PART 4 in Microsoft Office

Painting QR Code in Microsoft Office PART 4

PART 4
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MAJOR CATEGORIES OF NEUROLOGIC DISEASE
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dicts are likely to have dilated pupils and twitching of muscles The nding of morphine or opiate derivatives (heroin is excreted as morphine) in the urine is con rmatory evidence that the patient has taken or has been given a dose of such drugs within 24 h of the test The diagnosis of opiate addiction is also at once apparent when the treatment of acute opiate intoxication precipitates a characteristic abstinence syndrome Treatment of the Opioid Abstinence Syndrome (Physical Dependence) One approach that has achieved some degree of success over the past 30 years has been the substitution of methadone for opioid, in the ratio of 1 mg methadone for 3 mg morphine, 1 mg heroin, or 20 mg meperidine Since methadone is long-acting and effective orally, it need be given only twice daily by mouth 10 to 20 mg per dose being suf cient to suppress abstinence symptoms After a stabilization period of 3 to 5 days, this dosage of methadone is reduced and the drug is withdrawn over a similar period An alternative but probably less effective method has been the use of clonidine (02 to 06 mg twice a day for a week), a drug that counteracts most of the noradrenergic withdrawal symptoms; however, the hypotension that is induced by this drug may be a problem (Jasinski et al) Recently, a rapid detoxi cation regimen that is conducted under general anesthesia has become popular in a number of centers as a means of treating opiate addiction The technique consists of administering increasing doses of opioid receptor antagonists (naloxone or naltrexone) over several hours while the autonomic and other features of the withdrawal syndrome are suppressed by the infusion of propofol or a similar anesthetic, supplemented by intravenous uids Medications such as clonidine and sedatives are also given in the immediate postanesthetic period The addict is instructed to continue taking naltrexone for several days or weeks, a practice adopted by one of the outpatient treatment centers for addiction described later There are substantial risks involved in this procedure, and several deaths have occurred for which reason it has been all but abandoned in our hospitals Furthermore, a number of patients continue to manifest signs of withdrawal after the procedure and require continued hospitalization There are as yet few careful studies of the ef cacy and overall safety of this procedure Treatment of Opiate Habituation (Psychologic Dependence) This is in some ways far more demanding than the treatment of opioid withdrawal and can be best accomplished in special facilities and programs that are devoted wholly to the problem These are available in most communities The most effective ones have been the ambulatory methadone maintenance clinics, where more than 100,000 former heroin addicts are participating in rehabilitation programs approved by the Food and Drug Administration Methadone, in a dosage of 60 to 100 mg daily (suf cient to suppress the craving for heroin), is given under supervision day by day (less often with long-acting methadone) for months or years Various forms of psychotherapy and social service counseling often administered by former heroin addicts are integral parts of the program The results of methadone treatment are dif cult to assess and vary considerably from one program to another Even the most successful programs suffer an attrition rate of about 25 percent when they are evaluated after several years Of the patients who remain, the majority achieve a high degree of social rehabilitation, ie, they are gainfully employed and no longer engage in criminal behavior or prostitution The usual practice of methadone programs is to accept only addicts over the age of 16 years with a history of heroin addiction
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for at least 1 year This leaves many adolescent addicts untreated The number of addicts who can fully withdraw from methadone and maintain a drug-free existence is very small This means that the large majority of addicts now enrolled in methadone programs are committed to an inde nite period of methadone maintenance, and the effects of such a regimen are uncertain An alternative method of ambulatory treatment of the opiate addict involves the use of narcotic antagonists, of which naloxone and naltrexone are the best known The physical effects of abusing narcotics are thereby partially blocked, and there may be some degree of aversive conditioning if withdrawal symptoms are produced Naltrexone is favored because it has a longer effect than naloxone, is almost free of agonist effects, and can be administered orally Similar results have also been achieved with cyclazocine in a small number of highly motivated patients; this drug is administered orally in increasing amounts until a dosage of 2 mg/70 kg body weight is attained The drug is taken twice daily (for 2 to 6 weeks) and is then withdrawn slowly More recently, interest has centered on the use of buprenorphine for the treatment of heroin (and cocaine) abuse Buprenorphine is unique in that it has both opioid agonist and antagonist properties; it therefore mutes the effect of withdrawal and serves also as an aversive agent, like naltrexone In addition, there is evidence, based on animal experiments and experience with small numbers of addicts, that it may be useful for the treatment of dual dependence on cocaine and opiates (see Mello and Mendelson) Buprenorphine has the additional advantage of being administered as a sublingual tablet The FDA has recently approved its use Medical and Neurologic Complications of Opioid Use In addition to the toxic effects of the opioid itself, the addict may suffer a variety of neurologic and infectious complications resulting from the injection of contaminated adulterants (quinine, talc, lactose, powdered milk, and fruit sugars) and of various infectious agents (injections administered by unsterile methods) The most important of these is HIV infection, but septicemia and endocarditis and viral hepatitis may also occur Particulate matter that is injected with heroin or a vasculitis that is induced by chronic heroin abuse may cause stroke by an incompletely understood occlusion of cerebral arteries, with hemiplegia or other focal cerebral signs Amblyopia, due probably to the toxic effects of quinine in the heroin mixtures, has been reported, as well as transverse myelopathy and several types of peripheral neuropathy The spinal cord disorder expresses itself clinically by the abrupt onset of paraplegia with a level on the trunk below which motor function and sensation are lost or impaired and by urinary retention Pathologically, there is an acute necrotizing lesion involving both gray and white matter over a considerable vertical extent of the thoracic and occasionally the cervical cord In some cases a myelopathy has followed the rst intravenous injection of heroin after a prolonged period of abstinence We have also seen two cases of cervical myelopathy from heroin-induced stupor and a prolonged period of immobility with the neck hyperextended over the back of a chair or sofa In addition, we have observed several instances of a subacute progressive cerebral leukoencephalopathy after heroin use, similar to ones that occurred in Amsterdam in the 1980s, the result of inhalation of heroin pyrolysate or an adulterant (Wolters et al and Tan et al) In our cases the white matter changes were concentrated in the posterior regions of the hemispheres and in the internal capsules and, in one striking case, in the cerebellar white matter
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