Addiction Treatment Blog

Dependence

Before considering this in detail, we must exclude a type of physical dependence that occurs with a great number of drugs and ordinarily is of little consequence. Many drugs will cause rebound symptoms once they are discontinued. This happens particularly if they block receptors. This blockade leads to the blocked receptors becoming hypersensitive. When the blocking drug is then removed, these receptors are flooded with the normal neurotransmitter and they respond vigorously. It may take 48-72 hours for them to settle back down to normal.

Examples of this are the rebound phenomena that may occur with beta-blockers, such as propranolol, and the cholinergic rebound that may happen after stopping antidepressants with marked anticholinergic effects. Propranolol rebound may lead to palpitations, sweating and flushing. Cholinergic rebound may produce poor sleep and nausea or vomiting. These syndromes are not serious, and high doses of the relevant compounds are stopped abruptly. Read more…

Barbiturates

Concerns about the over-prescription of benzodiazepines in recent years have led some prescribers to look at alternative hypnotic agents – either older compounds such as members of the barbiturate or chloral families, antidepressants, or neuroleptics with a sedative profile. There are a number of problems with such prescriptions as will become clear.

Chloral Compounds

Chloral compounds (see the table below) were first produced in 1869. Their sedative effects were quickly recognised, leading to their use as hypnotics among other things. A number of factors militated against their widespread use. One was the difficulty in making them in other than foul tasting liquid formats. The subsequent discovery of the barbiturates, just before the First World War, largely put paid to them. Before that, however, many patients admitted to mental hospitals were treated with chloral draughts and would appear to have done well. Read more…

Benzodiazepine Structure

What is the place for hypnotics in this scheme of things? Basically the same place that alcohol has occupied for centuries. Most of us every so often, if we are anxious, worked up or have a lot of things on our mind will have on occasion resorted to alcohol to knock ourselves out. This it doers effectively on an episodic basis. There are drawbacks to alcohol, however. One is that it may produce a rebound insomnia – it knocks you out but also wakes you up several hours later as the effects wear off. It may also wake you up to pass urine or because of dehydration.

Hypnotics do roughly the same thing, with similar benefits and side effects. Judiciously used, they are wonderful. Taken in the early stages of a problem they may abort the later development of habitual anxiety-based insomnia. Taken too regularly or chronically, they may produce their own problems.

The place for the hypnotics lies in the management of sleeplessness rather than in the management of insomnia. Where there is genuine sleeplessness stemming from jet lag or an underlying physical condition, or problems with falling asleep in what may be uncomfortable circumstances or situations of stress, a hypnotic may be of great benefit. The presumption in these cases is that there is a transient sleeplessness and the condition is being managed until normality returns. In certain circumstances, such as where a chronic physical condition regularly compromises sleep, it would seem that hypnotics can be used chronically without causing much in the lines of dependence or other problems. Under the side effects section below, problems such as the risks posed to driving from sedative effects of these drugs will be outlined but it should also be borne in mind that the fatigue consequent on sleeplessness is seen as a rather trivial issue. Read more…

Beta-blockers

In recent years, with concern over benzodiazepine use, there has been interest in the use of beta-blockers in the treatment of anxiety, principally propranolol (Inderal) and atenolol (Tenormin). Although they are used mainly in the treatment of hypertension, angina and cardiac arrhythmias, the rationale for their use in psychiatry is that they block the peripheral manifestations of anxiety, such as increased heart rate or shaking in the hands. Signs such as these are the cues we all use to judge, how anxious we are. When these effects of anxiety are controlled, it seems that two sets of feedback loops may be interrupted. Part of becoming anxious involves anxiety at signs of becoming anxious, such as increased heart rate and shaky hands. These manifestations of anxiety can lead to worries in their own right, for example, for the concert performer who may worry about both the audience and the effects of shaky hand on the violin bow. Similarly public speakers may have their nervousness faced with an audience augmented by nervousness about the effects of tremulous voice or a dry mouth on the act of speaking itself. Controlling effects such as heart rate, voice timbre and hand steadiness, therefore, can interrupt one feedback loop by taking away a set of stimuli to further anxiety. It can also interrupt another and ease the central anxiety by, as it were, removing the cues by which we all judge just how anxious we are. Read more…

To attempt to write an impartial account of the benzodiazepines is all but impossible (1,2). When they were first introduced these drugs (see the table below) were seen as being of major benefit, and they were widely regarded as extremely safe and demonstrably effective. They were popular with both physicians, consumers and the pharmaceutical industry. Indeed, they appeared to be so effective and so effective and so popular they have caused serious problems for the development and marketing of any new anxiolytic.

More recently, the benzodiazepines have been described as the greatest menace in peace time. They have been seen as the epitome of the psychotropic drug juggernaut, whose prescription must be curbed at all costs. There has been a variety of TV and radio programmes highlighting their dangers and the horrors of dependence, and it has been claimed that coming off them is harder than coming off heroin. But strangely enough, benzodiazepine dependence is perhaps the only case of drug dependence in which the dependent person is viewed with sympathy. Read more…

The medicine increases the disease.

Virgil (70-19BC), ‘The Aeneid’.

Prescription Drugs

This chapter highlights the important areas of abuse of prescription drugs. Opioids, cocaine, dexamphetamine, anabolic steroids and many of their derivatives are prescription medicines in the UK but these have been the subject of earlier chapters. Similarly, some ‘smart drugs‘ and certain preparations used in association with anabolic steroids are also prescription drugs and are discussed elsewhere in the blog.

Anaesthetics

Many gaseous anaesthetics have been subject to abuse but in practice these all have a low abuse potential because although they may produce pleasurable effects they are not easily available and are inconvenient to use, even for healthcare professionals with access to them. The exception is ketamine abuse which is well-described problem at street level.

Nitrous oxide

Nitrous oxide gas is not a prescription medicine in the UK but is included in this chapter for ease of reference. It is used therapeutically to induce anaesthesia and also as an analgesic. In this setting it is usually mixed with oxygen and is available commercially as Entonox in characteristic blue and white cylinders. Abuse is most likely to involve healthcare personnel who use nitrous oxide in the workplace, e.g. dentists, anaesthetists and theatre staff. However, the gas is also the propellant used in many canisters of pressurised whipped cream. The experienced abuser is able to release the gas into containers, allowing subsequent gas inhalation with minimum cream contamination. Inhalation is usually via a plastic bag, balloon or similar device. Healthcare staff may, of course, use anaesthetic administration equipment. In 1979, a US survey of 524 medical and dental students showed that 16 per cent of those questioned had abused nitrous oxide on at least one occasion. Read more…