 2-3 days after use

•

Saliva test increasing in popularity due to being able to observe test the entire time

•

Saliva test can detect cocaine 1-2 days after use

Laws •

Cocaine is a schedule II drug

•

High abuse potential

•

Potential for both psychological and physical dependence

Professional Opinion I would not recommend the use of cocaine unless absolutely medically necessary, due to side effects and high addiction potential.

-H. Fagan

References 1.

The University of Arizona. Cocaine history. Available at: https://methoide.fcm.arizona.edu/infocenter/index.cfm?stid=168.

Accessed October 15, 2018.

2.

The University of Arizona. Cocaine pharmacology. Available at: https://methoide.fcm.arizona.edu/infocenter/ index.cfm?stid=170. Accessed October 15, 2018.

3.

Cocaine HCl. Drug Interactions. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 15, 2018.

4.

United States Drug Enforcement Agency. Drug scheduling. Available at: https://www.dea.gov/drug-scheduling. Accessed October 15, 2018.

5.

University of Rochester Medical Center. Cocaine screen. Available at: https://www.urmc.rochester.edu/ encyclopedia/content.aspx?contenttypeid=167&contentid=cocaine_screen. Accessed October 15, 2018.

6.

National Institute on Drug Abuse. Cocaine. Available at: https://www.drugabuse.gov/publications/drugfacts/cocaine.

Accessed October 15, 2018.

38

ERIN FLYNN STUDENT PHARMACIST Fall 2018

DEXTROMETHORPHAN BACKGROUND Dextromethorphan is a cough suppressant found in over one hundred over the counter products. It is often in combination with other cold and flu relief medicines. It is most commonly seen from of the drug is as a syrup, but it is also abused in capsule form. It is most commonly abused by youth ages 13- 16 years.

DRUG EFFECTS SLANG TERMS Dex Robo Skittles DXM CCC Poor Man's PCP Rojo Tipple C Velvet

In high quantities, dextromethorphan can cause mind-altering effects. Abusers often experience euphoria and hallucinations.

Dextromethorphan can also cause confusion, inappropriate laughter, agitation, paranoia, the feeling of floating and changes in hearing and touch.

DRUG INTERACTIONS/ TOXICOLOGY Dextromethorphan can have dangerous effects like confusion, disorientation, blurred vision, and slurred speech.

The most dangerous part of this drug the effects of the cold medicines it is often in combination with like acetaminophen and decongestants. Abuse of these can cause liver failure, tachycardia, seizures, hypothermia, and coma.

39

LAWS It is not a controlled substance or illegal, but the Consumer Healthcare Products Association supports laws that ban the sale of dextromethorphan to minors under the age of 18 years and that prevent the sale of raw dextromethorphan.

MONITORING/SCREENING Dextromethorphan is undetectable on a standard drug test. This enhances its popularity. One thing to monitor is for an excess of empty cough syrup bottles.

PROFESSIONAL OPINION In my opinion, I believe dextromethorphan is a danger to teenagers when abused. Requiring the purchaser to be 18 years old does make it harder to attain in the population that abuses it most. I believe we need to educate the youth on the danger of abusing OTC medicines in general because the most dangerous part of abusing dextromethorphan is the toxicities from the drugs in combination. ~ Erin Flynn REFERENCES  Drug Free VA. DXM. Available at: https://drugfreeva.org/sink-orswim/drug- facts/over-the-counter-drugs/dxm/.Accessed October 11, 2018.  Partnership for Drug Free Kids. DXM. Available at: https://drugfree.org/drug/dxm/? gclid=Cj0KCQjw6fvdBRCbARIsABGZvQ38c6AiAixF6a31dvr1OEQ92- Ex0kTcxRLxwRwMNVYnBX1802MwNkaAh HQEALw_wcB. Accessed October 11, 2018.  Drug Abuse. Dextromethorphan Abuse. Available at: https://drugabuse.com/library/dextromethorphan-abuse/#effects-ofdextromethorphan-abuse. Accessed October 11,2018.  Consumer Healthcare Products Association. Dextromethorphan: Preventing Teen Cough Medicine Abuse. Available at: https://www.chpa.org/Dex.aspx. Accessed October 11, 2018.

40

Claire Fellers Student pharmacist

Fall 2018 https://en.wikipedia.org/wiki/7-Keto-DHEA

History & Background

Slang Terms

-

DHEA

-

1930s: isolated by German biochemist

-

“fountain of youth”

-

Available without prescription as a dietary supplement

hormone -

“super-hormone”

-

“Anti-aging” hormone

-

Made naturally by the body as a precursor to testosterone and estrogen

-

Made from wild yam or soy

Uses

-

Claims to improve:

-

Anti-aging effects, cardiovascular disease, aging muscles, aging bones, sexual function, athletic performance, cognitive function, depression, immune system.

Pharmacology

-

Levels begin to decrease over time after peaking around the mid-20s

-

Binds to the GABA receptor, and also NMDA receptor

-

Exact mechanisms of action are still unknown

-

Increase androgen levels in women

-

Increase androgen & estrogen levels in men Side Effects

https://www.dhea.clinic/products/20-mg-dhea-performance-cream https://www.walmart.com/ip/Spring-Valley-DHEA-Tablets-50-mg-50Ct/872312

-

Hepatitis

-

Acne, oily skin

-

Hirsutism, facial hair in women

-

Hair loss

-

High blood pressure

-

Nasal congestion

-

Fatigue

-

Headache, insomnia,

-

Unfavorable changes in cholesterol 41

Drug Interactions/Toxicology

-

DHEA should not be taken if the patient has or has a history of breast, prostate, or ovarian cancer

-

Not recommended for pregnancy or lactation

-

This drug interacts with the following drugs: antipsychotics, carbamazepine, estrogen, lithium, SSRIs, testosterone, triazolam, valproic acids

Laws

-

DHEA is sold over-the-counter as a dietary supplement o OTC sales were banned in 1985, but resumed after the Dietary Supplement Health and Education Act of 1994 passed

-

It is banned by many major league sports such as http://spacecoastsports.com/

the NFL

Monitoring/Drug Screens

-

Monitor for side effects and monitor blood levels

-

DHEA can be detected in the urine if the ratio of testosterone to epitestosterone is greater than 6:1

http://www.stack.com/a/dhea-supplements

Professional Opinion

-

In my professional opinion, the patient should talk to their doctor before taking this drug due to the risks and side effects of taking a precursor to a hormone. Because of the lack of evidence, it shouldn’t be used as a first-line treatment or taken over-the-counter without consulting a doctor. ~C. Fellers References

1. Dehydroepiandrosterone. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com. Accessed Octover 14, 2018.

2. Dhea. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 14, 2018.

3. WebMD. DHEA Supplements. Available at: https://www.webmd.com/diet/dhea-supplements. Accessed October 14, 2018.

4. Berkely Wellness. Remedy Health Media. DHEA: Anti-Aging in a Bottle? Available at:

http://www.berkeleywellness.com/supplements/other-supplements/article/dhea-anti-aging-bottle. Accessed on October 14, 2018.

5. Bosy, TZ, Moore, KA, Poklis, A. The effect of oral dehydroepiandrosterone (DHEA) on the urine testosterone/epitestosterone (T/E) ratio in human male volunteers. J Anal Toxicol 1998;22(6):455-9

42

DIACETYLMORPHINE (HEROIN)

Sara Foreman Student Pharmacist, Fall 2018

drug-profiles/heroin

http://www.emcdda.europa.eu/publications/

HISTORY Diacetylmorhpine is an opioid drug derived from morphine, a naturally occurring substance derived from the seed pod of an opium poppy plant.

Diacetylmorhpine (heroin) was first made from morphine in 1874 by an English chemist. The drug was then produced commercially by Bayer Pharmaceutical Company in 1889. However, heroin was soon found to be highly addicted and it was pulled from the market and declared an illegal drug in the USA in 1924.

PHARMACOLOGY Once administered, Diacetlymorphine is broken down metabolically into 6-monoacetylmorhpine (6-MAM) and then further metabolized into morphine.

Morphine acts by binding to opioid receptors in the nervous system. When bound to these receptors, morphine blocks pain and depresses the CNS to signals and stimulus.

SLANG TERMS − BIG H − SMACK − HELL DUST − HORSE − BLACK TAR − SNOWBALL − JUNK − SKAG

https://www.livescience.com/44036-heroin.html 43

DRUG INTERACTIONS / TOXICOLOGY Drug interactions −

Benzodiazepines

Adverse Effects

−

Alcohol

− Respiratory depression

−

Other opioids

− Drowsiness

−

Anti-depressants

− Vomiting − Dizziness

Contraindications

− Dry mouth

− Pregnancy − Pediatrics

MONITORING Diacetylmorphine has a very narrow therapeutic window that needs to be closely monitored. A slight escalation of drug concentration can lead to overdose and death. The vital signs of the user should be monitored such as blood pressure, heart rate and respiratory rate to detect signs of overdose.

− Hypersensitivity to opioids

LAWS The Controlled Substances Act of 1970 declared heroin a Schedule 1 drug. The Schedule 1 classification deems diacetylmorphine to have no medicinal use as well as a high potential for abuse. The possession and sale of heroin is illegal in all 50 states in the USA.

PROFESSIONAL OPINION In my opinion, heroin should never be used because it is highly addictive and has a dangerously narrow therapeutic range, which can result in frequent overdosing and death in patients. ~ S. Foreman

https://www.belfasttelegraph.co.uk/news/northern-ireland/buying-heroinin-belfast-as-easy-as-getting-cigarettes-addict-warns-37195627.html

REFERENCES Huecker MR, Marraffa J. Heroin. [Updated 2017 Jun 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441876/. Accessed October 13, 2018.

The University of Arizona. Methoide. Available from: https://methoide.fcm.arizona.edu/infocenter/index.cfm?stid=174. Accessed October 13, 2018 National Institute of Health. Heroin. Available from: https://www.drugabuse.gov/publications/drugfacts/heroin. Accessed October 12, 2018.

PubChem. Diamorphine. Available from: https://pubchem.ncbi.nlm.nih.gov/compound/Diacetylmorphine#section=T ophttps://pubchem.ncbi.nlm.nih.gov/compound/Diacetylmorphine#section =Top. Accessed October 12, 2018. − −

44

Luke Fosbrink

Student pharmacist

Common names

Fall 2018

Benadryl, DPH

Pharmacology/Drug Effects

https://www.erowid.org/pharms/show_image.php? i=diphenhydramine/diphenhydramine_capsule__i2013e0076_disp.jpg

Background

Diphenhydramine works by blocking histamine, which your body makes during an allergic reaction.

It also blocks acetylcholine, Originally marketed as an which is the cause of watery over-the-counter antihistamine eye and runny nose symptoms. with sedative effects in 1946.

Abusers of diphenhydramine Can be found in both OTC and are said to experience visual prescription drugs used to treat distortions, auditory allergy symptoms, insomnia, hallucinations, loss of motion sickness, and coordination, muscle Parkinson’s disease. relaxation, and the amiability to differentiate hallucinations from reality.

45

Drug Interactions/Toxicology Alcohol may increase the side effects of diphenhydramine, including drowsiness and dizziness.

Severe toxicity usually happens after taking one gram of diphenhydramine in adults.

Oral diphenhydramine can contain analgesics like acetaminophen or aspirin.

Professional Opinion

Laws Diphenhydramine is sold as a prescription or over-the-counter medication.

It can be found as an oral tablet, capsule, solution, topical gel, and topical cream.

Monitoring/Drug Screens Not tested for in standard or extended drug tests in the US, but can be tested for.

Excess diphenhydramine can result in false positives in tests for benzodiazepines, phencyclidine, and tricyclic antidepressants.

In my opinion, I would recommend diphenhydramine to those with allergic symptoms. However, I would inform my patients about the Diphenhydramine can be detected possible side effects of the drug and in the urine for 2-4 days after use. consequences of the abuse of diphenhy-dramine. ~ L. Fosbrink References 1. Diphenhydramine. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 14, 2018.

2. Drugs.com. Diphenhydramine. Available at: https://www.drugs.com/diphenhydramine.html. Accessed October 14, 2018.

3. Erowid. Diphenhydramine. Available at: https://www.erowid.org/pharms/diphenhydramine. Accessed October 14, 2018.

4. WebMD. Diphenhydramine Oral. Available at: https://www.webmd.com/drugs/2/drug-1428/ 46 diphenhydramine-oral/details. Accessed October 14, 2018.

What Are They?

Fall 2018 Drug Classes Used Therapeutically for Diuresis: • Loop Diuretics • Thiazides (and thiazide-like drugs) • Osmotic Diuretics

Diuretics are abused with the goal of weight loss or to clear an illicit drug from the system.

Examples: Wrestlers, boxer, horse jockeys, cyclers, body builders Peidmont Health Care. Available at: https://www.piedmont.org/livingbetter/six-reasons-why-yourscale-wont-budge.

Those with eating disorders

History

Athletes

Women with idiopathic edema

Who could be abusing diuretics?

1919- First diuretic discovered 1959- Development of thiazide diuretics 1962- Furosemide, a loop diuretic) was discovered 1988- Pro bodybuilder, Albert Beckles, collapses and convulses while on stage. Upon resuscitation, he was found to be suffering from diuretic-induced dehydration.

1988- Diuretics first banned by the World Anti-Doping Agency

• • • •

• • • • •

Slang

Someone looking to cheat a drug test

Water pills Pee pills Getting dry Flushing

Natural Diuretics Tea Coffee Alcohol Hibiscus Asparagus

47

Abuse Related Toxicities

Interactions and mechanism of action depend on class of diuretic. In general blood pressure, electrolytes, and hydration should be monitored.

Kidney Failure Dehydration Hyponatremia Hypokalemia Arrhythmias Hyperuricemia Seizures Cardiac Arrest Rhabdomyolisis Hypochloremic metabolic alkalosis

Drug Screens Some drug screens do test for diuretics as a masking agent for other banned substances.

Diuretics are used to dilute the urine so candidate may fail the test regardless due to the sample being too diluted.

The only legal ramifications that apply to diuretics would pertain to prescription drug fraud or cheating on a drug test. These laws vary from state to state.

Professional Opinion “Getting dry” can be very dangerous, as these athletes are already pushing their bodies to the max. Abusing diuretics is not a safe way to lose weight due to the risk of severe dehydration, electrolyte imbalance, and the associated arrhythmias.

- Merideth Fritz, Student Pharmacist

References: 1. Cadwallader AB, de la Torre X, Tieri A, Botrè F. The abuse of diuretics as performance-enhancing drugs and masking agents in sport doping: pharmacology, toxicology and analysis. British Journal of Pharmacology.

2010;161(1):1-16. doi:10.1111/j.1476-5381.2010.00789.x.

2. Forney KJ, Buchman-Schmitt JM, Keel PK, Frank GKW. The medical complications associated with purging. The International journal of eating disorders. 2016;49(3):249-259. doi:10.1002/eat.22504.

3. Francisco LL, Ferris TF. The Use and Abuse of Diuretics. Arch Intern Med. 1982;142(1):28–32. doi:10.1001/archinte.1982.00340140030008 4. Gray B. Cleen Fleet. You can be fined or jailed for cheating a drug test in many states. Available at: https://www.cleanfleet.org/2018/06/you-can-be-fined-or-jailed-for-cheating-a-drug-test-in-many-states/.

Accessed Oct 13, 2018.

5. Marteski S. ALLMax. Diuretics in bodybuilding. Available at: http://www.allmaxnutrition.com/postarticles/supplements/diuretics-in-bodybuilding-the-good-the-bad-the-tragic/. Accessed Oct 11, 2018.

6. Moser M, Feig PU. Fifty Years of Thiazide Diuretic Therapy for Hypertension. Arch Intern Med.2009;169(20):1851– 1856. doi:10.1001/archinternmed.2009.342 7. Turner M, McCrory P, Halley W. Injuries in professional horse racing in Great Britain and the Republic of Ireland during 1992–2000. British Journal of Sports Medicine. 2002;36(6):403-409. doi:10.1136/bjsm.36.6.403. Accessed Oct 12, 2018.

48

Fall 2018

Street Drug Guide: Using Drug Tests to Trace Residues Jessica Zhao, Pharmacy Student

Purdue University College of Pharmacy, West Lafayette, IN

Background Drug tests were invented because of a need to keep the public safe from transporter officers that may have use being using illicit substances.1 There was also a need to test Olympic athletes on their substance use to gain unfair advantages during their events.2 After the Vietnam War, the US Military saw an increased use of heroin.

This prompted the launch of a largescale drug-testing frenzy.5

How do Drug Tests Work?

Slang Terms3 -

Kits Drug kit Drug test Drug tester The bane of humanity Exam

There are many different drug tests and the most common is a urine drug test (UDU).

Commonly tested for:6 - Amphetamines - Barbiturates - Benzodiazepines - Cocaine - Marijuana

-

Methadone Methamphetamines Opioids PCP

*The common “5 Panel Drug Test” consists of marijuana, cocaine,

Examples of Drug Tests

• 1988 Drug-Free Workplace Act4 Requires federal contractors and all federal workers to agree that they will provide a drug-free environment as a precondition before receiving a grant from the Federal agency

PCP, opiates, and amphetamines. 7

Common methods utilized to detect traces7 - Immunoassay - Gas chromatography-mass spectrometry (GC-MS test) What types of samples are obtained?7 -

• 1991 Omnibus Transportation Act1 Required mandatory drug testing to all federally-regulated employees and individuals employed by DOT (Department of Transportation) Source: www.walgreens.com

Urine Blood Saliva Hair

49

Monitoring for Admitted Patients8 Patient Monitoring - Collect urine specimen from newly admitted patient - Confirm and collect information on substance use history - Identify whether patient is currently intoxicated or not - Frequent monitoring required (every 3 days for first week of treatment) - After stabilization in treatment, patients will decrease frequency of randomized testing - Patients need proper education of effects with OTC medications

Collection Procedures and Policies - Provides a sink that is separate from toilet (discourage dilute samples) - Provide area for clients to leave coats/personal belongings outside of bathroom

Handling and Storage - Appropriate storage and handling of the urine sample (clean and tamper proof) - Specimen needs to be kept cool/refrigerated until analyzed

Urine Testing Techniques - EMIT test, fluorescent polarization immunoassay, radioimmunoassay (RIA), kinetic interaction of microparticles, thin-layer chromatography (TLC)

Law

Limitations of toxicology8

Professional Opinion

There is no federal law that regulates drug testing in private sectors. There are state-by-state regulations.9

Urine: detects only recent use Breath (alcohol): short detection times Saliva: oral cavity is easily contaminated Blood: highly invasive method Hair: no dose-response relation Sweat: high potential for contamination

Drug tests should be utilized in patients recovering in treatment to evaluate progression of therapy.

Example of per State Law (Ohio)9

In work forces, I believe that drug tests should be based on the employment field.

References 1.

Urban Dictionary. Drug tests. Available at: https://www.urbandictionary.com/define.php?term=Drug%20test. Accessed October 9, 2018.

2.

Joyce C. Test Vault. Available at: http://thetestvault.com/brief-history-drug-testing/. Accessed October 9, 2018.

3.

Truesdail Laboratories, INC. History of Drug Testing. Available at: http://www.truesdail.com/drug-testing-history/. Accessed October 9, 2018.

4.

Drug-Free Workplace Act of 1988. US Department of Labor. Available at: https://webapps.dol.gov/elaws/asp/drugfree/screen4.htm. Accessed October 9, 2018 5.

Russel J. Confirm Biosciences. Industry News: History of Workplace Drug Testing in the U.S. Available at: https://www.confirmbiosciences.com/knowledge/blog/industry-news-history-workplace-drug-testing-u-s/. Accessed October 9, 2018.

6.

Healthline. Urine Drug Test. Available at: https://www.google.com/search?q=how+does+a+urine+drug+test+work&oq=how+does+a+urine+drug+test+work&aqs=chrome..69i57j0l4.4692j0j4&sourceid=chrome&ie=UTF-8. Accessed October 9, 2018.

7.

Drugs.com. Drug Testing FAQs. Available at: https://www.drugs.com/article/drug-testing.html. Accessed October 9, 2018.

8.

Center for Substance Abuse Treatment. Appendix B. Urine Collection and Testing Procedures and Alternative Methods for Monitoring Drug . Substance Abuse and Mental Health Services Administration 2006.

9.

ACLU. State-by-state workplace drug testing laws. Table 410. Available at: https://www.aclu.org/other/state-state-workplace-drug-testing-laws. Accessed October 9, 2018.

50

Drug Test Deterrents Trenton Myers, Student pharmacist Fall 2018 History -

President Ronald Reagan instituted drug test for federal jobs in the 1980’s.

Thousands of private companies followed suit.

Now a regular test before a new job or for many sports teams.

The Law -

No federal laws against cheating a drug test.

Over a dozen states have come up with anti-drug test cheating laws.

Texas made it a misdemeanor to cheat.

South Carolina gives a fine up to $5,000 and/or three years in prison.

North Carolina considers it a class 1 felony to get caught cheating two times.

https://drugtestsinbulk.com/blog/best-way-tostart-drug-testing-in-my-company/

What can drug tests detect?

-

Alcohol - Marijuana Cocaine - Opiates Amphetamines - PCP Anabolic Steroids - Ecstasy Benzodiazepines - Barbiturates Hallucinogenic Drugs - Inhalants Methamphetamine

Ways to Alter a Hair or Saliva Drug Test

- New saliva will have less drug in it than the old, allowing one to possibly pass the test. - Ways to beat: 1. Stop the drug 72 hours in advance. (drug metabolites will not stay in the saliva for very long.) 2. Create new saliva. (Drinking lots of water, chewing gum, and sucking on sour candies all do this. New Saliva will not have as much drug in it.)

- Hair tests look for prolonged usage of a drug. If only a small amount used once, user should be good.

- Ways to beat it: 1. Shave off hair. (The hair will be too short to test but they will probably get it from another site.) 2. Try a detox shampoo. (most have been shown ineffective. They try to remove all toxins from your strands.) 3. Use home chemicals. (Most chemicals are very toxic and could damage your scalp/face. Also not shown to work well.)

51

Ways to Alter a Urine Drug Test 1. Dilution

3. Synthetics

- Most common way to cheat a test.

- Drink eight glasses of water or more, until urine is clear. Then take B- vitamins to add color back to urine.

- Does work, but “testers are prepared for dilution” and will fail the sample right away.

- They test the creatinine in the urine. If this is outside the normal limits they also check the specific gravity of the sample.

- Titled the hardest way to cheat the system.

- Need to smuggle in clean urine, use a pre-mix sample, or use a prosthetic penis which can be purchased online.

- Is actual urine, but temperature is checked. Urine needs to be kept close to body to ensure it stays warm or as close to body temperature as possible.

2. Detox Drinks

4. Home Agents

- Common agent used but often very expensive. Most can be purchased online.

- You have to drink them a couple of hours before the test and then you only have a certain gap to take the test.

- Have been proven to work, but some make the urine a highlighter color which could be suspicious.

- Commonly use vinegar, lemon juice, or drain cleaning products.

- Work by changing the pH of your urine.

- Almost all do actually work, but drug testers aren’t worried about these products. They state that they are very easy to detect which renders the sample contaminated.

Professional Opinion Since there are many repercussions for trying to trick a drug test, I would never recommend any patient try these methods. – Trenton Myers

References: 1.

2.

3.

4.

WebMD. Drug-test cheats try new tricks on labs. Available at: https://www.webmd.com/mentalhealth/addiction/news/20080728/drug-test-cheats-try-new-tricks-on-labs#2. Accessed October 3, 2018.

Nick Leftley. MAXIM. How to cheat a drug test: 5 tips for cleaning up your pee. Available at: https://www.maxim.com/maxim-man/how-cheat-drug-test-5-tips-cleaning-your-pee. Accessed October 3, 2018.

Next Generation Village. Drug testing to confirm or disprove suspicions of drug use. Available at: https://www.nextgenerationvillage.com/blog/drug-testing/. Accessed October 3, 2018.

Brian Gray. CleanFleet. You can be fined or jailed for cheating a drug test in many states. Available at: https://www.cleanfleet.org/2018/06/you-can-be-fined-or-jailed-for-cheating-a-drug-test-in-many-states/.

52

FENTANYL Seth Garries, Student pharmacist October 12th, 2018

Fentanyl is a synthetic opioid analgesic that was originally synthesized in 1959 by Janssen Pharmaceutica. It is a popular medication used to control chronic pain as well as for anesthesia. It is popular in the black market due to its low cost, ease of access, and high potency.

https://www.google.com/ url?sa=i&rct=j&q=&esrc=s

Slang Terms Fent Apache China Town China White He-Man Lollipop King Ivory

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source =images&cd=&cad=rja&uact=8&ved=2ahUKEwje-

Pharmacology The drug acts as an agonist on the opioid-mu receptors in the CNS causing analgesia, mood alterations, euphoria, dysphoria, and drowsiness.

Fentanyl is indicated for breakthrough cancer pain, general anesthesia, postoperative pain, and as a regional anesthetic when given as a transdermal patch.

Side effects include anemia, respiratory depression, confusion, somnolence, and N/V/D

53

Drug Interactions Fentanyl is contraindicated in combination with mu-opioid antagonists, safinamide, amifampridine, nalmefene, and mifepristone. Fentanyl may also be present in breast milk. Ingestion of ethanol may result in increased risk of respiratory depression.

Toxicology Misuse of intravenous fentanyl can result in rapid death due to respiratory depression. Intentional misuse of transdermal or buccal formulations (cutting them apart to snort, chew or inhale them) leads to rapid absorption of the drug and increases likelihood of fatal toxicity.

Laws

In the United States, fentanyl is listed as a C2 drug. Possession of 40-399 grams will lead to at least five years in

prison and a five million dollar fine.

Possession of >400g will result in at least 10 years in prison and 10 million in fines. Any illegal possession can lead to a year in prison or $1000 in

Monitoring and Drug Screens Immunoassay screens are commercially available to test for fentanyl in urine samples. To confirm this positive result, labs can use gas chromatography or mass spectrometry. This leads to a verified presence of fentanyl in the system and can lead to prosecution.

fines.

In my professional opinion, fentanyl is one of the drugs that we need to regulate the tightest. It’s commonly used to lace heroin products, which leads to thousands of overdoses yearly. Much of this fentanyl comes from China, and is picked up on west coast shores. Its use in the future is certainly something to watch closely. ~ S. Garries References

1)

Fentanyl Citrate. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at http:// micromedexsolutions.com. Accesed October 13th, 2018

2)

Fentanyl and Fentanyl Derivatives Drug Slang/Code Words. MPR. Available at https://www.empr.com/drug-slang-code-words/fentanyl-and-fentanyl-derivatives-drug-slangcode-words/ article/680892/. Accessed October 13th, 2018

3)

Fentanyl Drug Information. Redwood Toxicology Laboratory. Available at https://www.redwoodtoxicology.com/resources/drug_info/fentanyl. Accessed October 13th, 2018.

4)

Federal Drug Laws. Food and Drug Adminstration. Available at https://spu.edu/~/media/universityleadership/student-life/Summary.ashx. Accessed October 13th, 2018.

54

Flakka

Paige GILK,Student Pharmacist, Fall 2018

History

continued to grow in popularity from 2013-2015.

The chemical compound was patented in 1967.

The street drug ,flakka, was first brought to light when cases of bizarre behavior and delirium was reported in South Florida in 2010. The drug

Flakka​.;2015.Avaliable at: ​https://www.teenchallengeusa.com/wp-content/uploads/2015/04/Flakka-2-530x225.jpg​. Accessed October 5, 2018.

Slang terms ❖ ❖ ❖ ❖

La flaca Gravel Flakk Flock

Blu Pro​.;2018. Available at:​https://www.blu.com/en/US/e-cigs/blu-pro-kit-us.html​.Accessed October 5, 2018.

Pharmacology

Flakka is a cathinone with the brand name of alpha-pyrrolidinophenone (alpha-PVP). It’s a novel synthetic psychoactive stimulant that is often compared to bath salts. Flakka is available as a solution or a powder and can be eaten,injected,smoked,or snorted.Vaping significantly increases the effects of flakka and can lead to death. The drug produces similar effects to methamphetamine and cocaine combined however, the euphoria lasts longer than cocaine and meth.

Signs and symptoms: symptoms: ❖ Increase body temperature ❖ Increase blood pressure ❖ Bizarre behavior ❖ Agitation ❖ Paranoia ❖ Delusions of superhuman strength!

De Troya, E. ​Hulk​ .;2016. Avaliable at: https://www.medicaldaily.com/science-behind-adrenaline-and-why-it-wont-give-you-super-strength-369624​. Accessed October 5, 2018.

55

Complications: Complications:

"excited delirium”-medical emergency. Consists of an extreme struggle from the patient and can result in hyperthermia.This can then lead to metabolic issues which leads to rhabdomyolysis and dehydration. The proteins released during rhabdomyolysis and the dehydration can affect kidney function and ultimately lead to renal failure and death.

Withdrawal symptoms:​ symptoms:​ ​Anxiety,depression,sleep problems,tremors

Drug interactions & toxicology: ❖ Often when toxicology reports are run in the ER on people who reported using flakka the results come back indicating other stimulants. ❖ The half-life in humans is unknown which can affect the accuracy of toxicology reports. ❖ No known drug interactions. Avoid additional stimulants.

Laws ❖ Schedule 1 drug by the dea ❖ Illegal ❖ No acceptable medical use and high potential for abuse.

Monitoring/drug screens: ❖ A standard urine drug test kit does not detect synthetic cathinones found in alpha- pvp. ❖ bath salt drug test kit or Novel Psychoactive Substances (NPS) urine drug test. ❖ The cut-off for Alpha-PVP is 2.0 ng/ml and has a detection time of 1-3 days after drug consumption. ❖ Monitor blood pressure,mental status, and renal function.

Professional opinion I believe flakka is a dangerous drug that can cause extreme harm to the user and others. I support this drug being illegal and every effort should be made to keep this drug off the streets. I would not recommend anyone to use this substance. ~ P. Gilk

References Castellanos D,Menendez B,Logan BK, et al.“Flakka” Intoxication: What have We Learned?. ​Journal of Drug Abuse 2018;4(1:4):1-6.DOI:10.21767/2471-853X.100071.

Cunha JP .MedicineNet. Flakka. Available at: https://www.medicinenet.com/flakka/article.htm#what_is_flakka_what_are_the_signs_and_symptoms_of_flakka_abuse​. Accessed October 5,2018.

Drug Policy Alliance. Fact Sheet: Synthetic Cathinones. Available at: http://www.drugpolicy.org/sites/default/files/DPA_Fact_Sheet_Synthetic_Cathinones_%28June%202016%29.pdf​. Accessed October 5, 2018.

Confirm Biosciences. Flakka. Avaliable at: ​https://www.confirmbiosciences.com/knowledge/drug-facts/flakka/​. Accessed October 5, 2018.

56

Slang Terms Neurontin

Gabbies

Johnnies

Morontin

History • Introduced in 1993 • Generic since 2004 • Originally favored due to being a non-opioid treatment for pain relief • It was thought to have a low abuse profile

Background: - FDA approved for: - Off-label uses: - Low cost (a 300 mg tablet goes for 75 cents) - Doses range from 100 mg to 800 mg - Available as a capsule, tablet, or an oral solution - Does produce withdrawl symptoms due to physical dependence, must be tapered off - Has strong side effects o some of these include: drowsiness, dizziness, weakness, headache, blurry/doubled vision, memory problems, nausea, uncontrolled eye movements Pharmacology/drug effects - Involved with the GABA neurotransmitter - Gabapentin works by potentiating the inhibitory signaling of GABA and reducing the neural excitation associated with glutamate activity. As a result, it also reduces signals for pain, agitation, and anxiety.

- Acts as a sedative (gives a drowsy sensation) - Half life is 5-7 hours Aubrey Glazik

Student pharmacist

Fall 2018

57

Drug interactions/Toxicology: - Takes with opioids to make opioids feel stronger. When taken together, euphoria is enhanced - Signs of toxicity/abuse are rash, itching, swelling of the face or mouth, hoarseness, difficulty swallowing or breathing and seizures Patient counseling points: - alcohol worsens side effects (enhanced sedation) - do not take if pregnant - must be tapered on and off - separate from taking aluminum and magnesium - do not drive or operate machinery until it is know how gabapentin affects the patient Laws - Requires a prescription - Not a controlled drug - Legal penalties are associated with using or sharing prescription drugs

Monitoring

- Monitor for emergence or worsening of depression, suicidality, and/or any unusual behavioral or mood changes - Beers Criteria drug - must use caution in older adults - Clinical trials data do not indicate that routine monitoring of clinical laboratory parameters is necessary for the safe use of gabapentin.

How it is commonly abused as a street drug: -taken along with opioids

WHY it is commonly abused as a street drug: - enhances opioid euphoria -not controlled and commonly prescribed makes it readily available -low cost

Professional opinion My professional opinion is to refrain from prescribing gabapentin, until other options have been tried.

Due to the potential side effects, physical dependence, and the abuse potential. I also think that gabapentin should be considered for making it a controlled drug. I believe this because pregabalin, which is a drug extremely similar to gabapentin, is a schedule 5 controlled substance. ~ A. Glazik References 1. Gabapentin. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 13, 2018.

2. Med Shadow. Gabapentin’s Secret: The Drug Opioid Abusers Crave. Available at: https://medshadow.org/features/gabapentin-opioid/. Accessed October 13, 2018.

3. American Addiction Centers. Gabapentin: Withdrawal Symptoms, Abuse & Use in Drug & Alcohol Detox. Available at: https://americanaddictioncenters.org/addiction-medications/gabapentin/#treatment. Accessed October 13, 2018.

4. American Addiction Centers. Is Neurontin (Gabapentin) a Drug of Abuse? Available at: https://americanaddictioncenters.org/neurontin-abuse/. Accessed October 13, 2018.

58

Max Daly. VICE. Available at: https://www.vice.com/en_uk/article/qbxexv/dark-side-of-ghb-narcomania003. Accessed October 13, 2018.

59

Monitoring

• • •

Mental status changes/suicidal ideation Body temperature and hydration levels Heart rate and respiratory rate

Drug Screens

• •

GHB is also a naturally produced substance in the body (precursor to GABA). Blood levels can be tested to determine if concentrations are higher than normal.

In 2016, UK scientists developed a saliva test for victims of its potential “date rape drug” capabilities.

Law

Currently a C-III substance only when in its therapeutic form (sodium oxybate); otherwise, it is classified as C-I. Professional Opinion

Due to its serious side effect profile, I would not recommend use of this substance therapeutically unless other first-line anti-narcoleptic agents have failed. Also, under no circumstance would I recommend its recreational use. ~ M. Haile References 1.

2.

3.

4.

5.

Max Daly. VICE. Available at: https://www.vice.com/en_uk/article/qbxexv/dark-side-of-ghb-narcomania003. Accessed October 13, 2018.

GHB structure. Drugs-Forum. Available at: https://drugs-forum.com/media/ghb-structure.5974. Accessed October 13, 2018.

GHB. CESAR. Available at: http://www.cesar.umd.edu/cesar/drugs/ghb.asp. Accessed October 12, 2018.

New spit test for ‘date rape’ drug developed in the UK. BBC. Available at: http://www.bbc.co.uk/newsbeat/article/35262515/new-spit-test-for-date-rape-drug-developed-in-theuk. Accessed October 12, 2018.

Label for SODIUM OXYBATE. FDA. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/202090lbl.pdf. Accessed October 12, 2018.

60

HASHISH Sarah Harding | Student Pharmacist | Fall 2018

PHARMACOLOGY

SLANG -­‐ Hash

-­‐ - Potent form of cannabis (similar to marijuana) made from compressed trichomes, fine growths on cannabis plants -­‐ - Acts on cannabinoid type 1 and 2 receptors found in the adrenal gland, heart, liver, lung, vascular endothelial and immune tissues -­‐ - Active ingredient is THC (higher concentrations than marijuana)

-­‐ Blonde -­‐ Brick -­‐ Soap bar -­‐ # (used in texting)

HISTORY

-­‐ - Smoked or orally ingested - Effects will pass in 2-3 hours, but can last up to 24 hours

-­‐ 1123 CE: term hashish is first published in Cairo -­‐ 1500s: smoking became common consumption method -­‐ 1700s: arrives in Europe -­‐ 1880-1900: peak medicinal use in Europe and US

Weinberg B. https://hightimes.com/news/syrian-­‐hashish-­‐harvest-­‐workers-­‐stranded-­‐in-­‐lebanon/

-­‐ 1961: use as medicine is prohibited worldwide by UN 61

DRUG INTERACTIONS/TOXICOLOGY Drug Interactions: -­‐ Alcohol

Side Effects: -­‐ ↑ heart rate

-­‐ Anticholinergics

-­‐ ↓ blood pressure

-­‐ CNS depressants

-­‐ ↑ appetite

-­‐ Cocaine

-­‐ drowsiness

-­‐ CYP1A2 substrates

-­‐ altered mood/sensations

-­‐ CYP2C9 inhibitors

I would not recommend hashish for any use due to its class schedule and side effects. ~ S. Harding

-­‐ paranoia

-­‐ CYP3A4 inducers/inhibitors -­‐ St. John’s wort

Professional Opinion:

Contraindications: -­‐ pregnancy Shinwari, SA. Use of hashish among educated youth on the rise. DAWN. https://www.dawn.com/news/1261359

LAW: schedule 1 in US – illegal to manufacture, possess, use, or distribute

DRUG SCREENS: THC can be detected in urine rapid test anywhere from 2-60 days after last use References: 1. Hashish. Drugs.com. https://www.drugs.com/illicit/hashish.html. Accessed October 14, 2018.

2. How Long Does Hash Stay in Your System? Very Well Mind. https://www.verywellmind.com/how-­‐long-­‐does-­‐hash-­‐ stay-­‐in-­‐your-­‐system-­‐80261. Accessed October 14, 2018.

3. Cannabis. Drug Facts and Comparisons. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.factsandcomparisons.com. Accessed October 14, 2018.

4. THC urine test (cannabis). PharmaDrugtest. https://www.pharmadrugtest.com/urine-­‐drug-­‐tests/10-­‐cannabis-­‐thc-­‐ 62 test.html. Accessed October 14, 2018.

Heroin Ishmum Hasan Student Pharmacist Fall 2018 History/Background • Opium is derived from opium poppies, which dates back to the ancient civilizations in 3400 BC 7 • Morphine was synthesized from opium in the 1800s to relieve pain in cancer, spasms, tetanus and pain attendant to menstruation and childbirth 7 • Heroin was synthesized from morphine in 1874 to replace morphine due to morphine abuse 7 • Heroin was eventually turned out to be as highly addictive as morphine, and was officially classified as illegal drug in United States in 1924 7

Figure 1: Opium poppies are currently grown in many Asian countries, especially in Afghanistan1

Slang terms

Figure 2: Street names of heroin have been created and modified to obscure sales and trades from law enforcements3

• Illegal form of heroin was first available on the streets supplied from China, referred as “China White” 3 • The street name was popularized in a way to disguise heroin transaction between dealers, users and distributers 3 • Smack, Tar, Brown Sugar, He, Snow/Snowball, Scat/Skunk are some of the most common slang terms for Heroin used in the streets 8

Pharmacology/Drug Effects • Compared to morphine, heroine crosses the blood brain barrier 10 times more effectively. This high level of potency allows rapid entry of heroin into the brain 7 • 6-Acetyl-Morphine (6AM) is the main metabolite of heroine, which binds to the opioid receptors in the brain 7 • Opioids (in general) change neurochemical activity in the brain stem causing depression in breathing. It also increases in feelings of pleasure in the limbic system and block pain signals sent to the spinal cords 7

Figure 3: Heroin overdose and death is a public health epidemic many countries are currently facing463

Drug Interaction/Toxicology

Figure 4: Most common administration of heroin is via injection. Some even snort, smoke, or swallow heroine to avoid needle uses 2

• Diacetylmorphine (heroin), an opioid agonist, rapidly converts into to morphine. This rapid onset and potency results euphoria 9 • The most common drug interaction with heroin is benzodiazepine, which increases the sedative and respiratory depressants of heroin 9 • This combination increases the risk of overdose than any other combination of drugs 9

Laws • The laws and penalties for possession of heroin depends on the state, but most states have similar laws 5 • It is sometimes difficult to prove whether the defendant is an actual owner or a constructive owner of heroin 5 • In Florida, possession of heroin is a third degree felony which can be combination of the following punishments: minimum 5 years in prison, 5 years of probation, and/or $5000 fine 5

Figure 2: Heroin procession, whether actual or constructive, can lead to serious charges5

Monitoring/Drug Screening

Figure 2: 6AM metabolite is the best way to screen for heroin usage 6

• The standard five-panel urine test is used to test for opiates, but it is very difficult to determine whether positive test for heroin or other legal or illegal opioids6 • Heroine is very rapidly metabolized to 6AM metabolite, which is unique metabolite of heroin (morphine nor codeine can produce this metabolite) 6 • 6AM is most commonly tested for heroin screening through urine test 6

Professional Opinion The heroin addiction, overdose, and death is uprising in many regions in the world. It is public health epidemic that has been tormenting careers, reputations and relationships of many users. The addiction of heroin cannot be solved overnight, but new ideas such as the needle exchange programs are preventing overdose death of heroin use. Although many may argue that these programs enable heroin use, a short-term solution that saves many lives is better than doing nothing about this crisis. ~ I. Hasan

References 1.

2.

3.

4.

5.

6.

7.

8.

9.

McDonald D. Vice. What is the Future of British Heroin Addiction? Available at: https://www.vice.com/da/article/5gwxy8/what-does-this-yearsbumper-opium-crop-mean-for-british-junkies Accessed October 13, 2018 Vibes J. The Free Thought Project. How the War on Drugs is to Blame for Recent Spikes in Heroin Overdoses. Available at: http://thefreethoughtproject.com/prohibition-blame-deadly-fentanyl-laced-heroin-spike-deaths/ Accessed October 13, 2018 An American Addiction Centers Resources. Heroin Street Names. Available at: https://heroin.net/about/street-names-for-heroin/ Accessed October 13, 2018 Live Science. Heroin Facts: Effects, Addiction & Treatment. Available at: https://www.livescience.com/44036-heroin.html Accessed October 13,2018 Accessed October 13, 2018 Bottari & Doyle. Possession of Heroin in Florida. Available at: http://www.demo.matrixlatino.net/2018/01/27/possession-of-heroin-in-florida/ Accessed October 13, 2018 True Screen. Drug Testing for Heroin. Available at: https://www.truescreen.com/resource-center/occupational-health-screening/drug-testing-forheroin/ Accessed October 13, 2018 Methoide. Heroin Overview. Available at: https://methoide.fcm.arizona.edu/infocenter/index.cfm?stid=174 Accessed October 13, 2018 Casa Palmera. Nicknames, Street Names and Slang for Heroin. Available at: https://casapalmera.com/blog/nicknames-street-names-and-slang64 for-heroin/ Accessed October 13, 2018 Podiatry Today. Drug Interactions and Opioids. What You Should Know. Available at: https://www.podiatrytoday.com/drug-interactions-andopioids-what-you-should-know Accessed October 13, 2018

Hydrocodone Sharae Hightower Student pharmacist Fall 2018

History/Background -

-

Created in the 1920’s by a German pharmaceutical company, Knoll.

However, the FDA did not approve its use until 1943.

It was chosen as the preferable drug for pain over morphine and codeine because it was effective at eliminating pain but also had predictable side effects.

Slang Terms -

357s Norco Vikes Hydro

Pharmacology/Drug effects Hydrocodone is a semisynthetic opioid agonist that acts as a full agonist, binding to and activating opioid receptors at sites in the peri-aquaductal and peri-ventricular gray matter, the ventromedial medulla, and the spinal cord to produce analgesia. Although relatively selective for the mu-opioid receptor, it can interact with other opioid receptors at higher doses. The analgesia, as well as the euphorant, respiratory depressant, and physiologic dependence properties result because of the agonist action at the mu receptors.

65

Laws -

Hydrocodone was recently changed to schedule II drug Patients are limited to a single 90-day supply No refills Written prescriptions only In some states only physicians will be able to prescribe them Pharmacies will be subject to increased controls and recordkeeping on drugs If caught in possession of hydrocodone without a prescription, it is a felony charge because it is a narcotic.

- The amount of time faced by charge is dependent upon the amount found in possession

Drug Interactions - Opiod analgesics/naltrexone - Alfentanil; fentanyl; hydrocodone; oxycodone - Agents that may cause respiratory depression/sodium oxybate

Monitoring/Drug Screens - There are drug screens for hydrocodone.

- However, the drug is cleared out of the body in about 3-4 days, so the detection rates for hydrocodone are extremely low

Professional Opinion I believe that hydrocodone definitely has a place in therapy for the people who experience chronic pain and cannot get relief from any other agents or patients experiencing severe acute pain. However, the drug should have never just been overprescribed the way that has been in recent years because of the high potential for abuse. ~ S. Hightower References: 1. The History of Hydrocodone Addiction. Michael's House Treatment Centers. https://www.michaelshouse.com/hydrocodonerehab/history-of-hydrocodone/. Published 2018. Accessed October 13, 2018.

2. Hydrocodone Drug Slang/Code Words. Clinical Pain Advisor. https://www.clinicalpainadvisor.com/dea-drug-slang-codewords/hydrocodone-drug-slangcode-words/article/678817/. Published 2018. Accessed October 13, 2018.

3. Quest Diagnostics : Drug Testing Index™. Questdiagnostics.com. https://www.questdiagnostics.com/home/physicians/healthtrends/drug-testing.html. Published 2018. Accessed October 13, 2018.

4. Pain Medicine With Hydrocodone. Arthritis.org. https://www.arthritis.org/living-with-arthritis/treatments/medication/drugtypes/analgesics/dea-reschedules-hydrocodone.php. Published 2018. Accessed October 13, 2018.

5. Drug Possession Lawyer in Michigan | Michigan Drug Crimes Lawyer. Michigancriminalattorney.com. http://www.michigancriminalattorney.com/drug-crimes/prescription-pill-charges/possession-of-prescription-drug/. Published 2018. Accessed October 13, 2018.

66

Bhatia, Kul. Hydromorphone, Prescription Opioid. https://www.sciencesource.com/

(Dilaudid, Dilaudid-5, Exalgo, Palladone, Dilaudid-HP)4,5

Hannah Howell Student Pharmacist Fall 2018 History of hydromorphone •

1921: Synthesized in Germany and patented by pharmaceutical company, Knoll.

•

1926: Introduced into clinical practice

6

Background •

Opioid medication that is used to relieve moderate to severe pain (FDA use), as well as to relieve cancer pain (non-FDA use).

•

4,5

Street names •

Dust

•

Juice

•

Smack

•

D

•

Footballs

3

Interesting facts Naloxone is a medication that is used as an antidote for a hydromorphone overdose.3

Narcotic analgesic derived from morphine that acts on the central nervous system (CNS).

5

Pharmacology of Hydromorphone Dosage forms: •

Liquids

•

Tablets

•

•

Extended- Release tablets and capsules 4,5 o 12, 16 , 24, and 32mg strengths 3 Solutions 4,5

Oral Administration: •

Metabolism o Absorbed by small intestine

Metabolized extensively in l iver ( 62%) 3 Mechanism of Action: o

• •

Reacts with opioid receptors and alter pain reception, similar to the reaction of morphine and heroin 3 ,7

3-hydroxy-17-methyl-4,5αepoxymorphinan-6-one hydrochloride Hydromorphone. Wikipedia. https://en.wikipedia.org/wiki/ Hydromorphone

Releases large amounts of dopamine in the body, causing the person to feel a reward l ike they would when partaking in o Causes high r isk of addiction to pleasurable euphoric sensation, which can lead to addiction resulting in loss of consciousness, coma, or even 7 67

Drug Interactions & Toxicology Drug Interactions:

Side Effects:

5

•

Naltrexone

•

Benzodiazepines and other CNS depressants

•

Serotonergic/anticholinergic drugs

•

Mixed agonist/antagonist and partial agonist opioid analgesics

•

Muscle relaxants

•

Diuretics

•

Monoamine oxidase inhibitors (MAOs)

1

•

Flushed skin

•

Constipation

•

Nausea

•

Vomiting

•

Dizziness

•

Headache

•

Drowsiness

•

Low blood pressure

•

Drug withdrawal

Contraindications: Naltrexone

•

Taking with food

•

Using tobacco

•

Consuming alcohol

•

Respiratory depression

•

Acute/severe bronchial asthma

•

Gastrointestinal obstruction

1

4

Laws: • •

•

Medical Conditions: 3

Schedule-II controlled substance in the US Written prescription must include date the prescription was issued, the patient’s full name and address, the medication name, strength, and dosage form, the quantity prescribed to the patient, the directions for use, and the prescriber’s name, address, registration number, and signature.

In emergency situations, hydromorphone can be dispensed through an oral prescription for patient, but must be limited to an adequate amount. Prescription for this must say 2 “Authorization for Emergency Dispensing.”

•

The presence of certain medical problems may alter the effects of hydromorphone:

o o o o o o o o o o

Professional Opinion: I would personally recommend this medication to patients. There are no extremely severe side effects, and drug addiction can be controlled if monitored correctly. Hydromorphone is a great therapy for relieving moderate to severe pain. ~H Howell

References: 1.

2.

Gallbladder disease Head injury Obesity Severe BPH Kidney disease Liver disease

5

Blood pressure S/Sx of CNS and respiratory depression/drug abuse/reduced

Accessed

Hydromorphone. Micromedex Solutions. Truven Health Analytics Inc. Ann Arbor, MI. Hydromorphone (Oral Route). Mayo Clinic. Mayo Foundation for Medical Education and Research (MFMER), 2018. https://www.mayoclinic.org/drugs-supplements/hydromorphoneoral-route/. Accessed October 12, 2018.

Murray, Alison. Hydromorphone. Journal of Pain and Symptom Management: 29(5S), 2005.

https://www.jpsmjournal.com/article/S0885-3924(05)00033-3/pdf. Accessed October 12, 7.

Drug dependence/Alcohol abuse

•

gastric motility •

2018.

Patterson, Eric. Effects of Hydromorphone Abuse. Recovery Brands LLC. https://drugabuse.com/library/effects-hydromorphone-abuse/. Accessed October 12, 2018.

Patients with seizure disorder (risk of worsened seizure control

October 12, 2018.

6.

COPD/other lung problems

•

Hydromorphone. Drug Enforcement Administration. July 2013.

Available at: https://www-micromedexsolutions-com.ezproxy.lib.purdue.edu/. Accessed 5.

Brain tumor

Monitoring:

Gershman, Jennifer. 4 Controlled Substance Laws and Regulations You Should Know.

Pharmacy Times. July 24, 2017. https://www.pharmacytimes.com/. Accessed October 12, https://www.deadiversion.usdoj.gov/drug_chem_info/hydromorphone.pdf.

October 12, 2018.

4.

Thyroid problems

Diluadid. Rxlist. https://www.rxlist.com/dilaudid-drug.htm. Accessed October 12, 2018.

2018.

3.

5

•

•

Neonates in pregnant women (potential excess sedation/respiratory depression)

•

Renal function (kidney excretion)

1

68

Pharmacology

History Second half of the 19th century – First reports of ibogaine use in African spiritual ceremonies 1901- Chemical compound was first isolated 1930s-1960s- Ibogaine was sold as a stimulant in France 1960s- Anti-addictive effects of ibogaine was discovered by heroin addict, Howard Lotsof.

1966- Ibogaine was withdrawn from France market and deemed illegal 1985- Lotsof awarded US patent for ibgaine tablet to treat addiction 1990s- US National Institute on Drug Abuse began clinical trials for the development of Ibogaine

Ibogaine targets are NMDA, nicotinic, σ-, k-opioid, and μreceptors. Ibogaine acts on multiple transmitter sites in an antagonist function as a reducing agent, mitigating excitotoxic damage in the brain which is the mechanism of action in the antiaddictive process.

Ibogaine is quickly metabolized to noribogaine which is a potent serotonin reuptake inhibitor and full agonist of moderate k- and weak u-opioid receptors. This agonist action contributes to the psychoactive effects of ibogaine.

In low doses, ibogaine acts as a stimulant similar to cocaine and amphetamines; it increases energy and decreases fatigue. In larger doses, it has oneirogenic effects, meaning that it stimulates a dreamlike state while awake.

Ibogaine C20H26N2O 10-Methoxyibogamine

National Center for Biotechnology Information.

PubChem Compound Database. Ibogaine. https://pubchem.ncbi.nlm.nih.gov/compound/442 108. Accessed October 13, 2018.

Taylor Jones Student pharmacist Fall 2018

Ibogaine is naturally occurring in plants in the Apocynaceae family such as Tabernanthe iboga, Voacanaga Africana and Tabernaemontana undulata.

Slang: Iboga

Ketler, A. (2017, March 01). Ibogaine: A Powerful Plant That Could Kick Serious Drug & Alcohol Addictions. Retrieved from https://www.collectiveevolution.com/2017/02/21/ibogaine. Accessed 69 October 13, 2018.

69

Side effects Interactions -Anti-arrhythmic drugs such as metoprolol and propafenone -Antidepressant drugs such as citalopram and amitriptyline -Antipsychotics such as aripiprazole and haloperidol -Other drugs include amiodarone, bepridil, erythromycin, methadone, codeine, and a multitude of other drugs Interactions with these drugs can significantly contribute to cardiac complications when taken with ibogaine.

Toxicology Pre-existing heart conditions can lead to dangerous reactions with ibogaine as heart beat irregularities and irregular breathing may occur.

Ataxia, nausea, dry mouth, dizziness, and vomiting

Laws Ibogaine is illegal in the US (Schedule I) and several European countries, but is legal to possess and distribute in Brazil, Mexico, South Africa, Gabom, New Zealand, Netherlands, and Costa Rica.

Drug Screening Ibogaine does not show up on standard drug tests and would need a specific testing kit to be detected.

Monitoring Ibogaine can cause fatal cardiovascular complications, so it is important to monitor heart rate and any other breathing irregularities.

Professional Opinion I believe that with further research and in a controlled environment, there is potential for this drug to be used therapeutically as a treatment for addiction in patients without contraindications to ibogaine. ~ T. Jones

References 1. National Center for Biotechnology Information. PubChem Compound Database. Ibogaine. https://pubchem.ncbi.nlm.nih.gov/compou nd/442108. Accessed October 13, 2018.

2. Learn Everything You Need to Know About The Psychedelic Ibogaine. (n.d.). https://thethirdwave.co/psychedelics/ibogai ne/. Accessed October 13, 2018.

3. Ibogaine. (n.d.). https://www.sciencedirect.com/topics/neur oscience/ibogaine. Accessed October 13, 2018.

4. Ibogaine FAQ. (15, February 15). https://www.erowid.org/chemicals/ibogain e/ibogaine_faq.shtml. Accessed October 13, 2018.

70

70

Inhalants Josh Jovevski Student Pharmacist Fall 2018

Slang • • • • • • •

Whippets Rush Poppers Laughing gas Sniffing Huffing Bagging

History 1880- inhaled anesthesia generally accepted for child birth and surgery.

1940s- First outbreak of gasoline sniffing.

1960s- Practice of solvent sniffing (paint thinner, nail polish remover, spray paint) becomes popular.

1981- FDA states that nitrite odorants do not require regulations or restrictions.

Image available at: https://cyprus-mail.com/2018/07/27/policeconfiscate-large-stash-of-laughing-gas/.

Pharmacology • Although not fully known, it is proposed that inhalants work like alcohol to stimulate GABA receptors and inhibit NMDA receptors, which inhibit the CNS. o It is proposed that toluene inhalation leads to dopamine release, which is part of the reward and addiction pathways.

• Alkyl nitrites work differently by serving as vasodilators; hence, they are used as sexual enhancers.

• Peak plasma concentration occurs 15-30 minutes after inhalation.

• Drug effects: Dizziness, drowsiness, euphoria, depressed reflexes, slurred speech, tachycardia (nitrites), and general muscle weakness.

71

Drug Interactions and Toxicology • • • • • •

When used with other CNS depressants, inhalants can cause fatal CNS depression.

Inhaled nitrites can lead to dangerous hypotension when mixed with other vasodilators.

Sudden Sniffing Death Syndrome can result in death any time an inhalant is used.

Inhalants can cause arrhythmias and oxygen deprivation.

Chronic use can cause irreversible damage to kidneys, liver, heart, and lungs.

Use during pregnancy can lead to a condition like Fetal Alcohol Syndrome in the infant.

Laws • Inhalants are not covered by the Controlled Substances Act, but sale of potential inhalants is restricted to minors in 38 states.

• Some states have laws against using laughing gas recreationally.

Monitoring • Inhalants are not tested for in both standard and extended drug tests.

• It is unknown whether or not urine testing is possible, while it is believed hair testing does not detect inhalant use.

Professional Opinion I believe that some inhalants, like nitrous oxide, have a place in anesthetic therapy if they are responsibly administered by health care professionals.

I would not recommend recreational use of inhalants, due to exposure to harmful chemicals, long term organ damage, and the possibility of sudden death. ~ J. Joveski References 1. National Institute on Drug Abuse. Inhalants. Available at: https://www.drugabuse.gov/publications/researchreports/inhalants/what-are-unique-risks-associated-nitrite-abuse. Accessed October 13, 2018.

2. National Inhalant Prevention Coalition. About Inhalants. Available at: http://www.inhalants.org/about.htm. Accessed October 13, 2018.

3. The Vaults of Erowid. Inhalants. Available at: https://www.erowid.org/chemicals/inhalants/. Accessed October 13, 2018.

4. Medscape. Inhalants Clinical Presentation. Available at: https://emedicine.medscape.com/article/1174630-clinical.

Accessed October 13, 2018.

5. Foundation for a Drug-Free World. Inhalants. Available at: https://www.drugfreeworld.org/drugfacts/inhalants/are-theylegal.html. Accessed October 13, 2018.

72

INSULIN Karen Kandhola Student Pharmacist Fall 2018 https://biotechnologyfocus.ca/researchersdiscover-insulin-boosts-immune-system/

History: • 1869: Paul Langerhans, a medical student in Berlin, discovers the Islets of Langerhans within the pancreas.

• 1889: Oscar Minkowski and Joseph von Mering remove a dog's pancreas to study the effects on digestion. Flies are found to be feeding off the dog’s urine, which is shown to contain sugar.

• 1901: Eugene Opie discovers that the Islets of Langerhans produce insulin and that the destruction of these cells resulted in diabetes • 1921: Dr. Frederick Banting and Charles Best removed the pancreas of dogs and the dogs showed symptoms of diabetes. The pancreas was sliced and ground up and injected a few times a day which helped the dogs to regain health.

• 1922: A 14-year-old boy with type 1 diabetes named Leonard Thompson is given the first medical administration of insulin and lives for another 13 years.

• 1936: Danish physician Hans Christian Hagedorn discovers the action of insulin can be prolonged with the addition of protamine.

• 1950: NPH, an intermediate acting insulin, is marketed by Danish pharmaceutical company Novo Nordisk.

• 1982: Synthetic insulin is renamed ‘human insulin’ marking it as distinct from insulin derived from animals. Humulin, manufactured by Eli Lilly, becomes widely available through the 1980s.

• 1996: Eli Lilly markets analogue insulin lispro under the trade name Humalog.

Slang Terms: None Pharmacology/drug effects: Regular human insulin is a polypeptide hormone structurally identical to endogenous human insulin. The primary activity of insulin is regulation of glucose metabolism. Insulin binds to insulin receptors on muscle and fat cells, and lowers blood glucose by facilitating the cellular uptake of glucose. Insulin simultaneously inhibits output of glucose from the liver https://www.rxlist.com/novolin-r-drug.htm

Insulin helps athletes in two ways. In bodybuilders, it works alongside anabolic steroids such as testosterone or human growth hormone to consolidate muscle tissue. Steroids build up muscle, and insulin prevents it from being broken down.

Insulin also increases stamina in middle-distance runners and other track performers by enabling them to load their muscles with glycogen “fuel” before and between events. To do this, athletes would need to take insulin and glucose simultaneously for a couple of hours.

73

Drug interactions/toxicology: Major interactions: • Pramlintide • Metreleptin • Metoclopramide • Somatostatin alalogues • Fluoroquinolones • PPAR-g agonists • Thioctic acid

Contraindications: • During episode of hypoglycemia • Hypersensitivity to human regular insulin or any of its compounds

Adverse effects: Common: • Injection site reaction • Hypoglycemia • Lipodystrophy • Weight gain Serious: • Heart failure • Hypokalemia • Hypersensitivity reaction

Laws: • In all states new insulin analogs require a prescription.

• Older insulins such as regular insulin don’t require a prescription.

• The International Olympic Committee banned insulin use by non-diabetic athletes in 1998. https://www.chemistryworld.com/news/how-to-catch-aninsulin-doping-athlete/3001991.article

Monitoring/drug screens: Undetectable by currently available tests. Insulin is eliminated rapidly from the body and synthetic insulins can’t be differentiated from endogenously produced insulin.

Professional opinion: Insulin abuse by non-diabetics is dangerous and could increase risk of hypoglycemia, potentially resulting in coma and death. ~ K. Kandola

References: 1. Diabetes Co UK. History of Insulin. Available at: https://www.diabetes.co.uk/insulin/history-ofinsulin.html. Accessed October 13, 2018.

2. Andy Coghlan. New Scientist. Athletes may be increasingly abusing insulin. Available at: https://www.newscientist.com/article/dn1129-athletes-may-be-increasingly-abusing-insulin/.

Accessed October 13, 2018.

3. Evans PJ, Lynch RM. Insulin as a drug of abuse in body building. British Journal of Sports Medicine 2003;37(4):356-357.

4. Insulin Human Regular. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 13, 2018.

74

Ketamine

History •

Roza Karamacoski

•

Student Pharmacist •

Fall 2018

Slang • •

•

Cat Valium Cat tranquilizer K Special K Super K Vitamin K Kit Kat Purple Jet

• • • • • • •

•

•

1962: first developed by Calvin Stevens 1963: Belgium patented its use as a veterinary anesthetic 1965: determined that Ketamine could be a safe anesthetic to administer to humans 1970: federal government approved it for human use as a potent anesthetic Late 1970s & Early 1980s: abuse was prevalent across the country 1999: FDA classified Ketamine as a Schedule III drug

http://www.californiadrugabusehelp.com/blog/addiction/ketamine-addiction-and-its-associated-struggles/

Pharmacology

https://en.wikipedia.org/wiki/Ketamine#/media/ File:Ketamine.svg

•

C13H16ClNO

•

Mechanism of Action: unclear

•

It is a NMDA receptor antagonist with a potent anesthetic effect. Ketamine interacts with N-methyl-Daspartate (NMDA) receptors, opioid receptors, monoaminergic receptors, muscarinic receptors and voltage sensitive Ca ion channels.

Ketamine absorption is very rapid and the bioavailability is around 93%. After the first pass metabolism, only 17% of the administered dose is absorbed.

• •

Half life: 186 minutes

•

Toxicity: Preclinical studies related to the blocking of NMDA receptors have shown an increase in apoptosis in the developing brain which results in cognitive deficits when used for longer than three hours. Toxicity studies regarding carcinogenesis have not been performed. Regarding mutagenesis and fertility, ketamine showed to be clastogenic and to not have effects on fertility.

75

Drug interactions/toxicology

Drug Screening

Avoid: • Azelastine (Nasal) • Bromperidol • Conivaptan • Fusidic acid (Systemic) • Idelalisib • Orphenadrine • Oxomemazine • Paraldehyde • Thalidomide Contraindications: • Hypersensitivity to ketamine or any component of the formulation •

•

• • https://dancesafe.org/product/ketamine-drug-info-cards-100/

Law

Conditions in which an increase in blood pressure would be hazardous

•

Side Effects: • • • • • • • • • •

Urine Test: up to 14 days after last use.

Some research has shown it can show up to 30 days after last use.

Hair Test: months after use Blood Test: up to 24 hours after last use

Confusion Delirium Dreamlike state Excitement Hallucinations Irrational behavior Vivid imagery Bradycardia Cardiac arrhythmia Increased blood pressure

Ketamine is schedule III drug, which has a potential for abuse less than substances in Schedules I or II and abuse may lead to moderate or low physical dependence or high psychological dependence. It is illegal to possess or use ketamine outside of medical purposes, yet it is diverted and misused recreationally.

Professional Opinion Ketamine has proven to be medically beneficial as an anesthetic as long it is properly dispensed and monitored. Based off of the studies and data presented, I recommend Ketamine be used medically and monitored when appropriately determined by a physician. ~ R. Karamacoski

References

Monitoring • • • •

•

Heart rate Blood pressure Respiratory rate Cardiac function should be continuously monitored in patients with increased blood pressure or cardiac decompensation Hepatotoxicity

1.

2.

3.

4.

5.

6.

7.

“Street Names for Ketamine.” Ketamine.com, ketamine.com/what-is-ketamine/street-namesfor-ketamine/. Accessed October 5, 2018.

“Ketamine | CESAR.” CESAR: Center for Substance Abuse Research, www.cesar.umd.edu/cesar/drugs/ketamine.asp. Accessed October 5, 2018.

Rachael. “Ketamine Addiction and Its Associated Struggles.” California Drug Addiction Helpline, Rachael, 8 Sept. 2015, www.californiadrugabusehelp.com/blog/addiction/ketamine-addiction-and-its-associatedstruggles/. Accessed October 5, 2018.

Ketamine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com. Accessed October 5, 2018.

“Drug Scheduling.” DEA, www.dea.gov/drug-scheduling. Accessed October 5, 2018.

“Ketamine Injection - FDA Prescribing Information, Side Effects and Uses.” Drugs.com, Drugs.com, www.drugs.com/pro/ketamine-injection.html. Accessed October 5, 2018.

Knapp, Emily. “Ketamine How Long Does It Stay In Your System?” The Recovery Village, 25 July 2018, www.therecoveryvillage.com/ketamine-addiction/how-long-stay-in-system/#gref. 76 Accessed October 5, 2018.

KHAT Fatima Khan, Student Pharmacist Fall 2018

History Khat dates back thousands of years and is native to East Africa and the Arabian Peninsula where it’s been used as a cultural tradition in many social situations.

Drug Effects Khat is composed of both cathinone and cathine (shown on the right) which stimulate the central nervous system. Khat is very similar to amphetamines. It will increase blood pressure, state of euphoria, and produce an elated experience with increased alertness and arousal. However, it transcends into depression, irritability, anorexia and insomnia.

Also known as…

• • • • • •

Qat Chat Catha Kat Abyssinian Tea African Salad

Dosage Form: chewing leaves Dose: 100-200 g of khat leaves Onset: 1.5 – 3.5 hours Metabolism: excreted in urine (unchanged) Half Life: 1.5 hours

Khat. EMCDDA. http://www.emcdda.europa.eu/publications/drug-profiles/khat#pharmacology

77

Drug Interactions/Toxicology Interactions: Ampicillins → reduces the effectiveness of ampicillin Antihypertensives → Khat increases blood pressure, these medications won’t be as effective Contraindications: pregnancy & breast-feeding, diabetes, high blood pressure Side Effects: mood changes, increased alertness, excessive talkativeness, hyperactivity, excitement, aggressiveness, anxiety, elevated blood pressure, manic behavior, paranoia, trouble sleeping (insomnia), loss of energy (malaise), lack of concentration

Monitoring

Drug Screens

•

Diabetics must closely monitor blood sugars at least once daily

•

Rapid thin layer chromatography separation

•

Blood pressure should be evaluated and measured routinely

•

Urine drug screening

Law Cathine is a schedule IV stimulant and cathinone is a Schedule I stimulant under the Controlled Substances Act in the United States, meaning there is a high potential for abuse. It is illegal to possess, manufacture, and distribute Khat.

Professional Opinion Due to the primary components of Khat being controlled substances, posing a multitude of risks and side effects, I would not recommend the use of Khat for clinical or recreational use. – F. Khan

References 1. Khat. United States Drug Enforcement Administration. https://www.dea.gov/factsheets/khat. Accessed on October 13, 2018 2. Khat. WebMD. https://www.webmd.com/vitamins/ai/ingredientmono-536/khat.

Accessed on October 13, 2018 3. Khat Drug Profile. European Monitoring Centre for Drugs and Drug Addiction. http://www.emcdda.europa.eu/publications/drug-profiles/khat#analysis.

Accessed on October 13, 2018.

4. Effects of Cathinones Abuse. Narconon. https://www.narconon.org/drugabuse/cathinones-effects.html. Accessed on October 13, 2018.

78

KRATOM KOSTE KOCOSKI-STUDENT PHARMACIST, FALL 2018 History/Background  

A plant nati v e to Southeast Asi a In Thai land , Krat om l eav es are chewed on by workers when performing hard, physi cal work , for it acts as a sti mul ant . They al so use i t as a mood enhancer duri ng monot onous tasks.

  

1863- Kratom is used as an opium substitute in Malaysia Early 1880s: Kratom was documented by botanist Pieter Willem Korthals 1943: Thailand’s government makes it illegal to possess Kratom leaves or plant Kratom trees 1979: Thailand classifies Kratom as a Category 5 drug 2016: The CDC reports that between 2010-2015, US poison control centers received 660 reports of exposure to Kratom February 2018- FDA states that there is no evidence that Kratom is safe or effective

  

Slang terms 

Herbal speedball , Ket um , Kahuam, Ithang, Th om, Bi ak -Bi ak, Mambog

Pharmacology/Drug Effects   

 

 

Low doses of Kratom act as a stimulant, while high doses act as a sedative Mitragyna speciosa Mechanism of action o Mitragynine and 7-hydroxymitragynine, the two alkaloids mainly responsible for Kratom’s effects, are selective and full agonists of the u-opioid receptor.

Similar to opioids and used as an opium substitute Kratom is a powder o Can mix it in tea, toss it in your mouth and wash it down with a drink, mix it in yogurt, or as a capsule Duration of action: 5-6 hours Onset: 30-90 minutes

Lindell, Crystal. Everything I Learned About Using Kratom. Pain News Network. https://www.painnewsnetwork.org/stories/2018/ 9/17/everything-i-learned-about-using-kratomfor-pain. Accessed: October 14, 2018.

79

Drug interactions/Toxicology    

Drug interactions o Psychoactive substances, hydrocodone, morphine, Imodium, caffeine Side effects o Seizures, tremors, sweating, dizziness, nausea, vomiting, itching, facial flushing Long term effects o Anorexia, psychosis, hyperpigmentation Contraindications o Pregnancy/breast feeding o People with an alcohol dependence may have an increased risk of suicide o People with mental disorders may have an increased risk of suicide

Drug Screens/Monitoring    

People who have taken Kratom in the last 3-4 days… o Can fail a blood test People who have taken Kratom in the last 7 days… o Can fail a urine test There is no standard drug screening test intended towards detecting Kratom Monitor mental status changes

Law  Kratom is legal in 44 states. Indiana is one of the 6 states that Kratom is banned in.  In 2016 the DEA tried to classify Kratom as a Schedule 1 drug, but eventually withdrew its notice of intent after public outcry

Professional Opinion  I think that at low doses, Kratom is safe to use, for it can act like caffeine and may help work productivity. However, at high doses it can be used as an opioid, and for that reason I do not think it should be legal. ~ K. Kocoski References The History of Kratom. Zativo. https://www.zativo.com/blog/152-history-kratom. Accessed: October 14, 2018.

The History of Krotom. Nootroholic. https://nootroholic.com/the-history-of-kratom. Accessed: October 14, 2018.

Prozialeck, Walter, Jivan, Jateen. Pharmacology of Kratom: An Emerging Botanical Agent with Stimulant, Analgesic, and Opioid like effects. http://jaoa.org/article.aspx?articleid=2094342. Accessed: October 14, 2018.

Kratom. WebMD. https://www.webmd.com/vitamins/ai/ingredientmono-1513/kratom. Accessed: October 14, 2018.

Lindell, Crystal. Everything I Learned About Using Kratom. Pain News Network. https://www.painnewsnetwork.org/stories/2018/9/17/everything-i-learned-about-using-kratom-for-pain. Accessed: October 14, 2018.

80

Shs sss s

History

Krokodil

(desomorphine) Peter Kokkinias Student Pharmacist Fall 2018

1934: The drug was first created and patented to Lyndon Frederick Small.

1935: Roche is manufacturing the drug under the brand name Permonid.

1952: Permonid is removed from the market.

Early 2000s: Home brewing of the drug on the streets of Russia.

Slang Terms • •

Poor Man’s Heroin The “zombie” drug

Krokodil. Available at: https://lrudd.weebly.com/. Accessed October 10th, 2018.

Pharmacology • •

•

•

Assumed similar pharmacology as morphine.

The mu receptors specifically are located in the thalamus and brainstem to cause effects such as pain relief, sedation and euphoria.

The kappa receptors are in the brain stem and spinal cord causing dependence, loss of breath, pain relief, and sedation.

The delta receptors are located in the spinal cord and digestive tract causing analgesic/ antidepressant effects.

The Vaults of Erowid.

Available at: https://erowid.org/chemicals/desomorphine/ desomorphine_chemistry.shtml

81

Drug Interactions/ Toxicology • •

There is no information on drug interactions while on this medication.

Many negative side effects associated with the medication since its contraindicated in everyone.

Side Effects •

• • • • • • • •

DC Thomson Co Ltd. Scottish social workers on lookout for deadly krokodil. Available at: https://www.sundaypost.com/news/s cottish-news/scottish-social-workerson-lookout-for-deadly-krokodil/.

Rapidly followed by tissue necrosis and gangrene Scaly, gray-green dead skin forms Respiratory depression Sepsis Rotting gums and tooth loss Coronary artery rupture Motor skill impediement Slurred speech Sores/ ulcers on forehead and skull

Laws •

It is a scheduled I drug under the United States Code Controlled Substance Act and banned internationally.

Monitoring/ Screening •

The Immunalysis Opiates Direct ELISA produced the greatest cross-reactivity to be used to detect the use in patients for screening purposes.

Professional Opinion •

Under no circumstance should any individual attempt to use this medication for any purpose. ~ P. Kokkinias

References 1. Bellis, Mary. Thought Co. History of the Drug Krokodil., Available at: https://www.thoughtco.com/history-ofkrokodil-1992030. Accessed October 10, 2018.

2. DC Thomson Co Ltd. Scottish social workers on lookout for deadly krokodil. Available at: https://www.sundaypost.com/news/ scottish-news/scottish-social-workers-on-lookout-for-deadly-krokodil/. Accessed October 10, 2018.

3. Krokodil. Available at: https://lrudd.weebly.com/. Accessed October 10, 2018.

4. California Poison Control System. Krokodil. Available at: https://calpoison.org/news/krokodil. Accessed October 10th, 2018.

5. Oxford Academic. Desomorphine Screening Using Commercial Enzyme-Linked Immunosorbent Assays. Available at: https://academic.oup.com/jat/article/41/5/455/3073988. Accessed October 10, 2018

82

MORGAN KUENNING FALL 2018

Student pharmacist

S U B S T A N C E

A B U S E

O F

LAXATIVES Background EATING

DISORDERS

Some people have the common misconception that using laxatives excessively can lead to weight loss. As many as 56% of people with eating disorders abuse laxatives.

Slang Terms NONE

FOUND

There are not really any slang terms for laxatives. If you are concerned about a loved one having an eating disorder and find they have large quantities of laxatives, it is a good indicator that they need help.

Pharmacology HOW

THEY

WORK

Laxatives work by either pulling water into the stool to make them pass easier or by stimulating the colon to empty the intestine. Using laxatives after a meal will not actually promote the food to move through the body faster.

Health Risks WHEN

USED

IN

EXCESS

Dehydration Electrolyte deficiency Depression Dependence Kidney damage Heart failure

Laws OVER

THE

COUNTER

Laxative use is not regulated by law and many different brands and forms of laxatives are available in almost any grocery or drug store.

83

Monitoring WHEN

ABUSE

IS

SUSPECTED

As state before mineral and electrolyte deficiency are major concerns with laxative abuse. Thus sodium, potassium, magnesium, and phosphorous levels should all be monitored if laxative abuse is suspected.

Professional Opinion NOT

WORTH

IT

Laxative abuse causing weight loss is false and can just lead to bigger health issues in the long run. Any weight loss noticed when using laxatives is simply water which should be replaced with electrolyte rich drinks. Using laxatives can put you in the hospital, cause long term complications, and will not make you any thinner.

~ M. Kuenning

References

Everyday Health. What are Laxatives?. Available at: https://www.everydayhealth.com/laxatives/guide . Accessed October 10, 2018.

NEDA. Laxative Abuse. Available at: https://www.nationaleatingdisorders.org/learn/g eneral-information/laxative-abuse. Accessed October 10, 2018.

Eating Disorder Hope. Laxative Abuse: Side Effects and Lon-Term Health Risks. Available at: https://www.eatingdisorderhope.com/blog/laxati ve-abuse-long-term-risks. Accessed October 10, 2018.

MentalHelp. Dying to Be Thin: 7 Shocking Facts About Teen Laxative Abuse. Available at: https://www.mentalhelp.net/blogs/dying-to-bethin-7-shocking-facts-about-teen-laxativeabuse/. Accessed October 10, 2018.

Addiction Hope. Abuse of Laxatives: Signs and Symptoms. Available at: https://www.addictionhope.com/blog/abuse-oflaxatives-signs-and-symptoms/. Accessed October 10, 2018.

EATING DISORDER HELPLINE: 1-800-931-2237

84

Slang/Brand Names SARAH LAMON STUDENT PHARMACIST Fall 2018

Lopex

History -

First synthesized by Paul Janssen 1973 advertised under brand name Imodium US FDA approved December 1976 Began being sold OTC March 1988 In 2013 Imodium 2 mg tablets was added to WHO model list of essential medicines In 2015, reports of cases of extremely high-dose loperamide resulting in opioid misuse were published

Google Images

Imodium

Loperamide

FDA website

Pharmacotherapy/Drug Effects

- Synthetic antidiarrheal that is chemically related to opiates with antidiarrheal properties. It is a nonselective calcium channel blocker and binds to mu opioid receptors. It slows intestinal motility by affecting water and electrolyte movement through the bowel.

- Long acting synthetic antidiarrheal, Opioid agonist - Hepatically metabolized predominantly by oxidative N-demethylation and excreted in the bile - Average half-life of 10.8 hours - Normal dose: 8-16 mg/day - At high doses causes a mild high and relieves withdrawal symptoms to drugs such as hydrocodone, morphine, and heroine - Large doses can cause fatal cardiac events and seizures

A Poor mans methadone

Dimor

85

Google Images

85

Laws

Professional Opinion • In my professional opinion, loperamide is becoming more popularly abused due to it being cheap and OTC which makes it very accessible to users. I think that it is wise to monitor the trend of loperamide use, as well as the FDA continuing to problem solve in reducing the number of abusers. ~ S. Lamon

Drug Interactions • Desmopressin • Eluxadoline • Lumacaftor • Mifepristone • P-glycoprotein/ABCB1 inducers • QTc-prolonging agents • Ramosetron

• Is currently an OTC medication with no laws restricting the purchase of loperamide.

• FDA is looking to find ways to minimize abuse.

Monitoring • Signs of CNS toxicity in patients with hepatic impairment.

Google Images

Side Effects • • • • •

Drug Screenings • Will not show up on a traditional drug test • Requires a specific blood test to detect • Drug test companies are starting to offer specific tests to test for loperamide’s metabolites.

Dizziness Fatigue Drowsiness Constipation Dry mouth

Contraindications • Hypersensitivity • Children < 2 years old • Abdominal pain without diarrhea • Blooding or black stools • Acute dysentery

References: Crawford, Chris. “Imodium High | Dangers of Getting High on Imodium.” The Recovery Village, 20 Mar. 2018, www.therecoveryvillage.com/imodium-addiction/ imodium-high/#gref.

Loperamide, Drug Facts and Comparisons. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http:// online.factsandcomparisons.com. Accessed October 11,2018 National Center for Biotechnology Information. PubChem Compound Database; CID=3955, https://pubchem.ncbi.nlm.nih.gov/compound/3955 (accessed Oct. 13, 2018).

Wikipedia. Loperamide. Available at https://en.wikipedia.org/wiki/ Loperamide#History. Accessed October 12, 2018

86

86

Lysergic Acid Diethylamide

Slang Terms: LSD, Acid, California Sunshine, Cid, Golden Dragon, Hippie, Loony Toons, Superman, Yellow Sunshine Background/History: A chemist, Albert Hofmann, from Sandoz Pharmaceutical synthesized LSD for the first time in 1938. The hallucinogenic effects were discovered in 1943 were discovered by Hofmann when he accidentally took 25 micrograms of it. At one point, LSD was freely distributed to the public by Sandoz Pharmaceuticals for experiments and became very popular in the 1960s.

Pharmacotherapy: LSD binds to most serotonin receptor subtypes except for the 5HT3 and 5HT4 receptors. The pharmacokinetics were determined in 2015 with a small patient study. It followed first-order kinetics with a terminal half-life of 3.6 hours for up to 12 hours.

Drug Effects â&#x20AC;&#x201C; The physical effects of LSD vary from person-to-person, but common physical effects include dilated pupils, change in body temperature, loss of appetite, dry mouth and tremors. The mental effects of LSD include delusions, hallucinations, panic attacks, and depression.

87

Personal opinion: “I think the stigma with testing schedule 1 drugs in clinical trials is frowned upon especially in the views of the DEA and FDA so I don’t think there is a proper risk-benefit profile on LSD. With this being said, I think the general public should be educated on the physiological effects of LSD at their own discretion, but I would not recommend the use to patients therapeutically or recreationally. ~E.Lee

Law The DEA classifies LSD as a Schedule 1 drug in the United States. It is illegal to possess, manufacture, or distribute by law.

Drug Interactions & Toxicology Drug interactions include: monoamine oxidase inhibitors (MAOIs). Consumption of very large amounts of LSD can put patients into comatose states, along with symptoms of hyperthermia, vomiting, and respiratory problems.

Monitoring It is important to monitor blood pressure, heart rate, body temperature, and mental state.

Supportive care should be given if a LSD overdose is suspected.

Drug Screens LSD if hard to detect in standard or extended drug tests because of its elimination half-life.

Certain urine tests, Abuscreen and EMIT, can detect LSD and its metabolites in the urine.

Photo by School of Chemistry – University of Bristol

References: 1. Short- & Long-Term Effects of LSD Harmful Effects on the Body - Drug-Free World. Foundation for a Drug-Free World. https://www.drugfreeworld.org/drugfacts/lsd/ the-harmful-effects-of-lsd.html. Accessed October 8, 2018.

2. Austin P, Felix, Rebecca, Kyle, Nyx Eternal. Does LSD Show Up in a Drug Test?

Learn In This Article. The Third Wave. https://thethirdwave.co/lsd-drug-tests/.

Published December 31, 2017. Accessed October 8, 2018.

3. LSD. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://micromedexsolutions.com Accessed October 8, 2018.

4. LSD: Effects, Hazards & Extent of Use. Drugs.com.https://www.drugs.com/illicit/ lsd.html. Accessed October 8, 2018.

88

Daniel Lin Student Pharmacist Fall 2018

Name/Slang terms Scientific Name: 3,4 Methylenedioxymethamphetamine (MDMA) Slang terms: Molly, XTC, E, Ecstasy

Pharmacotherapy N-methyl-3,4-methylenedioxy-amphetamine or 3,4-methylenedioxy-methamphetamine MDMA act by increasing the net release of the monoamine neurotransmitter (serotonin, noradrenaline and, to a smaller extent, dopamine) from their respective axon terminals. MDMA does not act by directly releasing serotonin but, by binding to, and thus blocking the transporter involved in its reuptake.

• Dose: 50-150 mg • Dosage form: Tablets • Comparative to amphetamine and methamphetamine • Metabolism: CYP2D6

http://www.emcdda.europa.eu/publications/dr ug-profiles/mdma

History/Background

• 1912: Developed by German pharmaceutical company • 1970: Psychiatrists started using to enhanced communication in patient sessions • 1985: DEA declared an emergency ban on MDMA, listing it as a schedule 1 drugs • 1990: FDA approved the first human trial exploring whether MDMA could help relieve pain in terminally ill patients, as well as serve as an adjunct to psychotherapy

https://www.drugabuse.gov/public ations/drugfacts/mdmaecstasymolly

http://www.guelphpolice.ca/en/crim e-prevention-and-safety/Ecstasy-- 89 MDMA-.asp

Drug Interactions/Toxicology Contraindication Physical toxicity

Drug Interaction

•

• • • •

CYP2D6 Inhibitors

Side Effects:

Hepatic toxicity Cardiovascular toxicity Cerebral toxicity Hyperpyrexia pattern of toxicity: myoglobinuria and renal failure, liver damage, and rhabdomyolysis

• • • • • • •

Euphoria Sweating Muscle cramping Difficulty concentrating Jaw clenching/tight jaw Heightened senses Dehydration

Monitoring/Drug Screens Drug Screens:

Monitoring: • • •

• •

Heart rate, blood pressure, and CNS Monitor mental status changes Monitor for dehydration

Urine test detects the use of Ecstasy/MDMA Could cause false positive for amphetamine

Law Currently a C-1 substance in the United States; therefore, it is illegal to possess, manufacture, and distribute.

Professional Opinion MDMA and related drugs are potentially dangerous, both the acute and the chronic effects can lead to serious and even fatal toxicity. Since the main users are adolescents following the dictates of current drug fashion, physicians may need to be especially alert in this group of population. -H. Kalant

References 1.

2.

3.

4.

Ecstasy. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Hudson, OH. Available at: http://online.lexi.com. Accessed October 9, 2018.

MDMA (Ecstasy/Molly). National Institute on Drug Abuse.

Available at: https://www.drugabuse.gov/publications/drugfacts/mdmaecstasymolly. Accessed October 9, 2018.

The Pharmacology and Toxicology of “ecstasy” (MDMA) and Related Drugs. PMC. CMAJ. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC81503. Available at: https://rollsafe.org/mdma/. Accessed October 12, 2018.

MDMA (Ecstasy) Abuse. NIH. Available at: https://www.drugabuse.gov/publications/researchreports/mdma-ecstasy-abuse/what-is-the-history-of-mdma. 90 Accessed October 12, 2018.

Mescaline

History

Elise Mann, Student Pharmacist Fall 2018

-Peyote

is a spineless

cactus found in northern Mexico and southwestern United

Slang terms for Mescaline

States

-Peyote -Cactus -Buttons -Peyoto -Mesc -Devils root

-Used by natives for traditional religious rites -The rich, visual hallucinations were important to the native peyote cults https://famishedego.wordpress.com/tag/mescaline/

Pharmacology

3,4,5-trimethoxyphenethylamine

Law -In the United States, the legal use is restricted only to members of the Native American Church -It is used by some members for religious ceremonies and treatment for various



Naturally occurring exogenous phenylethylamine



Produces CNS stimulation and sympathomimetic effects



Degree of hallucinogenicity is largely determined by the methyl group in the side chain



The crown is cut from the roots and generally chewed or soaked in water to produce tea or ground into a powder



Hallucinogenic dose is approximately 0.3 to 0.5 grams and lasts about 12 hours



Has effects that are similar to LSD but less powerful

physical (joint pain, fever, wounds) and psychological ailments.

91 https://zoom50.wordpress.com/2011/04/08/peyote91 mescal-buttonlophophora-williamsii//

Drug Interactions/Toxicology Toxicity: 3.75 mg/kg can cause moderate to severe intoxication. 20-60 mg/kg may cause hypotension, bradycardia, vasodilation, and respiratory depression.

Side effects: nausea, vomiting, anxiety, paranoia, changes in vision, increased heart rate and blood pressure, psychosis Treatment: treat agitation with benzodiazepine (lorazepam 1 to 2 mg) or an antipsychotic (haloperidol 5 to 10 mg) Drug Interactions: no well-documented drug interaction; additive effects are likely with other hallucinogenic compounds or sympathomimetic drugs

MONITORING/DRUG SCREENS

Monitor Vital signs Mental status Monitor creatinine kinase in patients with prolonged agitation, seizures, or coma Routine laboratory studies are not indicated

Drug Screens Routine urine toxicology screens do not detect mescaline Qualitative analysis of a urine sample is sufficient to confirm the presence of mescaline, but the assay is not widely available.

PROFESSIONAL OPINION DUE TO THE ILLEGALITY, LACK OF THERAPEUTIC BENEFIT, AND SIDE EFFECT PROFILE, I WOULD NOT RECOMMEND THIS DRUG FOR THERAPEUTIC OR RECREATIONAL USE. ~ E. Mann

References 1.

2.

3.

4.

Mescaline (hallucinogen) Uses, Effects & Hazards. https://www.drugs.com/illicit/mescaline.htm. Accessed 1 October 2018.

Peyote: Uses, Side Effects, Interactions & Dosing. https://www.webmd.com/vitamins/ai/ingredientmono-473/peyote.

Accessed 13 Oct. 2018.

Plants- Peyote/Mescaline. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 1, 2018.

Peyote Natural Products Database. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.factsandcomparisons.com. Accessed October 13, 2018.

92

METHADONE AN OPIOID USED FOR OPIOID MAINTENANCE THERAPY

History/Background

-Methadone was developed in 1937 in Germany by scientists to solve Germany's morphine shortage problem. This medication that could be created easily from readily available materials.

-In 1941, the scientists filed an application for a patent for the substance they called Hoechst 10820 or PolamidonR. -In 1943, Methadone the German army used methadone during WWII. Bad side effects at high doses stopped the use by the German army.

- In 1947, Methadone was brought to the U.S by Eli Lilly and Company under the name DolophineR for its use in treating opioid dependence -Some say Nazi leader, Adolf Hitler, had a say in naming the drug DolophineR -In the 1970’s “adolphine” was seen as a drug name after Adolf Hitler but was never widely used.

JOSHUA MARTIN, STUDENT PHARMACIST

•

Fall 2018

Slang terms -Methadose -Dollies -Choccolate Chip Cookies -Done -Meth -Phy -Junk -Metho -Jungle Juice

Pharmacology/Drug Effects - Methadone binds to opiate receptors in the CNS, causing inhibition of ascending pain pathways, altering the perception of and response to pain. Methadone can mimic enkephalins and endorphins and inhibit the release of acetylcholine, norepinephrine, and substance P. - It is a mu-opioid receptor agonist with lower affinity than morphine, but higher intrinsic activity.

- It also acts as an NMDA receptor antagonist, where it decreases the craving for opioids and decreases tolerance.

93

Drug Interactions -­ Alcohol, Amiodarone, Benzodiazepines, Buprenorphine, Ciprofloxacin, Ketoconazole, SSRIs, Phenytoin, Rifampin -­ Contraindications: Acute bronchial asthma

Toxicology

-­ A small dose, such as one tablet, can lead to death -­ Little room between therapeutic methadone dose for an opioid tolerant person and a toxic dose with doses between 30 and 40 mg.

-­ Mu-receptor activity is responsible for the dependency, sedation, and respiratory depression (breathing emergency).

-­ Methadone prolongs the QT interval by interacting with potassium channels in the heart.

-­ Moderate toxicity: constipation, dizziness, sedation, nausea, vomiting, and lightheadedness.

-­ Severe Toxicity: seizure, respiratory depression, respiratory arrest, pulmonary edema, QT prolongation, dysrhythmias, rhabdomyolysis, coma, cardiac arrest and death.

Laws -­ Methadone is a Schedule II substance and can only be dispensed through an opioid treatment program (OTP) certified

by SAMHSA.

Monitoring/Drug screens

-­ Methadone does not produce a positive test for opiates such as morphine -­ The only way to detect methadone is to test for it specifically. This is not common.

-­ Patients taking methadone are covered under the Americans with Disabilities Act. This means that utilizing methadone cannot be used to deny employment.

Professional opinion

I support the use of methadone for maintenance and treatment programs under the supervision of a healthcare professional. Methadone is still a powerful opiate with potentially addictive qualities so patients need to be monitored closely. –Joshua Martin

References -­

-­ -­ -­ -­ -­

American Addiction Centers. What to Know About Methadone ClinicsAvailable at: https://americanaddictioncenters.org/methadone-addiction/clinic-facts/.

Accessed October 7, 2018.

MedlinePlus. Methadone. Available at: https://medlineplus.gov/druginfo/meds/a682134.html. Assessed October 6, 2018.

Methadone HydrochlorideMicromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 2, 2018.

Methadone Hydrochloride Oral. Drug Facts and Comparisons. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.factsandcomparisons.com. Assessed October 2, 2018.

SAMHSA. Methadone. Available at: https://www.samhsa.gov/medication-assisted-treatment/treatment/methadone. Assessed October 2, 2018.

National Institute on Drug Abuse. Methadone - Appropriate Use Provides Valuable Treatment for Pain and Addiction. Available at: https://www.drugabuse.gov/about-nida/directors-page/messages-director/2008/08/methadone-appropriate-use-provides-valuable-treatment-pain-addiction.

Assessed October 4, 2018.

Pictures: Drug Abuse. https://drugabuse.com/library/how-to-help-a-methadone-addict/ Methadone. https://www.narconon-suncoast.org/blog/methadone-the-wrong-solution-1-in-a-3-part-series-on-methadone-a-safe.html Methadone injections. https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2015/4/23/most-states-list-deadly-methadone-as-a-preferred-drug Opioid Therapy. https://methadonenearme.com/opioid-addiction/the-unbelievable-advantages-of-methadone-treatment

2

94

Jennifer Nguyen 2nd Year Pharmacy Student Fall 2018

METHAMPHETAMINE Street Names: meth, speed, crystal, crank, tweak, yaba, glass, sisa

Mountainside.; 2018. Available at: https://mountainside.com/img/containers/images/methamphetaminealso-known-as-crystal-meth.jpg/cf4365836ba62eff199ab2c9792b486a.jpg. Accessed October 5, 2018.

HISTORY

1919:

Amphetamine previously discovered in 1887.

Methamphetamine, a more potent form, was synthesized by Akira Ogata

1996:

Methamphetamine Control Act: strengthened criminal penalties for possession, distribution, and manufacturing

1937:

American Medical Association (AMA) approved use in treatment of narcolepsy and ADHD

1932:

Amphetamine marketed as Benzedrine®, an OTC inhaler to treat congestion

1960s:

Rise in methamphetamine use in U.S.

1939-1945:

U.S., Germany, U.K., and Japan documented use of amphetamine and methamphetamine for performance enhancement during World War II

1970:

Drug Enforcement Administration (DEA) classifies methamphetamine as a schedule II drug

2007:

Vyvance® (lisdexamfetamine dimesylate) marketed to treat ADHD

2006:

Combat Methamphetamine Epidemic Act of 2005: limits purchase of ephedrine or pseudoephedrine products to 9 grams per month

2013:

12 million people have reported trying methamphetamine at least once in lifetime

PHARMACOLOGY A sympathomimetic amine that stimulates CNS activity.

It increases blood pressure, causes bronchodilation, and stimulates respiratory activity.

Administration (in order of increasing onset): Oral → Nasal → Inhalation → Injection Duration: 3-5 hours Coming Down: 2-6 hours Normal State: up to 24 hours Dosage: - Obesity and ADHD treatment: 10-25 mg/day - Overdose can occur with 50 mg of pure drug for non-tolerant users.

Erowid.; 2007. Available at: https://www.erowid.org/chemicals/show_molecule.php? i=meth/methamphetamine_2d.jpg. Accessed October 05, 2018.

DRUG INTERACTIONS & ADVERSE EFFECTS Hypersensitivity to amphetamine class may cause anaphylactic reactions and Stevens-Johnson syndrome.

Insomnia Dry mouth Loss of appetite Seizure Myocardial infarction Sudden cardiac death

CONTRAINDICATIONS Monoamine Oxidase Inhibitors (MAOIs): Concurrent use of MAOIs can cause hypertensive crisis.

Avoid use in individuals with cardiac abnormalities.

Precaution should be exercised in patients with psychosis, as treatment may worsen symptoms.

Prior to initiating therapy, check for risk factors associated to bipolar disorder.

95

METHAMPHETAMINE CONTINUED

Erowid.; 2007. Available at: https://www.erowid.org/chemicals/show_image.php? i=meth/methamphetamine_crystals__i2016e0039_disp.jpg. Accessed October 5, 2018.

MONITORING Cardiac assessment Check mental and behavioral improvement, if used for ADHD treatment Check blood pressure and heart rate every 6-12 months

DRUG SCREENS Urine testing - Amphetamine: detectable 1-3 days after use - Methamphetamines: detectable 3-5 days after use Hair testing - Detectable 90 days after use - Detection period is shorter if hair is <1.5 inches Blood testing - Detectable 1-3 days after use - Levels over 100 ng/mL is consistent with abuse

LAW Classified as Schedule II in the U.S. - Illegal to sell without DEA license.

- Illegal to buy or possess without license or prescription Indiana Law - Level 4 felony: <5 g of drug involved - Level 3 felony: 5 g to 9.9 g of drug involved - Level 2 felony: â&#x2030;Ľ10 g of drug involved

PROFESSIONAL OPINION There is evidence of efficacy in treatment of ADHD and simple obesity. However, caution should be warranted when prescribing, as there is a high potential of abuse.

- J. Nguyen

REFERENCES 1. The Vaults of Erowid. Methamphetamine. Available at: https://www.erowid.org/chemicals/meth/. Accessed October 5, 2018.

2. Nation Institute on Drug Abuse. Methamphetamine. Available at: https://www.drugabuse.gov/publications/researchreports/methamphetamine/letter-director.

Accessed October 5, 2018.

3. Drug Enforcement Administration. Drug Scheduling. Available at: https://www.dea.gov/drug-scheduling. Accessed October 5, 2018.

4. Methamphetamine Hydrochloride. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 5, 2018.

5. State of Indiana. Meth Laws. Available at: https://www.in.gov/meth/2331.htm. Accessed October 5, 2018.

96

-

pan

-

-

·

·

·

-

-

-

97

·

·

·

· ·

·

·

·

·

·

h

·

b

h

·

r

b

p

·

·

·

~ J. Otis

· · -

-

·

-

-

-

· 98

Morning Glory (ipomoea violacea)

Naa Adokaley Pappoe, Student Pharmacist FALL 2018 HTTPS://WWW.ELEPHANTOS.COM/EN/SMART-SHOP/PSYCHEDELICS/MORNING-GLORY-SEEDS.HTML HTTP://WWW.BOTANICALSPIRIT.COM/MORNING-GLORY-IPOMOEA-TRICOLOR-BLUE-STAR-SEEDS-ORGANIC-VIABLE

History/Background Morning glory was first known in China, for its medicinal uses, due to the laxative properties of its seeds.

It was introduced to the Japanese in the 9th century, and they were the first to cultivate it as an ornamental flower. The Japanese have led the world in developing varieties. Hundreds have evolved, such as a brownish colored variant known as Danjuro, and varieties with such evocative names as “Brocade of Dawn”, “Moon in the Dusk” and “Wisteria Girl”.

It symbolized the summer in Japanese horticulture and art.

https://en.wikipedia.org/wiki/Morning_glory# https://en.wikipedia.org/wiki/Morning_glory#/media/File:Totoiriyaasagao_hiroshige.jpg

The Zapotecs used morning glory by grinding the seeds up and wrapping them in cloth and soaking it in cold water to

find out about illnesses, etc. The Aztec priests in Mexico also used morning glory seeds ritually due to their psychoactive properties. Spanish chroniclers in the mid 16th century reported on the divinatory use of these seeds. Their use continued in southern Mexico in the mid 1800’s, although it wasn’t until the 1900 that “tlitlitzin” was identified botanically as Morning Glory.

Pharmacology/Drug Effects The active constituent: d-lysergic acid amide. The seeds contain about 0.1% ergot alkaloids, including ergometrine, chanoclavine and lysergol.

The seeds of morning glory contain an intoxicating chemical similar to LSD known as LSA. LSA acts as a “psychedelic” or “hallucinogen” which can have strong mental effects.

It creates an LSD like experience that lasts for about 6 hours, but with less hallucinogenic effects. Nausea is common even with untreated seeds. It is typically less intense and causes less anxiety than LSD. Since this is used orally, the onset is affected by the last food that was ingested. On an empty stomach, the onset of effects is about an hour after ingestion, although it can be many hours before peak effects are reached. The primary effects last 6-10 hours when the seeds are taken orally. It also takes a couple of hours for the user to return to their normal psychological state.

Hallucinogenic effects include: tactile hallucinations (reported as a mild tingling sensation), visual hallucinations (especially color shifting or a sense of the world melting), auditory hallucinations, euphoria (comes in waves),

relaxation/sedation and vasoconstriction (tightening of the veins and arteries which can lead to sore muscles).

Psychedelic effects include: Thought connectivity, faster thinking, introspection, ego suppression, time distortion, thinking conceptually, enhancement of one’s current state of mind, feeling fascinated, full of awe or important and a feeling of familiarity.

LSA does not have any known toxic levels like LSD. LSA is not addictive as its counterpart LSD. The desire to consume more of the drug decreases as one uses more of it. LSD can be more appealing to some, while LSA loses its appeal after a few doses. LSA can rapidly produce physical tolerance, meaning a larger dose of the drug is required to produce the original effects. The first does of LSA begins to produce tolerance in the body and the individual must wait for about a week for the substance to metabolize completely out of the body in order for LSA to produce any pleasant/psychedelic effects in the next dose.

Slang Terms MG seeds, Tlilitzin (Aztec-seeds), Badoh negro (Plant), Piule (Mazatec), ipomoea, strawberry fields, bliss extra, druids’ fantasy, dionysus, mind broadening, BC2, mindscaping, shrooms.

Typical Dosing Threshold effects of LSA can be reached with a few as 25-50 seeds, though most recreational users find it necessary to ingest 100 and 400 seeds to reach the desired effects! (See chart and pricing, page 2) 99

Drug interactions/Toxicology

Price

Monoamine oxidase inhibitors (MAOI).

Examples are Nardil(phenelzine), Parnate (tranylcypromine), Marplan (isocarboxazid), Eldepryl (I- deprenyl) and Aurorex or Manerix (moclobemide)

When purchased in individual packets, it goes for $1-$3 for 30-50 seeds. When purchased in bulk, $15-$25 per pound.

Law Although LSA is a schedule III substance in the United States, Morning Glory seeds and plants are sold at about every nursery, garden store or botanical supply store. In practice little hassle is ever given to those who buy and ingests seeds, but extracting the active ingredient puts you in possession of a pure chemical which is illegal to possess.

Monitoring Parameters/drug screens •

• • • • • •

Affects heart rate, blood pressure and CNS Monitor mental status Monitor for muscle weakness Monitor breathing It is not tested for in standard or extended drug tests It is possible to test for in the urine (detection period unknown) It will trigger a false positive for substances such as LSD

Light Medium Strong Heavy

50-100 seeds 100-250 seeds 250-400 seeds 400+ seeds

1.5-3 grams 3-6 grams 6-10 grams 10+ grams

Varieties

Heavenly blue (most common) with highest amount of mg of alkaloid/g in seed (0.813mg/g)

https://www.highcountrygardens.com/wildflowerseeds/individual-species/ipomoea-tricolor-seedsheavenly-blue

• • •

Professional opinion

Since this drug has the potential of causing long term health effects such as gastrointestinal disorders, weakened muscles, psychological disturbances, indifference and apathy, decreased psychomotor activity and psychotic episodes, and also requires an upping of dose after the first to produce the same effect, I would not recommend this drug to be taken therapeutically or used recreationally. ~ NA Pappoe

1) Azarius. Morning Glory (Ipomoea Violacea) - Encyclopedia. Available at:https://azarius.net/encyclopedia/5/morn ing-glory-ipomoea-violacea/. Accessed October 13, 2018 2)DrugWise. Morning Glory. Available at: https://www.drugwise.org.uk/1265-2/.

Accessed October 13, 2018.

One common side effect of LSA is physical discomfort. While the drug can cause hallucinations, people who abuse morning glory seeds also experience illnesses.

Some signs of intoxication are: nausea, vomiting, diarrhea, delirium, high blood pressure, heart rate changes, cramping muscles and stomach.

• •

https://plantlust.com/plants/12147/ipomoeatricolor-wedding-bells/

References

Side effects

Warnings/Contraindication

Wedding Bells

Pearly Gates

https://www.edenbrothers.com/store/morningglory-seeds-pearly-gates.html

Liver disorders or hepatitis Pregnant women. LSA is closely related to LSD which is a Flying uterine contractor that can Saucers increase the risk of miscarriage during pregnancy Individuals currently in the midst of emotional or psychological stress in their everyday lives.

Individuals with a family history of schizophrenia or early onset of mental illness.

Do not drive or operate heavy machinery when using

3)The Vaults of Erowid. Morning Glory Seed Basics by Erowid. Available at: https://erowid.org/plants/morning_glory/ morning_glory_basics.shtml. Accessed October 13, 2018.

4)American Addiction Centers. Sunrise House. How is similar is LSA (Morning Glorty seeds) to LSD? Available at: https://sunrisehouse.com/herbal-drugs/lsamorning-glory-seeds/. Accessed October 13, 2018.

5)Drugs and Alcohol Information and Support. Drugs.ie. Available at:http://www.drugs.ie/drugtypes/drug/mo rning_glory_halluucinogen. Accessed October 13, 2018.

https://www.myseedneeds.com/products/flyingsaucers-morning-glory

100

Muscle Relaxers Maria Tordi Student pharmacist Fall 2018

History/Background Muscle relaxers play a big role in anesthesia. The paralyzing effect was first used in the 16th century of some Indian poisons. The active alkaloids of curare were discovered in the 20th century after the paralyzing effect was clinically used in the 18th century. When synthetic production came about, curare became part of the anesthesia routine. This is where the use of muscle relaxers occurred.

Anderson, L. (2018). Flexeril (cyclobenzaprine): How to Safely Use This Muscle Relaxant. Drugs.com. Available at: https://www.drugs.com/slideshow/flexeril-cyclobenzaprinemuscle-relaxants-1266 Accessed 14 Oct. 2018..

Slang Terms • • • • • • •

Mellow yellow Cyclone Moggies Vallies Jellies Blues Yellows

Pharmacology/Drug Effects Muscle relaxers work to cause the muscles to feel less tense. Most of these drugs work by acting on the central nervous system or even directly on the muscle. The specific drugs that work directly on muscles have fewer side effects than the ones that work on the central nervous system. Muscle relaxers relieve pain and discomfort in patients. Some are scheduled due to abuse such as Valium. Valium is a schedule IV drug due to its potential for abuse.

101

Drug Interactions/Toxicology Drug Interactions: • • • • •

MAOI Bupropion Guanethidine Antihistamines Alcohol

Contraindications: • • • • •

Seizures Liver diseases Myasthenia gravis Epilepsy MI and CHF

Side Effects: • • • • •

Drowsiness Light headedness Fainting Blurred vision Nausea

Monitoring Liver functioning tests should be done when using muscle relaxers. It is importing to monitor how well the liver is functioning due to its effects on the liver.

Drug Screening Most drug tests don’t target muscle relaxers. Usually only the scheduled muscle relaxers, like cyclobenzaprine, are targeted and detected by a comprehensive drug screening. These are not shown on a typical urine test.

Laws Muscle relaxers are legal for the use of tense muscle and muscle spasms.

These are prescribed by a doctor.

Professional Opinion: I believe muscle relaxers are beneficial for prescription to patients that show to have muscle pain. I feel that there is scientific use behind them that can be very useful for these specific patients. I feel that the benefits outweigh the risks for these types of medications. ~M. Tordi

References 1.

2.

3.

4.

5.

Drug Addiction Treatment. Flexeril Addiction. Available at: https://www.drugaddictiontreatment.com/types-of-addiction/prescription-drug-addiction/flexerilcyclobenzaprine-addiction/. Accessed October 14, 2018.

Trends in Anesthesia Critical Care. The History of Neuromuscular Blocking Agents. Available at: https://www.trendsanaesthesiacriticalcare.com/article/S0953-7112(00)90245-X/abstract. Accessed October 14, 2018.

Patient Info. Muscle Relaxants. Available at: https://patient.info/health/muscle-relaxants. Accessed on October 14, 2018.

PubMed. Cyclobenzaprine. Available at: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0009767/?report=details#how_to_use. Accessed on October 14, 2018.

Spine Health. Common Risks and Side Effects of Muscle Relaxants. Available at: https://www.spinehealth.com/treatment/pain-medication/common-risks-and-side-effects-muscle-relaxants. Accessed on October 14, 2018.

102

Naloxone (Evzio®,Narcan®)

Toria Piper Student Pharmacist FALL 2018

HTTPS://WWW.DRUGABUSE.GOV/RELATED-TOPICS/OPIOID-OVERDOSE-REVERSAL-NALOXONE-NARCAN-EVZIO

Typical Dosing

Monograph

by TORIA PIPER, Student Pharmacist

Background/History Naloxone was patented in 1961 by the pharmaceutical company Sankyo, Mozes Lewenstein, and Jack Fishman. It was FDA approved as treatment for opioid abuse in 1971, and distributed with opioid abuse kits in many states starting in 1996. According to the CDC, from 1996 to 2014, approximately 26,000 cases of opioid overdose were reversed.

Paramedics have been carrying Naloxone for years, but recently there has been an increase in its use by law enforcement officers to reverse heroin overdose when they arrive at the scene before a paramedic.

Pharmacology/Drug Effects Naloxone is used for acute opioid overdose, reducing respiratory/mental depression due to opioids, to prevent opioid abuse, and there various other off-label uses and ongoing research to extend its use even further.

Naloxone is lipophilic and acts as a nonselective competitive opioid receptor antagonist which binds to the mu-opioid receptor (highest affinity), delta-opioid receptor, and the κ-opioid receptor (lowest affinity). It has negligible affinity for the nociception receptor.

The mechanism of action is not completely understood, but there is evidence that naloxone functions to produce withdrawal symptoms by competing for opiate receptor site within the CNS preventing the action of endogenous and xenobiotic opiates on these receptors. However, if naloxone is administered in the absence of opioid use, there is no functional pharmacological activity.

When parenterally administered, naloxone rapidly distributes throughout the body. Its serum half life is 30-81 minutes which is shorter than some opiates, therefore a second dose may be required. It is primarily metabolized by the liver into naloxone-3glucuronide which is excreted in the urine.

When used in opioid prevention, naloxone is combined in oral preparations with buprenorphine and pentazocine. Only the oral opioid has an effect, but the naloxone will block the effect of the opioid if it is injected.

Naloxone can also be used in clonidine overdose, itchiness due to opioid use, and is experimentally used for congenital insensitivity to pain with anhidrosis (rare).

Slang Terms/Brand names Brand names: Narcan, Nalone, Evzio, Prenoxad Injection, Narcanti, Narcotan, and others. (No slang)

Injection: Initial dose is 0.4 to 2 mg IV, IM, or subcutaneously; may repeat at 2- to 3-minute intervals. A lower initial dose (0.1 to 0.2 mg) should be considered for patients with opioid dependence to avoid acute withdrawal or if there are concerns regarding concurrent stimulant overdose. Following reversal, additional dose(s) may need to be administered at a later interval (20 to 60 minutes) depending on the type/duration of opioid. If no response is observed after 10 mg (cumulative dose) has been administered, question the diagnosis of opioid-induced or partial opioid-induced toxicity. May also be administered via endotracheal tube as 2 - 2.5 times the initial IV dose (0.8 to 5 mg).

Auto-injection: 0.4 mg or 2 mg (contents of one auto-injector) IM or subcutaneously as a single dose; dose may be repeated every two to three minutes until emergency medical assistance becomes available.

Nasal Spray: For the initial treatment of an opioid-associated life-threatening emergency; 4 mg (contents of 1 nasal spray) intranasally in one nostril as a single dose; dose may be repeated every two to three minutes in alternating nostrils until emergency medical assistance becomes available.

Pediatric Dosing: Pediatric dosing is initially 0.1 mg/kg to a maximum of 2 mg and repeated every two to five minutes as needed.

103

Auto-injector: monitor infants for residual needle parts and signs of infection.

Opioid overdose: continuously observe patients until there is no further risk of recurrent respiratory depression.

Professional opinion

HTTPS://WWW.AMBROSIATC.COM/ADDICTION/NARCAN/

Key Steps to Administering Narcan PEEL: Peel back the package to remove the device. Hold the device with your thumb on the bottom of the plunger and 2 fingers on the nozzle.

PLACE: Place and hold the tip of the nozzle in either nostril until your fingers touch the bottom of the patient's nose.

PRESS: Press the plunger firmly to release the dose into the patient's nose.

NOT A SUSTITUTE FOR EMERGENCY MEDICAL CARE: When administering NARCAN® Nasal Spray, always be sure to call 911 right away, even if the person wakes up. Keep the patient under surveillance or close watch. If breathing does not return to normal or if breathing difficulty resumes, after 2-3 minutes, give an additional dose of NARCAN® Nasal Spray using a new device in the alternate nostril.

Drug interactions/Toxicology Methylnaltrexone may enhance the adverse/toxic effect of opioid antagonists.

Specifically, the risk for opioid withdrawal may be increased. Avoid combination.

Opioid Antagonists may enhance the adverse/toxic effect of morphine, naloxegol, oxycodone, oxymorphone, and naldemedine. Specifically, the risk for opioid withdrawal may be increased. Avoid combination.

Concurrent use of naloxone and yohimbine may result in increased adverse effects.

Concurrent use of clonidine and naloxone may result in hypertension.

Opioid overdose: Professionally, I agree with the changing climate in allowing pharmacies to carry and dispense naloxone to patients without a prescription from a doctor. Those looking to buy naloxone are frequently caregivers, therefore it would not make sense to make a person go to a physician to get a prescription for Narcan to save a loved one.

Pharmacists are beyond qualified to advise both caregivers and patients on how and when to dispense naloxone.

However, I do not believe naloxone is a long-term solution. Its availability can also lead to a more reckless use of opioids because they know if they take too much, the overdose can be reversed. But, if a small percentage of addicts who are “revived” using naloxone, and decide to get treatment and become drug-free, I believe the risk is worth it. For those who have been considering getting help in overcoming their drug addiction, this could be a pivotal life-changing action, giving them the drive to fight their addiction.

Opioid addiction treatment: Naloxone is also available in combination products such as buprenorphine/ naloxone to prevent the abuse of buprenorphine. From a pharmacist’s perspective, I think physicians should be encouraged to prescribe this form of the medication as an abuse deterrent to those already struggling with ~ T. Piper drug addiction.

References: Adapt Pharma. How to use Narcan. Available at: https://www.narcan.com/patients/how-to-usenarcan/#isi_anchor. Accessed October 10, 2018.

Laws

Wikipedia. Naloxone. Available at: https://en.wikipedia.org/wiki/Naloxone.

Accessed October 10, 2018.

In the United States, except for Hawaii, naloxone is now available without a prescription at pharmacies. Only pharmacists or physicians can distribute naloxone.

The formal agreements allowing pharmacists to dispense naloxone include standing orders, protocol orders, collaborative practice agreements, and pharmacist’s prescriptive authority.

Naloxone. Drug Facts and Comparisons. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.factsandcomparisons.com.

Accessed October 10, 2018.

Monitoring/drug screens General • • • • • • •

Respiratory rate heart rate blood pressure temperature level of consciousness arterial blood gases pulse oximetry

Naloxone. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com.

Accessed October 10, 2018.

SAMHSA. Understanding Naloxone Access Laws. Available at: https://www.samhsa.gov/capt/sites/default/file s/resources/naloxone-access-laws-tool.pdf.

Accessed October 10, 2018.

104

NALTREXONE (5a)-17-(cyclopropylmethyl)-4,5epoxy-3,14-dihydroxymorphinan-6-one

http://www.wikiwand.com/en/Naltrexone

October 13, 2018 Elizabeth Portteus

https://www.webmd.com/drugs/2/drug-7399/naltrexone-oral/details

Background

Pharmacology

• FDA-approved November 4, 1984 • Label indications: alcohol use disorder, opioid dependence

Competitive opioid antagonist: • blocks effects of opioids • reverses opioid overdose • non-addictive

• Off-label uses: cholestatic pruritus, pathological gambling disorder

Modifies hypothalamicpituitary-adrenal axis to suppress alcohol craving

Other Names:

ReVia*

VivitrolR 105

Drug Interactions

Adverse Effects

Lofexidine: • alpha-2 adrenergic agonist

• Upset stomach or vomiting • Diarrhea • Headache

• co-administration increases serum • Nervousness concentration of naltrexone • Sleep problems/tiredness • Joint or muscle pain Naldemedine/naloxegol: • opioid antagonists • naltrexone may increase toxicity of these drugs • increased risk for opioid withdrawal

Monitoring Parameters • Liver function tests possibility of liver injury • Opioid Withdrawal • Injection site reactions (intramuscular) • Depression/Suicidality

Law Naltrexone is a non-scheduled prescription only drug

Professional Opinion I would recommend the use of naltrexone for alcohol and opioid abuse only in patients that are serious about quitting who have already tried to quit using behavioral changes. ~ Elizabeth Portteus

References 1. Naltrexone. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com.

Accessed October 13, 2018.

2. Erowid. Naltrexone. Available at: https://www.erowid.org/pharms/naltrexone/. Accessed October 13, 2018.

3. National Institute on Drug Abuse. Opioid Addiction. Available at: https://www.drugabuse.gov/publications/principlesdrug-addiction-treatment-research-based-guide-third-edition/evidence-based-approaches-to-drug-addictiontreatment/pharmacotherapies. Accessed October 13, 2018.

4. Substance Abuse and Mental Health Services Administration. Naltrexone. Available at: https://www.samhsa.gov/ 106 medication-assisted-treatment/treatment/naltrexone. Accessed October 13, 2018.

Nicotine Leilanie Rivera Fores Pharmacy Student Fall 2018 https://publicdomainpictures.net/pictures/140000/velka/cigarette-leaf.jpg

HISTORY TOBACCO AS WE KNOW IT ORIGINATED IN AMERICA WHERE NATIVE POPULATIONS CHEWED AND SMOKED THE LEAVES. THROUGH THE 1500S TOBACCO USE BEGAN TO BE SPREAD AS IMMIGRANT SAILORS REACHED AMERICAS PORTS.CIGARETTE MAKING MACHICNES DEVELOPED IN THE LATTER HALF OF THE 1800S,MAKING SMOKING INCREASE AMONG POPULATIONS

SLANG

TERMS

Ciggies,

Smokes,

Darts,

Fags,

PHARMACOTHERAPY

Durries,

butts,

3-[(2S)-1-methylpyrrolidin-2-yl]pyridine

Rollies

cancer sticks Dosage forms: cigars,cigarettes,chewing tobacco Dosing:patient specific Metabolism: CYP2A6 Duration:depends on how much nicotine is used Nicotine binds to nicotinic cholinergic receptors, which facilitate neurotransmitter release and thereby mediate the complex actions of nicotine in tobacco users. Dopamine, glutamate, and gamma aminobutyric acid release are particularly important in the development of nicotine dependence, and corticotropin-releasing factor appears to contribute to nicotine withdrawal.

https://upload.wikimedia.org/wikipedia/commons/6/63/ 107

Drug Interactions

Drug Contraindications

Drug Side Effects

Tobacco smoke induces many of the CYP450 enzymes in the liver, which play an important role in medication absorption, distribution, metabolism, and elimination.

Some drugs that could be affected are:

-pregnancy

Coughing

-over 35 and with hormonal contraceptives use due to increased risk of cardiovascular effects

Dizziness, headaches

duloxetine,

clopidogrel,

Bad breath

-respiratory problems

Tingling and numbness in -insulin resistant or dependent pafingers and toes tients since smoking increases insuReduced appetite, lin resistance

Cancer, stroke and brain damage, heart attack and disease,eye disease,hearing loss and more.

Haloperidol.

LAW

Monitoring ∗

Pregnancy

∗

Cardiovascular complications

∗

Insulin and blood sugars

Drug Screens

fast heart beat

Nicotine is not a scheduled drug.

Law revolves around not allowing the sale to people under 18.

https://upload.wikimedia.org/wikipedia/en/

Qualitative testing: looks for whether or not a person has used nicotine Quantitative: measures the amount of nicotine in the body Nicotine leaves blood in three to four days Saliva keeps insulin for four days

Professional Opinion Smoking is the leading cause of preventable death. It has been shown to have no benefit and only serves to worsen health and exaggerate comorbidities. For this reason I am against anybody using nicotine. ~ L. Rivera Fores

Hair testing can test nicotine for up to 1-3 months References Dani, John A., and David J.K. Balfour. “Historical and Current Perspective on Tobacco Use and Nicotine Addiction.” Trends in Neurosciences, U.S. National Library of Medicine, July 2011, www.ncbi.nlm.nih.gov/pmc/articles/PMC3193858/.

“Nicotine.” DrugBank, 13 June 2005, www.drugbank.ca/drugs/DB00184. Accessed October,10,2018.

Center for Tobacco Products. “FDA Regulations for Tobacco Product Retailers.” U S Food and Drug Administration Home Page, Center for Tobacco Products, www.fda.gov/tobaccoproducts/guidancecomplianceregulatoryinformation/retail/ ucm205021.htm.

“What to Know If You Have to Take a Nicotine Test.” WebMD, WebMD, www.webmd.com/smoking-cessation/takingnicotine-test#1-2.

“Health Effects of Smoking.” Health Effects of Smoking | PMI - Philip Morris International, www.pmi.com/our-business/

108

Nightshade

Botany Gone Bad: The History of the Deadly Nightshade Plant. Ambius. www.ambius.com

Ross Robinson Student Pharmacist Fall 2018

Beauty Product or Deadly Poison?

Nightshade, Atropa belladonna, is a naturally occurring berry bearing plant that is found on nearly every continent on the planet. Nightshade became popular during the Renaissance period by woman in a desire to become more beautiful. Eye drops containing dilutes juices from nightshade can dilate the pupil, which the women then believed made them more “sexually aroused” and more desirable.

The name belladonna literally translates to “Beautiful woman.”

Nightshade has also been used for more diabolical uses over the years also. For centuries it has been used as a poison as only a small amount can cause death. It was used in political assassination as far back as the Roman Empire and has been mentioned countless times in literature, like in The Hunger Games by Suzanne Collins (an alternative version of it at least).

Also Known As… • • • • •

Atropa belladonna Belladonna Devil’s Berries Death Cherries Dwale

Laws There is only one state in the United States, Louisiana, that has a law criminalizing the use of Atropa belladonna for human consumption. It also is still illegal to kill people with it everywhere.

Parish Nighshade. San Elijo Lagoon Conservancy. www.sanelijo.com

Drug Monitoring The most important thing to monitor is dry mouth and eyes. This is one of the first signs of anticholinergic toxicity. Other parameters to monitor are fever, altered mental status, and hallucinations.

109

Pharmacology of Nighshade The active ingredient in Nightshade that causes problems in the body is atropine. Atropine is a reversible and competitive antimuscarinic (a specific type of anticholinergic) that is produced in the body and works on the parasympathetic nervous system. Some of the side effects of excessive atropine are…

• • • •

Enlarged Pupils Fever Hallucinations Mental cloudiness

• • • •

Blurred Vision Tachycardia Muscle Spasms Convulsions

Atropine. Sigma-Aldrich. www.sigmaaldrich.com

• Red Dry Skin • Inhibition of secretions • Coma

Drug Interactions/Toxicology Nightshade has compounds that cause a drying effect in the body. Taken with other drugs that dry out the body, ie. antihistamines and scopolamine, will cause and increased chance of this occurring.

Nightshade is an extremely potent and effective poison. Just brushing up against its leaves or roots or stems can cause skin irritation and bumps.

Consuming as few as 10 – 20 berries from the plant can prove fatal to a adult human. It is very easy to mistakenly eat these berries as they are sweet and can be mistaken for other wild berries.

Professional Opinion As a budding professional in the healthcare field I can not in good conscious recommend patient’s to take this medication. The risk of taking to much of this medication is too great as “overdosing” could easily cause death.

-Ross C Robinson

References • • • • •

Belladonna. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com Accessed October 10 ,2018.

Justia. 2006 Louisiana Laws – RS 40:989.1 – Unlawful production, manufacture, distribution, or possession of hallucinogenic plants.

Available at: https://law.justia.com/codes/louisiana/2006/48/321523.html. Accessed October 12, 2018.

WebMd. Belladonna. Available at: https://www.webmd.com/vitamins/ai/ingredientmono-531/belladonna. Accessed October 10, 2018.

Mother Earth Living. Deadly Nightshade: The Wicked Belladonna. Available at: https://www.motherearthliving.com/naturalhealth/deadly-nightshade-the-wicked-belladonna. Accessed October 10, 2018.

Simon’s Legal Highs. Simon’s Atropa Belladonna (Deadly Nightshade) Guide. Available at: https://simonsblogpark.com/legalhigh/simons-atropa-belladonna-deadly-nightshade-guide/. Accessed October 11, 2018.

110

Jessica Sarna Student pharmacist Fall 2018

History of Nitrous Oxide

Nitrous Oxide Slang terms: Hippie crack, whippets, laughing gas, buzz bomb Pharmacology

1772: nitrous oxide was discovered by Joseph Priestley

The chemical formula for nitrous oxide is N2O and at increased temperatures, nitrous oxide is a strong oxidizer. It is known to block NMDA and beta 2-subunits containing nAch channels. It also weakly inhibits AMPA, kainite, GABAc and 5HT3 receptors.

1844: introduced to be used as an anesthesia

Drug effects on the body

1863: started to be used for general usage in dentistry

• Euphoric, relaxation • Hallucinations, distorted thoughts • Dizziness, difficulty thinking straight

Dosage form: gas

1868: it was discovered that adding oxygen to nitrous oxide made administration safer 1979: an increasing number of people started to use nitrous oxide recreationally Present: not currently controlled except for certain states

https://pn.bmj.com/content/15/3/207 111

Monitoring -analgesia/anesthesia -complete blood counts (due to possibility of blood dyscrasias) -respiratory difficulties -nausea/vomiting (may be indications of nitrous oxide toxicity) -should not be administered without oxygen -should not be given for more than 24 hours

https://www.mirror.co.uk/news/uk-news/amazons-hippy-crack-30p-hit-5545894

Drug interactions • • •

Other CNS depressants Opioids Sleeping medications

Law Nitrous oxide is currently legal and is not subject to DEA purview. It is prohibited to sell or distribute nitrous oxide for recreational use. Certain states have laws that regulate the possession, sale of distribution, which mostly pertains to minors.

It is illegal to be using nitrous oxide and driving, people may even be unfit to drive the next day after using nitrous oxide.

Professional Opinion: In my professional opinion, I think that nitrous oxide should only be used only under the supervision of a medical profession. Nitrous oxide is not allowed to be given for longer than 24 hours due to its severe adverse effects. People should not be using this for recreational use. ~ J. Sarna

References: 1.

Nitrous Oxide. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http:// www.micromedexsolutions.com. Accessed October 11, 2018.

2.

Education in Chemistry. Nitrous Oxide. Available at https://eic.rsc.org/feature/nitrous-oxide-are-you-having-alaugh/2020202.article. Accessed October 14, 2018.

3.

4.

Formula1. Nitrous Oxide. Available at ://www.formula1-dictionary.net/nos.html. Accessed October 14, 2018.

5.

ACE. Slang terms for nitrous oxide. Available athttp://www.consumered.org/programs/inhalant-abuse-prevention/ signs-of-abuse. Accessed on October 14, 2018.

The Drug Classroom. Nitrous Oxide. Available at https://thedrugclassroom.com/video/nitrous-oxide/. Accessed on October 14, 2018.

112

Opium Maria Shelley Student Pharmacist Fall 2018 TANJA NIGGENDIJKER/WIKIMEDIA COMMONS (CC BY 2.0). https://www.sciencenews.org/article/poppy-genome-genes-morphine-pain-relief

SLANG TERMS GODâ&#x20AC;&#x2122;S MEDICINE CHINESE MOLASSES DREAM STICK BLACK PILL BIG O

Pharmacology

HISTORY 3400 BC: Opium poppy is cultivated in lower Mesopotamia 460 BC: Hippocrates acknowledges usefulness of opium as a narcotic 1500: The Portuguese initiate the smoking of opium 1840: Residents of New England bring opium into the United States, where US Customs puts a duty fee on the import

Carlin et al. Royal Society. http://rsos.royalsocietypublishing.org/content/4/10/170715

1905: US Congress bans opium 1978: US and Mexican governments try to eliminate the source of raw opium by spraying poppy fields with Agent Orange 2009: US FDA announces further plans to restrict access to opioid pain relievers by Americans and their doctors 113

DRUG INTERACTIONS/TOXICOLOGY DRUG INTERACTIONS : Opium interacts with over 700 drugs, many of which are metabolized by the CYP 2D6 enzyme, such as acetaminophen and rifampin.

CONTRAINDICATIONS : Severe respiratory instability, acute psychiatric instability, diagnosed non-nicotine substance use, acute diversion of controlled substances, and serious adverse effects.

SIDE EFFECTS: Nausea, constipation, vomiting, pruritis, sedation, tolerance, physical dependence, euphoria, dysphoria, miosis, urticaria, hypotension, and respiratory depression.

Professional Opinion: Opioid alkaloids have analgesic benefits in many circumstances, but severe side effects and potential for abuse. Therefore, they should only be prescribed when absolutely needed for acute pain management. -Maria Shelley

Monitoring ❖ ❖ ❖ ❖

LAW

Pain management Tolerance Signs of addiction Severe side effects

Abuse screening: urine or blood sample

Opium is a schedule II controlled substance in the US, meaning that it has a high potential for abuse that may lead to severe psychological or physical dependence.

REFERENCES 1. Partnership for Drug-Free Kids. Opium. Available at: https://drugfree.org/drug/opium/. Accessed October 12, 2018.

2. PBS. Opium Throughout History. Available at: https://www.pbs.org/wgbh/pages/frontline/shows/heroin/etc/history.html. Accessed October 12, 2018.

3. Booth, Martin. Opium: A History. Available at: https://www.opioids.com/timeline/. Accessed October 12, 2018.

4. ICSI. Opioid Pharmacology. Available at: https://www.icsi.org/guideline_sub-pages/pain/appendix_c__opioid_pharmacology/. Accessed October 13, 2018.

5. Drug Bank. Available at: https://www.drugbank.ca/drugs/DB11130. Accessed October 13, 2018.

114

HEADING 8

OTC Analgesics

AMANDA SCHOETTMER, STUDENT PHARMACIST FALL 2018 SinaiEM. Combination of acetaminophen and ibuprofen for acute extremity pain. https://sinaiem.org/combination-of-acetaminophen-and-ibuprofenfor-acute-extremity-pain/.

HISTORY &

SLANG TERMS

BACKGROUND

OTC analgesics arenâ&#x20AC;&#x2122;t typically referred to with slang terms, but rather their brand names, such as Tylenol or Advil. Despite the lack of slang terms for OTC analgesics, they are abused by some by intentionally taking more than the recommended dose to treat chronic pain, as an effort to get high, or to induce selfharm.

-Ancient and medieval times: willow and cinchona bark were used for antipyretic properties -1873: acetaminophen synthesized

by Harmon Northrop Morse -1955: acetaminophen went on sale in US under brand name Tylenol -1956: acetaminophen went on sale in UK under brand name Panadol

-1961: 2-(4-isobutylphenyl) propionic acid (later called ibuprofen) is discovered by Steward Adams and is filed for patent

Analgesics are used to relieve pain, Analgesics are used to by relieve pain, especially pain caused fevers, especially pain caused by fevers, headaches, arthritis, menstrual headaches, cramps, andarthritis, more. menstrual cramps, and more.

-Common OTC analgesics: - Common OTC analgesics: acetaminophen (Tylenol), ibuprofen acetaminophen (Tylenol), ibuprofen (Advil, Motrin), naproxen sodium (Advil, Motrin), and naproxen sodium (Aleve) (Aleve) --Dosage Dosageforms: forms:capsules, capsules,tablets, tablets, gelcaps, liquids, creams, ointments, ointments, gelcaps, liquids, creams, powders, patches, patches, sprays, sprays, and and powders, suppositories suppositories -Dosages -Dosages:: acetaminophen: 325 to 650 mg; ibuprofen: 200 mg; naproxen sodium: 220 mg

-1969: ibuprofen available in UK as prescription only -1983: ibuprofen available OTC -1984: US patent for Tylenol expired and generic versions widely available

PHARMACOLOGY & & PHARMACOLOGY DRUG DRUG EFFECTS dfsdfsdfs

NBC News. Heart Attack Risk With Painkillers Starts Within a Week: Study. https://www.nbcnews.com/health/healthnews/heart-attack-risk-painkillers-startswithin-week-study-n756991.

-MOA -MOA (NSAIDs) (NSAIDs):: reduces reduces pain pain by by inhibiting COX-1 and COX-2, inhibiting COX-1 and COX-2, resulting resulting in in decreased decreased prostaglandin prostaglandin synthesis synthesis -MOA (acetaminophfdsfen): reduces -MOA (acetaminophen): reduces fever by inhibiting endogenous fever by inhibiting endogenous pyrogens in the thermoregulatory pyrogens in the thermoregulatory center in the brain, resulting in center in the brain, resulting in decreased prostaglandin synthesis decreased prostaglandin synthesis in in the CNS the CNS 115

Drug Interactions/ Toxicology Drug Interactions -Ketorolac with other NSAIDs -Anticoagulants and antiplatelet agents with NSAIDs

Contraindications Hepatic disease (acetaminophen)

-Alcohol with acetaminophen

OT C a n a l g e s i c s a r e avai l abl e f or pat i ent s to buy wi t hout a pr escr iption. There is no limit to how much can be bought at one t i me.

-NSAIDs: rash, heartburn, indigestion, nausea, constipation, dizziness, headache, gastrointestinal ulcer -Acetaminophen: pruritus, constipation, nausea, vomiting, insomnia, headache

Chain Drug Review. Coalition formed to safeguard access to OTC pain relievers. https://www.chaindrugreview.com/coalition-formedto-safeguard-access-to-otc-pain-relievers/

Laws

Side Effects

Monitoring -NSAIDs: relief of pain, reduction in fever, signs and symptoms of cardiovascular events in patients with cardiovascular disease, signs and symptoms of gastrointestinal ulcers, signs of bleeding in patients taking anticoagulants or antiplatelet agents -Acetaminophen: relief of pain and reduction of fever

Erowid. Acetaminophen (Paracetamol). https://erowid.org/pharms/ acetaminophen/

Professional Opinion OTC analgesics are a suitable and effective option for the reduction of pain and fever. These medications should be used as the directions state on the bottle, and the doses should never be increased without consultation from a healthcare provider. I would recommend various OTC analgesics for patients looking for pain relief. -A. Schoettmer

References Ibuprofen. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 12, 2018.

2. Naproxen Sodium. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com.

Accessed October 12, 2018.

1.

3.

Acetaminophen. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 12, 2018.

4. Terrie YC. Pharmacy Times. Pain Control: Using Nonprescription Analgesics. Available at: https://www.pharmacytimes.com/publications/otc/2013/ otcguide-2013/pain-control-using-nonprescription-analgesics. Accessed October 12, 2018.

5.

New World Encyclopedia. Acetaminophen. Available at: http://www.newworldencyclopedia.org/entry/Acetaminophen#History. Accessed October 12, 2018.

BBC News. The hangover that led to the discovery of ibuprofen. Available at: https://www.bbc.com/news/health-34798438. Accessed October 12, 6.

2018.

7.

Alcohol and Drug Foundation. Ibuprofen. Available at: https://adf.org.au/drug-facts/ibuprofen/. Accessed October 12, 2018.

116

Chelsea Shi Student Pharmacist Fall 2018

PHARMACOLOGY

HISTORY

Brande. Oxycodone. drugabuse.com. https://drugabuse.com/library/the-effects-of-oxycodone-use/

• 1913 – German pharmaceutical company Bayer stopped mass production of heroin • 1916 – Freund and Speyer from U of Frankfurt first synthesized oxycodone • 1917 – First clinical use of the drug was documented • 1939 – Introduced to the US market by Merck • 1995 – Purdue Pharma developed OxyContin (painkiller)

• Principal therapeutic action: analgesia, anxiolysis, euphoria, respiratory depression, constipation, and cough suppression.

• Forms: tablets, ER tablets, capsules, ER capsule, and solution.

• Dose: 5-80 mg dihydrohydroxycodeinone • Duration: ~12 hours Vanscolloe. ACD/Chemsketch. http://Wikipedia.org/wiki/Oxycod • Metabolism: catalyzed by CYP2D6, one#/media/file:oxycodone.jpeg excreted by kidneys

• • • • • • • •

Hillbilly heroin Blues Kickers OC SLANG 20s 40s 80s Cotton

• • • • • • • •

Oxy OX Oxycotton Orange County Killers Beans Rushbo Percs 117

Contraindications: Side Effects:

Interactions:

Drug Interactions &Toxicology

• • • •

Benzodiazepines • Hypnotics • N/V Meds MAOIs Antidepressants • Antipsychotics Muscle Relaxants

• Severe respiratory depression • Heart conditions • Liver disease

• • • • •

Drowsiness • • N/V Constipation • Headache • • Low BP

Dizziness Dry mouth Confusion Sweating Itching

Monitoring

Law

Drug Screens

People who are taking a form of oxycodone should be monitored for baseline creatinine, signs or symptoms of respiratory depression (especially 24-72 hours after start of treatment.

Oxycodone is a C-II narcotic in the US, which means that it has a high potential for abuse.

Recent laws aim to reduce opioid abuse prevalence. (i.e. Michigan doctors can no longer prescribe for more than a 7-day supply.

Oxycodone does not produce a (+) response to regular screens for opiates (morphine & codeine).

Enzyme immunoassay (EIA) is often used to screen for oxycodone specifically.

Professional Opinion Since this drug is often used as an analgesic in practice, I believe that as long as it is prescribed lawfully & as needed, it could be an efficacious form of pain reliever. The side effects are typical of many medications on the market. ~ C. Shi

References: 1. Oxycodone Boxed Warning. http://dailymed.nlm.nih.gov/daily/oxycodone. Accessed October 13, 2018.

2. Oxycodone Hydrochloride. Micromedex Solutions. Truven Health Analytics, Inc. Available at http://www.micromedexsolutions.com.

Accessed October 13, 2018.

3. Package insert Oxycontin. Stamford, CT: Purdue Pharma LP. 2007 11-05.

Accessed October 14, 2018.

4. Monitoring oxycodone use in patients with chronic pain. J Opiod Management. 2014 Jan-Feb; 10(1):47-56. Accessed October 13, 2018.

118

PHENCYCLIDINE Rebecca Silvola Student Pharmacist Fall 2018 Birmingham, C. . 2015. Haiku Deck. https://www.haikudeck.com/pcp--cheyenne-birminghameducation-presentation-oZJjKjDQpF#slide0

SLANG o o o o o o o

PCP The peace pill Angel dust Amp Animal Trank Crystal superglass Rocket Fuel

HISTORY

• First synthesized in 1926 • Used as a surgical anesthetic throughout the 1950s by Parke, Davis and Company.

• Unexpected adverse effects led to decreased use in human patients veterinarians began using PCP as an animal tranquilizer • Today, small quantities are manufactured in research settings, but the majority of use is in illicit environments.

PHARMACOTHERAPY - DRUG EFFECTS • Mechanism of Action: Glutamatergic NMDA receptor antagonist • Mind altering effects: o Hallucinations o Dissociation o Delusions • Physiological effects: • Methods of Use: • Onset and Duration:

Increased BP, HR, temperature Ingested, snorted, smoked, injected *Snorted/smoked = 2-5 minutes, 4-6 hours *Pill/capsule = 30-60 minutes, 6-24 hours *Injection = uncommon 119

TOXICOLOGY ½ MONITORING ½ DRUG SCREENS Unwanted side effects: • • •

Post-operative psychosis Severe anxiety Dysphoria *Feeling of unease or general dissatisfaction

*HIGH DOSES OF PCP CAN LEAD TO COMA OR ACCIDENTAL OVERDOSE. ***PCP sold on the street today is often laced with other drugs – specifically marijuana

PCP affects heart rate and blood pressure, but the primary concern surrounds the unpredictable impact on the CNS.

• MONITOR MENTAL HEALTH STATUS

*DETECTION PERIOD: - Blood:

*Patients may become violent and/or suicidal – CAUTION when interacting with those under the influence of this drug. *Maintain a calm environment and do not leave them alone.

DRUG INTERACTIONS *PCP’s effects can combine with other CNS depressants (Examples – alcohol and benzodiazepines) to produce an exaggerated effect.

PROFESSIONAL OPINION Due to the high risk of severepsychological side effects associated with this drug in addition to a surplus of more appropriate treatment options, I do not recommend PCP for therapeutic or recreational purposes. ~ R. Silvola

TEST TYPES: • Urine • Hair • Blood

• APPROXIMATELY 1 – 3 days after use

- Urine:

• SINGLE USE = 3 – 7 days • REGULAR USE = up to 30 days

LAW • • •

1965 – Discontinued use 1967 – Veterinary use only 1978 – PCP became a C-II substance in the US

Schedule II substance: High potential for abuse which may lead to severe psychological or physical dependence.

References: Barker M. DrugAbuse.com. PCP History and Statistics.

Available at: https://drugabuse.com/library/pcp-history-andstatistics/. Accessed October 10, 2018.

Cesar. Phencyclidine (PCP). Available at: http://www.cesar.umd.edu/cesar/drugs/pcp.asp Accessed October 10, 2018.

Erowid. PCP Drug Testing. Available at: https://erowid.org/chemicals/pcp/pcp_testing.shtml.

Accessed October 10, 2018.

Partnership for Drug-Free-Kids. PCP. Available at: https://drugfree.org/drug/pcp/. Accessed October 10, 2018.

120

PSEUDOEPHEDRINE Wyatt Simpson, Student Pharmacist Fall 2018

History/Background: Pseudoephedrine is a nasal decongestant with a history of being used to synthesize methamphetamine. From 1989 to 2006, congress has enacted many laws to reduce illicit purchase, use, and manipulation of this product.

Whenever a law was enacted purity of methamphetamine dropped along with sales. These include some states requiring an electronic log of pseudoephedrine sales and limits on how much any individual can purchase in a period of time.

Pharmacology: Pseudoephedrine works to relieve nasal congestion by acting on alphaadrenergic receptors, causing vasoconstriction in the respiratory mucosa.

It also acts on beta-adrenergic receptors, resulting in bronchial relaxation. Side effects when used for nasal congestion include increased heart rate and elevation in blood pressure. When taken in high amounts, the side effects include weight loss, dental problems, itching, anxiety, confusion, violence, paranoia, and hallucinations.

Healthline. Pseudoephedrine vs. Phenylephrine: Whatâ&#x20AC;&#x2122;s the Difference? Retrieved from https://www.healthline.com/health/allergies/pseudoephendrine-vs-phenylephrine.

Street names for pseudoephedrine include Mahuang, Mormon Tea, Primatene, Bronchlate, Tedral, White Crosses, Truckers Speed, and Mini Thins.

121

Drug Interactions/Toxicology: Drug interactions include decreasing concentration of fentanyl, increase in blood pressure and heart rate, especially when used with other sympathomimetics, adrenergic antagonists will oppose the effect of pseudoephedrine, and monoamine oxidase inhibitors may increase the hypertensive effect. Urine drug screenings for amphetamines can be altered through use.

Monitoring and Drug Screens: Pseudoephedrine use can be monitored through urine drug screening. These screens are often used for amphetamine use and can lead to a false positive for amphetamine if the person is using pseudoephedrine.

Professional Opinion: Pseudoephedrine, like many other drugs, is a drug with positive effects if taken as directed as nasal congestion. It can, however, be abused or used to make illicit drugs. The current laws have been shown to decrease abuse. Pseudoephedrine should continue to be a drug for use by law abiding citizens, but should have regulations to restrict access to people that want to abuse it. ~ W. Simpson

Laws: In Indiana, no person can purchase more than 3.6 grams in one day or more than 7.2 grams in 30 days unless dispensed with a prescription. In a 365 day period a person can purchase no more than 61.2 grams. Products containing more than 60 mg cannot be sold to a person under 18 years old. It may only be sold by a pharmacy that uses the NPLEx tracking system. A person must have a valid government issued phot ID showing the date of birth of the person.

The purchaser must sign a log acknowledging responsibility for correct information.

stored behind the counter or in a locked display case.

References: Pseudoephedrine. Lexicomp. http://online.lexi.com.ezproxy.lib.purdue.edu/lco/action/doc/ retrieve/doci d/fc_rnp2/3750336. Date Modified: Feb 2017. Date Accessed: Oct 6, 2018.

National Alliance for Model State Drug Laws. CONTROLLING METHAMPHETAMINE PRECURSORS EPHEDRINE AND PSEUDOEPHEDRINE: A BRIEF HISTORY OF CONTROLS AND CURRENT INITIATIVES. Retrieved from http://www.namsdl.org/ library/80BA13FA-1C23-D4F9-748003E83D6F3B0C/.

National Association of Chain Drug Stores. Retrieved from https:// www.nacds.org/wp-content/PSE/IN_PSE.pdf.

The Denver Post. Colorado bill further targeting medications associated with meth manufacture. Retrieved from https:// www.denverpost.com/2011/04/10/colorado-bill-further-targetingmedications-associated-with-meth-manufacture/.

The Treatment Center. Understanding Common Street Drug Slang and Drug Abuse Definitions. Retrieved from https://www.thetreatmentcenter.com/resources/drug-slang/.

Addiction Hope. Pseudoephedrine Abuse: The Signs and Symptoms.

Retrieved from https://www.addictionhope.com/blog/ pseudoephedrine-abuse-the-signs-and-symptoms/.

124

Dominic Snemis

History

Student Pharmacist

Psilocybin

Fall 2018

In 500 BC Central Americans built temples to mushroom gods and carved mushroom stones. The first documented experience in a scholarly journal article was in 1799 which showed visions and laughter from the drug. Albert Hofmann isolated psilocybin from mushrooms in 1958 and was able to synthesize it the next year and the company he worked for, Sandoz, produced pills with 2 mg of psilocybin the following year of 1960.

Also in the 60s, Dr. Hofmann brought synthesized psilocybin to Maria Sabina in Mexico who is a famous mushroom 'shamanist'. Possession was federally banned in 1968.

Research on psilocybin came back up in the 1990s and then in the early 2000s other countries around the world banned the drug. A clinical trial for cancer patients showed significant and sustained decreases in anxiety and depression which was published in 2016 by Johns Hopkins University.

Slang terms

Shrooms, Magic Mushrooms, teonanacatl

Pharmacology

This is an hallucinogenic drug that activates serotonin receptors in the prefrontal cortex affecting the mood, cognition, and perception of the user. Hallucinations do not always occur but perception of objects and people are the user is often altered. The onset of action is about 30 to 60 minutes and last four to six hours. Flashbacks of the experience can occur up to four months later. Doctors have tested this to treat cluster headaches, end stage cancer anxiety, depression, and others.

https://media.mnn.com/assets/images/2017/12/Psilocybe-pelliculosa-BC.jpg.838x0_q80.jpg https://www.mushroom-magazine.com/site/wp-content/uploads/2015/06/82762-Magic-Mushrooms.jpg https://novascotia.ca/natr/wildlife/conserva/images/mushroom01.jpg

123

Toxicology

The rate of fatality of psilocybin is much less than 1%. Most emergency department documentation is from anxiety related attacks from the psychiatric effects of the drug.

The concentration of psilocybin varies greatly between species, origin, climate, and other factors, so an exact dose is difficult to know. Common doses of 5-15 mg show effects, it is thought that above 12 mg hallucinations may occur.

Laws

In 1970, psilocybin is categorized as a Schedule I drug under the Controlled Substance Act. Possession and distribution is illegal in the United States as stated in the History section. Cultivation of mushrooms for the use of psilocybin is also illegal, a common thing in the new online era of the 1990s was spore syringes with growing kits which the FDA and DEA dealt with by arresting those online vendors.

Monitoring

Unless specifically tested for, common urinalysis does not check for psilocybin.

Professional Opinion

Moderation is key, with all of the research that was conducted in the past, and even research that has been encouraged recently to help with many different disease states, psilocybin seems to have medicinal benefits with lower risk profile compared to drugs used for the same disease states. Low doses that used in clinical trials showed benefits for patients with uncommon adverse events. ~ D. Snemis

References 1.Erowid. Psilocybin Mushrooms. Erowid Psilocybin Mushroom (Magic Mushrooms) Vault. https://www.erowid.org/ plants/mushrooms/mushrooms.shtml. Accessed October 15, 2018.

2.FNP KD. Psilocybin and magic mushrooms: Effects and risks. Medical News Today. https:// www.medicalnewstoday.com/articles/308850.php. Published July 18, 2018. Accessed October 15, 2018.

3.Griffiths RR, Johnson MW, Carducci MA, et al. Psilocybin produces substantial and sustained decreases in depression andanxiety in patients with life-threatening cancer: A randomized double-blind trial. Journal of Psychopharmacology (Oxford, England). 2016;30(12):1181-1197. doi:10.1177/0269881116675513.

4.Mushrooms - Hallucinogenic. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at:http://www.micromedexsolutions.com. Accessed October 14, 2018.

124

QUETIAPINE Kristina Stoncius Student Pharmacist Fall 2018 https://www.papaloizou.com/?products=seroquel-xr

l

• Quetiapine registererd in the US

1997

2012

•Long acting formulation came off patent

• Short acting formulation came off patent

HISTORY

2017

ALSO KNOWN AS: Quell Susie-Q Baby Heroin Snoozeberries Q-Ball https://www.2daydietshopping.com/product/seroquel

Pharmacology: Quetiapine is a second generation antipsychotic medication that is used to treat schizophrenia and dipolar disorder. It is a potent serotonin 5-HT2a-receptor antagonist and a moderate dopamine D2-receptorantagonist.

https://en.wikipedia.org/wiki/Quetiapine

Drug is abused for its hallucinogenic effects.

Street value is anywhere from $3 to $8.

The half-life of the drug is about six hours.

125

Avoid in

Drug Interactions Antipsychotics: chlorpromazine, thioridazine iloperidone, asenapine, paliperidone, ziprasidone.

Antiarrhythmics: procainamide, quinidine, amiodarone, dronedarone, sotalol.

This drug should not be used in elderly patients who are suffering from dementia.

Side Effects

The most commonly reported side effect is solemnest. Other effects include: low blood pressure, dizziness, fatigue, dry mouth, constipation.

Monitoring - Patients should be monitored for irregular heartbeat if taking high doses.

- Blood sugar, cholesterol, and A1C should be checked regularly for patients taking this medication.

Drug Screening - False positive urine drug screenings may occur for patients receiving quetiapine.

Laws - Quetiapine is not a controlled substance but has the potential to be abused by its self or in combination with other drugs. Tablets can be snorted or injected. IV injection of quetiapine with cocaine, an illegal substance, is known as a Q-ball.

Professional Opinion - Although this drug has a potential for abuse because of its hallucinogenic effect; however, it is very effective at treating schizophrenia. Therefore, I would recommend using this medication in a patient with schizophrenia with no history of drug abuse. ~ K. Stoncius References Seroquel [package insert] Wilmington, DE: AstraZeneca Pharmaceuticals; 2003.

NAMI. Seroquel. Available at: https://www.nami.org/Learn-More/Treatment/Mental-HealthMedications/Quetiapine-(Seroquel). Accessed October 12th, 2018.

New York State. Office of Alcoholism and Substance Abuse Services. Available at: https://www.oasas.ny.gov/admed/fyi/seroquel.cfm. Accessed October 12th, 2018.

Brett J. Concerns about quetiapine. Aust Prescr 2015;38:95-7.

126

Jessica Stone Student Pharmacist

Fall 2018 Background: n A benzodiazepine that is famous for being a “date rape drug” due to its extreme effects of drowsiness, muscle relaxation, and memory loss. n Also used as a “rave/party” drug due to its hypnotic properties and ability to enhance the effects of other substances such as alcohol.

Slang Terms: n Roofie # n Roofenol n Mexican Valium n n n n

Roach La Rocha Roof and Fall Rope Drug Effects: n Drowsiness n Confusion n Memory loss n Muscle relaxation n Slurred speech n Loss of motor control

Rohypnol. AllBiz. https://my.all.biz/rohypnol-g65983

History: n 1950s – Benzodiazepine class first developed n 1975 – Rohypnol first introduced by Hoffman-La Roche in Switzerland n 1984 – Rohypnol introduced in the United States n 1990s – Becomes popular in the United States as a party/date rape drug n 1997 – Banned in the United States

Mechanism: n Nonspecifically binds to benzodiazepine (BZD) receptors n BZD1 contributes to sleep

Rohypnol Structure. All About Drugs. www.allfordrugs.com/tag/rohyonol/

n BZD2 contributes to memory, muscle relaxation and motor

127

Laws: n Controlled Substance Act determined

rohypnol to be a schedule IV

Professional Opinion:

Although rohypnol has been found to have medical use in other countries, due to the high incidence of use in cases of rape and sexual assault the manufacture and sale of Rohypnol should remain illegal in the United States. ~ J. Stone

Screening: n Not found on typical 5 or 10 panel drug screenings n Requires individual test n Urine must be tested within 72 hours n Hair can be tested within a week and shows use within 90 days

medication n Not legal for manufacture or sale in the United States due to its frequent abuse and use in rape cases n Legal in over 50 other countries in the world n In the United States penalties for possession and sale are similar to that of schedule I medications

Rohypnol. American Addiction Centers. http://www.treatment4addiction.co m/drugs/depressants/rohypnol/#

Drug n n n n n n

Interactions: Opioids Alcohol MAOIs Barbiturates Grapefruit Other

benzodiazepines

References: 1. Education Specialty Publishing. In The Know Zone. Available at:

2.

3.

4.

5.

http://www.intheknowzone.com/substance-abuse-topics/date-rape-drugs/street-names.html.

Accessed October 13, 2018.

American Addiction Centers. Sunrise House. Available at: https://sunrisehouse.com/clubdrugs/rohypnol/. Accessed October 13, 2018.

National Drug Screenings Inc. Rohypnol. Available at: https://www.nationaldrugscreening.com/rohypnol-drug-test.php. Accessed October 13, 2018.

Canadian Institute of Heath Research. Drugbank. Available at: https://www.drugbank.ca/drugs/DB01544. Accessed October 13, 2018.

The Gale Group. Rohypnol.. Available at: https://www.encyclopedia.com/science/appliedand-social-sciences-magazines/rohypnol. Accessed October 13, 2018.

128

Rx Anorectics Kiley Strakis Student Pharmacist Fall 2018

Background •

There are many different types of prescription anorexiants; some that are commonly seen are: o Benzphetamine, phentermine, methamphetamine, diethylpropion, phendimetrazine, chlorphentermine

•

Many anorexiants are derivatives of amphetamines.

Amphetamines are stimulants which increase the activity of the central nervous system that provide energy and euphoria. o Stimulants can be used for a wide variety of medical conditions, including obesity due to their ability to suppress appetite.

•

FDA Approval Dates o Benzphetamine: October 26, 1960 o Diethylpropion: November 7, 1960 o Phentermine: August 14, 1973

DAT. Phentermine and Addiction. Available at:https://www.drugaddictiontreatment.com/types-ofaddiction/prescription-drug-addiction/phentermine-and-addiction/. Accesed: October 14, 2018.

Slang Terms • • • • •

Uppers Speed Didrex Adipex-P Fastin

Pharmacology • •

•

Anorexiants are used in obese patients to decrease appetite and stimulate weight loss.

Anorexiants are stimulants which work by increasing the activity of the central nervous system. o MOA: appetite suppressing effects are due to stimulatory effects on the hypothalamus which in turn releases norepinephrine.

Example: Phentermine o Amphetamine derivative o CNS Stimulant, Anorexiant, Sympathomimetic o Oral tablet or capsule o Dose: 15-37.5 mg/day o Hepatic metabolism o Excreted in the urine o Long duration of action

Sigma Aldrich.

Phentermine HCl. Available at:https://www.sigmaaldrich.com/catalog/product/sigma/p865 3?lang=en&region=US. Accessed October 14 2018.

Phentermine 2-methyl-1-phenylpropan-2-amine

129

Drug Interactions & Toxicology Drug Interactions • • • •

MAO inhibitors Other centrally acting appetite suppressants Fenfluramine Dopamine and norepinephrine reuptake inhibitors

Contraindications • • • • • • •

Hypersensitivity to drug History of cardiovascular disease Hyperthyroidism Glaucoma History of drug abuse Concurrent use of MAO inhibitors Pregnancy or breast-feeding

Side Effects • • • • • • •

Palpitations and increased heart rate Insomnia Increased blood pressure Euphoria Restlessness Psychosis Tremors

Laws •

•

Drug Class – different types of anorexiants are in different drug classes. o Phentermine: C-IV o Benzphetamine: C-III o Methamphetamine: C-II These medications should not be used unless prescribed by a doctor.

Monitoring • • •

Anxiety Meds. Didrex. Available at: http://anxietymedsonline.com/shop/pillstablets/didrex-50mg-benzphetamine/ October 14, 2018.

Drug Screens

Renal function – may cause renal impairment Weight every month for the first 3 months o Then move to 3-month intervals Waist circumference every month for the first 3 months o Then move to 3-month intervals

• • •

Could cause false positives for amphetamines Can be detected in the urine for 1-4 days after a dose. (Up to one month in hair tests.)

Drug screens don’t typically assess for phentermine, benzphetamine, etc., but since they are related to amphetamines it is important to know that they can cause a false positive for amphetamines.

Professional Opinion •

Upon evaluation, these medications can be efficacious for weight loss in obese patients in which diet and exercise did not work well. These medications should only be used for stated indication and should only be used if you have a valid prescription from your doctor. ~ K. Strakis

References 1.

2.

3.

4.

5.

6.

7.

Benzphetamine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com.ezproxy.lib.purdue.edu/lco/action/doc/retrieve/docid/patch_f/6438. Accessed: October 13, 2018.

Benzphetamine. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 13, 2018.

Craddock, D. Anorectic drugs: use in general practice. Drugs. 1976;11(5):378-93.

Phentermine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com.ezproxy.lib.purdue.edu/lco/action/doc/retrieve/docid/patch_f/7481. Accessed: October 13, 2018.

Phentermine. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com.

Accessed October 13, 2018.

PubChem. Phentermine. Available at: https://pubchem.ncbi.nlm.nih.gov/compound/phentermine. Accessed October 14, 2018.

Michael Leonard. Streetdrugs.org. Didrex. Available at: https://www.streetdrugs.org/didrex/. Accessed October 13, 2018.

130

Michaela Todd, Student Pharmacist Fall 2018

 

Mbtskoudsalg. Medical Clipart Prescription Drug. https://mbtskoudsalg.com/explore/medical-clipartprescription-drug/.

Drug class includes sedatives, tranquilizers and hypnotics.

From 1992 to 2002, the number of depressant abusers grew by about 150%.       

Pubchem. Benzodiazepine https:// pubchem.ncbi.nlm.nih.gov/compound/ Benzodiazepine#section=Top

• • • •

•

A-minus Barbs Candy Downers Phennies Red Birds Reds

     

Tooies Tranks Yellows Yellow Jackets Zombie Pills Sleeping Pills

Pubchem. Barbituric Acid. https:// pubchem.ncbi.nlm.nih.gov/compound/ barbituric_acid#section=Top

Slows down brain effects or “depresses” the central nervous system.

Can cause drowsiness so are often used to treat insomnia.

Slows brain activity which is useful for treating anxiety and other disorders related to stress.

Benzodiazepines: Definite mechanism not known.

Thought to bind to receptors on GABA neuron in the CNS. Activity is thought to involve the spine, brain stem, cerebellum, and limbic/cortical areas.

Barbiturates: Depress sensory cortex, reduce motor activity, and change function of cerebellum.

Scholastic. Drug Facts: Prescription Drug Abuse. http:// headsup.scholastic.com/students/drug-facts-prescription drug-abuse

131



Drug Interactions: -Barbiturates: No significant interactions. Be careful with duplicate therapy.

-Benzodiazepines: Should not be used with opioids due to risk of sedation and respiratory depression. Should not be administered with CYP 450 3A inhibitors.  Contraindications: -Barbiturates: Liver impairment, patients with nephritis, previous addiction to the class, and sensitivity to barbiturates.

-Benzodiazepines: Hypersensitivity to benzodiazepines, pregnancy, glaucoma, liver disease, sleep apnea, and myasthenia gravis.  Adverse Effects: bradycardia, hypotension, nightmares, confusion, dizziness, lethargy, constipation, nausea, vomiting, liver damage, skin rashes, apnea, and respiratory depression.



Monitoring: Periodically evaluate organ function, especially hematopoietic, renal and hepatic systems.  Drug Screening: -Ask about prescriptions at routine visits and note rapid increases in doses or early refill requests for CNS depressants.

-8-panel tests that are commonly used by employers can detect barbiturate and benzodiazepine use.



Most depressants are controlled substances and are either schedule II, or IV depending on their potential for addiction

♦

Depressants should be used clinically. They are helpful in treatment of anxiety and sleep disorders. ♦ Despite the benefits, these drugs are addictive and should be used with caution. ♦ Abuse of these substances could be deadly because the CNS could become too depressed. This could slow or stop breathing which would lead to death if the patient is not treated. ~ M. Todd

1.Benzodiazepines. Drug Facts and Comparisons. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http:// online.factsandcomparisons.com. Accessed October 14, 2018.

2.Center on Addiction. More Than 15 Million Americans Abuse Opioids, Depressants, Stimulants; Teen Abuse Triples in 10 Years. Available at: https:// www.centeronaddiction.org/newsroom/press-releases/2005-under-the-counter-controlled-prescrption-drug-abuse-at-epidemic-level. Accessed October 14, 2018 3.Drug and Alcohol Testing Industry Association. Workplace Drug Testing. Available at: http://www.datia.org/datia-resources/27-credentialing/cpc-and-cpct/931workplace-drug-testing.html#q6. Accessed October 14, 2018.

4.Drug Enforcement Agency. Controlled Substances Security Manual. Available at: https://www.deadiversion.usdoj.gov/pubs/manuals/sec/app_law.htm. Accessed October 14, 2018.

5.Drug Screening.org. Prescription Pain and Other Medications. Available at: http://www.drugscreening.org/prescription.aspx. Accessed October 14, 2018.

6. National Institute on Drug Abuse. Prescription CNS Depressants. Available at: https://www.drugabuse.gov/publications/drugfacts/prescription-cns-depressants.

Accessed on October 14, 2018.

7.Sedatives and Hypnotics, Barbiturates F&C. Drug Facts and Comparisons. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.factsandcomparisons.com. Accessed October 14, 2018.

132

RX STIMULANTS FOR ADHD:

Common Slang Terms for Dextroamphetamine ──── Dexies Double Trouble Turnarounds ────

Common Slang Terms for Methylphenidate

DEXTROAMPHETAMINE AND METHYLPHENIDATE

──── Kiddy Coke Poor Man’s Cocaine Vitamin R Diet Coke ────

History of Prescription Stimulants

Pharmacology of Prescription Stimulants

Dextroamphetamine is an “upper” that was used widely in the mid 1950’s as a diet pill and as a way to stay awake to be able to perform tasks longer. Because of its wide usage, its negative side effects and addictive nature were soon realized. It because closely regulated with laws passed by the FDA. Now it can only be obtained if you have a prescription and is commonly prescribed to treat ADHD.

Dextroamphetamine MOA: Stimulate the CNS by activating alpha and beta receptors Therapeutic uses: ADHD, narcolepsy

Methylphenidate was originally prescribed to treat chronic fatigue, narcolepsy, and depression. Its therapeutic uses began to be researched in the 1950’s and it was being used to treat ADHD by the early 1960’s. The use of RitalinR skyrocketed in the 1990’s and is still heavily used to treat ADHD.

https://en.wikipedia.org/wiki/Dextroamphetamine

Methylphenidate MOA: Blocks reuptake of norepinephrine and dopamine into the presynaptic neuron, which activates the arousal system and cortex Therapeutic Uses: ADHD, narcolepsy

https://en.wikipedia.org/wiki/Methylphenidate

Grace Whitham Student Pharmacist Fall 2018 133

Drug interactions/ toxicology

Drug Screening

Dextroamphetamine:

Dextroamphetamine:

Interactions- MAOI, CYP2D6 inhibitors, alkalizing agents, thiazide diuretics

Test name – Amphetamine Screen

Side Effects- Increased heart rate, decreased body growth, stroke, heart attack, aggressive behavior

This test requires a urine sample and will yield a positive result if there is any type of amphetamine substance in the urine.

Methylphenidate:

Methylphenidate:

Interactions- MAIO,s phenytoin, SSRIs

Test name – NarcoCheck MPD

Side effects- Increased heart rate, decreased weight, decreased appetite, dizziness, anxiety

This test requires a urine sample and will yield a positive result if there is methylphenidate in the urine.

Dextroamphetamine

Methylphenidate

https://www.erowid.org/chemicals/amphetamines/amphetamines.shtml

https://www.erowid.org/chemicals/amphetamines/amphetamines.shtml

Laws

Professional Opinion

Both dextroamphetamine and methylphenidate are schedule II drugs. This means it is illegal to be in possession of it without a license or prescription.

Due to the potentially dangerous side effects of dextroamphetamine and mythylphenidate, I would always recommend that these drugs be used exactly as prescribe and never recreationally. ~ G. Whitham

References: -Amphetamine. The Vaults of Erwid. https://www.erowid.org/chemicals/amphetamines/amphetamines.shtml. Updated December 8, 2016. Accessed September 22, 2018.

-University of Rochester Medical Center. Amphetamine Screen (Urine). Available at: https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=167&contentid=amphetamine_urine_screen. Accessed September 22, 2018 -PhamaDrug Test. Methylphenidate (Ritalin) test. Available at: https://www.pharmadrugtest.com/urine-drug-tests/91-methylphenidate-testritalin.html. Accessed September 22, 2018.

-Michael’s House Treatment Centers. What are Street Names for Ritalin? Available at: https://www.michaelshouse.com/ritalin-addiction/what-arestreet-names-for-ritalin/. Accessed September 22, 2018.

-Center for Substance Abuse Research. Ritalin. Available at: http://www.cesar.umd.edu/cesar/drugs/ritalin.asp. Accessed September 22, 2018.

-Drugenquirer. Dextroamphetamine Side Effects and Warnings. Available at: https://www.drugenquirer.com/side-effects/dextroamphetamine.html.

Accessed September 22, 2018.

-BehaveNet Inc. Dextroamphetamine. Available at: https://behavenet.com/dextroamphetamine. Accessed September 22, 2018.

-Dextroamphetamine. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: htts://www.micromedexsolutions. com.

Accessed September 22, 2018.

-Methylphenidate Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: htts://www.micromedexsolutions. com. Accessed September 22, 2018.

134

Rx Sleep Drugs MADELINE VERBEKE

Chill Pills

Zdrugs French Fries

Student pharmacist Fall 2018

History/Background:  In the nineteenth century, drugs that could knock people out were discovered.  The earliest drug used for insomnia in the clinical setting was chloral hydrate. Some other drugs that used to be prescribed for severe sleep problems were paraldehyde and sulphonal.  New prescription drugs were introduced in the 1990s geared specifically towards insomnia with less side effects. These drugs included zaleplon and zolpidem, which are still the main sleep aids on the market today.

http://rebloggy.com/post/drugs-sleep-pills/25177375950

Pharmacology/Drug Effects:

 Rx sleep drugs are used to help a person fall asleep easier or stay asleep longer.  Enhance the signaling of GABA, which is the brain’s major inhibitory neurotransmitter. This is done via the type A receptor.

https://www.nytimes.com/2007/03/15/business/15drug.ready.html

 High doses of these drugs can cause respiratory depression, especially when mixed with alcohol.  Rx sleep drugs can cause an unusual euphoria.  A user will usually not even know they’re addicted until they stop taking the drug and realize they cannot sleep without it.

135

Drug Interactions/Toxicology: Azelastine Bromperidol Orphenadrine Oxomemazine Paraldehyde RifAMPin Sodium Oxybate Thalidomide St. John’s Wort Contraindications:

Daytime alertness Behavior profile

Fall risk

Monitoring Insomnia persistence

Tolerance

Hypersensitivity to a component of the formulation Dependence

Side Effects:

Abuse

Dizziness/lightheadedness

Headache GI problems Prolonged drowsiness Daytime memory and performance problems https:// www.nytimes.com/2013/01 /11/health/fda-requirescuts-to-dosages-ofambien-and-other-sleepdrugs.html

References:  



Drug Screens:

 Urine tests do not normally detect sleep drugs, but a false positive for benzodiazepines may occur.  More sophisticated tests may be able to detect sleep drugs

Professional Opinion It is not difficult to become dependent on Rx sleep drugs, but can be very helpful for people dealing with insomnia. Because of this, I would only recommend using Rx sleep drugs under the supervision of a doctor to help avoid the possible addiction potential. ~ M. Verbeke

Laws:

 A prescription from a doctor is required to obtain Rx sleep drugs.  If the drug is not prescribed for a patient, it is illegal.

https://health.clevelandclinic.org/ how-you-can-safely-use-sleepingpills-for-insomnia/

Escobar A. Prescription Drug Addiction. Sonata Addiction. Available at: https://www.drugaddictiontreatment.com/types-of-addiction/prescriptiondrug-addiction/sonata-addiction/. Accessed October 14, 2018.

Casa Palmera Staff. Casa Palmera. Nicknames and Slang for Abusing Prescription Drugs. Available at: https://casapalmera.com/blog/nicknames-andslang-for-abusing-prescription-drugs/. Accessed October 13, 2018.

Mayo Clinic Staff. Mayo Clinic. Prescription Sleeping Pills: What’s right for you? Available at: https://www.mayoclinic.org/diseases-conditions/insomnia/ in-depth/sleeping-pills/art-20043959. Accessed October 13, 2018.



Rihel J, Schier AF. Sites of Action of Sleep and Wake Drugs: Insights from Model Organisms. Curr Opin Neurobiol 2013; 23(5): 831-840. DOI: 10.1016/ j.conb.2013.04.010.



Tuck. History of Sleep Medication. Available at: https://www.tuck.com/history-sleep-medication/. Accessed October 13, 2018.



Zolpidem. Drugs Facts and Comparisons. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http:// online.factsandcomparisons.com. Accessed October 13, 2018.

136

Salvia Divinorum HISTORY/BACKGROUND • •

• •

Found in the Sierra Mazateca in Oaxaca, Mexico.

The Mazateca Indians believed the plant was an incarnation of the virgin Mary.

By the late 1970s salvia was being smoked in Mexico City.

It is now banned in many places due to its hallucinogenic effects.

https://www.imdb.com/title/tt6983586/mediaviewer/rm2310678528

PHARMACOTHERAPY/EFFECTS

• •

•

• •

The only natural psychedelic without a nitrogen group.

Has a high binding affinity for the kappa-­‐opioid receptors.

Agonists of these are known to cause hallucinations or altered mental state.

Research shows that it is unlikely to be able to overdose on this herb. Researchers also do not believe salvia to be addictive.

Has a very rapid onset when smoked; effects declining after 5-­‐30 minutes.

Side effects include tingling, hyperawareness of the body at low doses and hallucinations or physical impairment at higher doses.

http://www.sagewisdom.org/valdes94.html

OTHER NAMES • • • •

Magic Mint Sally-­‐D Shepherdess’s Herb Diviner’s Sage

Emily Woods, Student Pharmacist Fall 2018

https://simonsblogpark.com/legalhigh/simons-salvia-guide/

137

Salvia Divinorum

DRUG INTERACTIONS

SIDE EFFECTS CONTRAINDICATIONS Pregnancy

There were no drug interactions found.

More research is needed.

Do not operate machinery until effects are known.

Slurred speech Short term memory loss Irregular heart beat Visions Nausea Chills

LAWS

MONITORING/SCREENING

Salvia is not a controlled substance in the US. In some states salvia is legalized while in others it has been banned. In Canada it is illegal to sell salvia but not to have it. Australia was the first country to completely ban salvia use.

Because of the short duration that it is in the blood stream, it will most likely not show up on drug tests. Usually it is not even tested for because it was a lot less popular than other drugs. Also very unlikely to cause false positives.

PROFESSIONAL OPINION: Although some research states that this is relatively safe, I would never recommend that someone use this product. I do not think enough research has been done to know the long term effects of this drug. The impairment that it causes could be dangerous if not closely monitored.

–E. WOODS FUN FACTS: The unusual characteristics of this psychedelic drug, could be used to better understand diseases with hallucinogenic effects such as Alzheimers or schitzophrenia.

Studies show that Salvia may also help in the treatment of depression by promoting relaxation and improving mood.

References: 1.“Learn Everything You Need To Know About Potent Psychedelic Salvia Divinorum.” The Third Wave, thethirdwave.co/psychedelics/salvia/.

2. Ps94amay99, www.sagewisdom.org/valdes94.html.

3.“List of Street Names for Drugs.” DrugAbuse.com, 9 Mar. 2018, drugabuse.com/library/list-of-street-names-for-drugs/#salvia.

4.“Diviner's Sage Effectiveness, Safety, and Drug Interactions on RxList.” RxList, www.rxlist.com/diviners_sage/supplements.htm.

5.“What Is Salvia: Side Effects, Overdose & Addiction Risks.” American Addiction Centers, americanaddictioncenters.org/salvia/.

6.“Drug Tests For Salvia a Can Salvia Be Detected In A Urine Test.” Marijuana Seeds For Sale P The 8 Best Seed Banks To Buy From, www.marijuanaseedsavings.com/salviaa druga test.html.

138

Scopolamine Austin Wooten PharmD Student Fall 2018 Vice – World’s Scariest Drug, Scopolamine “The Devil’s Breath”. Third Monk. http://thirdmonk.net/knowledge/vice-scariest-drug-scopolamine-video.html

Slang: Devil’s Breath, Burundanga

History: • 4000 – 1400 CE: First incorporation into ointment

deemed “Witches Brew” due to hallucinogenic effects.

•

1760: Giovanni Antonio Scopoli publishes Flora Carniolica first documenting scopolamine plant.

• 1800: Scopla Carniolica medicinal properties recognized after isolation of tropane alkaloid by Ernest Schmidt.

• 1900: First use of Scopolamine as anesthetic.

• 1922: First used as truth serum by U.S. police Scroll. Deviant Art. http://orig05.deviantart.net/5d48/f/2013/136/c/3/ scroll_png_by_aarzikhan-d65h0si.png

https://99designs.co m/other-designtasks/contests/devilbreath-herbalincensedesign-109004 Tundlove. Popeye Gangsta. OPSD’s. https:// officialpsds.com/popeyegangsta-psd-rql5y7

Pharmacotherapy: •

• • • •

Scopolamine acts as a competitive inhibitor on muscarinic receptors for acetylcholine and a nonselective muscarinic antagonist, producing both peripheral antimuscarinic properties and central sedative, antiemetic and amnestic effects.

Compared to rohypnol (roofies) Dosage forms: Transdermal patch, IV/IM/SC injection, tablet Dose: IV/IM/SC 0.32-0.65mg; transdermal 1.5mg patch every 72 hours; 0.4-0.8mg Orally Duration of Action: 90 minutes IM, 5-6 hours IV, three days transdermal

Hyoscine. Wikipedia. https://en.wikipedia.org/wiki/Hyoscine

139

Drug interactions/toxicology: Contraindications

Drug Interactions • Potassium (contraindicated) • Seizure lowering agents o Donepezil o Bupropion • Anticholinergics (major) o tiotropium o glycopyrrolate o amantadine

• • •

Closed angle glaucoma Pregnancy Hypersensitivity to belladonna alkaloids

Side effects • • •

Dry mouth Drowsiness Blurred Vision

Laws: Scopolamine is not a scheduled drug but does require a prescription to obtain.

Monitoring/Drug Screens: Monitoring •

Open angle glaucoma patients should be monitored and adjusted in therapy during scopolamine use due to possible increase in IOP from the mydriatic effect.

Patients with a pre-existing GI or urinary bladder obstruction should be monitored closely with use.

Patients with seizures or psychosis should be monitored as scopolamine can aggravate these conditions Use in children and elderly should be monitored due to increased risk for CNS effects that could lead to injury.

• •

•

Drug Screens •

•

Can be detected through blood, urine and hair sample but more difficult to detects in hair and urine.

T ½ is nine hours for scopolamine but the effect of the drug can last days dependent on route of administration.

Professional Opinion: Scopolamine is appropriate for use in the patch form for n/v, motion sickness, and pre-op sedation, but I would not recommend the use of the oral form in p ediatric or geriatric patients due to their higher susceptibility for adverse effects. ~ A. Wooten References: •

• • • •

•

C., & Cotroneo, C. (2013, September 03). Devil's Breath: Scopolamine, AKA Burundanga, Hailed As 'World's Scariest Drug'. Retrieved October 14, 2018, from https://www.huffingtonpost.ca/2013/09/03/devils-br eath-scopolamine_n_3860318.html Scopolamine. (n.d.). Retrieved October 14, 2018, from https://toxnet.nlm.nih.gov/cgi-bin/sis/search/a?dbs hsdb:@term @DOCNO 4074 Scopolamine. (n.d.). Retrieved October 14, 2018, from https://www.sciencedirect.com/topics/neuroscience/scopolamine Scopolamine(R) [package insert]. Parsippany, NJ: Novartis Consumer Health, Inc. ; 2013.

The Origins and History of Scopolamine. (2014, November 17). Retrieved October 14, 2018, from https:// pbiogroup8.wordpress.com/2014/11/15/the-origins-and-history-of-scopolamine/ "Truth" Drugs in Interrogation. (2008, July 01). Retrieved October 14, 2018, from https://www.cia.gov/library/center-for-the-study-ofintelligence/kent-csi/vol5no2/html/v05i2a09p_0001.htm 140

History Sildenafil, or more commonly known as ViagraR, is known as one of the most well-known drugs in the US market. It was originally developed by Pfizer as a treatment of high blood pressure and it wasnâ&#x20AC;&#x2122;t until the clinical trials where researchers discovered that the drug was helpful in inducing erections and the treatment of erectile dysfunction. After the FDA approved the drug in 1998, this drug became the first oral treatment for erectile dysfunction and quickly became a success.

Slang Terms Sildenafil is also known as: -

Viagra The little blue pill Blue diamond. https://medicalxpress.com/news/2018-03-viagrachronicle-global-success.html

Pharmacology Sildenafil acts as a selective inhibitor of phosphodiesterase type 5 (PDE5). By inhibiting PDE5 and blocking the degradation of cGMP in the corpus cavernosum, sildenafil increases the effect of nitric oxide due to sexual stimulation. The increased levels of cGMP in the corpus cavernosum leads to smooth muscle relaxation and inflow of blood to the corpus cavernosum, resulting in an erection.

This drug is recommended due to having no effect in the absence of sexual stimulation https://www.livestrong.com/article/245560-what-pills-contain-the-ingredient-sildenafil/

XUPING YAN

Dosage forms: oral tablet Dose: 50 mg prn approximately one hour before sexual activity Dose may be increased to 100 mg or decreased to 25 mg with a maximum frequency of one day.

Student pharmacist Fall 2018

141

Drug Interactions

Monitoring

Drug Interactions

While using Sildenafil it is important to monitor blood pressure and pulse when used with medications that lower blood pressure and also those with pulmonary edema when used to treat pulmonary arterial hypertension.

- Concurrent regular or intermittent use of organic nitrates - Concomitant use with HIV protease inhibitors - Concomitant use with guanylate cyclase stimulators Contraindications

-

Hypersensitivity to sildenafil or any of its components

https://www.health.harvard.edu/blog/keeping-bloodpressure-control-reduces-risk-second-stroke-201403287096

Adverse Effects

-

Indigestion Headache Erythema Flushing Insomnia Visual disturbances

- Nasal congestion - Cardiovascular morbidity Retinal hemorrhage - Decreased hearing - Prolonged erection of penis

Professional Opinion When used correctly for what it is intended for, Sildenafil is an effective drug in the treatment of erectile dysfunction. However, I would not recommend it for recreational use. ~ X. Yan

Laws Sildenafil has been reclassified from a S4 drug to a non-scheduled medication, meaning that patients can buy the drug with a prescription without many tight regulations on the drug. This drug has become the most counterfeited drug in the world and is increasingly abused

https://stories.avvo.com/news/politics/5 -new-laws-making-news-in-2016.html

https://www.edrugstore.com/sildenafil-citrate/

References 1.

Viagra. Drugs.com. Available at: https://www.drugs.com. Accessed October 12, 2018.

2.

Viagra. RxList. Available at: https://www.rxlist.com/viagra-drug.htm#description.

Accessed October 12, 2018.

3.

Sildenafil. Drug Facts and Comparisons. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: https://online.factsandcomparisons.com. Accessed October 12, 2018.

4.

Viagra. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 12, 2018

5.

Sildenafil [package insert]. New York, New York: Pfizer Labs; 2018.

142

Hannah Karam Student pharmacist

https://health.howstuffworks.com/wellness/drugsalcohol/synthetic-marijuana-theres-nothing-nice-aboutspice.htm

History Spice is man-made marijuana that is often used as a replacement for regular marijuana. It first materialized in Europe in 2004. Later in 2008, spice came to the USA. It was legally sold in stores, making it easy to obtain. A label was displayed on it stating that is was not for consumption, but that did not stop the public. The negative effects of Spice caught the DEA’s eye. In 2010, the DEA used emergency tactics to try to combat it2,3.

Slang Terms • • • • • • • • • •

Spice K2 Blaze Red X Dawn Bliss Black Mamba Bombay Blue Fake weed Genie Zoh4

Drug Effects Spice has many similar side effects as marijuana, but the negative side effects are more dangerous, frequent, and unpleasant in spice. These include psychotic episodes, paranoia, increased anxiety, hallucinations, increased heart rate, agitation, vomiting, seizure, uncontrollable body movements, sweating, red eyes, and dry mouth. Also, spice is highly addictive when compared to marijuana5.

143

Drug Interactions Since Spice is a relatively new drug, not a lot of information is known about what drugs it interacts with.

Because of this, most of the information on drug interactions comes from interactions with natural marijuana. Drugs that can be dangerous by slowing down the central nervous system when used with natural marijuana are barbiturates, narcotics, alcohol, and antihistamines. Some other drugs it can interact with are antidepressants (Prozac and Xanax), blood thinners, and asthma medications6.

Laws Back in 2008, Spice was legally sold in various gas stations and stores. In 2012, the DEA made it a schedule 1 drug2.

This means that there is low medical use and a high risk of danger. In every state it is illegal to ingest this drug, but it variesbetween states whether possession of Spice is allowed or not. In states where it is illegal, possession may lead to fines and/or one year spent in jail8. Another point to add, is that it takes months for the DEA to add a specificsynthetic cannabinoid to the banned drugs list.

Because of this, manufactures are continually changing their chemical formula once their current synthetic cannabinoid is banned. The DEA is trying to fix this to make sure Spice stays out of the publicâ&#x20AC;&#x2122;s hands for good7.

Drug Screening In a regular 5-panel urine drug screening test, Spice is not detected. This is because the synthetic cannabinoids in Spice are chemically different than natural cannabinoids in natural marijuana. Even though in a standard test it is not detected, tests that specifically screen for Spice do exist, however these are more expensive and therefore less common. A blood test may also screen for Spice but since it is not standard, this is more expensive7.

Professional Opinion Considering the extremely negative side effects of Spice and low benefit profile, I would not recommend taking Spice. It can cause an array of symptoms, such as paranoia and seizures, and it is highly addictive. Just because you can access a substance easily from a gas station does not mean that it is safe for you.

Addiction is a slippery slope, and I would advise everyone to stay clear of this drug. ~ H. Karam

References 1. Tatro, Carrie. How Stuff Works. Synthetic Marijuana: Thereâ&#x20AC;&#x2122;s Nothing Nice About Spice.

Available at: https://health.howstuffworks.com/wellness/drugs-alcohol/synthetic-marijuanatheres-nothing-nice-about-spice.htm. Accessed October 14, 2018.

2. Drug Free World. Synthetic Marijuana: A Short History. Available at: https://www.drugfreeworld.org/drugfacts/synthetic/synthetic-marijuana-short-history.html.

Accessed October 14, 2018.

3. Narconon. The History of Synthetic Drugs. Available at: https://www.narconon.org/drugabuse/synthetic-drugs-history.html. Accessed October 14, 2018.

4. Drug Free New Jersery. K2 Spice. Available at: http://www.drugfreenj.org/drugencyclopedia/k2-spice/. Accessed: October 14, 2018.

5. Spice Addiction Support. Side Effects of Spice Use. Available at: https://spiceaddictionsupport.org/side-effects-of-spice-use/. Accessed: October 14, 2018.

6. Drug Addiction Treatment. Synthetic Marijuana (Spice) Addiction. Available at: https://spiceaddictionsupport.org/side-effects-of-spice-use/. Accessed: October 14, 2018.

7. Tomo Drug Testing. What is K2?. https://www.yourdrugtesting.com/what-is-k2/. Accessed: October 14, 2018.

8. Legal Match. What is Spice Drug?. Available at: https://www.legalmatch.com/lawlibrary/article/what-is-spice-drug.html. Accessed: October 14, 2018.

144

History/Background

Tetrahydrocannabinol is a psychoactive component of a plant called marijuana. The history of marijuana starts in 500 B.C. in Asia and eventually was traded in Africa and Europe.

Hemp was used in the makes of clothing, paper, sails, rope, and food (seeds). The cultivation of the plant began in America when hemp was used for textiles and rope. In the 20th century, political and racial factors lead to what many may know to be an illicit drug federally.1

http://www.foxcrawl.ro/editorial/nicusor-dan-plangerepenala-ponta-ghita-soros/attachment/justitie-simbol-logo/

Laws:

Cannabis is illegal under federal laws and the Controlled Substances Act does not differentiate between medical and recreational marijuana use. Cannabis is a Schedule I drug and cannot be prescribed for use but may be â&#x20AC;&#x153;recommendedâ&#x20AC;&#x2122; under the First Amendment of the Constitution. Although some states m ake the use of cannabis legal Gonzales v. Raich (2005) ruled that the federal government has the right to prosecute. 5

Tetrahydrocannibinol

Monitoring/Drug Screens Slang Terms: Pot, Mary J, Mary Jane, grass, ace, baby, green goddess, alfalfa, asparagus, bud, Christmas tree, green, herb, Aunt Mary, da kine, dona Juanita, ganja, rainy day woman, thirteen, alligator cigarette, blunt, stoagie cabbage, chronic, dank, Nixon2 https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwidre6Cx4beAhUHLK0KHatnDdU QjRx6BAgBEAU&url=https%3A%2F%2Fmbtskoudsalg.com%2Fvector-alligator.html&psig=AOvVaw15BgRji28K36k6ro1dT08&ust=1539627806608903

THC is highly fat-soluble and has a long half-life of elimination so can be detected through urine. The most commonly used immunoassay drug screen panel is the SAMHSA-5. Heavy users could continue excreting THC via urine for up to one month. Other tests to test for THC include: hair, oral fluid, and sweat.4

https://westfaironline.com/100159/stamford-approves-medical-marijuana-dispensary/

145

Pharmacology/ Drug Effects

THC’s psychoactive component is activated by the CB 1 receptors in the central nervous system. The CB1 receptors are the most abundant GPCRs and heavily expressed in the substantia nigra, globus pallidus, hippocampus, cerebral cortex, putamen, caudate, cerebellum, and amydala (in that order from most to least expressed). THC has been proven to provide analgesic as well as potentially neurologic effects and stimulates hunger.3 Drug Interactions/Toxicology: The concurrent administration of ketoconazole with THC increases the maximum serum concentration by 1.2-2-fold.

Coadministration of rifampin causes a reduction of THC levels.3 Short-term adverse effects of THC include: short-term memory, impaired motor coordination, altered judgement, paranoia, or psychosis at high doses.3 Long term adverse effects of THC include: addiction, altered brain development, cognitive impairment, poor educational outcome, diminished life satisfaction.

Long term adverse effects THC is associated with include: chronic bronchitis, risk of chronic psychosis-related health disorders (schizophrenia, depression), vascular conditions (myocardial infarction, stroke, transient ischemic attack).

References: 1

History. Marijuana. Available at: https://www.history.com/topics/crime/history-of-marijuana.

Accessed October 15, 2018.

2

Time. 420 Day: Why There Are So Many Different Names for Weed. Available at: http://time.com/4747501/420-day-weedmarijuana-pot-slang/. Accessed October 15, 2018.

3

Bridgeman MB, Abazia DT. Medicinal Cannabis: History, Pharmacology, And Implications for the Acute Care Setting. P T. 2017; 42(3): 180–188.

4

Hadland SE. Levy S. Objective Testing – Urine and Other Drug Tests. Child Adolesc Psychiatr Clin N Am. 2016; 25(3): 549–565. doi: 10.1016/ j.chc.2016.02.005 5

Americans For Safe Access. Federal Marijuana Law. Available at: https://www.safeaccessnow.org/federal_marijuana_law.

Accessed: October 15. 2018.

https://www.fool.com/investing/201 8/10/14/is-this-high-flying-marijuanastock-the-next-tilra.aspx

Professional Opinion: THC is a highly controversial topic due to its recent criminalization. I believe the use of THC has many medical benefits in analgesia and neurological disease states as it has been proven3. Although it may not be legal right now, the component of cannabis, CBD, is not illegal and allows a small percentage of THC to be mixed in to activate the CBD component3,5.

Picture Background: https://wallpaper-house.com/group/marijuana-wallpaper-

hd/index.php

146

Tramadol GraceYun Student pharmacist Fall 2018

Tramadol (Ultram). The Vaults of Erowid. https://www.erowid.org/pharms/ show_image.php?i=tramadol/tramadol_tablet i2015e0115_disp.jpg

History/background • • • • •

1962: created by a German drug company that specializes in treating pain 1977: approved and brought to the foreign market under the name Tramal® 1995: tramadol became available in the US 2013: prescriptions increased from 23.3million in 2008 to 44million 2014: became a Schedule IV drug in the US

Slang • Ultras • Chill Pills • OxyContin Lite

Pharmacology/Effects • • • • • • • •

Trans-(+/-)-2-[9dimethylamino]methyl]-1-(3-methoxyphenyl) cyclohexanol Centrally-acting synthetic opioid analgesic that binds to mu-opioid receptors and weakly inhibits norepinephrine and serotonin uptake Analgesic and central nervous system agent Available as immediate release tablets and extended release tablets or capsules Dose: 50-100mg/day Total duration: 6-14 hours After effects: 1-5 hours Effects: pain relief, sense of well-being, positive outlook

Tramadol Update Review Report. World Health Organization. http://www.who.int/medicines /areas/quality_safety/6_1_Upd ate.pdf

147

Drug Interactions/Toxicology Drug Interactions •

Naltrexone , monoamine oxidase inhibitors, lithium, clopidogrel, hydromorphone, amphetamines, cyclobenzaprine, CYP2D6 inhibitors, desmopressin, CNS depressants, methadone, hydrocodone, fentanyl, CYP3A4 inducers, morphine

Contraindications •

Respiratory depression, acute intoxication with alcohol, hypnotics, centrally acting analgesics, opioids, or psychotropic drugs, acute or severe bronchial asthma, children younger than 12 years, hypercapnia, hypersensitivity to opioids or tramadol, gastrointestinal obstruction, concurrent use of MAOIs

Adverse Effects •

Nausea/vomiting, constipation, dry mouth, dizziness, headache, flushing, difficulty urinating or increased urination, anxiety, heartburn, may lower seizure levels, itching, sweating, agitation, tremor

Laws • •

Schedule IV in the US and controlled specifically in a number of states Available by prescription only

Monitoring/Drug Screens Monitoring •

Pain reduction/control, blood pressure, seizure frequency or severity, respiratory depression, suicidal ideation or worsening depression

Drug Screens •

Tramadol can be detected in urine within 2 hours and up to 40 hours, in hair up to 90 days, in saliva for up to 24 hours, and in blood for up to 24 hours

Professional Opinion •

When used as prescribed, tramadol can be effective in treating moderate to severe pain. However, I do not believe this should be used recreationally. ~ G. Yun

References • • • • • •

Understanding Common Street Drug Slang and Drug Abuse Definitions. The Treatment Center. Available at: https://www.thetreatmentcenter.com/resources/drug-slang/. Accessed October 15, 2018 Tramadol Hydrochloride. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 15, 2018.

Tramadol. The Vaults of Erowid. Available at: https://www.erowid.org/pharms/tramadol/tramadol.shtml. Accessed October 15, 2018.

Tramadol Update Review Report. World Health Organization. http://www.who.int/medicines/areas/quality_safety/6_1_Update.pdf. Accessed October 15, 2018.

How Long Does Tramadol Stay in Your System?. The Recovery Village. https://www.therecoveryvillage.com/tramadoladdiction/faq/how-long-does-tramadol-stay-in-system/#gref. Accessed October 15, 2018 Tramadol History and Statistics. Drugabuse.com. Available at: https://drugabuse.com/library/tramadol-history-andstatistics/. Accessed October 15, 2018.

148

[ZACH ZAJAC STUDENT PHARMACST FALL 2018 TRAMADOL] https://www.atvgh.com/wp-content/uploads/2018/04/TRAMADOL1.png

History 1962: Tramadol was first made by German Company Gruenenthal GmbH. 1977: Launched in Germany as TramalR after going clinical trials.

1995: Received FDA approval in the U.S. under the brand name UltramR. 2014:Tramadol is now a Schedule IV substance

Slang There are no known slang words with tramadol. The closest synonyms are: Adolan, Anadol, Contramal, Dolol, Dolzam, Dromadol.

Pharmacotherapy (±)cis-2-[(dimethylamino)methyl]-1-(3methoxyphenyl) cyclohexanol hydrochloride

 Comparative to VicodinR and PercocetR  Tramadol is an analgesic used for moderate to severe pain  Dosage forms: tablets, IV, injection, suppository

https://dailymed.nlm.nih.gov/dailymed/fda/f daDrugXsl.cfm?setid=f6d34d61-9175-4106a497-0598b25212fa&type=display

 Dose: 50mg – 300mg  Duration: One 50mg tablets PO every 4-6 hours

149

Drug Interactions/Toxicology Drug Interactions:

     

quinidine fluoxetine paroxetine amitriptyline ketoconazole erythromycin

Contraindications:  



  

Not for those who experienced hypersensitivity in the past.

Contraindicated in any situation where opioids are contraindicated, including acute intoxication with any of the following: alcohol, hypnotics, and narcotics, centrally acting analgesics, opioids or psychotropic drugs.

Tramadol hydrochloride may worsen central nervous system and respiratory depression in these patients.

Side Effects:        

Dizziness/Vertigo Nausea Constipation Headache Somnolence Vomiting Pruritus Dry mouth

Creatinine at baseline Signs and Symptoms of respiratory depression, especially 24-72 hours after treatment start or increase in dose Assess for patient’s reduction in pain as a therapeutic response to tramadol

Tramadol is detectable in the urine for two to four days. It generally will not show up as a positive for opiates on a drug screening test such as might be done for employment, but tramadol can be detected on a prescription drug screening test

As a Schedule IV drug, the only legitimate way to obtain this drug in the United States is by obtaining a prescription from a licensed prescriber.

“Using tramadol can feel as good as getting a blood transfusion for athletes. You can pop a pill 18 hours into a 24-hour endurance race and it’s an immediate boost that helps you power through the end.” ~ I. Mullins

1.

Tramadol. Why Some Athletes and Experts Want It Banned. Available at: https://www.usada.org/tramadolwhy-some-athletes-and-anti-doping-experts-want-it-banned/. Accessed October 15, 2018

2.

Tramadol. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 15, 2018

3.

Tramadol Hydrochloride. Available at: https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl .cfm?setid=f6d34d61-9175-4106-a497-0598b25212fa&type=display. Accessed October 15, 2018.

4.

Tramadol Dosage. Available at: https://www.drugs.com/dosage/tramadol.html. Accessed October 15, 2018.

150

Yohimbe By: May Zhang, Student Pharmacist – Fall 2018

History: ▪ Yohimbe was first discovered and used for its aphrodisiac qualities by the Pygmies and the San in West Africa, where it grows in the wild.

▪ Originates from the inner bark of the tropical Western African evergreen tree called the Pausinystalia yohimbe.

▪ The active ingredient from the bark is known as yohimbine and has been used primarily in the treatment for weight loss, xerostomia, and as an aphrodisiac.

▪ Yohimbe have been investigated by the US FDA for the treatment of organic and psychogenic erectile dysfunction.

▪ Yohimbe has been misused as a mild hallucinogen.

Slang: ▪ ▪ ▪ ▪

Johimbe Yo Yo Yohimbine Yohimbehe

▪ Johimbi

Mother Earth’s Healing. Yohimbe. Available at: https://motherearthshealing.wordpress.com/2013/06/13/yohi mbe-bark-the-herbal-viagra/. Accessed October 13, 2018.

Pharmacology/Pharmacotherapy:

▪ Classification: central/autonomic system agent, alpha-adrenergic blocker, erectogenic, anxiogenic, mydriatic ▪ Yohimbine is an indole alkaloid derivative ▪ Acts as a selective antagonist at alpha-2-receptors, thus yohimbe can increase sympathetic outflow and potentiate the release of norepinephrine producing an increase in peripheral sympathetic activity at high concentrations.

▪ Dosage form: bark, caplet, capsule, liquid, extract, tablet ▪ Dose: 5.4 milligrams three times daily for less than or equal to ten weeks ▪ Metabolism: readily penetrates the central nervous system

Yohimbe. Wikipedia.

Available at: http://en.wikipedia.org/wiki /Yohimbine. Accessed October 13, 2018.

151

Drug Interactions:

Drug Interactions/Toxicology

▪ Antianxiety agents, antihypertensives, aripiprazole, monoamine oxidase inhibitors, peginterferon alfa-2, and tricyclic antidepressants Contraindications: ▪ Hypersensitivity to yohimbe, pediatric and psychiatric patients, history of gastric and duodenal ulcers, renal and liver disease, concurrent use with mood altering drugs, antidepressants, tyramine-containing foods, pregnancy, lactation and chronic inflammation of the sexual organs or prostate gland Adverse Effects: ▪ Increased blood pressure, tachycardia, dizziness, headache, nervousness, tremor, anxiety, irritability, agitation, nausea, vomiting, antidiuresis, bronchospasm, cough, skin flushing, sleeplessness, and manic symptoms Toxicology: ▪ No long-term toxicological and carcinogenicity studies available ▪ Not recommended for long-term use and use cautiously in individuals with hypertension Monitoring: ▪ Monitor vital signs, renal functions, and mental status ▪ Routine laboratory studies are not needed unless otherwise clinically indicated ▪ Monitor fluid/electrolytes status in patients that develop significant vomiting/diarrhea Drug screens: ▪ Qualitative tests are available, which includes thin layer chromatography and gas chromatography.

▪ Yohimbine may be quantified in the plasma by high performance liquid chromatography; however, toxic levels have not yet been established.

Laws: ▪ Yohimbine HCl (Aphrodyne®, Yocon®) is the prescription form of yohimbe in the US. ▪ Yohimbe products containing man - made yohimbine hydrochloride as an ingredient are illegal to be sold as a dietary supplement in the US.

Professional Opinion: ▪ Since the toxic serum concentrations have not yet been established and because of the adverse effect profile, I would not recommend the use of yohimbe therapeutically or recreationally. ~ M. Zhang References: ▪ ▪ ▪ ▪ ▪

Yohimbe. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com. Accessed October 10, 2018.

Yohimbe. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed October 10, 2018.

Yohimbe. The Vaults of Erowid. Available at: https://www.erowid.org/plants/yohimbe/. Accessed October 110x, 2018.

Yohimbine. IPCS INCHEM. Available at: http://www.inchem.org/documents/pims/pharm/yohimbin.htm#SectionTitle:6.4%20Metabolism.

Accessed October 13, 2018.

Yohimbe. WebMD. Available at: https://www.webmd.com/vitamins/ai/ingredientmono-759/yohimbe. Accessed October 13, 2018.

152

Last impressions from class â&#x20AC;&#x201C; ABCs