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Caffeine, along with nicotine and alcohol, is one of the most commonly used drugs worldwide About 10 billion pounds of coffee (the richest source of caffeine) are consumed yearly throughout the world Tea, cocoa, and cola drinks also contribute to an intake of caffeine that is often astoundingly high in a large number of people Low to moderate doses (30 200 mg/d) tend to improve some aspects of performance (eg, vigilance) The approximate content of caffeine in a (180-mL) cup of beverage is as follows: brewed coffee, 80 140 mg; instant coffee, 60 100 mg; decaffeinated coffee, 1 6 mg; black leaf tea, 30 80 mg; tea bags, 25 75 mg; instant tea, 30 60 mg; cocoa, 10 50 mg; and 12-oz cola drinks, 30 65 mg A 2-oz chocolate candy bar has about 20 mg Some herbal teas (eg, morning thunder ) contain caffeine Caffeine-containing analgesics usually contain approximately 30 mg per unit Symptoms of caffeinism (usually associated with ingestion of over 500 mg/d) include anxiety, agitation, restlessness, insomnia, a feeling of being wired, and somatic symptoms referable to the heart and gastrointestinal tract It is common for a case of caffeinism to present as an anxiety disorder It is also common for caffeine and other stimulants to precipitate
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chronic exposure produces a variety of symptoms related to the liver, kidney, bone marrow, or heart Lead encephalopathy can be associated with sniffing leaded gasoline In addition, studies of workers chronically exposed to jet fuel showed significant increases in neurasthenic symptoms, including fatigue, anxiety, mood changes, memory difficulties, and somatic complaints These same problems have been noted in long-term solvent abuse The so-called designer drugs are synthetic substitutes for commonly used recreational drugs and are produced in small, clandestine laboratories The most common designer drugs have been methyl analogues of fentanyl and have been used as heroin substitutes MDMA (methylenedioxymethamphetamine), an amphetamine derivative sometimes called ecstasy, is also a designer drug with high abuse potential and neurotoxicity Often not detected by standard toxicology screens, these substances can present a vexing problem for clinicians faced with symptoms from a totally unknown cause
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Collins ED et al Anesthesia-assisted vs buprenorphine- or clonidine-assisted heroin detoxification and naltrexone induction: a randomized trial JAMA 2005 Aug 24;294(8): 903 13 [PMID: 16118380] Fudala PJ et al Office-based treatment of opiate addiction with sublingual-tablet formulation of buprenorphine and naloxone N Engl J Med 2003 Sep 4;349(10):949 58 [PMID: 12954743] Lundqvist T Cognitive consequences of cannabis use: comparison with abuse of stimulants and heroin with regard to attention, memory and executive functions Pharmacol Biochem Behav 2005 Jun;81(2):319 30 [PMID: 15925403]
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severe symptoms in compensated schizophrenic and manicdepressive patients Chronically depressed patients often use caffeine drinks as self-medication This diagnostic clue may help distinguish some major affective disorders Withdrawal from caffeine (> 250 mg/d) can produce headaches, irritability, lethargy, and occasional nausea
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The principal over-the-counter drugs of concern have been phenylpropanolamine and an assortment of antihistaminic agents, frequently in combination with a mild analgesic promoted as cold remedies Medications containing phenylpropanolamine have been removed from sale in the United States due to an FDA ban The major problem in use of phenylpropanolamine relates to its side effects as a stimulant, including precipitation of anxiety states, increased pressure effects, auditory and visual hallucinations, paranoid ideation, and occasionally delirium Aggressiveness and some loss of impulse control were reported as well as sleep disturbances even with small doses Antihistamines usually produce some central nervous system depression thus their use as over-the-counter sedatives Practically all of the so-called sleep aids are antihistamines The mixture of antihistamines with alcohol usually exacerbates the central nervous system effects Scopolamine and bromides have generally been removed from over-thecounter products The abuse of laxatives sometimes can lead to electrolyte disturbances that may contribute to the manifestations of a delirium The greatest use of laxatives tends to be in the elderly and in those with eating disorders, both of whom are the most vulnerable to physiologic changes Anabolic steroids are being abused by people who wish to increase muscle mass for cosmetic reasons or for greater strength In addition to the medical problems, the practice is associated with significant mood swings, aggressiveness, and paranoid delusions Alcohol and stimulant use is higher in these individuals Withdrawal symptoms of steroid dependency include fatigue, depressed mood, restlessness, and insomnia Amyl nitrite has been used as an orgasm expander The changes in time perception, rush, and mild euphoria caused by the drug prompted its nonmedical use, and popular lore concerning the effects of inhalation just prior to orgasm has led to increased use Subjective effects last from 5 seconds to 15 minutes Tolerance develops readily, but there are no known withdrawal symptoms Abstinence for several days reestablishes the previous level of responsiveness Long-term effects may include damage to the immune system and respiratory difficulties Sniffing of solvents and inhaling of gases (including aerosols) produce a form of inebriation similar to that of the volatile anesthetics Agents include gasoline, toluene, petroleum ether, lighter fluids, cleaning fluids, paint thinners, and solvents that are present in many household products (eg, nail polish, typewriter correction fluid) Typical intoxication states include euphoria, slurred speech, hallucinations, and confusion, and with high doses, acute manifestations are unconsciousness and cardiorespiratory depression or failure;
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