Effects of Addictive Drugs

Expected Effects

Intoxication effects

Dependence & potential adverse health effects

Withdrawal Symptoms

Alcohol

dopamine +, GABA + then - (inhibitor at high doses)

more controversial on catecholamines

interactions with endorphins

reduced pain, lower anxiety at low doses, feeling of well-being, lower inhibitions, lower: shame & guilt feeling, tranquilizing, alexithymia, isolation, emptiness, reduce intole-rance for closeness or self-assertion, mouthwash / germicide, as an expression of post-traumatic stress, suicidal prevention,

inappropriate sexual or aggressive behavior, unsafe sexual practices, mood lability, impaired judgment, impaired social or occupational functioning, slurred speech, drowsiness, uncoordinated, unsteady gait, nystagmus, impairment in attention or memory, stupor or coma, hangovers, insomnia, road & industrial accidents, violence, 90% alcohol metabolized by liver, acute alcoholic hepatitis, acute alcoholic myopathia,vascular cerebral accident (7times higher relative risk), Shoshin beriberi (metabolic acidosis, lactic acidosis, shock, agitation); elimination rate: 0.15g/liter.hour, partially eliminated by respiration, hyponatremia, hypoglycemia, vasopressin inhibition, alcoholic meningitis, pneumonia, bronchoaspiration, sepsis, rhadomyolysis, femoral osteonecrosis, suicidal risk, violence risk

high general toxicity: respiratory (infections), gastro-intestinal (esophagus, gastritis, hepatitis, pancreatitis), hematological & high neurotoxic dependence, absenteeism from work or school, accidental injuries, depression, anxiety, sexual dysfunction- impotence, sleep disorders, mild tremor, alcoholic foetor, 'aftershave / mouthwash syndrome’ (to mask the smell of alcohol), enlarged-tender liver, fluctuating hyper-pression , tachycardia and/or cardiac arrhythmias, fatty liver or cirrhosis, esophageal varices, peripheral neuritis, tolerance, irritability, weight gain,memory loss, financial issues, raised serum GGT or MCV, liver enzymes (ALAT, ASAT); serious inter current illness e.g. head injury, diabetes, epilepsy, psychosis, infection, poor nutrition, cerebral hematoma (extra-, subdural, intern).Make the difference between heavy drink - binge drinking (not heavy) - alcohol use (not heavy)

admission/ assessment of alcohol withdrawal syndrome: regular alcohol use of > 80 grs per day (males), > 60 grs per day (females) patient > 30 years (unlikely under the age of 30) autonomic hyperactivity (e.g. < 10 days after last drink (withdrawal usually starts within 6–24 hours of last drink & may last 2–12 days); harmful alcohol signs: parotid swelling, abnormal skin vascularization, conjunctiva injection, respiratory polypnea, sweating, pulse rate > 100, tremor, restlessness,intense fear, insomnia, nausea, vomiting, transient visual, tactile, hyper arterial pressure (dias. & systolic), auditory hallucinations or illusions, anorexia except for alcohol, psycho motor agitation, anxiety, confusion, marked insomnia & nightmare, seizures, grand mal seizure, life's risk , Gayet-Wernicke-encephalopathy risk

Opioids

heroin, fentanyl, codeine, morphine, methadone, LAAM pethidine, buprenorphine

initial euphoria "rush" then sedation sense of well-being, analgesia, tranquilizing, attenuation or normalizing influence, pain relief, sedation, drowsiness, reflex internal disorganization, rage/anger control, control after intolerable aggression, anorexic, insomnia control

reduce cough

sedation, facial flushing or itching, unconsciousness, coma, respiratory depression & arrest, nausea & vomiting, confusion, drowsiness, apathy & possible dysphoric, psycho motor retar-dation or occasionally agitation, apnoea, respiratory distress, impaired judgment - social & occupational, functioning, slurred speech, impaired attention or memory, pupillary constriction- myosis (or dilation due to anoxia from severe overdose), coma, constipation, biliary spasm (elevated tone of Oddi's sphincter).Most opioid related deaths occur following use of opioids with other drugs (alcohol, benzodiazepines). LAAM has serious cardiac effects - prohibition in therapeutic use. Fentamyl is more potent than morphine, higher risks of respiratory distress & cardio-vascular collapse

constipation tolerance, dependence; low follicle stimulating hormone (FSH) & low luteinising hormone (LH) in woman, raised prolactin resulting in menstrual changes, redu-ced libido, galactorrhoea, reduced testosterone in man affecting libido, elevated antidiuretic hormone (ADH), reduced ACTH, itching, sweating, flushed skin (histaminic reaction), dry / mouth-skin-eyes, difficulty passing urine, low blood pressure, estimated mortality rate (from all causes) for heroin users is approximately 1–2% per annum, more common in male he-roin users over age 25, high physical dependence (+++) & psychological (++), low neuro-toxicity; high general toxicity, alternate period of rest (look like cured by ) & dependence: craving, phobia

6 to 12 hours: dysphoric mood, nausea or vomiting, diarrhea, myalgia, lacrymation, rhinorrhoeaea, pupillary dilation, piloerection, sweating, high attention, yawning, fever, insomnia.12 to 24 hours: agitation & irritability, goosebumps, sweating, hot - hyperthermia & cold flushes, loss of appetite. > 24 hours: strong cravings, stomach cramps, diarrhea, poor appetite, nausea vomit, back pain, pain in joints, legs or arms, headache, poor sleep, lethargy, fatigue, restlessness, irritability, agitation. 2nd to 4th days: symptoms reach their peak 5th to 7th days: most physical symptoms begin to settle down, appetite returns. 2nd week: physical discomfort subsiding. may have ongoing problems with poor sleep, tiredness, irritability, cravings feeling weeks to months.

Stimulants

ecstasy / MDMA

initially enhances extracellular brain concentrations of serotonin but eventual-ly it becomes depleted

liberation of (catecholamines, serotonine, dopamine)

since 50-200mg, immediate euphoria, increased energy & feeling of closeness to others (empathy), interpersonal sensitivity,

feelings of exhilaration (less common), energy increased mental alertness, affective blunting, changes in sociability, hypervigilance

most serious effect is hyperthermia 4-5 hours after, hot & cold flushes, chills, nausea or vomiting, weight loss, sweaty palms, dehydration, muscular weakness, rhabdomyolysis, dis-seminated intravascular coagulation renal & liver impairment,electrolyte imbalance, hypo-natrihemia (‘water intoxication’), psychomotor agitation or retardation, tension or anger, stereo-typed behaviors, impaired judgement , features of confusion, reduced consciousness, in some cases, seizures or convulsions, dyskinesias, dystonias or coma, pupil dilation, jaw tension & grindging of teeth; loss of appetite, dry mouth, tachycardia, chest pain or aryth-mias, cardiac arrest mydriasis, increased or lowered blood pressure, paranoia, anxiety & depression, unpredictable nature of adverse events, death risk if > 42°C, respiratory depression,sympathomimetic symptoms, ataxia,, hepatitis toward encephalopathy

rapid or irregular heart beat, arrhythmias, reduced appetite, weight loss, heart failure, dependence, hypertension, anevrism rupture, hemiplegic, insomnia, depression, head-aches, muscle stiffness, seizures, chronic neuropsychiatric problems: depression, or low mood & concentration and/or memory problems (commonly reported in the week following ecstasy use), persistent depression, panick disorders, ‘flashbacks’ & delusions, risk of psychiatric sequel is probably greater when other drugs misuse, particularly cannabis when ecstasy is used repeatedly & at high doses over a period of months, family or personal history of psychiatric, hepatic steatosis, cirrhosis; neurotoxicity:high; general toxicity: high, impaired social or occupational functioning

myalgia, drowsiness, depression, acne, dysphoric mood, fatigue, vivid unpleasant dreams, insomnia or hypersomnia, increased appetite, psychomotor retardation or agitation, no specific signs when multiple consumption where MDMA is not abusive

Stimulants

amphetamines

alpha methylphenidate, 2-CB, 2-CT-7, dexamphetamine, 'speed’ or ‘whiz’ variable / dopamine, catecholamines, serotonine, direct sympathomimetic

euphoria; increased well being & energy, confidence & physical perfor-mance, improves cognitive, suppression of appetite, suppress sleeprest-less, increased blood pressure. over-stimulation, talkative, excited with need to speak, increased confidence, selfawareness, increased energy, stamina, fatigue reduction, improved performance / concentration, may increase libido.

mild confusion, panic (rarely psychotic episodes) agitation, weight loss, palpitations, tachycardia or reflex bradycardia, arhythmias, cardiovascular problems, increased respiration rate, dehydration, hyperthermia, lower immunity, restlessness, sleeplessness, seizures, teeth grinding, collapse & stroke, myosis (soon), headache, stereotypic or unpredictable

behavior, violent or irrational, mood swings, hostility & aggression, slurred speech, perce-ptual disorders, blurred vision, dizziness psychosis (hallucinations, delusions, paranoia), cerebrovascular accident, seizures, coma, nausea & vomiting, constipation, diarrhea or abdominal cramps, pale sweaty skin, hyperpyrexia, increased deep tendon reflexes, vaso-constriction / hyper-tension, respiratory difficulty / failure, dry mouth, diaphoresis, rhabdo-myolysis . death is rare. Crash phase (days 1–4 post cessation of use): fatigue & exhaus-tion, hunger, emotional lability (irritable, agitated, depressed), overwhelming desire to sleep or sleeping difficulties.

Next week: strong cravings, generalized aches & pains, increased appetite, irritability, possibly paranoia or misinterpretation, weight loss, malnutrition, lowered immunity. depression, restlessness, suicidal ideas job issues, flat mood, physical dependence (+) psychological dependence (+). aggression / fights, alcohol use, risk taking, accidents / injuries, unsafe sex, social avoidance, associated drugs used. lack of money, police involvement, jail, underworld, alienation, secrecy / stigma, vein absces-ses & scarring, vein thrombosis, contaminants BBV, nasal infections, needle sharing (neurotoxicity:high) (general toxicity: high), often intent to balance effects with other drugs or alcohol, paranoid drug thus able to turn agressive

depression, restlessness, craving, suicidal ideas , lapse to drug use, job issues, bizarre thoughts, flat mood, dependence, poor social functioning, with reestablish-ment selfcare likely to resolve over time eating disorders, anorexia or nutritional deficiency

Stimulant

cocaine crack

increase dopamine (n.accumbens), block serotonine & norepinephrine transporters

coca loaf incense, crystal snuff

flash (crack), euphoria, sociability, gre-garious-talkativeness, increased con-fidence, interest , feelings of control, high energy state, decreased need for sleep, temporary increase in functional activity or efficiency, suppressed ap-petite, mydriasis, vasoconstriction, in-creased respiration, paradoxic calm, higher self esteem, reduce boredom & frustration, hypomania or hyper-activity, topical analgesic-anesthetic

stereotyped, repetitive behavior, anxiety/severe agitation/panic, aggression /hostility, muscle twitches / tremors / uncoordinated, heightened reflexes, respiratory failure, markedly ele-vated blood pressure, chest pain / angina, pulmonary edema, acute renal failure, convul-sions, blurred vision, acute stroke, pallor, confusion/delirium, hallucinations (often auditory or tactile), e.g. fornication, tactile hallucinations: feeling of bugs crawling under the skin, dizzy-ness, muscle rigidity, weakness, rhabdomyolysis, rapid pulse, cardiac arrhythmias including malignant arrhythmias, myocardial ischemia & infarction, sweating / high body tempe-rature, headache, stomach pain / nausea / vomiting , lack of attentive focus. very fast depen-dence from crack. Most death from crack, , erratic pains (which can proceed from meningeal bleeding), convulsions resistant to antiepileptics, hyperthermia, dyspnea, bleeding: pneumo-mediastin -pericard, cardiac arrest arrhythmias.

insomnia, depression, aggression or violence, loss of appetite & concomitant anore-xia - weight loss, libido increase, muscle twitching, anxiety, psychosis , paranoid delusions, hallucinations loss of libido and/or impotence, heightened reflexes, increased pulse rate, physical dependence (+), threshold value: 2-3/ week; psychological dependence (+++). nasal irritation (neurotoxicity:high), nasal necrosis, thrombosis,kidney ischemia via vasoconstriction, eventually acute renal insufficiency, (general toxicity: high), paranoid violence

anhedonia, loss of motivation, depression, confusion, fatigue, sleep, impaired coordination, impaired memory, judgment, respiratory depression & arrest dependence

Stimulant

caffeine

neurostimulant, lower fatigue, balance sedative component, reduce sleep period, slight bronchodilatator, higher muscular contractibility

poorer sleep period, agitation, seizure, nausea, tachy-dysrhythmia, slight hypertension, vomiting, sometimes nausea,digestive pain, anxiety, mood instability, enhance anxiety in depressed.

dependence & tolerance with long term use diuretic &cardiovascular effects

acute withdrawal produce some signs during 1 - 7 days: headache, irritability, sleepiness, anxiety, mood disorder, lower concentrations, muscles pain, nausea, vision disorder

Depressants

barbiturates

reduced pain & anxiety, feelings of wellbeing, lowered inhibitions, hypno-tic, anti-convulsant, still used as gas-trointestinal & asthmatic sedatives or adverse central stimulant: ephedrine, dextroamphetamine, theophyllin

slowed pulse & breathing, lowered blood pressure, poor concentration, sleepiness central nervous system depression: confusion, disarthria, low reflexes, respiratory depress, hypoxia, mysosis, coma, toxic doses 4–6 times higher than the therapeutic dose as hypno-tics of the short-acting barbiturates, frequent cases of death by overdose, given the small therapeutic margin of these substances, common method in suicide attempts

dysphoric mood (anhedonia or sadness, rather than depression) & at least 2 of the following symptoms: fatigue, insomnia or hypersomnia, psychomotor agitation or retarda-tion, craving, hunger, vivid, unpleasant dreams, dysphoric symptoms persist for up to 10 weeks, paranoid drug thus able to turn agressive

withdrawal reaches its peak in 2–4 days, anxiety, panic attacks, confusion, delirium, even after withdrawal is complete mood normal & ability to enjoy experiences have returned. Some suggest that used in cocaine craving make desire to resume use may persist indefinitely

Sedative hypnotic

benzodiazepines

short / long half life

reduced pain & anxiety, feelings of wellbeing, lowered inhibitions, anticon -vulsant, hypnotic, myorelaxant, polydrug or concurrent use of benzo-diazepins, alcohol, opioids increases effects, euphoria, helping to mask bad sides feeling effects of opiates

slowed pulse & breathing, respiratory depression, lowered blood pressure, poor concentra-tion, memory impairment (especially anterograde amnesia), motor incoordination, decreased reaction time, ataxia, excess sedation, cognitive impairment & increased risk of accidents, lethargy, fatigue, confusion, muscle weakness, nystagmus, vertigo, dysarthria, slurred spe-ech, blurred vision, dry mouth, headaches, paradoxic euphoria, excitement, restlessness, hypomania & extreme disinhibited behavior (at high dose, users may feel ‘invulnerable, invincible & invisible’), orexic (increase food intake). Cross the placental barrier & can result in neonatal drowsiness, respiratory depression, hypotonic at withdrawal

dependence & withdrawal can occur even when recommended doses are used (within 3–6 weeks), similar to short-term effects, no known tolerance to sedative / hypnotic & psycho-motor effects, conflict whether tolerance develops from anxiolytic actions & memory) emotional blunting (inability to feel normal highs or grief due to inhibition, menstrual irregularities, breast engorgement, benzodiazepines sleepers have a similar quantity but poorer quality of night-time sleep / normal subjects; neurotoxicity: low; general toxicity: low physical dependence (++) psychological dependence (+), induce amnesia

withdrawal may be apparent while still taking medication, possibly because increased tolerance or adverse mood effects: insomnia, anxiety, irritability, restlessness, agitation, depression, tremor, dizziness, seizures (less common / high dose ± alcohol), delirium, muscle twitching & pains, anorexia, nausea, metallic taste, fatigue, tinnitus, hyperaccousia, photophobia, perceptual disturbances (kinesthetic), depersonalization, derealization, blurred vision; rebound insomnia after stop. Nevertheless rare compared to high rates of use

Sedative hypnotics

solvents volatile

dichloromethane butanediol, GHB

often additive to (design or smart or party - drugs), drowsiness, euphoria, anxiolytic, hallucinogen.

excitation, exhilaration, sense of invulnerability, drowsiness or stimulation & desinhibition,loss of consciousness , death

inappropriate sexual or aggressive behavior, mood lability, impaired, judgment, impaired social or occupational functioning, slurred speech, uncoordinated, unsteady gait, nystag-mus, impaired attention or memory, stupor/coma, volatile substances displace oxygen & can damage lung tissue, loss of consciousness. nausea, vomiting, headaches, diarrhea, abdominal pain. toxic hepatitis, stupor or coma, disorientation, confusion, delusions, weak-ness, tremor, visual distortions & visual hallucinations, then: ataxia followed by stupor, final stages associated with seizures, respiratory acidosis, hyperglycemia, hypo-thermia, proteinuria, medullar aplasia, acute pulmonary edema, cardiopulmonary arrest, sudden death from ventricular fibrillation & cardiac arrhythmia is a major concern. "sud-den sniffing death". Toluene cause renal tubular acidosis, complete kidney & liver failure have been associated. Chloroform & chlorinated hydrocarbon vapors result in toxic hepatitis, liver dysfunction associated with trichloroethane & trichloroethylene. Burnings accidents

drying of mucous membrane irritation, increased sputum production, cough, wheeze, salivation, sneezing or conjunctiva injection, facial skin permit bacterial infections. Patchy redness of skin (erythematous spots) or pus producing skin lesions around the mouth & nose referred to as ‘sniffer’s or Huffer's rash’, decreased reflexes & oscillatory movement of the eyes, excessive mood swings, desinhibition or inappropriate aggression, self harmed symptoms associated with polysubstance use may mask those of volatile substances, toxicity to the fetus autonomic hyperactivity (e.g. sweating or pulse rate greater than 100), increased hand tremor, insomnia, nausea, vomiting, transient visual, tactile, auditory hallucinations, or illusions, psychomotor agitation, anxiety, grand mal seizures. Burnings accidents

dependence is generally considered mild in comparison with that produced by heroin or tobacco, nervous, irritability, malaise, ‘withdrawal syndrome’ of two to five days in toluene, craving, irritability, psycho-motor retardation, dry mouth, & insomnia

Hallucinogen

lysergic acid diethyl

Illusions & hallucinations, altered per-ception of time & distance, violent drowsiness, letargia, anticholinergic, broncho-dilatator

irregular use implies often acute toxicity. symptoms vary,hallucination,disturbed perception in LSD & psilocybin, sympathomimetic effects: tachycardia, tremor, hyper-reflexia, emphasis on perceptual & cognitive abnormalities & less on heightened autonomic state, marked anxiety or depression, ideas of reference, fear of losing one’s mind, paranoid ideation, impai-red judgment - social - occupational, perceptual changes occurring in full wakefulness & alert-ness e.g. hallucinations of all kinds, synaesthesias, pupillary dilation (mydriasis), swea-ting, nausea blurred vision, muscle tension, uncoordinated. anticholinergic overdose is life threatening, high toxicity of datura, scopolamine, atropine (often been used as poisons)

LSD physical dependence (low) psychological dependence (+) persistent psychosis, hallucinogen persisting perception disorder seizures (rare) hyperthermia (rare), flashbacks (LSD), paranoid drug (phencyclidine) inducing agressivity

almost none, just psychological frustration

Hallucinogen

mescaline

illusions & hallucinations, altered perception of time & distance

mydriasis, abdominal pain, vomiting, dizziness, sympathomimetic symptoms

rare complications

almost none, just psychological frustration

Hallucinogen

GHB

G, liquid ecstasy, grievous bodily harm, gib, soap, scoop, nitro

dizziness, hypersalivation, hypotonia,

& amnesia, placidity, mild euphoria, ple-asant desinhibition, mild sedative, weight controller (bodybuilding), narcolepsia

drowsiness, dizziness, nausea, vomiting, overdose is a real danger, usually occurring within 15–20 minutes of ingestion, most when taken with other substances (alcohol), seizures, ag-gressive outbursts, respiratory depression, muscles contractions, clonus, narrow peripheric vision, amnesia. GHB produces euphoria, with higher doses, Cheyne-Stokes' respiration, seizures, coma, death, coma may be interrupted by agitation, bradycardia & hypothermia

mediate: sleep cycles, body temperature (high), cerebral glucose metabolism & memory,

uncontrolled movements & depression of the respiratory & central nervous systems, potential high neurotoxic

within one day after discontinuing drug intake with tachycardia, tremor, agitation, hypertension, anxiety, insomnia for several days, hallucinations

Hallucinogen

ketamine

sympathomimetic, anticholinergic & cholinergic signs

essentially dissociative, thought disorders, out of body experiences, aphrodisiac effects, hallucinations & other perceptual distortion (psychedelic effects), stimulant effects

‘bad trips’ (known as the ‘k hole’), nausea & vomiting (especially if taken, with alcohol), palpitations,chest pain, hyperpression, tachycardia, temporary paralysis, analgesia & sensory dissociation, creating a high risk of accidental injury, myosis or mid sized pupils, nystagmus, anterograde amnesia, delirium, respiratory depression with apnea, coma

anesthesia without respiratory depression

“flashbacks” & visual disturbances, days or weeks after ingestion. recurrent, coma, seizures, hyperthermia, rhabdomyolysis, hypertension, hypoglycemia

some chronic users become addicted & exhibit severe withdrawal symptoms that require detoxification

Cannabinoids

cannabis, hash, anandamide,

2-arachidonylglycerol, tetrahydrocannabinol (THC)

calming effect, relaxation,sense of well-being, euphoria, spontaneous laugh, de-sinhibition, heightened visual & auditory perceptions, increased appetite, relaxed inhibitions, increased desire, disorien-tation, control mood swings-temper ouburst-irritable aggression, anger

effects start after 3mg doses, altered time perception, slowed time, concentration: general difficulty tendency to focus awareness on a particular activity. anxiety & panic, higher than 15-20mg psychotic-like syndrome: paranoia, visual or auditory hallucinations confusion, impaired balance & coordination, impaired motor coordination,sensation of impaired judgment, social withdrawal, short term memory loss supra ventricular arrhythmias, tachy-cardia., drowsiness, could induce schizophrenia, cannabis is not associated with fatal overdoses.

impaired memory & learning, increased heart rate, anxiety, panic attacks, tolerance, de-pendence. inability to control use, subtle cognitive impairment: affecting attention, inte-gration of complex information, reversibility unknown, cough, frequent respiratory infections, teratogenic & carcinogenic histo-pathological changes of the pulmonary parenchyma & epithelial cells, reduced sperm count negative effects on the developing fetus, exacerbate psy-chotic symptoms, schizophrenia very sensitive. physical dependence (low) psycholo-gical dependence (++) conjunctival irritation; neurotoxic: low; general toxicity: medium, mood troubles commonly depressive

during 1-5 days after withdrawal: anxiety, restlessness & irritability, anorexia disturbed sleep & increases in vivid dreams gastro-intestinal disturbances, night sweats (less than tobacco), stomach pain, tremors, strange dreams, difficult sleep, headache, combine often with tobacco effects.

Nicotine Tobacco

social & physiological addiction, identification, feeling of well being, relaxation, intellectual stimulant, anorexic, antidepressant.

taxes collector

Acute system effects: central nervous system (cns) , headache, insomnia, dreams; gastrointestinal (gi) , nausea, vomiting, heartburn, diarrhea; musculoskeletal system (mss) ,

myalgia, arthralgias, coronary heart disease , angina, myocardial infarction, sudden death

congestive, heart failure; cerebrovascular disease , transient ischaemic attacks (tias), stroke peripheral vascular diseases , claudication, aortic aneurysm. airways disease through mucous, hypersecretion, interference with ciliary function & alveolar destruction exacerbates existing hay fever & asthma contributes to acute & chronic rhinitis; lung cancer, oral cavity cancers (tongue, pharynx), esophageal & stomach cancer, cancer of the larynx, kidney & bladder cancer, pancreatic cancer, leukemia, cancer of the liver; risk factor for both peptic ulcer & Crohn's disease, exacerbates gastro-esophageal reflux; aging of skin, delays wound healing, contribute to osteoporosis. physical dependence (+) psychological dependence (++) (neurotoxic: low) (general toxicity: high).

within several hours of the last cigarette, peak in the first 24–72 hours & resolve in 2–4 weeks. withdrawal similar to amphetamine & cocaine, but greater emphasis on anxiety, smoking craving (more than cannabis), agitation, head ache, fatigue, increased appetite & hunger: weight gain. dysphoric or depressed mood, restlessness, mood swings,restlessness, difficult to concentrate insomnia, irritability, frustration, anger, anxiety & depression, difficulty concentrating, decreased heart rate, dizziness, increased appetite, shakiness. Local toxic effects: these effects are observed with nicotine replacement therapy (nrt): sore mouth, mouth ulcers (nicotine gum) local itching, erythema, burning (nicotine patches) nasal irritation, sneezing, watery eyes (nicotine spray)