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of body image, combativeness, unusual feats of strength (partly due to its anesthetic activity), and loss of ability to integrate sensory input, especially touch and proprioception Physical symptoms include dizziness, ataxia, dysarthria, nystagmus, retracted upper eyelid with blank stare, hyperreflexia, and tachycardia There are increases in blood pressure, respiration, muscle tone, and urine production Usage in the first trimester of pregnancy is associated with an increase in spontaneous abortion and congenital defects Severe intoxication (20 mg or more) produces an increase in degree of moderate symptoms, with the addition of seizures, deepening coma, hypertensive crisis, and severe psychotic ideation The drug is particularly long-lasting (several days to several weeks) owing to high lipid solubility, gastroenteric recycling, and the production of active metabolites Overdosage may be fatal, with the major causes of death being hypertensive crisis, respiratory arrest, and convulsions Acute rhabdomyolysis has been reported and can result in myoglobinuric renal failure Differential diagnosis involves the whole spectrum of street drugs, since in some ways phencyclidine mimics sedatives, psychedelics, and marijuana in its effects Blood and urine testing can detect the acute problem Treatment is discussed in 38

FIGURE 7-33

either method Methadone maintenance programs are of some value in chronic recidivism Under carefully controlled supervision, the narcotic addict is maintained on fairly high doses of methadone (40 120 mg/d) that satisfy craving and block the effects of heroin to a great degree

2 Sedatives (Anxiolytics)

.

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About 6000 species of plants have psychoactive properties All of the common psychedelics (LSD, mescaline, psilocybin, dimethyltryptamine, and other derivatives of phenylalanine and tryptophan) can produce similar behavioral and physiologic effects An initial feeling of tension is followed by emotional release such as crying or laughing (1 2 hours) Later, perceptual distortions occur, with visual illusions and hallucinations, and occasionally there is fear of ego disintegration (2 3 hours) Major changes in time sense and mood lability then occur (3 4 hours) A feeling of detachment and a sense of destiny and control occur (4 6 hours) Of course, reactions vary among individuals, and some of the drugs produce markedly different time frames Occasionally, the acute episode is terrifying (a bad trip ), which may include panic, depression, confusion, or psychotic symptoms Preexisting emotional problems, the attitude of the user, and the setting where the drug is used affect the experience Treatment of the acute episode primarily involves protection of the individual from erratic behavior that may lead to injury or death A structured environment is usually sufficient until the drug is metabolized In severe cases, antipsychotic drugs with minimal side effects (eg, haloperidol, 5 mg intramuscularly) may be given every several hours until the individual has regained control In cases where flashbacks occur (mental imagery from a bad trip that is later triggered by mild stimuli such as marijuana, alcohol, or psychic trauma), a short course of an antipsychotic drug eg, olanzapine, 5 10 mg/d, or risperidone, 2 mg/d, initially, and up to 20 mg/d and 6 mg/d, respectively is usually sufficient Lorazepam, 1 2 mg orally or intramuscularly every 2 hours as needed for acute agitation, may be a useful adjunct An occasional patient may have flashbacks for much longer periods and require small doses of neuroleptic drugs over the longer term.

Cannabis sativa, a hemp plant, is the source of marijuana The parts of the plant vary in potency The resinous exudate of the flowering tops of the female plant (hashish, charas) is the most potent, followed by the dried leaves and flowering shoots of the female plant (bhang) and the resinous mass from small leaves of inflorescence (ganja) The least potent parts are the lower branches and the leaves of the female plant and all parts of the male plant Mercury may be a contaminant in marijuana grown in volcanic soil The drug is usually inhaled by smoking Effects occur in 10 20 minutes and last 2 3 hours Joints of good quality contain about 500 mg of marijuana (which contains approximately 5 15 mg of tetrahydrocannabinol with a half-life of 7 days) Marijuana soaked in formaldehyde and dried ( AMP ) has produced unusual effects, including autonomic discharge and severe though transient cognitive impairment With moderate dosage, marijuana produces two phases: mild euphoria followed by sleepiness In the acute state, the user has an altered time perception, less inhibited emotions, psychomotor problems, impaired immediate memory, and conjunctival injection High doses produce transient psychotomimetic effects No specific treatment is necessary except in the case of the occasional bad trip, in which case the person is treated in the same way as for psychedelic usage Marijuana frequently aggravates existing mental illness and adversely affects motor performance Studies of long-term effects have conclusively shown abnormalities in the pulmonary tree Laryngitis and rhinitis are related to prolonged use, along with chronic obstructive pulmonary disease Electrocardiographic abnormalities are common, but no long-term cardiac disease has been linked to marijuana use Chronic usage has resulted in depression of plasma testosterone levels and reduced sperm counts Abnormal menstruation and failure to ovulate have occurred in

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