Recreational drugs

• 3 main types – stimulants, depressants/sedatives, hallucinogens

Table 12.4Illicit substance abuse: a summary of hallmarks

Drug	Physical symptoms	Look for	Dangers
Amphetamines including methamphetamines  (3 forms) speed—powder base—oily paste ice—crystalline	Aggressive or agitated behaviour; giggling; silliness; euphoria; rapid speech; fever; confused thinking; anorexia; insomnia; extreme fatigue; dry mouth; shakiness; anxiety	Jars of pills of varying colours; chain smoking; white powder and crystals can also be snorted or injected	Hypertension; death from overdose; hallucinations; paranoia; may cause temporary psychosis; stroke; cardiac arrest
Ecstasy (methylene-dioxymethamphetamine)	Anxiety; panic; sweating; ‘loving’ feelings; jaw clenching, teeth grinding; bizarre overactive behaviour; hallucinations; increased heart rate, BP and body temperature; confidence; feelings of happiness and love	Small tablets of various colours, shapes, sizes and designs; also comes in powder and capsules	Convulsions; risk of death from heart attack, cerebral haemorrhage, hyperthermia, fluid imbalance with hyponatraemia, acute kidney failure, DIC, liver toxicity; hangover; depression
Fantasy (gamma-hydroxybutyrate)	Relaxation and drowsiness; dizziness; relaxed inhibition/euphoria; increased sexual arousal; impaired mobility and speech	Colourless, odourless liquid; also powder and capsules	Tremors and shaking; amnesia; coma; convulsions; death from high doses
Barbiturates	Drowsiness; stupor; dullness; slurred speech; drunk appearance; vomiting	Pills of various colours	Death from overdose or as a result of withdrawal; addiction; convulsions
Cannabis/marijuana	Initial euphoria; floating feeling; sleepiness; lethargy; wandering mind; enlarged pupils; lack of coordination; craving for sweets; changes of appetite; memory impairment; tacchycardia	Strong odour of burnt leaves; small seeds in pocket lining; cigarette paper; discoloured fingers	Inducement to take stronger narcotics; recent medical findings reveal that prolonged usage causes cognitive defects, precipitates or exacerbates schizophrenia; hyperemesis
Volatile substances including glue, solvents or petrol sniffing	Aggression and violence; drunk appearance; slurred speech; dreamy or blank expression; hallucinations; ataxia	Tubes of glue; glue smears; large paper or plastic bags or handkerchiefs	Lung/brain/liver damage; death through suffocation or choking
LSD (lysergic acid diethylamide)	Severe hallucinations; feelings of detachment; incoherent speech; cold hands and feet; vomiting; laughing and crying	Cube sugar with discolouration in centre; strong body odour; small tube of liquid	Suicidal tendencies; unpredictable behaviour; chronic exposure causes brain damage; LSD causes chromosomal breakdown
Narcotics (a) opioids (e.g. heroin)	Stupor/drowsiness; marks on body; watery eyes; loss of appetite; running nose; constricted pupils; loss of sex drive; agitation; hypoventilation	Needle or hypodermic syringe; cotton; tourniquet— string, rope, belt; burnt bottle, caps or spoons; bloodstain on shirt sleeve; glass in envelopes	Death from overdose; respiratory depression; mental deterioration; destruction of brain and liver; hepatitis; embolisms
(b) cocaine	Similar effects to amphetamines—muscle pains, irritability, paranoia, hyperactivity, jerky movements, euphoria, dilated pupils	Powder: in microwave ovens; inhaled, snorted or injected	Hallucinations; death from overdose—sudden death from arrhythmias; seizures; mental disorders; severe respiratory problems

A street drug dictionary

Amphetamines or uppers
Benzedrine	Roses, beanies, peaches
Dexedrine	Dexies, speed, hearts, pep pills, fast, go-ee, uppers, sulphate
Methamphetamines	Meth, crystals, white light, ice, whiz
Drinamyl	Purple hearts, goof balls
Amphetamine derivatives
Ecstasy Crank	E, eggs, eckies, XTC, ‘the love drug’, Mitsubishis, MDMA, vitamin E, X, Adam, death Crystal M, crank
Hallucinogens
LSD	Acid, blue cheer, strawberry fields, barrels, sunshine, pentagons, purple haze, peace pills, blue light, trips
Cannabis (Indian hemp)	Hash, resin
1 Hashish (the resin)	Pot, tea, grass, hay, weed, locoweed, Mary Jane, rope, bong, jive, Acapulco gold
2 Marijuana (from leaves)	Reefers, sticks, muggles, joints, spliffies, head, smoko, ganga
Cigarettes	Blow a stick, blast a joint, blow, get high, get stoned
Smoking pot
Narcotics
Morphine	Morph, Miss Emma
Heroin	H, Big H, Big Harry, GOM (God’s own medicine), crap, junk, horse dynamite (high-grade heroin), lemonade (low-grade heroin). Injection of dissolved powder: mainlining, blast, smack. Inhalation of powder: sniffing
Cocaine	Coke, snow, lady of the streets, nose candy, ICE, snort, C, flake, rock, blow, vitamin C, crack, shabu, baby
H & C	Speed balls
Oxycontin	Hillbilly heroin
Miscellaneous
Fantasy	GBH (grievous bodily harm), liquid G, liquid E, liquid ecstasy, liquid X, fantasy
Barbiturates	Devils, barbies, goof balls
Benzodiazepines	Rowies, moggies
Ketamine	‘K’, vitamin K, special K, K hole
Solvents	Chroming

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Substance Use Toxicity and Management Summary

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🔷 Stimulants

Examples: Amphetamines, Cocaine, MDMA (Ecstasy)
Clinical Effects:

• CNS excitation, sympathomimetic features
• Diaphoresis, flushing, mydriasis
• Hallucinations, agitation
• May precipitate:
  • Acute coronary syndromes (ACS)
  • Arrhythmias
  • Hypertension, possible hypotension with severe toxicity

Management:

• Sedation (e.g. benzodiazepines)
• IV fluid resuscitation
• Cooling measures for hyperthermia
• Monitor ECG and cardiovascular function

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🔷 Cannabis Toxicity

Clinical Features:

• Ocular: Red eyes, ↓ intraocular pressure (IOP)
• Autonomic: Dry mouth, dry skin, ↑ heart rate
• Neurological/psychiatric:
  • Depersonalisation, disorientation
  • ↓ inhibition, mood changes, memory impairment, poor attention
  • Psychosis, agitation
• Hyperemesis syndrome

Management:

• Symptomatic treatment:
  • Antiemetics
  • Benzodiazepines (if severe agitation or anxiety)
  • Antipsychotics (if psychotic features)

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🔷 Opioid Overdose

Clinical Features:

• CNS depression: Drowsiness, coma
• Respiratory depression
• Hypothermia
• Miosis (pinpoint pupils)
• ↓ HR and BP (but may be normal)

Management:

• Airway support and ventilation
• Naloxone IV boluses:
  • Start with 100 micrograms (mcg) IV, repeat every 2–3 minutes as needed
  • Titrate to respiratory rate >10/min
  • Consider continuous infusion if long-acting opioids involved

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🔷 Opioid Withdrawal

Preferred pharmacotherapy: Buprenorphine-controlled withdrawal
Used to prevent withdrawal symptoms during detoxification (vs long-term maintenance).

Initial Buprenorphine Regimen:

• Day 1: 4–8 mg SL as a single daily dose
• Day 3: Can increase to 12 mg
• Gradually taper over 3–5 days

Adjunctive Treatments:

• Clonidine: 5–15 mcg/kg/day orally in 3 divided doses × 7–10 days, then taper
• Diazepam: 5–20 mg PO QID with caution (risk of sedation/overdose)
  • Use only if supervised
• Note: Buprenorphine is preferred over clonidine or methadone in withdrawal

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🔷 Opioid Maintenance Treatment (for long-term dependence)

Should be initiated with specialist input.

1. Methadone

• Initial: 20 mg PO daily
• Stabilisation: Gradual increase over 3 weeks
• Maintenance: 50–80 mg/day (max 120 mg/day)
• Caution: Doses >40 mg can cause overdose, especially in unwell patients

2. Buprenorphine

• Initial: 2–8 mg SL daily
• Maintenance: Titrate to 8–24 mg/day or alternate-day dosing
• Safer profile: Lower risk of overdose, but may precipitate withdrawal if started too soon after full opioid use

3. Naltrexone

• Requires opioid-free state: use naloxone challenge test first
• Initial: 25 mg PO on Day 1, then increase to 50 mg daily from Day 2
• Requires close supervision and comprehensive counselling

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🔷 Key Notes on Opioid Dependence

Offer naloxone (Take Home Naloxone) to high-risk patients

Natural history: Many individuals outgrow dependence, with many achieving recovery by mid-30s

Psychosocial support (counselling, housing, employment, peer support) is essential