Neurobiological Impact of Stimulants Depressants and Hallucinogens

Foreign. I'd like to welcome everybody to today's presentation on the neurobiological impact of stimulants, depressants and hallucinogens. I'm your host, Dr. Donnelly Snipes. Today we're going to define stimulant depressants and hallucinogens and discuss how they work, symptoms of intoxication and withdrawal, and short and long term effects of use of those substances. A lot of this information, not all of it, a lot of this information can be found@drugabuse.gov Drug topics, commonly used drugs charts. And that link obviously is right here on your objective slide. So let's just review really quickly. For those of you who haven't been around for one of my discussions of tolerance and withdrawal, let's review really quickly what we're talking about here. All psychoactive drugs cause alterations in your neurotransmitter balance. They may increase some things, decrease some things. That's the way our brain works. When our HPA axis is activated, for example, then our excitatory neurotransmitters are enhanced and our relaxation neurotransmitters are suppressed. So that's how our body helps regulate our heart rate, our breathing, you know, our energy levels, all that stuff. So when we talk about tolerance, I want you to think about, you know, and this hopefully would never, ever happen, but being in a, in a bath and somebody keeps coming in and throwing buckets of ice into your bath. And that would be absolutely miserable. Through exposure to either persistent or abnormally high levels of a substance, that would be the ice. In this case, bodily tissues develop resistance to prevent system overload. So what your body does is it says, you know, one of the ways it does that to ice is you start feeling numb. You know, that's not pleasant. And then another way it does it is by balancing the neurotransmitters in your brain. So if you're taking for example, stimulants, you are amping up those excitatory neurochemicals and the body says, well, if we've got six gallons of this going on, we should have six gallons of calming neurotransmitters. Obviously, gallons is not what we're talking about, but bear with me to balance it out. So in terms of the bath, this would sort of be akin to turning up the water heaters. Like, okay, if you're going to keep throwing in these ice cubes, then in order to keep the bath warm, to keep it a temperature that I can tolerate, I need to have much hotter water Coming in once the bodies come to depend or expand that higher level of the substance. So it's adjusted. So think of that water heater again. You've adjusted your water heater, you know, way, way up. But all of a sudden the person's not bringing the ice cubes anymore and you've got that hot water running. It's going to get really hot, really fast before all the water in that tank goes out and you realize that you need to turn the water heater down. Same sort of thing for your body. It doesn't get the message right away when you say, oh, I'm not going to use cocaine anymore. It doesn't get the message right away that, hey, you know, I need to rebalance and prepare for a lower level of stimulation. It takes a while for those tissues to adapt. So that's when you start experiencing withdrawal. Basically you can think of substance use. Whatever action it produces. Withdrawal is going to be the opposite action because those neurotransmitters, the body has tried to rebalance itself. So the opposing neurotransmitters are going to be in excess when you withdraw the offending substance. The method of administration greatly affects the intensity and duration of onset for, or just about any drugs that you take. Oral is the slowest because your body has to digest it. It's got to go through the system before it can reach its effects. Inhalation through snorting or smoking is obviously much faster. Injection and rectal suppositories are other ways that people get substances into their system. And skin patches, we see skin patches, for example, for pain relief. You know, some people have fentanyl patches that they we. And even smoking cessation, which provides a monitored amount of nicotine for nicotine replacement activities. So we can get substances into our system in a whole bunch of different ways. We also need to remember that drugs affect everybody differently based on their size. You know, a 250 pound person with, you know, 30% body fat is going to react differently than 115 pound person with 2% body fat. So we need to consider their, their size, their overall, you know, weight, but also their body fat percentage. Because certain drugs are more lipophilic, they respond. People with more body fat respond differently. And people's health, somebody who has cardiac problems is going to probably react differently to stimulants and depressants than someone whose heart is functioning normally or who has normal blood pressure. Same thing if they've got thyroid issues or even their biological neurotransmitter levels. And the best example I can give of this is when someone who doesn't have a ADHD takes an ADHD medication, they tend to have a much different reaction to it than someone who has ADHD because their inherent neurochemical levels are different. And the way their norepinephrine system they expect. Now, the norepinephrine system functions is different than someone who doesn't have adhd. It also affects people differently based on whether they're used to taking it. Do they have a tolerance to it? Other drugs that are taken concurrently. So if you take a depressant and a stimulant at the same time, you may. They may counterbalance each other. If you take two depressants at the same time, a lot of times those are exponentially additive. So so instead of, you know, one plus one equals two, it's like one plus one equals four in terms of the impact that it has on the body. And we're gonna talk about that when we get down here later. The amount taken is obviously going to affect different people differently. When it comes to medications, for example, I am a lightweight. I take one 25 milligram Benadryl and I'm out like a light. My husband can take, you know, the full adult 50mg of Benadryl, and it really doesn't affect him at all. So the amount taken, in addition to size, weight, and health, can also impact the effect on the person. Likewise, you know, if you take too much of something, the effects are going to be different. If you reach toxic levels, your effects may be very different. And in terms of illegal drugs, the strength of the drug varies from batch to batch. And this is also true. I need to add this now with cannabis, because cannabis is legal And I believe 35 states now that cannabis, which is a naturally grown plant, is not going to be as regulated in terms of its THC levels, as tightly regulated as something that comes from the pharmacy, for example. So we do want to recognize that, you know, generally certain strains of cannabis are going to have, you know, between X percentage and X percentage of THC and cbd, but it's probably is not going to be nearly as exact as something from the pharmacy. So let's talk about stimulants first. Stimulants are substances that excite the central nervous system by activating that HPA axis or your threat response system. Examples of stimulants. This is not an exhaustive list, but caffeine, amphetamines, and cocaine are the ones that we most commonly talk about. Now let's think about is there any good use, is there any positive use of stimulants? Well, yes. Stimulants help treat asthma. When our HPA axis is activated to prepare us to fight or flee, one of the things that happens is our airways open up so we can breathe faster, which enables us to run or fight or do whatever we need to do. So it is a natural reaction when somebody takes stimulants that their airways are dilated. Obesity stimulants increase the HPA axis, which triggers the release of thyroxin from the thyroid gland, which can help increase metabolism. But it also, stimulants also are known to help suppress appetite. So ADHD and narcolepsy and even occasionally treatment resistant depression can be treated with stimulants. Stimulants activate the HPA axis, enhancing cortisol, your stress hormone, thyroxin, your thyroid hormone, norepinephrine, which is kind of your focus chemical glutamate, which is your main excitatory energy neurotransmitter, and dopamine, which is associated with motivation and, well, motivation and perseveration. All of these, when they're activated, increase people's energy level, which can make them feel somewhat euphoric, especially if they were kind of flat before. Increasing norepinephrine and dopamine can have positive effects. We know that when thyroid hormones are low, we have hypothyroid. We tend to see symptoms of apathy and depression when they're increased, we tend to see people's mood improve. So we do see improvements of mood, sometimes excessive improvements, especially when we're talking about things like amphetamines that people are taking recreationally, which can create a situation that is positive and reinforcing, which means that dopamine is going to be even stronger. Norepinephrine also increases blood pressure and heart rate, constricts blood vessels, increases blood glucose and opens up those breathing passages. So think about how this would help someone in terms of fight or flee. Increased blood pressure helps, you know, get the blood where it needs to be. Increased heart rate, increases the circulation, increases in blood glucose, give them, give people energy to fight or flee. So you can see that basically stimulants, amphetamines, cocaine, those things are going to trigger that fight or flight reaction, although the context often is in a more euphoric situation. How do these things work? And this isn't just amphetamines. This is for any of our neurotransmitters when we start monkeying with them. How does it increase the amount of A particular neurotransmitter. And there's four ways the substance can cause an increase in the release of that neurotransmitter or hormone into the synaptic space. It can increase the duration that substance stays in the synaptic space, you know, between the, the secretion and the receptor. By preventing reuptake, which is what your SSRIs, for example, do selective serotonin reuptake inhibitors. Or it can reduce degradation. When we have substances in that synaptic space, there are other substances that come along and help break them down so they are rendered basically inert, if you want to think of it that way. But if you inhibit either one of those things reuptake or degradation, then that substance stays in the synaptic space longer, so it can do its damage. The other way it can happen is by binding to the reuptake trans transporter and causing it to act in reverse. So instead of think of it this way as sucking up the substance from the synaptic space, it actually shoots it out again. So think of it like wringing out a. A sponge. Instead of sopping some. The, the stuff up, the sponge is actually putting it back into the synaptic space. It can also. I already talked about reducing degradation. Signs of intoxication of stimulants. A generalized state of euphoria. The person feels pretty good and they are, they're excited. Increased energy, sometimes increased confidence. Mental alertness. Sexual arousal. Itching and scratching. Large pupils, which is. I have that bolded because it's in contrast to your depressants, which are going to result in constricted pupils. They have pinpoint pupils, dry mouth, fast heartbeat, teeth grinding, reduced appetite and excessive sweating. So think about how these symptoms make sense in terms of helping the organism fight or flee. You know, they have energy, they have more confidence, or they feel, you know, sort of invincible. They can fight, they're more alert. They, with the exception of the itching and scratching, they have a faster heartbeat. So they are ready to fight or flee. Reduced appetite. Now is not the time to be resting and digesting. It's time to fight or flee. And then sweating helps us regulate our body temperature. So when you understand, when you look at what's the function of these symptoms that the person has and why does it happen? With stimulation of the HPA axis, it makes perfect sense. In the four to six days after stimulant use, the following effects may be experienced. Restless sleep and exhaustion. The person's serotonin levels are out of whack. Their melatonin levels are out of whack. Their circadian rhythms are probably out of whack. So they're going to be tired. They have been full bore because of being hyper stimulated. So the rebound from that is going to be exhaustion. Headaches, we know that as blood flow alters, it can contribute to headaches, which is one of the reasons why some of your headache medicines tend to have stimulants like caffeine in them. But when you take away that caffeine, you have that rebound cerebral pressure, dizziness and blurred vision, possibly from the headaches, but also possibly due to alterations in serotonin levels. We know that when people are depressed, when they have low levels of serotonin contributing to their depression, they actually do have more blurred vision, life is more gray, things are not as crisp. Which, you know, I think is a really interesting although, albeit odd side effect of serotonin alterations. They can have paranoia, hallucinations and confusion, irritability, mood swings and depression, anxiety and insomnia. So they tend to be sort of agitated and exhausted all at the same time. It's important to note if you're working with people who might be using or abusing stimulants, methamphetamine has a substantially longer half life than cocaine, leading to a more intense and longer withdrawal. Now, methamphetamine, unfortunately, is one of those things that can be made. You've all heard of meth labs that can be made pretty easily with things that can be pretty easily acquired, which is why methamphetamine can be such a problem, especially in rural areas. We see it a lot more because that's, it's the substance. Substances needed to make meth are easy to access. Chronic methamphetamine users may have episodes of violent behavior, paranoia, anxiety, confusion and insomnia. When you are altering the HPA axis, you're also impacting the amygdala. You're also impacting a bunch of, a bunch of the other areas of the brain, which can lead to chaotic behavior. Another stimulant that, you know, you wouldn't think of necessarily. You're thinking amphetamines, cocaine, you know, coffee. Caffeine is a stimulant. And caffeine can be found in a lot of things, not just coffee. It can be found in workout supplements, it can be found in stay awake pills like Vibran. It can be found in chocolate. But it's not. There's, I can't see how any one person can get 1200 milligrams of caffeine. From chocolate in a single sitting. But toxic effects like seizures can be seen with consumption of over 5,000 milligrams per day. Sometimes less, sometimes more, but in general, 5,000 milligrams in a day. Now, if a cup of coffee has 200 milligrams, that's a whole lot of freaking coffee. So most people aren't going to reach daily toxic levels. However, people can and have been known to consume large amounts of caffeine quickly because caffeine has such a long half life, it builds up in the body. And 1200 milligrams of caffeine consumed quickly can result in things like seizures. So we want to be aware. Now the max recommended amount of caffeine per day is 400 milligrams, which I think a lot of us probably exceed one cup of coffee, depending on the bean. And the preparation method is anywhere from 80 milligrams to 200. Red Bull Monster, they're around 80 milligrams. Stacker 2, one capsule or Vibran, one tablet, they're 200 milligrams. So you can think about, you know, what people are, that you're, that you're working with, are taking, you know, how many pots of coffee do they drink every day and how strong do they make it? And it's important to consider that because the rebound effects can be very depressive in nature and the intoxication effects can be very anxiety like in nature. Possible side effects for stimulants include hostility, paranoia, psychotic symptoms, unsafely elevated body temperature, irregular heartbeat or heart failure, stroke, seizures, or exacerbation of existing anxiety. When your blood pressure gets up high enough, it puts you at risk for cardiovascular crises. And people who are taking too much in the way of stimulants can cause that long term effects of stimulants. And this includes stimulants of abuse. You know, things that you're using like cocaine and, or abusing, not taking as prescribed. But there are side effects for prescribed stimulants and which is why doctors typically do a whole lot of monitoring in people who are taking stimulants for weight loss, for add, for, you know, anything where it's prescribed because it can lead to long term reductions in appetite, restless sleep, disrupted circadian rhythms, dry mouth and dental problems, reduced immunity, trouble with concentrating or breathing, muscle stiffness and anxiety and paranoia, depression and suicidal ideation, heart and kidney problems, increased risk of stroke, tolerance, confusion, sexual dysfunction, chest pain or palpitations, and even seizures and delirium. So, you know, there's a whole long List of side effects. You know, that whole list they go through on the ads for different drugs. You know, stimulant use over activating or hyperactivating that HPA axis repeatedly can cause the body to make permanent changes in order to adapt. Depressants exert the opposite effect of stimulants because they slow everything down. Unlike what you would think it's not. They don't make you depressed. They tend to be slowing, calming, theoretically relaxing. Depressants exert their effect through a number of different pharmacological mechanisms, mostly facilitation of gaba, our natural volume, so to speak, and inhibition of glutamate and mono aminergic activity like your dopamine, noradrenaline and serotonin. So it starts suppressing the activity of your, some of your stimulatory neurotransmitters. Now serotonin's there because serotonin in certain receptors can be antidepressant in nature and can be energizing too much serotonin can contribute to anxiety and other receptors tend to be more responsible for calming. So it depends on which serotonin receptors are being activated. But in terms of depressants, we're talking about opioids. Anything that makes you sleepy is probably going to fall somewhere in this category. Opioids, your barbiturates, like sedatives, typically they end in barbital, like phenobarbital. Your benzodiazepines, like valium and those others, they typically end in lam and pram or pam. Inhalants, aerosols, paint, gasoline and glue. Now, we're not going to talk a lot about the inhalant in this, in this presentation, but do consider that if you are in an environment in which they're painting, it can affect your mood. It can produce, especially in people who are super sensitive like me, can produce sort of depressive symptoms, difficulty concentrating. So be aware of that. A lot of times people don't even really think of it when they are, you know, at work and they the people decide to paint the inside of your building. Encourage your clients who may have depression to be aware of their surroundings and if they are painting somewhere, to be aware of that. If you get your house painted, you may need to move, you know, stay at a hotel for a while or Airbnb or, and, or consider. There are certain paints that are available now that have no VOCs, volatile organic compounds. They're organic paints and those have been found to be much less in, in influencing of people. And Pat points out that rugs Evidently also may have some chemicals in them, I guess in the backing and stuff that go along with that inhalant problem. So have people be aware of their surroundings. Muscle relaxants also tend to be sedating and non benzodiazepine hypnotics. Your sleep aids like Lunesta and Sonata, and then alcohol, which we're going to talk about in a couple of weeks. But alcohol initially has a sedative effect and then as it leaves the body, it leaves more quickly than the body can adapt. So there tends to be a rebound, anxiety or stimul, stimulatory effect. So let's talk about opioids. That's one of our more common depressants. It is considered an analgesic or a painkiller. It's a depressant and it's an antitussive. Sometimes people will be prescribed an opioid to help them stop coughing. Now codeine is an opioid. And so if you've ever had cough medicine with codeine, well, there you go in the first five hours. The short term impact of opioids depends heavily upon the dose that's used, the route of administration and previous exposure. The effects can include euphoria, a feeling of well being, relaxation, drowsiness, sedation, disconnectedness or even delirium. People who have high levels of anxiety tend to feel relief when they take opioids, which is why it can be so addictive to them. Physiologically, when people take opioids, they have pain relief, depressed heart rate and respiration. It's slowing the system down. Constipation again slowing the system down. Flushing of the skin, pupils that are fixed and constricted and diminished reflexes again slowing everything down. So things are just kind of going in slow motion. Medical complications among opioid abusers arise primarily from adulterants in non sterile injecting practices. They include skin, lung and brain abscesses. When you inject, inject adulterants, it can get ugly really fast. Collapsed veins from over, injecting endocarditis, which is inflammation of the heart. Hepatitis and HIV are aids. Alcohol or other depressants like benzodiazepines, hypnotics or even antihistamines increase the CNS effects of opioids. So if somebody's taking opioids, even as prescribed after surgery and they take something else that's a depressant, it's going to add up exponentially and exponentially increased sedation, decrease in motor skills and respiratory depression and hypotension. When your blood pressure gets too low, people tend to get dizzy, they may be at more at greater risk for falls. But more problematic here is the respiratory depression. So we do want to make sure that people are extra aware of the fact that opioids make it dangerous to mix medications and the reason that they need to talk with their physician when they're trying to take anything and they're already on opioids. Long term impact of opioids may include vein collapse, depression, brain changes and damage and and reduction of the production of natural painkillers. When the body starts getting flooded with exogenous opioids, codeine, morphine, heroin, whatever it is, it quits making its endogenous, it's natural painkillers. It says, I don't need to do this because you're ingesting fifty hundred times more than we need. Unfortunately, when the person quits using, the body takes a while to recognize that it's got to start up production of those endogenous opioids again. So pain goes up. People who are in the detox and withdrawal phases from opioid abuse tend to have more aches and pains, tend to feel more joints stiffness and things because they don't have the benefit of those endogenous opioids. That's another reason that for someone who's been prescribed opioids a lot of times the humane thing is to detox them by, by gradually tapering their dosage. Even when people are exiting methadone or suboxone or buprenorphine treatment, most of the time the protocol is to gradually taper them so they don't have that increase in pain. With people who've been abusing opioids, that increase in pain is a trigger for relapse, which is another reason that not only do we not want them to feel bad, but we also don't want to trigger a relapse. So tapering is usually the best option. Symptoms of intoxication for opioids include constricted pupils. They are pinpoint pupils and they aren't super reactive to light drowsiness, inattention, scratching and picking low blood pressure and heart rate, which again can make people more susceptible to dizziness and incoordination. Even if they're not abusing substances. Maybe they had surgery and, or you know, oral surgery even, and they were prescribed opioids if they're not used to taking them. It's important to make sure that they are aware that they may be at greater risk of falls and dizziness, especially when they stand up, especially if they stand up quickly when they're Taking the opioids so they can take precautions so they don't hurt themselves even worse. And yes, Xanax is a depressant. It falls in the benzodiazepine category. Symptoms of withdrawal from opioids begin within 6 to 12 hours, last 5 to 10 days, and tend to peak within 48 to 72 hours. Now, an interesting thing with opioids as well as benzos is there can be a pre protracted withdrawal where they may have a resurgence of symptoms, you know, several weeks after they've quit taking, especially if they didn't taper off. Symptoms of withdrawal include yawning. Now you might think, well, you're supposed to have the opposite reaction. And so when you stop taking opioids, you're not supposed to be feeling as tired when. Well, yes, but yawning doesn't necessarily mean tired when you're on. When people are using opioids, their blood pressure reduces, their respiration reduces, so their oxygenation often reduces. And opioids interact with a lot of functions in the brain stem, one of them being respiration. So the body is basically having a paradoxical effect, a rebound. I call it rebound oxygenation. But the body is exaggerating its response. So instead of breathing, it wants to get, you know, just really get that oxygen into the body. There can be drug craving, usually is irritability, dysphoria and depression as the neurotransmitters become unbalanced. You know, they got used to being in a certain balance in response to having the opioids in the system. Now you've taken the opioids out, so now there's an imbalance in those neurotransmitters which leads to mood issues, high blood pressure, which is one of those rebound symptoms, and then flu like symptoms, including runny nose, sweating, vomiting, chills, abdominal cramps, body aches, muscle and bone pain, muscle spasms and insomnia. Detox issues. The biggest issue in detox for most people is that tolerance decreases rapidly. So after somebody's been off opioids, they quit taking their opioids, you know, maybe even a week if they relapse and they start using at the same dose that they were using when they stopped, they are really likely to be using too much and they are at high risk for overdose because the body reacts, the tolerance decreases very, very rapidly. The biggest focus during opiate withdrawal is often to address the unpleasant symptoms like we just talked about and prevent dehydration, because when they have flu like symptoms, there's a lot of dehydration in general, opiate withdrawal is not life threatening. But in some people, hallucinations and seizures are possible. So it's important to watch for decompensation in people who are detoxing from anything, including opioids, which means they don't want to ideally be doing it alone. They preferably are under supervision somehow. Fentanyl is 30 to 50 times stronger than heroin. So fentanyl is really powerful stuff. And fentanyl is used, you know, like I mentioned earlier, fentanyl patches that fentanyl is used by prescription in the United States even still. So it's important to recognize that that is some really powerful stuff. There's difficulty getting prescription opioids has led to increases in demand for heroin and diversion of things like Suboxone, methadone and buprenorphine. So we do want to recognize, as y' all know, opioid misuse and abuse is a huge problem. Your benzodiazepines are another class of depressants. They are anti anxiety medications, they are sedating, they can be sleep inducing, they can be used for anticonvulsant effects and even their muscle relaxant properties. They can be short acting, which means they go into your system, they peak really fast and then they exit really fast or long acting in which they kind of go into your system a little bit more gradually and out a lot more gradually. So you don't have that, you know, peak and trough which can be very helpful because the, when you have the short acting, people tend to have a lot more rebound anxiety. Benzodiazepines mainly act by enhancing the effect of gaba. Short term impact of your benzos, drowsiness, blurred vision, poor coordination, amnesia, hostility and irritability, disturbing dreams, reduced inhibition, impaired judgment and rebound anxiety. So, you know, it's not the panacea that you might think it is. It's not just a, you know, hug everybody and sing Kumbaya. Benzodiazepines do affect people very, very differently and can impair their ability to function in their day to day life because obviously if they're drowsy with blurred vision, driving is not going to be helpful or going to be something they can do. Poor coordination can make them at risk for falls. And that rebound anxiety that's some people experience when they take a benzo can be almost worse than the anxiety that they felt before they took the drug. In the elderly, benzos are cleared through the liver and as we age, our liver loses its effectiveness or speed at which it can clear certain substances. Benzos are one of them. Benzodiazepines can build up very quickly in the elderly population, leading to confusion, the appearance of dementia and potential benzodiazepine overdose. It's really important that people who are over the age of 60 or have some sort of liver problem, you know, whatever, you know, liver dysfunction, that they are very, very closely monitored by their physician. Combining benzos with other depressants has an exponential additive effect. Rufinol is a benzodiazepine, just kind of throwing, throwing that in there. Long term impact of benzodiazepines can cause impairment in several cognitive domains including visuospatial ability. So your ability to, you know, determine where things are and your perceptual abilities, your speed of processing and verbal learning. Benzodiazepine use for three months or more. Now this is talking about, you know, consistent like every four hours or however often you're supposed to take it every day. Not just your sporadic as needed use, but consistent. Benzodiazepine use for three months or more was associated with an increased risk of Alzheimer's disease of up to 51%. So that was a really staggering set of studies. Symptoms of benzo withdrawal include sleep disturbance, you know, the opposite of being relaxed and sedated, irritability, increased tension and anxiety, panic attacks, hand tremor, sweating, palpitations, difficulty concentrating, dry heaves, nausea, headache, muscle pain, stiffness, seizures and potentially psychosis. Remember, benzodiazepines do impact muscle contraction, which is why sometimes they're used as muscle relaxants. And as a result, when you withdraw them, especially if you withdraw them quickly, you can create the paradoxical OC opposite effect. In terms of detoxification, symptoms for benzos appear around the end of the half life. So for your short acting benzos, that can be a matter of hours. For your longer acting benzos, that can be a day or more. Rebound anxiety and insomnia peak within a couple of days and withdrawal symptoms can last for two to four weeks, depending on which drug, which benzodiazepine the person was taking. That's a long time to experience high anxiety symptoms as well as high blood pressure and some of the other things that go along with it. Protracted withdrawal is not uncommon in heavy and or long term users. And again, this is when somebody goes through withdrawal, they start feeling a lot better, life is good, and then all of a sudden they start having those withdrawal symptoms again days or weeks later. In terms of detoxification from benzos, a grand mal seizure may occur in as many as 20 to 30% of individuals undergoing untreated withdrawal from these substances. So benzos are not something that you just randomly detox yourself at home. It is something like alcohol that can be a life threatening situation. Flumazenil is a competitive antagonist that can reverse the sedative and overdose effects of benzos, but not of alcohol or other sedative hypnotics. So there are ways to reduce or reverse overdose issues. There are medications that can be used to address withdrawal symptoms, but all of those are going to be prescriptions. Benzo is the most frequently used class of drugs for anxiety disorders. No joke. An estimated prevalence of use in the United States right now is 12.9%. Wow, 12.9%. So roughly 1 in 10 people is on some level of some prescription for benzodiazepines. Other depressants include ghb which is the date rape drug. It acts on GHB and GABA receptors. Some athletes also use GHB in order to increase human growth hormone. So if you work with athletes, be aware they may be recreationally or self medicating with this non benzo sleep medications like Ambien have a different chemical structure than benzodiazepines but act on some of the same brain receptors. Barbiturates. Your barbitals like phenobarbital are used to reduce anxiety or help with insomnia and are readily available in many hospice involved patients. The reason I put that out there is because it's easy to divert if one if your client has a hospice involved loved one. Inhalants are other depressants. Paint and paint thinners, markers, glue, shoe polish, gasoline, cleaning fluids, aerosols can all depress have have depressive symptoms on people. Other sedating substances include herbs and supplements like valerian, melatonin, passion flower and gaba. All of those people can get over the counter and misuse or not recognize that they are sedating and combine them with something like a prescription for an opioid or a benzo and cause themselves problems. Muscle relaxants are also sedating. Atypical antipsychotics typically work by causing sedation through reducing dopamine levels as opposed to working on GABA levels. But they are very sedating and some of and mood stabilizers like Depakote are also hallucinogens cause profound distortions in a person's perception of reality. Some plants and mushrooms or their extracts are hallucinogenic. But hallucinogens can also be man made. Psilocybin is one that they are working on making in the lab. Now they're commonly divided into two Broad categories, your classic hallucinogens like LSD and your dissociative drugs like pcp. Dissociatives also include things like ketamine, also known as Special K and is odorless and tasteless and has amnesia inducing and dissociative properties. It can be used as a date rape drug. It also is being investigated though, interestingly enough because of its interaction on the gaba. Neurotransmitters for treatment resistant depression and acute suicidal ideation. So that's kind of interesting. DXM or dextromethorphan. Think of some of your cough syrups that you take. It's a cough suppressant and expectorant. It acts on a lot of different things, but it increases one of the take home messages. It increases serotonin levels. Expect exponentially and abuse of DXM can precipitate serotonin syndrome. Salvia divinorum, also known as Diviner sage, is a psychoactive plant that is typically ingested by chewing fresh leaves or by drinking their extracted juices. Hallucinogens interfere with the action of serotonin and glutamate, which regulate mood, sensory perception, sleep, hunger, body temperature, sexual behavior, muscle control, pain perception and learning and memory. Serotonin has its little fingers in just about everything. LSD is potent in terms of affecting mood and perception. It's clear or white, odorless and water soluble and consumed from microdots, little tiny tablets, thin squares of gelatin, diluted water or alcohol that is sold in liquid form or LSD soaked paper punched into small individual squares known as blotters. Peyote or mescaline, also known as button and cactus is a small spineless cactus with mescaline as its main ingredient. The top or crown of the peyote cactus has disc shaped buttons that are cut out, dried and either chewed or soaked in water to produce a tea or a tincture that's intoxicating. The effects of hallucinogens can begin within 20 to 90 minutes and last as long as 12 hours and range depending on the person from increased heart rate, nausea, intensified feelings of sensory experiences, changes in the sense of time passing, increased blood pressure, respiration, body temperature, loss of appetite, dry mouth, sleep problems, spiritual experiences, feelings of relaxation or detachment, uncoordinated movements, panic, paranoia and psychosis. So a lot of the actions seem to be more stimulatory than relaxing for people. Repeated use of PCP can result in long term effects that maybe continue for a year or more after use stops, including speech problems, memory loss, weight loss, anxiety, depression and suicidal thoughts. Though rare, long term effects of some hallucinogens include persistent psychosis, including visual disturbances, disorganized thinking, paranoia and mood changes, and even flashbacks, which are recurrences of certain drug experiences. In the DSM, it's referred to as Hallucinogen Persisting Perceptual Disorder or HPPD. Over 10,000 people come to BetterHelp every day looking for a counselor. BetterHelp makes it easy for you to move your practice online and focus on what you love most, helping others. Better Help's easy to use platform, takes care of referrals and billing and provides a secured platform to communicate with your clients. Join more than 18,000 therapists at better Help helping to improve people's mental health and lives. Stimulants range from caffeine to methamphetamine and amp up the system. Opioids, benzos, barbiturates, alcohol and inhalants are all CNS depressants. They tend to suppress blood pressure, heart rate, respiration, mood. Combinations of depressants have an exponential additive effect. It's important that we evaluate patients for exposure to all CNS depressants, intentional and incidental. Just like, you know, take, you wouldn't want to take opioids and benzos together. If you have somebody who is taking benzos or opioids and in an environment in which they're inhaling paint fumes all day long, specifically painters or people who work in construction, we want to recognize that there is a potential that those drugs could interact even though the person is not like intentionally ingesting or inhaling the paint. The paint fumes can combine with any substances that they're intentionally taking. Hallucinogens include lsd, pcp, peyote, ketamine, and dextromethorphan. Recent research has indicated, and this is just kind of one of those side notes, that hallucinogen perceptual, persistent perceptual disorder is not due to to traces of the drug being freed up. They don't know why it happens, but they do know that it does happen. Patricia asks, is there a brain receptor that's related to inducing amnesia as ketamine stimulates? There is not any particular brain receptor that I'm aware of. We do want to recognize that when somebody is. Under stress, alterations in glutamate levels can impair memory formation, which can create difficulty remembering what happens in certain situations. But in terms of specifically a receptor that induces amnesia, there's not one that I'm aware of. Cannabis is its own kind of little animal part of it depends on which cannabinoids the person is being exposed to. THC tends to be more stimulating in nature, whereas CBD tends to be more sedating and calming in nature. So cannabis itself is really interesting, which is why there's so many different strains, and because the balance of THC to CBD impacts the effect that the cannabis has on the person, from making them completely relaxed and sedated to helping them increase their focus a little bit. So without getting into huge details about different, different types of cannabis, it's typically just kind of put out there in its own little category and not lumped in necessarily with either stimulants or depressants.