*Psicoestimulantes, Inhalables, y Marihuana: Aspectos Mdicos y Aproximaciones al Tratamiento

*Objetivos de la capacitacinEntender los efectos agudos y crnicos de los psicoestimulantes, las sustancias inhalables y la marihuana, y los peligros mdicos y psiquitricos asociados a la intoxicacin, la sobredosis, la abstinencia y las interacciones con otras sustancias. Conocer los protocolos para tratar la intoxicacin y la sobredosis.Conocer los protocolos y estrategias para el manejo de la abstinencia.Saber cules son los tratamientos requeridos despus de la desintoxicacin. Saber cules son los escenarios y los servicios de apoyo necesarios para realizar tratamientos apropiados.

*EstimulantesCRACKMETANFETAMINACOCANA

*EstimulantesDescripcin: Un grupo de drogas sintticas o derivadas de plantas que incrementan el estado de alerta y excitabilidad por estimulacin del SNC. Aunque el xtasis (MDMA) tiene algunas propiedades sensorializantes o alucingenas, a menudo se clasifica como estimulante. Usos mdicos: Tratamiento a corto plazo de la obesidad, la narcolepsia, y la hiperactividad en los nios. Forma de uso: Intravenosa, intranasal, oral, fumada.

*Tipos de drogas estimulantesEstimulantes de Tipo Anfetamnico (ETA)

AnfetaminaDexanfetaminaMetilfenidatoMetanfetamina (speed, crystal, ice, meth)

*Tipos de drogas estimulantes Derivados de la coca

Cocana (clorhidrato de cocana): Generalmente aspirada, aunque tambin puede inyectarse lo cual es una prctica poco comn en Amrica Latina, con excepcin de Brasil, donde es frecuente.Base de coca / pasta bsica de cocana; llamada basuco en la regin Andina, o paco en los pases del Cono Sur. Se fuma, generalmente mezclada con picadura de cigarrillo.Crack: Resulta de hervir cocana en una solucin de bicarbonado de sodio. Se consume inhalando los vapores que produce su combustin en una pipa o cucharilla metlica.

*Tipos de drogas estimulantesMetilenedioximetanfetamina (MDMA) Droga sinttica con propiedades sensorializantes (ms que alucingenas) y psicoestimulantes

Comnmente se denomina xtasis. Se vende en forma de pastillas.En el mundo se estiman en 10 millones los consumidores.

*Segn estudios y estimaciones de la OMS y UNODC, los ETA son la categora de drogas ilcitas ms usadas en el mundo despus de la canabis (marihuana/hashish). Los usuarios regulares de anfetamina, metanfetamina y xtasis se estiman en 26 millones en el mundo. Los usuarios de herona, por su parte, son 16 millones, mientras los de cocana son 14 millones. La metanfetamina representa algo ms del 90% del consumo total de ETA en el mundo. Extensin del problema de los estimulantes de tipo anfetamnico (ETA) en el mundo

*Metanfetamina vs. cocanaDuracin media del efecto de la cocana: 2 horas.Duracin media de la metanfetamina: 10 horas.Paranoia de cocana (rara vez ocurre): 4 - 8 horas despus del consumo.Paranoia de metanfetamina (cuando ocurre): 7-14 das.Psicosis de metanfetamina Puede requerir medicacin/hospitalizacin y puede no ser reversible. Neurotoxicidad: Parece ser ms grave con las sustancias anfetamnicas.

*Efectos agudos de los estimulantesPsicolgicos

Sensacin de energa incrementadaSensacin de mayor claridad mentalSensacin de mejor desempeo Aumento de la libidoMayor sociabilidadExaltacin / euforia

*Efectos agudos de los estimulantesFsicos

Aumento de la frecuencia cardiacaDilatacin de la pupilaAumento de la temperatura corporalAumento de la frecuencia respiratoriaArritmia cardiacaConstriccin de los vasos sanguneosPrdida del apetitoInsomnio

*Efectos crnicos de los estimulantesFsicos

Prdida de peso / anorexiaDeprivacin de sueoEnfermedades respiratoriasEnfermedades cardiovascularesCefaleasDeterioro/prdida de la dentaduraMarcas de agujas e infecciones por uso intravenosoConvulsiones

*Efectos de los estimulantes a largo plazoDerrame cerebral, convulsiones, cefaleasIrritabilidad, desasosiegoDepresin, ansiedad, irritabilidad, irascibilidadPrdida de memoria, confusin, problemas de atencinInsomnioParanoia, alucinaciones auditivas, reacciones de pnicoIdeacin suicidaSinusitisPrdida del olfato, hemorragia nasal, rinitis Boca seca, labios cuarteadosPrdida del esmalte dental (debido a bruxismo)Problemas de deglucinDolor en el pecho, tos, insuficiencia respiratoriaArritmias cardiacas e infartosComplicaciones gastrointestinales (dolor abdominal y nausea)Disminucin de la libidoDesnutricin, prdida de peso, anorexiaDebilidad, fatigaTembloresSudoracinPiel grasosa

Boca MethEl uso de metanfetamina produce deterioro severo de la dentaduraFuente: The New York Times, Junio 11, 2005

*Exposicin prenatal a la metanfetaminaObservaciones realizadas en nios expuestos prenatalmente a la metanfetamina indican:Baja talla y bajo peso al nacer.Dficits neuroconductuales, con indicio de relacin directa entre la dosis y la magnitud del efecto. (Lester et al., 2005)

*Efectos crnicos de los estimulantesPsicolgicos

Ansiedad severaParanoiaPsicosisIrritabilidadConfusinAislamientoPrdida de memoriaDificultad de concentracinAgresividad y prdida de control

*Metanfetamina: Consecuencias psiquitricas

Adiccin rpidaReacciones paranoidesDeterioro de la memoriaReacciones depresivas, distimiaAlucinacionesReacciones psicticasAtaques de pnico

*Sintomas de abstinencia de estimulantesDepresinDificultad de concentracinNecesidad de dormir / insomnioDisfuncin de memoriaAnsiedadDisminucin del deseo sexualBaja energa IrritabilidadCefaleaAnsias de consumir

*Actividad sinptica

LeveModeradoTxicoVigiliaPrdida de apetitoBoca secaEstrsNerviosismoCefaleaBruxismoAnsiedadAgitacin extremaIncoherenciaAumento de temperaturaDeshidratacinPensamiento desordenadoAgresividad / violenciaDerrame cerebralInfarto cardiacoSensacin de bienestarAlertaEnergaAutoconfianzaSensacin de grandezaAumento de libidoMayor resistenciaVigilia prolongadaEfectos de las anfetaminas

Patrn de uso tpico(Pead, et al., 1996, p. 37)

*Aspectos para la evaluacinOcupacinEdadActividades socialesHistoria de consumo de alcohol y otras drogas Patrones de uso, tipo de sustancia, va de admin., uso de otras drogasSalud fsica (ej., estabilidad de peso)Salud mental (debilidad emocional, psicosis/paranoia)Nivel actual de intoxicacin / abstinenciaExmenes de laboratorio

*Manejo de reacciones txicas Prioridades: Respiracin, circulacin, flujo de aire Control de temperatura (hidratacin, agua fra, hielo) Control de ataques (IV diazepam) Manejo de sntomas psicticos (antipsicticos) Restablecimiento, soporte, comodidad, estimulacin mnima

El tratamiento depende de la condicin que presente el paciente.

*Actividad: Estudio de casoRal, un estudiante de 24 aos, se presenta con cefalea persistente, letargo, y prdida inexplicable de peso. Sus jornadas transcurren a mil por hora, entre el estudio y su trabajo en un bar, y dice que su vida ahora es muy agitada. Los estimulantes le ayudan a sobrellevar la faena.

Describa una intervencin breve para Ral.

Abstinencia de psicoestimulantes From Pead et al. (1996, p. 84)

Bajn

(13 das)

Sntomas pico

(210 das)

Sntomas residuales (de 18 semanas)

agotamiento

depresin

somnolencia

sin ansias

disforia

falta de energa

aumento de apetito

dolores y malestar

reaparicin de psicosis leve, incluyendo:

distorsin perceptual,

ideacin paranoide,

alucinaciones,

anisedad.

insomnio

ansias intensas

ansias espordicas

insomnio

Fluctuantes:

irritabilidad

agitacin

inquietud

disforia

letargo

desmotivacin

*Tratamiento de la abstinenciaTratamiento inmediatoModalidad: ambulatorio, en casa o internoAmbiente de apoyo, informacin y tranquilidadHacer monitoreo constantePlanear estrategias de largo plazo Planeacin para abstinencia prolongadaPrever la duracin de los sntomas (ej., problemas de sueo, alteraciones anmicas, ansias intensas de consumir)Plan para reincidencia y/o recada

*Farmacoterapias para abstinencia de psicoestimulantes Orientadas a disminuir el malestarBenzodiacepinasAyudan a dormir y reducen la ansiedad y la agitacin Evitar la prescripcin prolongadaAntipsicticos y antidepresivosLa investigacin disponible muestra eficacia reducida

*Farmacoterapias promisorias? Newton, T. et al (Biological Psychiatry, Dic, 2005): Bupropion reduce las ansias y los efectos reforzantes de la metanfetamina, segn un estudio de auto administracin en laboratorio. Elkashef, A. et al (Neuropsychopharmacology, 2007): Bupropion reduce el consumo de metanfetamina en pacientes externos, con mejores efectos en usuarios menos severos. Tiihonen, J. et al (reportado en una tele conferencia sobre metanfetamina en la ACNP, Kona, Hawai): Metilfenidato LP (liberacin prolongada) se ha mostrado promisorio en un estudio finlands con usuarios duros de anfetaminas inyectadas.

*Actividad: Estudio de casoKaren, una abogada de 33 aos, recientemente supo que estaba embarazada. Ella trabaja mucho y tiene una vida social muy activa, por lo que tiende a alimentarse mal. El embarazo no fue planeado. Est preocupada por la salud de su beb y por su estilo de vida que le dificulta tener buenos hbitos alimenticios. Cmo incorporara usted la historia de consumo de alcohol y otras drogas en la consulta? Qu desencadenantes le haran pensar en el uso de psicoestimulantes?

*CocanaEs un alcaloide de la hoja de la planta de coca (Erythroxylon coca).Se conoce tambin como coca, perico o nieve.Es un polvo blanco. Se vende en papeletas, tubos o pequeas bolsas plsticas Estimulante del SNC, con efecto anestsico local. Tambin acta en el sistema nervioso perifrico. Bloquea la recaptacin de dopamina, noradrenalina y serotonina. CocanaCrack

*Cocana: MetabolismoAccin rpida (24 minutos).Nivel pico en la sangre: 530 minutos.Efecto breve:Duracin media de 1530 minutos, inyectada.Duracin media de aprox. 30 minutos, aspirada.Metabolizada en el hgado; 1%2% excretada sin cambios en la orina. Metabolitos inactivos pueden detectarse en:Sangre u orina 2436 horas despus del uso.Cabello, semanas o meses despus del uso.

*Cocana: Efectos agudos y crnicosSimilares a los de la metanfetamina. Sin embargo, como la duracin media de la cocana es mucho menor, en comparacin con la metanfetamina hay:Neurotoxicidad un poco menos severa.Menor frecuencia de psicosis inducida por la sustancia.Sntomas de abstinencia menos prolongados.

*Cocana: Sntomas de abstinencia Disforia (ms que depresin), que puede persistir por varias semanas. Adicionalmente, dos o ms de los siguientes sntomas:FatigaInsomnio / hipersomniaAgitacin psicomotoraAnsias intensasAumento del apetitoSueos vvidos angustiososEl pico de la abstinencia es en 2-4 das despus del ltimo consumo.

*Farmacoterapia para la cocanaDisulfiram ha mostrado reducir significativamente el uso de cocana en personas dependientes de la sustancia y no consumidoras de alcohol. Sin embargo, se requiere ms investigacin. Hay un empleo sustancias de otros medicamentos para tratar los efectos a corto y largo plazo del uso de cocana. No obstante, estudios controlados no muestran evidencia suficiente para sustentar el uso de tales medicaciones.

*Cocana: Manejo de la abstinenciaAmbiente no amenazante y con poca estimulacin.Prever posibles intentos suicidas. Hasta ahora no se ha comprobado una medicacin efectiva para el manejo de la abstinencia.Medicaciones prescritas: Uso de benzodiacepinas en periodos cortos (para reducir la ansiedad y la agitacin, y mejorar el sueo).

*Intervenciones para psicoestimulantesNo juzgar, ni insistir en la abstinencia.Motivar y animar al consultante para que persevere en el tratamiento.Comprender las metas de tratamiento del consultante.Ajustar la intervencin al paciente, incluyendo el nivel, la intensidad y las posibles remisiones.Ofrecer un servicio acorde con las metas y las necesidades cambiantes de la persona. Brindar apoyo psicosocial. Atender necesidades concurrentes de salud mental; ej., ansiedad, trastorno bipolar y dficit de atencin son comunes entre los usuarios de cocana.

*Tratamientos para trastornos por consumo de estimulantes con soporte empricoTerapia cognitiva conductual (TCC)Refuerzo en comunidad Manejo de contingenciasFacilitacin con el modelo de 12 pasosTerapia cognitiva conductual breve Modelo Matriz (Matrix Model)

Todos estos enfoques han demostrado efectividad en el tratamiento de la dependencia a la cocana y la metanfetamina.

*Sustancias inhalables (voltiles)

*Inhalables (sustancias voltiles)Comnmente se denominan inhalantes, solventes, pegantes. Otros trminos comunes en el lenguaje de la calle son: sacol, pega, gala, galochera, huele. Comprenden un grupo de compuestos qumicos que cambian desde un estado lquido o semi-slido (coloidal) a gaseoso cuando se exponen al aire. La inhalacin de los vapores por la boca o la nariz produce un efecto psicoactivo (intoxicacin y euforia).

* Sustancias utilizadas

Los inhalables se encuentran en cientos de productos caseros, industriales y de oficina que se venden en supermercados, tiendas, ferreteras, papeleras y otros establecimientos. Cuatro categoras principales:SolventesAerosolesGasesNitritos

*Farmacologa La alta lipofilidad promueve la rpida absorcin desde los pulmones. La intoxicacin aguda ocurre despus de 35 minutos (1015 inhalaciones son suficientes).La mxima concentracin plasmtica se alcanza en 1530 minutos. La duracin media de la sustancia en el organismo vara de horas a das.Metabolizados en los riones y el hgado.Se acumulan en rganos ricos en tejido graso (ej., hgado, cerebro).Atraviesan la barrera hemoplacentaria

*La ms alta prevalencia de consumo es entre menores de 14 a 17 aos de edad

*Atractivos de las sustancias voltiles

Bajo costo.Fcilmente adquiribles a pesar de la restriccin legal para su venta a menores de edad. Pueden envasarse en contenedores pequeos, fciles de esconder, como frascos y bolsas plsticas.Efecto rpido y de corta duracin, lo que permite usarlos y llegar sobrio a casa (o usarlos en casa y estar sobrio cuando llegan los padres).

*Quines usan inhalables?Los estudios epidemiolgicos son escasos. La informacin disponible (especialmente en Amrica Latina) indica: La ms alta prevalencia de consumo es entre jvenes de 14 a 17 aos de edad. El uso de inhalables est ampliamente extendido en nios y adolescentes de y en la calle; en particular en las grandes ciudades.Una pequea proporcin de jvenes en condiciones normales de vida experimentan con estas sustancias, pero la gran mayora dejan de usarlas despus de algunas experiencias. El uso experimental u ocasional es mayor entre jvenes varones. Algunos usuarios recreacionales tienden a consumir inhalables en combinacin con otras sustancias, como alcohol y marihuana. Aunque el uso no est limitado a nios y adolescentes de y en la calle, en esta poblacin se observa:Mayor consumo habitualUso con mayor frecuencia diaria y en dosis altasUso durante periodos prolongados

*Patrones y formas de usoTres patrones principales de consumo:Experimental / ocasionalSocialProlongado / crnico

Formas de uso:Olido, inhaladoAspirado con la boca

*Seales de uso recienteOjos rojos y llorososTos, estornudosOlor a qumico en el alientoManchas o rastros de pegante, solvente o pintura en los dedos, la nariz, la boca o la ropa. Intoxicacin aparente / conducta alterada / temeridad Incoherencia, confusinDescoordinacinSudor excesivoPuntos, marcas, brotes o peladuras alrededor de la nariz y la bocaSecrecin nasal excesiva

*Efectos de los inhalables a corto plazo Efectos deseadosEuforiaExcitacinHilaridad Sensacin de invulnerabilidadDesinhibicinEfectos negativos agudosLetargoSntomas como de gripa o resfroNausea y vmitoDolor de cabezaDiarrea, dolor abdominalRespiracin difcilHemorragia nasal, picaznConducta temeraria

*Efectos de los inhalables en dosis altas

Verbalizacin lenta, torpePobre coordinacinDesorientacin, confusinTemblorCefalea DeliriosDistorsiones visuales o alucinacionesConducta impredeciblePosibles:AtaxiaEstuporEstados finales: convulsiones, coma, paro cardio-respiratorio, muerte.

*Sobredosis de inhalablesDosis altas ponen al usuario en riesgo de:Convulsiones, ataques, comaDepresin respiratoriaArritmias cardiacas

Heridas o muerte pueden ocurrir por:Conducta temeraria (resbalones, cadas, etc.)SofocacinAspiracin de vmitoIncendios, explosionesEnvenenamiento, falla de rganos (uso crnico)Espasmo larngeo (Butano), paro respiratorioEnvenenamiento con hidrocarburos (gasolina / petrleo)

*AbstinenciaInicio y duracinNo clasificada en el DSM IV, pero las caractersticas de un posible sndrome de abstinencia pueden comenzar 24-48 horas despus de suspenderse el uso. Sntomas de abstinenciaTrastornos del sueoTemblorIrritabilidad y depresinNauseaDiaforesis (secrecin de humores)Ilusiones momentneasTratamiento Sintomtico

*Problemas por el uso prolongadoLos pacientes pueden presentar una variedad de sntomas como consecuencia del uso prolongado de sustancias voltiles, incluyendo:

Cefalea crnicaSinusitis, hemorragia y congestin nasalDficit cognitivoAtaxiaTos crnicaDolor en el pecho, anginaTinnitus (zumbido en los odos)Agotamiento, debilidad, mareoDepresin / ansiedadDificultad respiratoriaIndigestinlceras estomacales

*Complicaciones por el uso prolongadoEn el SNCEncefalopata agudaDficits neurolgicos crnicosMemoria, pensamientoPrdida auditiva y olfativaNistagmo (oscilacin espasmdica del globo ocular)Alteracin motoraDao de nervios perifricos En otros sistemasRenal nefrolitiasis, glomerulopatasHeptico hepatotoxicidad reversiblePulmonar ej., hipertensin pulmonar, estrs respiratorio agudoCardiovascular ej, falla ventricular, arritmias, cardiomiopata agudaHematolgico ej., discracias sanguneas

*ImpactoEl uso de sustancias voltiles, como el de otras sustancias psicoactivas, afecta no solo la salud de las personas que consumen, sino tambin:FamiliasEntornos laboralesComunidad en general (ej., conducta antisocial)

*Respondiendo a la intoxicacinVentilacin, aire libreConservar la calma y tranquilizar a la persona afectadaNo discutir, ni usar la fuerzaDisuadir / persuadir de suspender el uso Llevar a la persona a un ambiente seguroNo intentar consejera mientras haya intoxicacinHacer seguimiento con la familia o allegadosSi la persona presenta sopor o alta intoxicacinLlevarla a una clnica u hospital y monitorear su salud fsica y mental

*IntervencionesIntervencin breve

ConsejeraTerapia grupalApoyo familiar y consejeraPromover respuestas comunitarias (ej., grupos de ayuda comunitaria)

Evitar conferencias a grupos escolares y otros jvenes, ya que la evidencia sugiere que estas actividades pueden aumentar la curiosidad e inducir el uso.

*CanabinoidesHashishMarihuana

*MarihuanaEs la sustancia ilcita ms usada en el mundo.Es la sustancia ilcita que ms se reporta en la prctica clnica. Su uso es principalmente experimental o recreacional, pero tambin es la sustancia ilcita ms asociada a situaciones de abuso o dependencia.Su uso es muy comn entre policonsumidores de sustancias.

THC o delta9tetrahidrocannabinol es el componente activo de la marihuana

*Estudio de casoMarcos es un joven de 23 aos, trabajador de la construccin desempleado, que presenta seales notorias de fatiga. Durante el examen, se observan algunos sntomas de psicosis. Al interrogarlo, dice que ha estado fumando entre cinco y diez cigarrillos de marihuana al da. Est inquieto, con fluctuaciones de nimo, pensamiento acelerado y paranoia, pero sin rasgos reales de psicosis permanente. Su presentacin es consistente con su uso de drogas? Cunto tiempo podran durar sus sntomas? Qu asesora se le podra dar con respecto a su conducta posterior de consumir sustancias?

*Canabis: Formas

*Canabis: PropiedadesFrecuentemente, pero de manera errada, se clasifica como narctico, sedante o alucingeno. En realidad es una sustancia nica, de una categora especial.

Sus efectos estn determinados por la concentracin de THC que presenta la forma especfica de la sustancia utilizada: Hojas o resina -hashish-, y segn provenga de plantas silvestres o cultivadas en interiores, con semillas mejoradas, o de regiones y condiciones climticas diferentes, etc. El principal componente activo es el delta-9-tetrahidrocannabinol (THC). Se absorbe y se metaboliza rpidamente cuando se fuma, y ms lentamente cuando se ingiere.Los efectos psicoactivos duran 13 horas.

Se fija a un receptor especfico de canabinoides (molcula endgena del cerebro anandamida).

*Canabis: Receptores cerebralesHay dos tipos de receptores:CB1 y CB2 Receptores CB1 en el cerebro (corteza, hipocampo, ganglios basales, amgdala) y tejidos perifricos (testes y clulas endoteliales).Receptores CB2 asociados al sistema inmune.

La mayor parte de los efectos son mediados por los receptores CB1, que facilitan su accin en las neuronas dopaminrgicas mesolmbicas.

*Canabis: Formas y vas de usoLas presentacions incluyen:Flores/hojas/moos secos (marihuana).1% 24% de THC (dependiendo de factores gentios y ambientales).Resina seca, a veces mezclada con flores y presionada para formar pequeas bolas o cubos (hashish). Aproximadamente 10% 20% de THC.Aceite extraido usando un solvente orgnico (aceite de hashish). 15% 30% de THCLa va de uso influye sobre la dosis: Fumada (cigarrillo, pipa, pipa de agua, dosis).50% se absorbe, concentracin pico en 10 30 min, y el efecto dura 2 4 horas.Ingerida (tortas, galletas o con bebidas calientes).3% 6% se absorbe, concentracin pico en 2 3 horas, y el efecto puede durar aproximadamente 8 horas.

Canabis: Tiempo para el efecto pico(Fumada)

*Canabis: Efectos agudosAnalgesia.Euforia, concentracin alterada, relajacin, sensacin de calma o bienestar, desinhibicin, confusin.Aumento del apetito, sed.Percepciones visuales, auditivas y olfativas aumentadas. Apreciacin del entorno alterada.Reduccin de la presin intra-ocular (por lo que se usa para tratamiento del glaucoma).En ocasiones, nausea y cefalea. Posibles problemas de intoxicacin.

La sobredosis de marihuana/hashish no representa un riesgo de muerte.

*Cortesa del Dr. John Sherman, St. Kilda Medical CentreMarihuana / Hashish

*Efectos a corto plazo de dosis altasLa marihuana afecta:La memoria de corto plazo La habilidad para aprender y retener informacin nuevaLa ejecucin de tareasEl equilibrio, la estabilidad y la habilidad mentalLos sistemas cardiovascular y respiratorio

A corto plazo las dosis altas pueden ocasionar:SinestesiaPseudo alucinacionesDelirios, sensaciones de despersonalizacin Paranoia, agitacin, pnico, psicosis

*Efectos a largo plazoSNC Sistema respiratorioSistema cardiovascularSistema inmunolgicoSistemas endocrino y reproductivoEfectos sociales adversos Problemas de salud mentalDeterioro cognitivoDependencia

*Canabis y psicosisEl THC puede exacerbar los sntomas de esquizofrenia, por un incremento en la liberacin de dopamina. El THC probablemente desencadena la esquizofrenia en personas vulnerables o propensas a este trastorno; p.ej., con antecedentes familiares de esquizofrenia. Existen algunos reportes de inicio de esquizofrenia asociada a la marihuana en personas sin antecedentes familiares de este trastorno.

*Dependencia de marihuanaEl llamado sndrome de dependencia de marihuana, aunque descrito claramente en la actualidad, es menos evidente que el de otras sustancias (ej., opioides y alcohol).No se menciona todava en el DSM IV.Las variaciones en la frecuencia, la duracin del consumo y la dosis conllevan dificultades para predecir el surgimiento, la dinmica y la duracin de los sntomas de abstinencia.

*Sntomas de abstinenciaAnsiedad, inquietud, irritabilidad, agitacinAceleracin del pensamientoFluctuaciones anmicas y agresividadSensacin de irrealidadTemor; en ocasiones paranoiaAnorexia, dolor de estmagoPrdida de pesoAumento de la temperatura corporalNausea y salivacinLetargo, trastorno de sueo, y eventualmente pesadillas

*EvaluacinLa evaluacin debe centrarse en:Tipo (forma) de sustancia, historia, va de administracin, patrn de uso, gasto asociado.Tolerancia, dependencia, posibles sntomas de abstinencia/privacin. Historia o evidencias de secuelas psiquitricas.Complicaciones de salud por el consumo.Contexto psicosocial: tiempo dedicado al consumo, forma de conseguir la sustancia, impacto en la familia o el entorno social, etc. Intentos previos de reducir o suspender el consumoHerramientas de evaluacin:Escala de Severidad de la Dependencia (ESD / SDS)ASSIST

*Perspectivas de tratamiento (1)Intervencin breve: Proporcionar informacin sobre los daos asociados a:IntoxicacinUso frecuente y prolongado de marihuanaBrindar asesora para la suspensin del consumo:Postergar, Distraerse, Evitar, Escapar, y manejar los Deslices Adoptar tcnicas motivacionales y cognitivo-conductuales para manejar la abstinencia y las ansias de consumir. Otras estrategias pueden incluir:Ejercicio fsico, manejo del estrs, relajacin, pasatiempos, dieta alimenticia, interaccin social con personas no involucradas en el consumo de sustancias. La intervencin temprana es ms efectiva que la reeducacin.

* Perspectivas de tratamiento (3)

La prevencin de recadas se puede lograr con:Tratamiento de soporte.Seguimiento/monitoreo constante.Motivando al consultante a perseverar en un tratamiento con consejera o grupo de apoyo. Herramientas y tcnicas de auto-ayuda.

Ayudando al paciente a identificar los perjuicios y las posibles soluciones.Discutiendo con el paciente los riesgos en el desempeo de las responsabilidades habituales.Examinando con la persona las posibles consecuencias futuras del consumo para su salud fsica o mental.

*Manejo de la abstinenciaPuede hacerse un manejo efectivo mediante consulta externa (tratamiento ambulatorio). Sin embargo, la dependencia severa requiere asistencia especializada. Son recomendables intervenciones breves que incluyan prevencin de recadas, entrenamiento en habilidades de solucin de problemas y educacin en estilo de vida saludable. Se debe considerar un trabajo en equipo con psiclogos y otros especialistas en abuso de sustancias.

*Farmacoterapia para la abstinenciaMedicaciones que pueden ser tiles en periodos breves:Sedantes ej., diazepam 5 10 mg (clonazepam 0.25 0.5 mg), Antipsicticos (para psicosis o agitacin severa)ej., haloperidol.El uso prolongado de ansiolticos est contraindicado, a menos que un psiquiatra tratante los prescriba y monitoree su administracin.

*Gracias por su atencin!

*********************NotesAmphetamines (including methamphetamine) are synthetic substances structurally related to naturally occurring adrenaline and ephedrine. Amphetamines activate the central nervous system (CNS) and sympathetic nervous system (SNS), increasing synaptic concentrations of excitatory neurotransmitters and/or inhibiting their reuptake. The monoamines commonly affected by amphetamines are:dopaminenoradrenalineserotoninThrough stimulating neurotransmitter release and preventing reuptake, amphetamine use results in:CNS effects: euphoria; increased sense of wellbeing, confidence and physical activity; improved cognitive and physical performance; suppression of appetite and a decreased need for sleep.SNS effects: increased blood pressure, tachycardia or reflex bradycardia, increased core temperature.

Sources: Latt, N., White, J., McLean, S., Lenton, S., Young, R. & Saunders, J. 2002, Central Nervous System Stimulants, in Hulse, G., White, J. & Cape, G. (eds.) 2002, Management of Alcohol and Drug Problems, ch. 8, Oxford University Press, South Melbourne, pp. 124140.Victoria Police 2002, Custodial Drug Guide: Medical Management of People in Custody with Alcohol and Drug Problems, Custodial Medicine Unit, Victoria Police, Mornington, Victoria.Diagram Source: www.nida.nih.gov

*NotesThe figure shows the expanded array of negative effects from amphetamines as frequency of use increases.Effects often perceived as negative by health professionals may not necessarily be perceived that way by someone used to experiencing and managing those effects. For example, teeth grinding, dry mouth, or headache may be perceived by the person using speed as a manageable irritation. Other effects (such as effects on sleep or appetite) may be desired. Increased alertness and mood are generally sought-after effects readily gained from mild doses.Moderate effects include increased confidence, libido or stamina. However, the trade-off may be an inability to perform or a hangover-like crash the following day.Although higher doses may be associated with elevated mood, increasingly negative effects occur at high doses, e.g., agitation, delusions or markedly increased body temperature.Recent references to speed are most likely to refer to methamphetamine rather than the formerly more common amphetamine sulphate. Sources: adapted from Pead. J., Lintzeris, N., & Churchill, A. 1996, From Go To Whoa: Amphetamines and Analogues, The Trainers Package for Health Professionals, Commonwealth Department of Health and Human Services, AGPS, Canberra, p. 26.Latt, N., White, J., McLean, S., Lenton, S., Young, R. & Saunders, J. 2002, Central Nervous System Stimulants, in Hulse, G., White, J. & Cape, G. (eds.) 2002, Management of Alcohol and Drug Problems, ch. 8, Oxford University Press, South Melbourne, pp. 124140.

*NotesEffective GP interventions require the identification of drug type and patterns of use (level and frequency). The pattern shown above is relatively common. A run or binge may last a few days to a week before the negative effects (e.g., sleeplessness, agitation, anxiety, delusions, hallucinations, tolerance, exhaustion from lack of sleep and food) outweigh the positive effects (e.g., alertness, raised mood). Some patients may seek or use other depressant drugs (e.g., alcohol or benzodiazepines) to reduce the effects of intoxication or to manage the after-effects of use. Others may experience an acute paranoid state following repeated high dose use. Methamphetamine may be used regularly (up to 3 times a day) for months at a time.The crash/amphetamine hangover may occur even after a single-occasion of use, or on cessation of use, and may last one to two days. Main features include restless oversleeping, depressed mood, exhaustion, overeating, lethargy and absence of desire for amphetamines. Concurrent hazardous or harmful patterns of alcohol use may result in an alcohol hangover.Withdrawal follows cessation of regular, sustained use. This is generally a phase of considerable discomfort, commencing two to three days after cessation of use and lasting weeks to months. General effects include flat mood, sleeplessness, craving, agitation, aggression and possible recurrence of delusional thoughts and hallucinations.Prolonged withdrawal is frequently avoided by many users, who choose to return to speed use rather than experience unwanted effects. A prolonged episode of withdrawal is commonly described, whereby emotional unresponsiveness to pleasant events (anhedonia), or episodic craving may continue.

*continued from previous page.

Mental healthFor example, hyperactive, emotional lability, psychosis/paranoia, evidence of depression and suicidal ideation.Laboratory investigationsUrine drug screen may be valuable. Detects recent use (metabolites of speed in urine for up to 4872 hours, cocaine metabolites for 2436 hours ). In addition to routine Ix, CPK, cardiac enzymes, serum troponin concentrations if appropriate.Other Disinhibition and poor decision-making may lead to risk-taking behaviour, e.g., assess for consequences of unsafe sex, injecting etc.Sources: adapted from Pead. J., Lintzeris, N., & Churchill, A. 1996, From Go To Whoa: Amphetamines and Analogues, The Trainers Package for Health Professionals, Commonwealth Department of Health and Human Services, AGPS, Canberra.Latt, N., White, J., McLean, S., Lenton, S., Young, R. & Saunders, J. 2002, Central Nervous System Stimulants, in Hulse, G., White, J. & Cape, G. (eds.) 2002, Management of Alcohol and Drug Problems, ch. 8, Oxford University Press, South Melbourne, pp. 124140.

*NotesRefer to NCETA 2004 Cocaine. Alcohol and Other Drugs, A Handbook for Health Professionals, Chap. 8, Commonwealth Department of Health & Ageing, Canberra, for further information.**Source: adapted from Pead. J., Lintzeris, N., & Churchill, A. 1996, From Go To Whoa: Amphetamines and Analogues, The Trainers Package for Health Professionals, Commonwealth Department of Health and Human Services, AGPS, Canberra, p. 84.

*NotesImmediate withdrawal treatmentAssess suitability of home versus inpatient withdrawal according to support available in the home, medical and psychological functioning and psychological and emotional stability. Ideally, home withdrawal should take place in a supportive, quiet place where emotional and physical support can be provided by a trusted person who is not currently using drugsPsychosocial supportive care, information, and reassurance should be provided by: qualified health professional/s (e.g., outpatient support, GP, home withdrawal support nurse, social worker, case management/shared care strategy) to assist the patient to develop psychosocial strategies for coping with relapse and lapses, for managing mood and sleep disturbances and to assist with managing anger or irritation over subsequent months psychosocial support includes managing cravings, sleeping patterns, anhedonia, emotional lability 24-hour help line (ADIS)Inpatient treatment is the most appropriate option when a person is experiencing medical or psychiatric complications as a result of use of amphetamines. Residential or inpatient care may be indicated when supportive environments are unavailable. Long-term residential programs may demand that patients attend services drug free including being free from prescribed medications. Hence medications for ongoing management of depression or relapse, for example, may not be acceptable. Check with the program in the first instance.

Source: adapted from Pead. J., Lintzeris, N., & Churchill, A. 1996, From Go To Whoa: Amphetamines and Analogues, The Trainers Package for Health Professionals, Commonwealth Department of Health and Human Services, AGPS, Canberra.

.*NotesPharmacotherapies (general aim is to reduce discomfort):Benzodiazepinessleeplessness and anxiety may be prolonged during withdrawal; prepare patient for this. Avoid long term prescribing of benzodiazepines to prevent benzodiazepine dependence.Dopamine agonistshave only been studied in relation to cocaine, with mixed reviews of their effect on cravings and withdrawal.Antidepressantstricyclic antidepressants are generally not helpful and are not recommended unless there is a prior diagnosed affective condition, or on advice from the patients psychiatrist. SSRIs may be helpful. Symptoms such as tearfulness and suicidal thoughts often resolve within a week of withdrawal.Antipsychoticshave only been studied in relation to cocaine as an anticraving agent, with limited effect.Haloperidol may be indicated for anxiety and distress resulting from features of psychosis. Amphetamine-induced symptoms of psychosis tend to resolve after about 7 days. Should mental health problems persist, refer for specialist psychiatric assessment. Pharmacotherapies indicated if intoxicated, or during withdrawal: if severely agitated (benzodiazepine, e.g., Diazepam).if experiencing symptoms of psychosis (antipsychotic, e.g., Haloperidol).Source: adapted from Pead. J., Lintzeris, N., & Churchill, A. 1996, From Go To Whoa: Amphetamines and Analogues, The Trainers Package for Health Professionals, Commonwealth Department of Health and Human Services, AGPS, Canberra.

***NotesThe plant Erythroxylon coca, chewed by South American Indians for its stimulant effects, is primarily available in Peru and Bolivia. Cocaine is extracted from the coca leaf and exported in the form of a salt, cocaine hydrochloride. The salt is a white, odourless, crystalline powder with a bitter taste.Cocaine base is extracted from the powder to form rocks or crystals known as crack or freebase. When smoked, the subjective effects are almost immediate.Blockade of neurotransmitter reuptake results in increased concentration at post-synaptic receptor sites.Dopamine is thought to be responsible for the reinforcing effects.

Sources: Latt, N., White, J., McLean, S., Lenton, S., Young, R. & Saunders, J. 2002, Central Nervous System Stimulants, in Hulse, G., White, J. & Cape, G. (eds.) 2002, Management of Alcohol and Drug Problems, ch. 8, Oxford University Press, South Melbourne, pp. 124140.Victoria Police 2002, Custodial Drug Guide: Medical Management of People in Custody with Alcohol and Drug Problems, Custodial Medicine Unit, Victoria Police, Mornington, Victoria.Picture source: The DEA. http://www.usdoj.gov/dea/index.htm

*******Nota:Para informacin especfica en espaol sobre el Modelo Matriz (Matrix Model), se recomienda consultar el sitio web: www.nida.nih.gov/PODAT/Spanish/PODAT10.htmlAdicionalmente, se puede obtener informacin ms amplia en ingls en el sitio: www.nida.nih.gov/BTDP/Effective/Rawson.html**NotesThe term volatile substance has been used in this topic as it is a term that is inclusive and applies to a wide range of substances that are inhaled. Other terms used include glues, solvents, inhalants or chroming, which do not describe the breadth of substances used in this fashion.See also Volatile Substances handouts. *NotesFour categories of inhalants:1. Volatile solvents toluene and xylene are the common compounds found in a multitude of inexpensive, accessible products used for common household and industrial purposes. These include paint thinners and removers, dry-cleaning fluids, degreasers, petrol, glues, contact adhesives, plastic cement, correction fluids and felt-tip markers.2. Aerosols pressurised aerosols can contain halons and freons (flurocarbon propellants). Increasingly butane may be used to protect the ozone layer. Products include spray paints, deodorant and hairsprays, insect sprays, vegetable oil sprays for cooking and fabric protector spray.3. Gases medical anaesthetic gases include ether, chloroform, halothane and nitrous oxide (laughing gas). Household gases can include commercial products containing gas fuels such as butane cigarette lighters, bottled domestic gas and cylinder propane gas.4. Nitrites act primarily to dilate blood vessels and relax the muscles rather than acting directly on the central nervous system. They include amyl nitrite and butyl nitrite. Primarily used as sexual enhancers.

*NotesFat solubility results in ready absorption from the blood into high fat tissues, including nerve cells. This action results in generalised reduction of nerve membrane functioning, which causes CNS depression.CNS damage identified in long-term, chronic users includes: damage to white matter cortical atrophy cerebellar damageperipheral neuropathyoptic atrophyhearing lossToluene is the most harmful volatile substance.Maternal and neonatal concerns/issuesFat solubility results in crossing of placental barrier. Fetal toluene exposure is associated with: oral cleft and microcephalyspontaneous abortionfetal growth retardationlow birth weightprematuritydevelopmental delays.

See: NCETA 2004, Alcohol and Other Drugs, A Handbook for Health Professionals, 3rd edn., Commonwealth Department of Health & Ageing, Canberra.

***NotesVolatile substance users are mostly young teenagers. Occasionally there are reports of use by young children (612 yrs) and older individuals (i.e., over 30 years). Greatest trend is for teens over 12 years.While predominantly an activity undertaken by young males, there is a trend towards increased use by young females.

Sources: Goldfields South East Health Region 2002, Management of Inhalants in the Goldfields Industry Information Package, Kalgoorlie, WA Country Health Service, Government of Western Australia.Victoria Police 2002, Custodial Drug Guide: Medical Management of People in Custody with Alcohol and Drug Problems, Custodial Medicine Unit, Victoria Police, Mornington, Victoria.

*NotesSniffing or inhaling from a container gives the lowest vapour concentration - much vapour dissipates into the air.Huffing refers to saturating material (e.g., sleeve cuff, handkerchief, collar, lapel, rag) which is held against nose or mouth or sometimes in the mouth. The practice is designed to be unobtrusive.Bagging involves inhaling vapours from a plastic or paper bag, which is held over the mouth or nose. Bags are alternately collapsed and inflated to obtain greatest vapour concentration. Some people place a larger plastic bag over the head to prevent further vapour loss. A particularly dangerous practice to be strongly discouraged.

Sources: NCETA 2004, Volatile Substances, Alcohol and Other Drugs, A Handbook for Health Professionals, 3rd edn., ch. 10, Commonwealth Department of Health & Ageing, Canberra.Victoria Police 2002, Custodial Drug Guide: Medical Management of People in Custody with Alcohol and Drug Problems, Custodial Medicine Unit, Victoria Police, Mornington, Victoria.

*NotesAs with other psychoactive substances, a list of signs that may suggest drug use should be viewed with extreme care, to prevent otherwise ordinary reactions to situations (distress, lack of sleep, challenging behaviour, etc.) being misinterpreted by health workers or parents. While some signs may appear obvious (smell of petrol or paint on clothes, nasal sores, chemical smell on breath etc.), other signs (such as tiredness, anxiety, irritability, poor school performance) may be the result of a range of other problems. Creating distrust between either parents or health workers will disrupt relationships and prevent discussion of a range of issues or concerns that may or may not be associated with the use of psychoactive drugs.GPs are advised to establish good communication and rapport with young persons and parents where volatile use is suspected.

Source: ADAC 2000, Petrol Sniffing and Other Solvents, Booklet 4, ADAC, South Australia, www.adac.org.au.

*NotesFor most users, most effects are achieved after a few breaths and occur within an hour after inhaling.Hangovers and headaches may occur after the immediate effects have passed, lasting several days. Hangovers from inhaling are generally less severe and less common than those caused by alcohol.Larger quantities may result in disorientation and lack of coordination, visual distortions, and possibly blacking out.Tolerance rapidly develops, within several days, and the person requires increased amounts to achieve the desired effect. Source: Goldfields South East Health Region 2002, Management of Inhalants in the Goldfields Industry Information Package, Kalgoorlie, WA Country Health Service, Government of Western Australia.See: NCETA 2004, Alcohol and Other Drug: A Handbook for Health Professionals, Australian Government Department of Health & Ageing, Canberra.

***NotesSome users report withdrawal symptoms (as shown on the slide). Medical intervention is rarely required although some individuals may benefit from symptomatic treatment and treatment for sores or irritant effect of vapour around eyes, nose and mouth.Withdrawal may occur 2448 hours after cessation of use, and last for 25 days.

Source: Victoria Police 2002, Custodial Drug Guide: Medical Management of People in Custody with Alcohol and Drug Problems, Custodial Medicine Unit, Victoria Police, Mornington, Victoria, p. 2-28.

**NotesLead poisoning is less commonly encountered since the introduction of unleaded fuel.

Source: Victoria Police 2002, Custodial Drug Guide: Medical Management of People in Custody with Alcohol and Drug Problems, Custodial Medicine Unit, Victoria Police, Mornington, Victoria, p. 1-35.

**NotesResponse will depend on the persons situation, your relationship with that person, and whether the person is alone or in a group.If uncertain what to do, seek advice from:major hospital Emergency DepartmentPoison Information Service.

Source: ADAC 2000, Petrol Sniffing and Other Solvents, Booklet 4, ADAC, South Australia, www.adac.org.au.

*NotesBrief Intervention includes providing education to individuals who are currently using and encouragement of involvement in other activities.

A cautionary note: provision of information/education to non-users can lead to uptake.

Harm Reduction responses include information regarding:safer use (changing from harmful to less harmful products, safer methods of use)monitoring usesafety while using (compare risks of flammable versus non-flammable products, environment)development of tolerancereduction of acute and chronic tissue toxicity and damagenon-use of plastic bags (bags can cause asphyxia)Counselling may be valuable, but insure context of use and family situation is assessedGroup counselling may be useful if part of group activityFamily support and counselling. Family involvement is especially important for Indigenous familiesCommunity involvement by GPs.

Sources: ADAC 2000, Petrol Sniffing and Other Solvents, Booklet 4, ADAC, South Australia, www.adac.org.au.

NCETA 2004, Alcohol and Other Drugs: A Handbook for Health Professionals, Australian Government Department of Health & Ageing, Canberra.

**NotesThis slide set contains introductory information about the forms and routes of cannabis administration, prevalence of use, its properties, detection, peak effect and effects of use (acute and long-term). Sources: Hulse, G., White, J. & Cape, G. 2002, Management of Alcohol and Drug Problems, Oxford University Press, South Melbourne, pp. 141157.Victoria Police 2002, Custodial Drug Guide: Medical Management of People in Custody with Alcohol and Drug Problems, Custodial Medicine Unit, Victoria Police, Mornington, Victoria.

**

E)Hydroponically Grown Cannabis F)Hashish Bar G)Dried Cannabis Buds (Head or Flower).

NotesA)Cannabis Head/Flower/Bud B)Cannabis Plant C)Cannabis Leaves & Dried Cannabis D)Cannabis Head/Flower/Bud

Cannabis plants are annuals, well suited to warm conditions. Male and female forms contain THC, although the flowers of the smaller female plant contain higher concentrations. Hydroponic varieties tend to produce higher concentrations of THC.Source: http://www.erowid.org/index.htmlDried flowers/leaves/buds (marijuana/ganja): 115% THC (depending on genetic and environmental factors)Extracted dried resin, sometimes mixed with dried flowers and pressed into a cube (hashish): around 10%20% THCExtracted oil using an organic solvent (hashish oil): 1530% THCRoute of administration can affect dose: smoked (joint, pipe, bong, bucket bong): 50% absorbed, peak concentration 1030 mins, lasts 24 hoursingested (cake, biscuits): 36% absorbed, peak concentration 23 hours, lasts up to 8 hours

Sources: Todd, F., McLean, S., Krum, H., Martin, J., & Copeland, J. 2002, Cannabis, in Hulse, G., White, J. & Cape, G. (eds.) 2002, Management of Alcohol and Drug Problems, ch. 9, Oxford University Press, South Melbourne, pp. 141157.

Victoria Police 2002, Custodial Drug Guide: Medical Management of People in Custody with Alcohol and Drug Problems, Custodial Medicine Unit, Victoria Police, Mornington, Victoria.

*NotesTHC is only one of 60 cannabinoids present in the plant Cannabis sativa, but it is the one responsible for its psychoactive effects. The metabolite 11-carboxy-THC remains at high plasma levels for some hours after absorption. This metabolite is inactive, but is what is measured in urine drug screens. Presence of this metabolite merely confirms recent use. Its presence does not indicate patterns of use, dependence, or intoxication.Blood levels of THC vary and do not necessarily match the effects experienced. The presence of THC in urine does not necessarily indicate recent use. (Todd et al., 2002, p. 143)When used orally, the onset of effects is delayed and may vary considerably from those experienced when smoked. To reduce the severity and duration of intoxication. advise those who use oral forms to wait for the effects to commence (up to half an hour or more) before taking another dose.THC is not water soluble and therefore not suited for use by injection. THC is lipophilic - taken up and stored by body lipids. Slow elimination of metabolites results in detection of THC metabolites in urine for weeks or months after use.Approximate detection times for:one-off use= 2 days3 times per week use= 2 weeksdaily use= 24 weeksheavy daily use= 46 weeks, for some up to 12 weeksUsual cut-off detection point is 100 nanograms but lower for defence personnel and prisoners.Source: Todd, F., McLean, S., Krum, H., Martin, J., & Copeland, J. 2002, Cannabis, in Hulse, G., White, J. & Cape, G. (eds.) 2002, Management of Alcohol and Drug Problems, ch. 9, Oxford University Press, South Melbourne, pp. 141157.

Additional information is available at: http://www.cdc.gov/mmwR/preview/mmwrhtml/00000138.htm**NotesJoint a cigarette containing cannabis or cannabis + tobacco.Pipe a tube with a cone/reservoir at the end. There are many different styles.Bong a cone attached to a vessel containing water with a mouthpiece.Bucket bong similar to a bong but uses water pressure to force smoke into the lungs.

Source: Todd, F., McLean, S., Krum, H., Martin, J., & Copeland, J. 2002, Cannabis, in Hulse, G., White, J. & Cape, G. (eds.) 2002, Management of Alcohol and Drug Problems, ch. 9, Oxford University Press, South Melbourne, pp. 141157.Victoria Police 2002, Custodial Drug Guide: Medical Management of People in Custody with Alcohol and Drug Problems, Custodial Medicine Unit, Victoria Police, Mornington, Victoria.

*Source: www.erowid.org*NotesThis list describes some of the possible physiological or psychological effects that may occur as a result of using cannabis. However, the relative severity of these effects or their consequences may vary enormously according to personal makeup, previous use, experiences and expectations, and a range of environmental or other factors. For GPs, gaining an understanding of the impact, benefits, and harms for the person using psychoactive drugs, rather than focusing on the drug itself, is a key step in gaining credibility and developing a relationship with patients who use psychoactive drugs. Remember that adverse effects (considered of clinical importance from the perspective of a GP), may have little relevance for the person using the drug. *

NotesReddened Conjunctiva Cannabis IntoxicationCannabis use can cause infused vasculature/red eyes.*NotesSynaesthesia melding of one sensory modality with another.Pseudo-hallucinations are those whereby the person is able to tell that the hallucinations are not real. A true hallucination is where the person is unable to recognise that their hallucinations are not real.Cardiovascular and respiratory system effects include tachycardia, vasodilation, hypotension, arrythmias. and bronchodilation.A short-lived psychotic state associated with a high dose. It usually resolves within a week of abstinence. It may be difficult to distinguish from the precipitation of psychosis in those with a predisposition to mental illness.

Sources: Todd, F., McLean, S., Krum, H., Martin, J., & Copeland, J. 2002, Cannabis, in Hulse, G., White, J. & Cape, G. (eds.) 2002, Management of Alcohol and Drug Problems, ch. 9, Oxford University Press, South Melbourne, pp. 141157.Victoria Police 2002, Custodial Drug Guide: Medical Management of People in Custody with Alcohol and Drug Problems, Custodial Medicine Unit, Victoria Police, Mornington, Victoria.

*NotesCNS problems associated with intoxication. Respiratory system bronchitis, asthma, sore throat, chronic irritation (e.g., COAD, exacerbates asthma). cannabis contains more tar than cigarettes. Cannabis smoke may be more highly carcinogenic than tobacco smoke. Many cannabis users are also dependent tobacco users. harms are mostly associated with the route of administration (smoking); e.g., chronic bronchitis. Smoking can result in mutagenic and carcinogenic histopathological changes of the parenchyma and epithelial cells.Cardiovascular system Increases heart rate but decreases strength of contraction. people with cardiovascular disease may experience a decreased exercise tolerance.Immune system animal studies suggest that chronic cannabis use results in immunosuppression, although findings are inconclusive for humans. Cognitive impairment depression, anxiety, rapid mood changes reported. precipitation of schizophrenia. effects may be subtle, but include effects on memory, attention, organisation, and integration of complex information. Although the current evidence suggests that these effects are not grossly debilitating, their reversibility is unknown.

**NotesCannabis dependence syndromeCharacterised by a variety of cognitive, physical, and behavioural symptoms, e.g., poor impulse control/inability to control use, continued use despite evidence of problems, withdrawal syndrome (anxiety, depression, mood swings, sleep disturbance, memory problems, non-specific physical discomfort) and tolerance (Palmer 2001).Concerns are emerging that dependence may develop rapidly in younger people and be more severe than previously thought.It is estimated that 2 joints per day for 3 weeks is sufficient to induce withdrawal symptoms after cessation in some people, although in others daily use for several years has not resulted in withdrawal symptoms on cessation.Sources: Palmer, B. 2001, Alcohol and Drug Withdrawal: A Practical Approach. A Manual for Doctors to Assist in the Treatment of Patients Withdrawing from Alcohol and Other Drugs, Next Step Specialist Drug and Alcohol Services, Mt Lawley, Perth, Western Australia, www.nextstep.health.wa.gov.au.Todd, F., McLean, S., Krum, H., Martin, J., & Copeland, J. 2002, Cannabis, in Hulse, G., White, J. & Cape, G. (eds.) 2002, Management of Alcohol and Drug Problems, ch. 9, Oxford University Press, South Melbourne, pp. 141157.

*NotesWhile not recorded as a diagnosis in the DSM-IV, the cannabis dependence syndrome is well described. Cannabis withdrawal tends to be less pronounced than that of other drugs (e.g., alcohol and opioids) and may take longer to become established. There is significant variation in symptomatology according to frequency and duration of use, and the rapidity and severity of withdrawal. Some (e.g., Todd et al., 2003) argue that younger people are increasingly reporting dependence of a greater severity than previously. In assessing and managing cannabis withdrawal, keep in mind that many polydrug users also tend to use cannabis. Assess for polydrug use, as withdrawal from a range of drugs will increase the severity and nature of withdrawal.

Source: Todd, F., McLean, S., Krum, H., Martin, J., & Copeland, J. 2002, Cannabis, in Hulse, G., White, J. & Cape, G. (eds.) 2002, Management of Alcohol and Drug Problems, ch. 9, Oxford University Press, South Melbourne, pp. 141157.

*NotesDrug history:pattern and frequency of usenumber of hours spent intoxicated per daycostactivities undertaken while intoxicatedPart of plant (e.g., bud/head or leaf) and type (e.g., ordinary, hydroponically grown, skunk).Route of administration (e.g., joint, pipe, bong, bucket bong, oral (cakes, biscuits, butter)).Brief psychosis precipitated by cannabis is controversial, though the precipitation of a comorbid psychiatric disorder (e.g., schizophrenia) is well documented. Onset of the disorders often occurs in early adulthood coinciding with cannabis use. Thorough investigation of psychotic symptoms and family history are important.Examination of respiratory function may be useful. Significant respiratory problems such as emphysema, chronic bronchitis or exacerbation of asthma may be evident.Spirometry may be considered to provide feedback to a user regarding the acute consequences of smoking cannabis (alone or mixed with tobacco).Acute cardiovascular signs may also be present, either related to panic (e.g. hypertension, tachycardia) or an exacerbation of angina pectoris.

ASSIST source: WHO (World Health Organization) unpublished, Assist Version 2.1 [2003].Cannabis source: NRDGP (Northern Rivers Division of General Practice ) no date, 11 Cannabis Questions, http://www.nrdgp.org.au/directory/documents/23/cannabis-1.pdf.SDS source: Gossop, M., Darke, S., Griffiths, P., Hando, J., Powis, B., Hall, W. & Strang, J. 1995, The Severity of Dependence Scale (SDS): Psychometric Properties of the SDS in English and Australian Samples of Heroin, Cocaine and Amphetamine Users, Addiction, vol. 90, issue 5, pp. 607614.

*NotesSome people at the severe end of the dependence spectrum or with co-morbid disorders may be helped by referral, consultation, or shared care arrangements with specialist AOD and/or psychiatric services.

*NotesThere has been a substantial increase in the number of cannabis smokers seeking professional assistance to quit, or to manage cannabis-related problems.There are no specific pharmacotherapies available for the management of cannabis withdrawal or relapse prevention. Short-term sedative-hypnotics may be helpful if withdrawal symptoms are severe and antipsychotic medications may assist in the treatment of psychosis (if antipsychotics are used, insure prophylaxis to prevent extrapyramidal side-effects). Psychosocial interventionsPsychosocial interventions for cannabis use disorder are still in their infancy. Most interventions used for cannabis dependence have been adapted from alcohol interventions. Psychosocial interventions are of greater benefit than no therapy. Even one session of cognitive behavioural therapy can produce clinically significant reductions in the frequency and amount of cannabis use and related problems among severely dependent users (Copeland et al., 2001). Studies show that 69 sessions of cognitive behavioural therapy produce more favourable outcomes than brief motivational interventions, especially with more severely dependent users.

Source: Copeland, J., Swift, W., Howard, J., Roffman, R., Stephens, R. & Berghuis, J. 2001, A Randomised Controlled Trial of Brief Interventions for Cannabis Problems Among Young Offenders, Drug and Alcohol Dependence, vol. 63(s1), s32.

**NotesIt may sometimes be useful to prescribe relatively small amounts of hypno-sedatives, e.g., diazepam, to assist with severe agitation and anxiety in the first few days.Long-term use of anxiolytics is contraindicated unless specifically recommended by a treating psychiatrist.Antipsychotic agents may be employed in response to psychotic symptoms in the short term. If antipsychotics are used, insure prophylaxis to prevent extrapyramidal side-effects. If symptoms do not settle within a week, psychiatric review is recommended.*InstructionsThank your audience for their time.Encourage your audience to keep in touch with you.Provide your contact information.