BARBITURATE INTOXICATION Benzodiazepines have l a rg e l y r e p l a c e d barbiturates, or “downers,” as sedatives, hypnotics (sleeping pills), or anxiolytic (anti-anxiety) agents. Barbiturates are still used to treat various seizure disorders. They are classified based on their duration of action: ultra-short acting, short acting, intermediate acting, and long acting. Barbiturate use classically causes various degrees of CNS depression with nystagmus (eyes moving up and down, or side-to-side involuntarily), vertigo (sensation of the room spinning), slurred speech, lethargy, confusion, ataxia (difficulty walking) and respiratory depression. Severe overdose may result in coma, shock, apnea (stopped breathing), and hypothermia. In combination with ethanol or other CNS depressants, there are additive CNS and respiratory depression effects. Prolonged use of barbiturates can lead to a state of physical and psychological dependence. Upon discontinued use, the dependant person may go into withdrawal. Unlike narcotic (opiate) withdrawal, barbiturate withdrawal is LIFE THREATENING! Depending on type of barbiturate, signs and symptoms start within 24 hours. The withdrawal syndrome includes nausea, vomiting, sweating, tremors (trembling or shaking), weakness, insomnia, and restlessness. These clinical findings progress to apprehension, acute anxiety, fever, increased blood pressure, and increased heart rate. If untreated, severe and life-threatening effects include delirium, hallucinations, and seizures. The signs and symptoms will stop upon re-administration of the barbiturate and by tapering the dose slowly over several days. NONBARBITURATE SEDATIVE- HYPNOTIC INTOXICATION Nonbarbiturate sedative-hypnotics (a “hypnotic” is a sleeping pill) have actions very similar to the barbiturates. However, they have a higher margin of safety; overdose and addiction require larger doses and addiction requires a longer time period to occur. Like the barbiturates, when combined with ethanol or other d e p r e s s a n t s , t h e r e a r e a d d i c t i v e C N S - a n d respiratory-depression effects. Most of the traditional, nonbarbiturate sedative-hypnotics are either no longer a v a i l a b l e ( M e t h a q u a a l o n e , E t h c h l o r o v y n o l , Glutethimide) or rarely used today (chloral hydrate) because of their profound “hangover effect.” Newer sedative-hypnotics are emerging for the temporary treatment of insomnia. Benzodiazepines are widely used to treat seizure disorders, anxiety, muscle spasms, and insomnia. STIMULANT INTOXICATION The stimulants (“uppers”) directly affect the central nervous system by increasing mental alertness and combating drowsiness and fatigue. One group of stimulants, called amphetamines, is legitimately used in the treatment of conditions such as mild depression, obesity, and narcolepsy (sleeping sickness). Amphetamines are also commonly abused. Usually referred to as stimulants, speed, or uppers, amphetamines can be taken orally, intravenously, or smoked as “ice.” Amphetamines directly affect the central nervous system by increasing mental alertness and combating drowsiness and fatigue. They are abused for their stimulant effect, which lasts longer than cocaine. Amphetamines cause central nervous system stimulation with euphoria, increased alertness, intensified emotions, aggressiveness, altered self-esteem, and increased sexuality. In higher doses, unpleasant CNS effects of agitation, anxiety, hallucinations, delirium, psychosis, and seizures can occur. When stimulants are combined with alcohol ingestion, patients have increased psychological and cardiac effects. Signs and symptoms associated with amphetamine use include mydriasis (dilated pupils), sweating, increased temperature, tachycardia (rapid pulse), and hypertension. Patients seeking medical attention usually complain of chest pain, palpitations, and shortness of breath. “Heavy use” (involving large quantities) of amphetamines is physically addicting, and even “light u s e ” ( i n v o l v i n g s m a l l a m o u n t s ) c a n c a u s e psychological dependence. Tolerance to increasingly higher doses develops and withdrawal can occur from these levels. Abruptly stopping chronic amphetamine u s e d o e s n o t c a u s e s e i z u r e s o r p r e s e n t a life-threatening situation. The withdrawal is typically characterized by apathy, lethargy, muscle aches, stomachaches, increased appetite, anxiety, sleep disturbances, and depression with suicidal tendencies. Cocaine, although classified as a narcotic, acts as a stimulant and is commonly abused. It is relatively ineffective when taken orally; therefore, the abuser either injects it into the vein or “snorts” it through the 5-19