which provide anonymized data to the appropriate national or regional Drug Misuse Database (DMD). Key points Prescription of controlled drugs Preparations which are subject to the prescription requirements of the Misuse of Drugs Regulations 2001 are labelled CD. The principal legal requirements are as follows: Prescriptions ordering Controlled Drugs subject to prescription requirements must be signed and dated by the prescriber and specify the prescriber’s address. The prescription must always state in the prescriber’s own handwriting in ink or otherwise so as to be indelible: • the name and address of the patient; • in the case of a preparation, the form and, where appropriate, the strength of the preparation; • the total quantity of the preparation, or the number of dose units, in both words and figures; • the dose. Prescriptions ordering ‘repeats’ on the same form are not permitted. It is an offence for a doctor to issue an incomplete prescription (see the British National Formulary for full details). DRUGS THAT ALTER PERCEPTION Cannabis (marijuana) is the most widely used illicit drug in the UK. The most active constituent is Δ-9-tetrahydrocannabinol, which produces its effects through actions on cannabinoid CB1 receptors. It is most commonly mixed with tobacco and smoked, but it may be brewed into a drink or added to food. The pleasurable effects of cannabis include a sensation of relaxation, heightened perception of all the senses and euphoria. The nature and intensity of the effects varies between individuals, and is related to dose, and to the mood of the subject. The effects usually occur within minutes and last for one to two hours. Conjunctival suffusion is common. Tetrahydrocannabinol and other cannabinoids are extremely lipid soluble and are only slowly released from body fat. Although the acute effects wear off within hours of inhalation, cannabinoids are eliminated in the urine for weeks following ingestion. It is claimed that cannabis may be of value in the symptomatic management of multiple sclerosis, particularly if nausea is a prominent symptom. It has no approved medicinal use in the UK. Acute adverse effects include dysphoric reactions, such as anxiety or panic attacks, the impairment of performance of skilled tasks, and sedation. This may lead to road traffic accidents. Chronic use has been associated with personality changes, including ‘amotivational syndrome’ which is characterized by extreme lethargy. The association of chronic cannabis use with onset of schizophrenia is unproven. A physical dependence syndrome has been reported for cannabis, but only after extremely heavy and frequent intake. Dependence on cannabis as a primary problem is rare and there are no specific DRUGS THAT ALTER PERCEPTION 437 treatments for cannabis dependence. Similarly, there are no treatments for cannabis intoxication, although dysphoric reactions may require brief symptomatic treatment (e.g. with benzodiazepines). LYSERGIC ACID DIETHYLAMIDE AND OTHER PSYCHEDELICS Psychedelics produce hallucinations (e.g. visual, somatic, olfactory) and other changes in perception, e.g. feelings of dissociation and altered perception of time. Psychedelics can be divided into serotonin- or indoleamine-like psychedelics (e.g. lysergic acid diethylamide (LSD) and psilocybin) and phenylethylamines (e.g. mescaline, phencyclidine – angel dust – and methylenedioxymethylamphetamine – MDMA or ‘ecstasy, XTC’). These are agonists at the serotonin 5-HT 2-receptor and their potency as hallucinogens is closely correlated with their affinity for this receptor. Some phenethylamine psychedelics stimulant properties and can produce feelings of increased energy and euphoria and heightened perception. MDMA is the most commonly abused recreational hallucinogenic central stimulant in the UK. The most common users are adolescents. In high-dose hyperpyrexia, trismus, dehydration, hyponatraemia, rhabdomyolysis, seizures, coma, hepatic damage and death have been reported. Interactions with antidepressants are life-threatening. Impulsivity and impaired memory are serious long-term effects. Chronic MDMA usage produces degeneration of serotonergic neurones. MDMA is metabolized via the CYP 2D6 system and is a potent CYP 2D6 inhibitor. The elimination kinetics are saturable. Psychedelics were used historically as adjunctive treatment in psychotherapy, but were subsequently found to be of no benefit. Most are taken orally and perceptual changes occur approximately one hour later. The duration depends on dose and clearance, and is often several hours to one day. Tolerance to behavioural effects can occur, but no withdrawal syndrome has been demonstrated. In addition to the uncommon life-threatening adverse effects caused by MDMA, physicians come into contact with psychedelic drug abusers when they contact emergency services, e.g. as a result of dysphoric reactions or ‘bad trips’. These symptoms can respond to reassurance and quiet surroundings, although chlorpromazine (which has 5-HT 2-antagonist effects) or diazepam may be of benefit. Phencyclidine (‘PCP’, ‘angel dust’) was originally developed as an injectable anaesthetic. It binds to the glutamate ion channel. Its therapeutic use in humans was stopped after early clinical studies showed that it produced confusion, delirium and hallucinations. It is used for anaesthetic purposes by veterinarians. Patients may show extreme changes in behaviour and mood (e.g. rage and aggression, lethargy and negativism, euphoria), hallucinations, autonomic arousal (hypertension, hyperthermia) and, in extreme cases, coma and seizures. Symptoms of PCP intoxication should be treated symptomatically. PCP abuse is rare in the UK.
438 DRUGS AND ALCOHOL ABUSE CENTRAL STIMULANTS Amphetamines are abused for their stimulant properties, which are related acutely to the release of dopamine and noradrenaline. Their therapeutic use is limited to specialist treatment of narcolepsy and hyperactivity in children. They should not be prescribed in the management of depression or obesity. Acutely they may alleviate tiredness and induce a feeling of cheerfulness and confidence, and because of their sympathomimetic effects they raise blood pressure and heart rate. With high doses, particularly after intravenous use, a sensation of intense exhilaration may occur. Users tend to become hyperactive at high doses, especially if these are repeated over several days. Repeated use of amphetamines can produce ‘amphetamine psychosis’, which is characterized by delirium, panic, hallucinations and feelings of persecution, and can be difficult to distinguish from acute schizophrenia. Anxiety, irritability and restlessness are also common. Prolonged use leads to psychological dependence, tolerance and hostility, as well as irritation due to lack of sleep and food. The most commonly used amphetamine is amphetamine sulphate in oral or injectable forms, which are only available illegally. More recently, free-base amphetamine has become available (‘ice’), which can be smoked, and this has pharmacokinetic and subjective effects similar to those of injected amphetamine sulphate. There are no specific drug treatments for amphetamine dependence, and the mainstay of therapy involves counselling and social management. MDMA is described under drugs that alter perception. Cocaine is derived from the Andean coca shrub. It has powerful stimulant properties which are related to its action in blocking synaptic re-uptake of dopamine, and to a lesser extent noradrenaline and serotonin. As the salt it is most commonly sniffed up the nose, although it can also be injected. In the USA, the free base of cocaine (‘crack’) is widely available. The pharmacokinetics of smoked crack cocaine are almost identical to those of intravenous cocaine. Acutely cocaine causes arousal, hypertension, exhilaration, euphoria, indifference to pain and fatigue, and the sensation of having great physical strength and mental capacity. Repeated large doses commonly precipitate an extreme surge of agitation and anxiety. Myocardial infarction or arterial dissection can occur acutely. In contrast to alcohol and opioids, which addicts tend to use on a regular basis, cocaine is used in binges, where doses may be taken several times an hour over a day or several days until exhaustion or lack of money prevents this. Tolerance of the euphoric effects occurs. However, upon stopping a cocaine binge, withdrawal symptoms including excessive sleep, fatigue and mild depression, may occur. Repeated cocaine use may produce adverse effects including anorexia, confusion, exhaustion, palpitations, damage to the membranes lining the nostrils and, if injected, blood-borne infections. Use of cocaine in pregnancy is associated with damage to the central nervous system of the fetus. ‘Crack babies’ can usually be cured of their ‘addiction’ by abstinence over a few weeks. Currently, there are no specific drug treatments for cocaine dependence. Counselling and social management of patients have been shown to be of only modest benefit in maintaining abstinence. Nicotine is an alkaloid present in the leaves of the tobacco plant. The only medical use of nicotine is as an aid in smoking cessation. Its importance relates to its addictive properties and its presence in tobacco. The smoke of a completely burned cigarette usually contains 1–6 mg and that of a cigar contains 15–40 mg of nicotine. Acute administration of 60 mg of nicotine orally may be fatal. Nicotine first stimulates the nicotinic receptors of autonomic ganglia and then blocks them. Thus smoking can accelerate the heart via sympathetic stimulation, or slow it by sympathetic block or parasympathetic stimulation. Adrenaline and noradrenaline are secreted from the adrenal medulla. The motor end-plate acetylcholine receptors are initially stimulated and then blocked, producing a paralysis of voluntary muscle. The results of extensive central stimulation include wakefulness, tremor, fits, anorexia, nausea, vomiting, tachypnoea and secretion of antidiuretic hormone (ADH). Adverse effects of smoking Smoking is a potent risk factor for malignant and cardiovascular disease. Some of the specific causes of death which are related to smoking are listed in Table 53.5. Chronic obstructive pulmonary disease including chronic bronchitis and emphysema are also associated with smoking as is peptic ulcer disease. Smoking during pregnancy is associated with spontaneous abortion, premature delivery, small babies, increased perinatal mortality and an increased incidence of sudden infant death syndrome (cot death). In households where the parents smoke, there is an increased risk of pneumonia and bronchitis in preschool and school-age children, which is most marked during the first year of life. Pharmacokinetics About 90% of nicotine from inhaled smoke is absorbed, while smoke taken into the mouth results in only 25–50% absorption. As well as being absorbed via the gastro-intestinal (GI), buccal and respiratory epithelium, nicotine is absorbed through the skin. A high concentration of nicotine may be present in the breast milk of smokers. Around 80–90% of circulating nicotine is metabolized in the liver, kidneys and lungs. The plasma elimination t1/2 is 25–40 minutes. Nicotine and its metabolites are excreted in the urine. The metabolite cotinine can be used to quatitate exposure. Table 53.5: Principal causes of death associated with smoking Ischaemic heart disease (strongest correlation) Cancers of the lung, other respiratory sites and the oesophagus, lip and tongue Chronic bronchitis and emphysema, respiratory tuberculosis Pulmonary heart disease Aortic aneurysm
Soliman s Auricular Therapy Textbook: New Localizations and Evidence Based Therapeutic Approaches was created ( M.D. Nader Soliman )
with customer reviews [BEST]
Soliman s Auricular Therapy Textbook This textbook is considered the finest ever written in the field of auricular therapy. The auricular acupuncture microsystem is one of the most widely used special acupuncture techniques. This textbook is dedicated to teaching the sound foundations of this unique approach as introduced by its founder Dr. Paul Nogier of France. The scientific bases of the acupuncture microsystem with its three dime... Full description
To Download Please Click http://yp.filetrends.club/?book=1434328597