the final group of recreational drugs that we will cover are the hallucinogens along with cannabis which is not classified as a hallucinogen but does not fit well into any other category in contrast to stimulants and depressants hallucinogens do not follow your traditional sympathetic versus parasympathetic rules in addition their physiologic effects are not as clearcut and tend to have to be memorized directly therefore some extra attention needs to be applied here the three main classes of recreational drugs we will cover here or cannabis otherwise known as pot or marijuana serotonergic psychedelics like LSD and peyote and dissociative psychedelics like PCP and ketamine cannabis also known as THC or simply marijuana is one of the most famous and widely used psychoactive substances with over 4% of the world's population having used it at least once in the past year historical records of cannabis use date back to at least 3,000 BC and it was likely used even before that cannabis has diverse effects both psychologically physiologically in a cognitive sense it is often associated with feelings of relaxation and Euphoria the subjective high that comes from marijuana use however there are also some downsides as marijuana use can also be associated with the onset of paranoid delusions impaired memory formation and lack of motivation physiologically two famous side effects are the increased appetite known colloquially as the munchies and conjunctival injection or red eyes you can remember this using the ponic pier as cannabis use often begins in the company of one's peers P for paranoia e for Euphoria and relaxation the other e for eating and R for red eyes whether there are withdrawal symptoms from Cannabis remains an area of debate but at least in some people there does appear to be a clinical syndrome associated with it characterized by increased anxiety and irritability difficulty sleeping nausea and a decreased appetite these aren't really high yield from a clinical standpoint and there's no significant morbidity or mortality associated with either cannabis intoxication or withdrawal mechanistically cannabis works by binding to cannabinoid receptors within the brain we haven't gone over this particular receptor yet but throughout your body there are receptors which bind to endogenous molecules known as endoc canabo these endoc canabo modulate a variety of functions including appetite pain sensation memory and mood however these receptors are bound much more strongly by tetrah hydroc canaby the active ingredient in cannabis this is analogous to the opioid receptors which bind weakly to naturally existing endorphins but respond much more strongly to external drugs like morphine and Codine within the medical field cannabis remains controversial on one hand there does not appear to be any significant morbidity or mortality associated with its use and while Federal Regulation has impeded efforts at studying the drug scientifically there is some evidence that it may be an effective treatment for disorders such as PTSD and chronic pain syndromes on the other hand there is some concern from a psychiatric standpoint that marijuana use May exacerbate psychotic symptoms in patients with pre-existing mental disord disorders or a strong family history of mental illness this is not to say that cannabis causes psychosis but only that it may bring it out in genetically vulnerable individuals these are important points to counsel your patients on especially those going into Pediatrics as marijuana use often starts during adolescence a quick note on synthetic cannabis also known as spice or K2 this newer more potent form of cannabis has been available since about 2004 spice is basically a strong form of cannabis and accordingly has been shown to have even more significant side effects such as withdrawal and a stronger link to psychosis there's not too much to know about it from a clinical standpoint just be aware of it especially when working in an adolescent population and know that unlike marijuana synthetic cannabis is at this point not illegal and can be purchased easily usually labeled as POI or incense the next class of poens we will cover are the serotonergic psychedelics which includes drugs such as LSD siloc cybin and mesculin serotonergic psychedelics are primarily known for their effects on one senses these are not hallucinations necessarily which are more associated with dopamine but they are distortions of perception of objects that are actually there serotonin plays a critical role in synthesizing the various senses such as sight sound and touch into a cohesive hole in the frontal cortex so over stimulation of these receptors results in sensory abnormalities such as those seen in the glasses here the most famous of the serotonergic psychedelics we will cover is lysergic acid diethylamine or LSD which became very very famous for its involvement in the 60s counterculture movement this is your prototypical serotonergic psychedelic with pronounced sensory irregularities and visual disturbances coupled with subjective feelings often described as openness and Oneness with the world intoxication with LSD is often called the trip and lasts anywhere from 6 to 12 hours this interesting video from the 1950s shows the effects of the drug in a normal psychologically healthy test subject this is a glass of water colorless tasteless it contains 100 gamma of LSD 25 1/10 of a milligram the equivalent of 1600th of a grain an ounce of this material will make 150,000 such doses let us observe the effect some 3 hours later well tell me well I just couldn't I couldn't possibly tell you it's it's here can't you feel it this whole room this this everything is in color and and I can feel the air I can I can see it I can see all the molecules I I I'm part of it I can't you see it I'm trying oh it's just like like you're released or you're free or I don't know how I can tell you mesculin from the peot plant is another serotonergic psychedelic that has historical significance in that it is used by several Native American tribes as part of their religious rituals from a clinical standpoint mesculin should be regarded similarly to the other serotonergic psychedelics sybin also known as mushrooms magic mushrooms or just shrooms also has psychic effects very similar to LSD clinically there's not much to distinguish silus ibin from LSD or mesculin the effects of serotonergic psychedelics such as LSD are primarily focused on sensory abnormalities as well as perceptual distortions such as depersonalization occasionally use of LSD can result in significant symptoms of anxiety and paranoia known colloquially as a bad trip many of these serotonergic psychedelics affect dopamine and norepinephrine as well which accounts for some of their phys ological effects such as pupilary dilation hypertension and tachicardia however these effects are inconsistent and unreliable from a clinical standpoint and therefore are unlikely to be tested withdrawal symptoms from serotonergic psychedelics are questionable and inconsistent if any in comparison with other drugs serotonergic psychedelics are considered to be significantly less harmful both physiologically and psychologically except for the bad trips talked about in previous slides drugs such as LSD are well tolerated in the short term one potential long-term effect of chronic hallucinogen use is called hallucinogen persisting perception disorder this condition which occurs in a small minority of patients who have used hallucinogens for years is characterized by Visual and sensory abnormalities that do not go away possibly a result of permanent alterations to the serotonin receptors in the frontal cortex these abnormalities include Halos surrounding objects visual snow and changes in perceived dimension on boards this will show up in a classic vignette about a patient driving down in empty desert highway when he begins to have visual abnormalities they will probably ask you what drug was likely used several decades ago look through the answer choices for the serotonergic hallucinogen such as LSD and pick that one don't get confused this rarely happens with marijuana so don't pick that as your answer the last class of drugs that we will cover are known as dissociative psychedelics in contrast with serotonergic psychedelics which affect the senses primarily these drugs are characterized by state known as dissociation where the person not feel like they're connected with their body dissociative psychedelics work by antagonizing the glutamate receptor specifically the nmda subtype the first associative psychedelic we'll cover is Fen cycline or PCP PCP is almost guaranteed to show up on a test somewhere so pay close attention PCP has significant hallucinatory effects but is better known for clinically inducing belligerence impulsiveness agitation psychosis and delirium on boards there's a classic vignette about a patient who is so agitated in belligerent that it takes five cops or nurses to restrain him if you see this always think PCP test questions on PCP intoxication will sometimes state that the patient is exhibiting signs of horizontal vertical and or rotary than a stagis on exam this is also classic for PCP intoxication know it well nagus is a rhythmic involuntary movement of the eyes this is one of the first signs that parents May observe in a child with a congenital visual impairment it is most often a horizontal pendular nagus where the eyes Rock back and forth equally like a pendulum but other forms of movement are common stress emotions and direction of gaze can cause changes in the nagus and may cause vision to decrease here we see the nagus can change direction and speed as the patient looks in different directions withdrawal from PCP is a poorly characterized state but generally it can be said that these patients aren't feeling their best the very last drug we will cover is ketamine which is used both in clinical settings for emergency anesthesia such as setting a broken bone in a kid who fell off playground equipment as well as in recreational settings since the 1970s like ecstasy ketamine is popular as a club drug in addition to its use as an anesthetic ketamine has significant psychological effects these effects are complex with people on ketamine reporting feelings of depersonalization Detachment from their bodies Euphoria loss of time perception and even spiritual Revelations like PCP withdrawal from ketamine is poorly understood when used on a short-term basis in a medical setting there does not appear to be any significant withdrawal effects it is unclear if there are withdrawal effects when used on a longer term basis anyway this isn't high yield so let's move on as a final review for recognizing toxid dromes on boards I like to remember the phrase it's all in the eyes on questions asking you to recognize different drug States they will often give you some information about the eyes for example if the peoples are dilated you know your either dealing with stimulant intoxication or depressant withdrawal conversely constricted or pinpoint pupils mean you're dealing with opiate overdose or stimulant withdrawal nagus in the context of substance abuse is likely PCP and finally conjunctival injection is probably marijuana know these well they will help you on tests last break we're almost done so go get some air and then come back to wrap our discussion by going over other treatment modalities for psychiatric disorders