常見濫用藥物危害特性 及案例介紹

1. 常見濫用藥物危害特性及案例介紹 劉清輝醫師 高雄市立凱旋醫院 成癮防治科

2. 成癮物質的分類 • 鴉片類(Opioids):海洛英(Heroin)、速賜康(Pentazocine)、配西汀(Demerol) • 安非他命及其相關化合物(Amphetamine):甲基安非他命(Methamphetamine)、快樂丸(MDMA) • 古柯鹼(Cocaine) • 大麻(Cannabis) • 幻覺劑(Hallucinogens):LSD(Lysergic acid) • PCP(Phencyclidine):天使塵

3. 成癮物質的分類 • 鎮靜、安眠或抗焦慮劑(Sedatives、Hypnotics、or Anxiolytics) • 吸入劑(Inhalants):強力膠(Glue)有機溶劑 • 酒精(Alcohol) • 尼古丁(Nicotine):香菸 • 咖啡因(Caffeine):咖啡、茶 • 其他:Ketamine 、GHB

4. 「毒品危害防制條例」之毒品分級 • 第一級毒品:海洛英(Heroin)、嗎啡(Morphine)、鴉片(Opium)、古柯鹼(Cocaine)及其相類製品。 • 第二級毒品:罌粟(Opium Poppy)、古柯(Coca)、大麻(Cannabis)、MDMA 、安非他命(Amphetamine)、配西汀(Demerol)、潘他挫新(Pentazocine)及其相類製品。 • 第三級毒品:西可巴比妥(Secobarbital)、異戊巴比妥(Amobarbital)、Ketamine 、 GHB 、酣樂欣(Triazolam)、FM2(flunitrazepam) 、可待因(Codeine)及其相類製品。 • 第四級毒品: Allobarbital 、 Alprazolam

5. Dependence Abuse Intoxication Withdrawal Intoxication Delirium Withdrawal Delirium Dementia Amnestic Disorders Psychotic Disorders Mood Disorders Anxiety Disorders Sexual Dysfunctions Sleep Disorders Diagnoses Associated with Class of Substances

6. 藥物成癮的四個階段: • 第一階段:初嚐快感常用藥物:酒、菸、大麻、強力膠一類。 • 第二階段:感受快感的盪漾常用藥物:加上大麻、大麻油,和安非他命、安眠藥之類。 • 第三階段:迷上快感常用藥物:加上古柯鹼、迷幻藥、鴉片。 • 第四階段:服用藥物才感覺正常常用藥物:加上海洛英。

7. 酒精 • (一)歷史:幾萬年前,人類已知發酵水果、穀類以製酒。西元800年,阿拉伯發明蒸餾製酒,’alcohol’乃源自阿拉伯字”alkuhl”,意為精髓(essence)。1849年之瑞典首先提出「酒癮」(alcoholism),之後被廣泛使用。在美國,醫院自1840年代開始治療酒癮患者,而19世紀後半,酒癮相關問題成為醫學研究之主要課題。台灣近年來酒癮有逐年昇高的趨勢。 • (二)藥理作用:中樞神經抑制作用,及影響多種生理、代謝作用。

8. 酒精 • (三)中毒過量: • 判斷力損害、言詞含糊、運動協調障礙、步態不穩、眼球震顫、注意力或記憶力損害、木僵或昏迷。 • 血中酒精濃度0.5%以上:影響呼吸和心跳,可能致命。 • (四)戒斷症狀: • 失眠、焦慮、手抖、噁心或嘔吐 、自主神經系統活躍、激動、幻覺或錯覺、大發作癲癇。 • 震顫性譫妄(Delirium Tremens):通常在戒斷後24-72小時發生,表現為意識不清、波動性變化、激躁不安、自主神經系統過度亢奮、高燒、幻覺(主要為視幻覺)。若不治療死亡率高達20%,死因常為併發高燒、感染、內外科疾病和自主神經系統亢奮過久,造成心臟循環衰竭而死亡。

9. 酒精 • (五)酒癮相關疾病: • 精神科:酒精中毒、戒斷、病態性中毒、精神病、憂鬱症、失憶、痴呆等。 • 神經科:魏尼基氏腦症(Wernicke’s syndrome),柯沙科夫精神病 (Korsakaff’s syndrome),周邊神經病變、肌肉病變等。 • 胃腸系統:胃炎、酒精性肝炎、脂肪肝、肝硬化、急慢性胰臟炎、膽結石。 • 血液系統:貧血、血小板功能失常等。 • 其他:如代謝問題、意外傷害等。

10. 鎮靜安眠劑 • (一)歷史:1962年Bayer發明bartituric acid,1903年barbital問世,1903年至1960年代末期,巴比妥鹽類(barbituates)是最普遍的鎮靜安眠藥,1960年代Benzodiazepine崛起,因其具有較佳的安全性,迅速取代巴比妥鹽類的角色。在台灣,民國68年之後,因速賜康被管制,此類藥物便逐漸流行氾濫。 • (二)使用途徑:口服、靜脈注射。 • (三)藥理作用:作用於GABA type A 接受器。中樞神經抑制作用。具鎮靜、安眠、抗焦慮、肌肉放鬆、抗痙攣等效果。

11. 鎮靜安眠劑 • (四)中毒過量:判斷力損害、言詞含糊、運動協調障礙、步態不穩、眼球震顫 、注意力或記憶力損害、木僵或昏迷。 • (五)戒斷症狀:失眠、焦慮、手抖、噁心或嘔吐 、自主神經系統活躍、激動、幻覺或錯覺、大發作癲癇。 • (六)併發症: • 中毒或戒斷的併發症可能導致死亡。 • 精神神經科:感覺、運動、認知、情感、自我控制等方面的改變。 • 其他內外科併發症或意外傷害。

12. Rohypnol (FM2) • Rohypnol, a trade name for flunitrazepam, has been of particular concern for the last few years because of its abuse in date rape. It belongs to a class of drugs knows as benzodiazepines. When mixed with alcohol, Rohypnol can incapacitate victims and prevent them from resisting sexual assault. It can produce "anterograde amnesia," which means individuals may not remember events they experienced while under the effects of the drugs. Also, Rohypnol may be lethal when mixed with alcohol and/or other depressants.

13. Rohypnol • Rohypnol is not approved for use in the United States, and its importation is banned. Illicit use of Rohypnol started appearing in the United States in the early 1990s, where it became known as "rophies," "roofies," "roach," and "rope." • Abuse of two other similar drugs appears to be replacing Rohypnol abuse in Miami, Texas, and Boston. These are clonazepam, marketed in the U.S. as Klonopin and in Mexico as Rivotril, and alprazolam (marketed as Xanax). Rohypnol, however, continues to be a problem among treatment admissions in Texas, particularly among young Hispanic males along the Mexican border.

14. Rohypnol • Slang or Street Names: Roofies, Rophies, Roche, Forget-me Pill • Rohypnol® (flunitrazepam) belongs to the class of drugs known as benzodiazepines (such as Valium®, Halcion®, Xanax®, and Versed®). It is not approved for prescription use in the United States, although it is approved in Europe and is used in more than 60 countries as a treatment for insomnia, as a sedative, and as a presurgery anesthetic.

15. Rohypnol • Rohypnol is tasteless and odorless, and it dissolves easily in carbonated beverages. The sedative and toxic effects of Rohypnol are aggravated by concurrent use of alcohol. Even without alcohol, a dose of Rohypnol as small as 1 mg can impair a victim for 8 to 12 hours. • Rohypnol is usually taken orally, although there are reports that it can be ground up and snorted.

16. Rohypnol • The drug can cause profound "anterograde amnesia"; that is, individuals may not remember events they experienced while under the effects of the drug. This may be why one of the street names for • Rohypnol is "the forget-me pill" and it has been reportedly used in sexual assaults. • Other adverse effects associated with Rohypnol include decreased blood pressure, drowsiness, visual disturbances, dizziness, confusion, gastrointestinal disturbances, and urinary retention.

17. 鴉片類藥物 • (一)歷史： • 鴉片乃由罌粟植物未成熟之蒴果，以刀割痕取其流出之汁液而得，六千年前的蘇美人即記載罌粟為’快樂的植物’。滿清政府於1664年頒發吸菸處死的律令,故”菸民”將鴉片(煙)摻入香菸裡,以做為脫罪之用。後來變成以吸食鴉片為主,1840年”鴉片戰爭”戰敗後,對鴉片沒有任何管制。 • 嗎啡是由德國人於1806年在鴉片內提煉出主要的有效成份,以希臘神話裡夢幻之神Morphius命名為Morphine。嗎啡在臨床上具有鎮痛、止咳、止瀉及催眠作用。 • 海洛英乃由嗎啡加上雙乙醯合成,在1874年在德國首先合成,而由拜爾藥廠生產製造,其商品名乃由德語Heronisch 而來,意為”少量而有強效之奇妙藥品”。它的止痛效力為嗎啡的4-8倍,但毒性則為嗎啡的10倍。

18. 鴉片類藥物 • (二)使用途徑：吸入、鼻吸、口服或注射。 • (三)藥理作用：鴉片、嗎啡、海洛英或合成的類似作用於中樞神經的鴉片受器的化合物通稱為鴉片劑(Opiate)。具強烈的成癮性。 • (四)中毒過量： • 其特徵為意識障礙,針狀瞳孔、呼吸、心跳變慢、體溫及血壓下降(若嚴重缺氧則可能瞳孔放大,反射消失,發紺)。 • 死亡最常見原因是呼吸抑制。

19. 鴉片類藥物 • (五)戒斷症狀： • 愈短效的藥物,其戒斷症狀及高峰期越快出現。一般海洛英(heroin)約在戒斷後6小時開始出現症狀,48至72 小時為高峰期,7至10天後消失。 • 戒斷6小時後：焦慮、失眠、哈欠、流汗、流鼻水、流淚,進一步出現瞳孔放大,起雞皮疙瘩、發冷、噁心、肌肉疼痛。18-24小時後:加上呼吸、脈搏、血壓、體溫均上升、嘔吐。24-36小時後:加上腹瀉、脫水。

20. 鴉片類藥物 • (六)併發症： • 生理方面：因使用不潔或共用針頭而傳染到愛滋病、肝炎、肌肉血管病變或敗血症等。 • 心理社會方面：因成癮者以追逐藥物使用為生活的重心,無法過一般正常的生活,造持人格敗壞,家庭、人際關係的破壞,甚至為了籌措金錢而導致種種不法行為。

21. 安非他命 • (一)歷史：1887年合成，1931年上市(噴鼻劑，主治鼻塞)，1935年出現錠劑(主治嗜睡)，1935至1946年認為安非他命有39種合法醫療用途，1960年末濫用大盛,1970年後因管制而減少。民國78年日本嚴格取締後台灣開始氾濫，79年10月列為麻醉藥品管制。 • (二)使用途徑：蒸發吸入、與煙草混合抽吸、口服、鼻吸或注射。 • (三)作用機轉：增加多巴安、新腎上腺素釋放,並抑制回收。

22. 安非他命 • (四)藥理作用：自覺疲勞消失,注意力、知覺變得敏銳,興奮、欣快感，心跳加速、瞳孔放大、食慾及睡眠下降、血壓上升。 • (五)中毒過量：多疑敏感、焦慮易怒、躁動不安、妄想、幻覺、血壓上升、心跳加快、瞳孔放大、高燒、心律不整、出血性中風、癲癇、心臟循環衰竭死亡。 • (六)戒斷症狀：心情低落易怒、疲倦、焦慮、睡眠障礙(嗜睡)、食慾增加、激躁或遲緩。最嚴重的症狀是憂鬱(甚至有自殺意念或行為)。 • (七)安非他命精神病：表現似妄想型精神分裂症。

23. Methamphetamine • Methamphetamine is an addictive stimulant drug that strongly activates certain systems in the brain. Methamphetamine is closely related chemically to amphetamine, but the central nervous system effects of methamphetamine are greater. Both drugs have some medical uses, primarily in the treatment of obesity, but their therapeutic use is limited.

24. Methamphetamine • Methamphetamine is made in illegal laboratories and has a high potential for abuse and dependence. Street methamphetamine is referred to by many names, such as "speed," "meth," and "chalk." • Methamphetamine hydrochloride, clear chunky crystals resembling ice, which can be inhaled by smoking, is referred to as "ice," "crystal," and "glass."

25. Health Hazards • Methamphetamine releases high levels of the neurotransmitter dopamine, which stimulates brain cells, enhancing mood and body movement. It also appears to have a neurotoxic effect, damaging brain cells that contain dopamine and serotonin, another neurotransmitter. Over time, methamphetamine appears to cause reduced levels of dopamine, which can result in symptoms like those of Parkinson's disease, a severe movement disorder.

26. Health Hazards • Methamphetamine is taken orally or intranasally (snorting the powder), by intravenous injection, and by smoking. Immediately after smoking or intravenous injection, the methamphetamine user experiences an intense sensation, called a "rush" or "flash," that lasts only a few minutes and is described as extremely pleasurable. Oral or intranasal use produces euphoria - a high, but not a rush. Users may become addicted quickly, and use it with increasing frequency and in increasing doses.

27. methamphetamine • Animal research going back more than 20 years shows that high doses of methamphetamine damage neuron cell-endings. Dopamine- and serotonin-containing neurons do not die after methamphetamine use, but their nerve endings ("terminals") are cut back and re-growth appears to be limited. • The central nervous system (CNS) actions that result from taking even small amounts of methamphetamine include increased wakefulness, increased physical activity, decreased appetite, increased respiration, hyperthermia, and euphoria. Other CNS effects include irritability, insomnia, confusion, tremors, convulsions, anxiety, paranoia, and aggressiveness. Hyperthermia and convulsions can result in death.

28. Methamphetamine • Methamphetamine causes increased heart rate and blood pressure and can cause irreversible damage to blood vessels in the brain, producing strokes. Other effects of methamphetamine include respiratory problems, irregular heartbeat, and extreme anorexia. Its use can result in cardiovascular collapse and death. • A study in Seattle confirmed that methamphetamine use was widespread among the city's homosexual and bisexual populations. Of these groups, members using methamphetamine reported they practice sexual and needle-use behaviors that place them at risk of contracting and transmitting HIV and AIDS.

29. Methamphetamine • Slang or Street Names: Speed, Ice, Chalk, Meth, Crystal, Crank, Fire, Glass • Methamphetamine is a toxic, addictive stimulant that affects many areas of the central nervous system. The drug is often made in clandestine laboratories from relatively inexpensive over-the-counter ingredients. It is being used by diverse groups, including young adults who attend raves, in many regions of the country. • Available in many forms, methamphetamine can be smoked, snorted, injected, or orally ingested.

30. Methamphetamine • Methamphetamine is a white, odorless, bitter-tasting crystalline powder that easily dissolves in beverages. • Methamphetamine is not sold in the same way as many other illicit drugs; it is typically sold through networks, not on the street. • Methamphetamine use is associated with serious health consequences, including memory loss, aggression, violence, psychotic behavior, and potential cardiac and neurological damage.

31. Methamphetamine • Methamphetamine abusers typically display signs of agitation, excited speech, decreased appetite, and increased physical activity levels. • Methamphetamine is neurotoxic. Methamphetamine abusers may have significant reductions in dopamine transporters. • Methamphetamine use can contribute to higher rates of transmission of infectious diseases, especially hepatitis and HIV/AIDS.

32. 古柯鹼 • (一)歷史：第六世紀時,南美印地安人以咀嚼古柯葉提神。十五世紀傳入歐洲,但未流行。1860年Niemann 純化出古柯因(Cocaine)並廣被當做局部麻醉劑使用。十九世紀末時,被注意到有成癮性,1930年代因安非他命合法、便宜、容易取得且效用相似而銷聲匿跡。在美國,1970年代安非他命被禁止後,再度流行,1980年代中期古柯鹼(Cocaine free base)大量生產,價錢便宜而氾濫成災。在台灣也有人引入國內。

33. 古柯鹼 • (二)使用途徑：蒸發吸入、鼻吸或靜脈注射。 • (三)作用機轉：抑制多巴安、新腎上腺素回收。 • (四)藥理作用、中毒症狀、戒斷症狀：似安非他命,但更嚴重,更容易上癮。

34. Crack and Cocaine • Cocaine is a powerfully addictive drug of abuse. Once having tried cocaine, an individual cannot predict or control the extent to which he or she will continue to use the drug. • The major routes of administration of cocaine are sniffing or snorting, injecting, and smoking (including free-base and crack cocaine). Snorting is the process of inhaling cocaine powder through the nose where it is absorbed into the bloodstream through the nasal tissues. Injecting is the act of using a needle to release the drug directly into the bloodstream. Smoking involves inhaling cocaine vapor or smoke into the lungs where absorption into the bloodstream is as rapid as by injection.

35. Crack • "Crack" is the street name given to cocaine that has been processed from cocaine hydrochloride to a free base for smoking. Rather than requiring the more volatile method of processing cocaine using ether, crack cocaine is processed with ammonia or sodium bicarbonate (baking soda) and water and heated to remove the hydrochloride, thus producing a form of cocaine that can be smoked. The term "crack" refers to the crackling sound heard when the mixture is smoked (heated), presumably from the sodium bicarbonate.

36. cocaine • There is great risk whether cocaine is ingested by inhalation (snorting), injection, or smoking. It appears that compulsive cocaine use may develop even more rapidly if the substance is smoked rather than snorted. Smoking allows extremely high doses of cocaine to reach the brain very quickly and brings an intense and immediate high. The injecting drug user is at risk for transmitting or acquiring HIV infection/AIDS if needles or other injection equipment are shared.

37. Health Hazards • Cocaine is a strong central nervous system stimulant that interferes with the reabsorption process of dopamine, a chemical messenger associated with pleasure and movement. Dopamine is released as part of the brain's reward system and is involved in the high that characterizes cocaine consumption.

38. Health Hazards • Physical effects of cocaine use include constricted peripheral blood vessels, dilated pupils, and increased temperature, heart rate, and blood pressure. The duration of cocaine's immediate euphoric effects, which include hyper-stimulation, reduced fatigue, and mental clarity, depends on the route of administration. The faster the absorption, the more intense the high. On the other hand, the faster the absorption, the shorter the duration of action. The high from snorting may last 15 to 30 minutes, while that from smoking may last 5 to 10 minutes. Increased use can reduce the period of stimulation.

39. cocaine • Some users of cocaine report feelings of restlessness, irritability, and anxiety. An appreciable tolerance to the high may be developed, and many addicts report that they seek but fail to achieve as much pleasure as they did from their first exposure. Scientific evidence suggests that the powerful neuropsychologic reinforcing property of cocaine is responsible for an individual's continued use, despite harmful physical and social consequences. In rare instances, sudden death can occur on the first use of cocaine or unexpectedly thereafter. However, there is no way to determine who is prone to sudden death.

40. cocaine • High doses of cocaine and/or prolonged use can trigger paranoia. Smoking crack cocaine can produce a particularly aggressive paranoid behavior in users. When addicted individuals stop using cocaine, they often become depressed. This also may lead to further cocaine use to alleviate depression. Prolonged cocaine snorting can result in ulceration of the mucous membrane of the nose and can damage the nasal septum enough to cause it to collapse. Cocaine-related deaths are often a result of cardiac arrest or seizures followed by respiratory arrest.

41. Added Danger: Cocaethylene • When people mix cocaine and alcohol consumption, they are compounding the danger each drug poses and unknowingly forming a complex chemical experiment within their bodies. NIDA-funded researchers have found that the human liver combines cocaine and alcohol and manufactures a third substance, cocaethylene, that intensifies cocaine's euphoric effects, while possibly increasing the risk of sudden death.

42. 強力膠 • (一)歷史：1960年代流行於美國,1965年傳入日本,1972傳入台灣,在青少年中流行起來。 • (二)使用途徑：裝入塑膠袋搓揉使其揮發而吸食。 • (三)藥理作用：主要成份為甲苯(44%)。生理反應與酒精類似,具中樞神經抑制作用。先有去抑制化現象,欣快感、飄浮感,繼而進入幻旅(trip),出現錯覺、幻覺,然後進入抑制期,略微嗜睡、口齒不清。

43. 強力膠 • (四)中毒過量：頭暈、視覺障礙(模糊或複視)、眼球震顫、運動協調障礙、言辭含糊、步態不穩、震顫、欣快感。更高劑量會導致昏睡、精神運動性遲滯、廣泛肌肉無力、反射降低、木僵或昏迷。 • (五)戒斷症狀：輕微,可能會失眠、胃口不佳、顫抖、噁心嘔吐。 • (六)併發症：感覺異常、運動障礙、聽力喪失、周邊神經病變、心肌病變、肝腎傷害、缺氧、窒息、意外死亡。

44. 新興藥物濫用形態 • 新的藥物濫用形態 • “毒品” v.s. “非法藥品” v.s. “合法物質” • “成癮” v.s. “控制使用”

45. 俱樂部用藥 • Club drug • Pub, Rave, 夜總會, 地下舞廳 , KTV • 網咖 私人聚會

46. 俱樂部用藥 • Recreational use, 助興, 流行 • Perceived harm 下降 • Availability 增加 • 使用容易 • 公開及半公開使用

47. 新聞媒體報導的club drugs • 快樂丸 • 搖頭丸 • 搖腳丸, 一粒沙(elisa) • 神仙水 • 安非他命(甲基安非他命) • FM2 • 大麻 • K安 • 笑氣 • Others . ..

48. Club Drugs • A number of our Nation's best monitoring mechanisms are detecting alarming increases in the popularity of some very dangerous substances known collectively as "club drugs." This term refers to drugs being used by young adults at all-night dance parties such as "raves" or "trances," dance clubs, and bars. MDMA (Ecstasy), GHB, Rohypnol, ketamine, methamphetamine, and LSD are some of the club or party drugs gaining popularity. NIDA-supported research has shown that use of club drugs can cause serious health problems and, in some cases, even death. Used in combination with alcohol, these drugs can be even more dangerous.

49. "Club drug" is a vague term that refers to a wide variety of drugs. Uncertainties about the drug sources, pharmacological agents, chemicals used to manufacture them, and possible contaminants make it difficult to determine toxicity, consequences, and symptoms that might be expected in a particular community. • No club drug is benign. Chronic abuse of MDMA, for example, appears to produce long-term damage to serotonin-containing neurons in the brain. Given the important role that the neurotransmitter serotonin plays in regulating emotion, memory, sleep, pain, and higher order cognitive processes, it is likely that MDMA use can cause a variety of behavioral and cognitive consequences as well as impairing memory.

50. Club drugs • Because some club drugs are colorless, tasteless, and odorless, they can be added unobtrusively to beverages by individuals who want to intoxicate or sedate others. In recent years, there has been an increase in reports of club drugs used to commit sexual assaults - yet another reason why NIDA is alerting you to these escalating trends.