Substance Abuse - Navy Medicine

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Purpose & Goals The goal of the enclosed course is to provide nurses and other health care professionals with a comprehensive overview of the most commonly used and abused substances in the United States today. Emphasis is on short-and long-term effects, as well as treatment strategies DQGSULQFLSOHVIRUSUHYHQWLRQ1RWH'XHWRWKH volumes of information available, this course DGGUHVVHV RQO\ ´,OOHJDOO\µ DEXVHG VXEVWDQFHV and will NOT cover alcohol, or nicotine.

Substance Abuse &RXUVH‡&(+RXUV

Instructional Objectives 

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substance use, abuse, and addiction.

Newly Updated 2010

About the Authors Peggy M. Goulding, PhD received a doctoral degree in educational psychology from the UniYHUVLW\RI7H[DVDW$XVWLQDQGFRPSOHWHGDSRVW doctoral program in clinical neuropsychology at the University of Houston. She has over twenty years RISURIHVVLRQDOH[SHULHQFHLQDYDULHW\RIVHWWLQJV LQFOXGLQJSULYDWHLQGXVWU\KRVSLWDOVUHKDELOLWDWLRQ IDFLOLWLHVQXUVLQJKRPHVDQGSXEOLFDQGSULYDWH schools. A former faculty member in neurology DWWKH6DLQW/RXLV8QLYHUVLW\6FKRRORI0HGLFLQH she has also taught at the University of Houston, University of Missouri, and Maryville University. Shelda L. Hudson, RN, BSN, PHN comSOHWHGKHU%DFFDODXUHDWH'HJUHHLQ1XUVLQJDQG UHFHLYHG KHU SXEOLF KHDOWK FHUWLÀFDWH DW $]XVD 3DFLÀF8QLYHUVLW\6KHLVDPHPEHURIWKH,QWHUnational Association of Forensic Nurses (IAFN) DQGDQDFDGHPLFPHPEHURIWKH$PHULFDQ%RWDQLcal Council. She is the Nurse Supervisor of the ,QVWUXFWLRQDO 6\VWHPV 'HYHORSPHQW VHFWLRQ RI the National Center of Continuing Education. In this capacity, she is responsible for directing the DFWLYLWLHVRIWKLVGHSDUWPHQWVHOHFWLQJTXDOLÀHG credentialed authors for the courses offered by the National Center as well as advising staff of required course design and criteria. Ms. Hudson has over  \HDUV RI H[WHQVLYH H[SHULHQFH LQ SXEOLVKLQJ courses in continuing education for health care professionals with the National Center.

substance abuse.

use. 

,GHQWLI\VRPHFRPPRQO\DEXVHG drugs and their characteristic short and long-term effects.



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ated with various drugs of abuse. effects of various classes of drugs of abuse. 

2XWOLQHLVVXHVDQGFRQFHUQVVSHFLÀF to the abuse of prescription & overthe-counter (OTC) medications.



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drug overdose. treatment of substance abuse and addiction.   (YDOXDWHWKHHIÀFDF\RIFXUUHQWVWUDW egies for prevention of drug abuse.

Introduction Recreational drugs have been around for centuries, but drug abuse has never been so ZLGHVSUHDG0DULMXDQDZDVOLVWHGDVDQDJHQW for achieving euphoria in a Chinese medical

FRPSHQGLXPWUDGLWLRQDOO\GDWHGIURP%& $VIDUEDFNDV%&WKH*UHHNVXVHGRSLXP DQGWKH$]WHFVLQFRUSRUDWHGKDOOXFLQRJHQVLQWR their religious rituals. Andean Indians chewed the leaves of the coca plant to decrease hunger DQGLQFUHDVHWKHLUVWDPLQDIRUZRUN:LWFKHVLQ the Middle Ages brewed potent concoctions, and New World merchants peddled a little opium along with their rum and slaves. Soldiers were DPRQJWKHÀUVWDGGLFWVWRSUHVFULSWLRQVGUXJV 'XULQJWKH&LYLO:DUWKHQDUFRWLF/DXGDQXP dulled the pain from their battle wounds. Then along came cocaine and heroin, recomPHQGHGIRUHYHU\PDODG\IURPKHDGDFKHVWRVNLQ UDVKHV&RFDLQHZDVÀUVWH[WUDFWHGIURPWKHFRFD SODQWLQWKHWKFHQWXU\DQGLWZDVKDLOHGDV a miracle drug, prescribed for everything from H[KDXVWLRQWRGHSUHVVLRQDQGZLGHO\DYDLODEOHLQ SDWHQWPHGLFLQHV+HURLQÀUVWSURGXFHGLQ was sold by traveling salesmen and through mail RUGHUFDWDORJVLWZDVWKRXJKWWREHXVHIXODVD cure for respiratory illnesses and for relieving morphine withdrawal. Eventually, the addicWLYHSRWHQWLDORIWKHVH´KDUPOHVVFXUHDOOVµZDV UHFRJQL]HGWKH\ZHUHVKXQQHGE\PDLQVWUHDP society and their use driven underground. 7KH XVH RI PDULMXDQD DV DQ LQWR[LFDQW ZDV FRPPRQSODFHIURPWKHVWRWKHVDQG ZDVUHLQIRUFHGE\XVHDPRQJPLJUDQWZRUNHUV IURP 0H[LFR 7KH )HGHUDO *RYHUQPHQW FRQGXFWHGDFDPSDLJQLQWKHVWRGLVFRXUDJH LWVXVH7KHPHVVDJHRIDPRYLH´5HHIHU 0DGQHVVµZDVWKDW´VPRNLQJWKHNLOOHUZHHG was a direct road to hell, suicide, or at least inVDQLW\µDQGPDULMXDQDXVHFDPHWREHUHJDUGHG as a gateway to addiction to more powerful and dangerous drugs. 'UXJVUHPDLQHGRQWKHIULQJHVRIVRFLHW\LQWR WKHVZKHQWKH´EHDWJHQHUDWLRQµEHQWWKHLU minds with hallucinogens and enhanced their ZRUOGO\ SHUFHSWLRQV ZLWK SRW %\ WKH V youth rebellion was in full swing, while the hipSLHVRI´+DLUµDQGWKHDQWLKHURHVRI´(DV\5LGHUµ URPDQWLFL]HGWKHGUXJFXOWXUH5HFUHDWLRQDOXVH RIGUXJVZDVWKH´LQµWKLQJDQDFWLYLW\VKDUHG by young people with a common point of view. Following this era, drug use continued to gain in social acceptance, as people thought they could H[SHULPHQWZLWKDZLGHUDQJHRIVWUHHWGUXJVEXW not become addicted. Use of the old standbys was on the rise, even as more and more use of amphetamines, inhalants, and designer drugs was recorded.

([WUDRUGLQDU\ HIIRUWV KDYH EHHQ PDGH E\ WKH DXWKRU V  WKH HGLWRU V  DQG WKH SXEOLVKHU V  RI WKH 1DWLRQDO &HQWHU RI &RQWLQXLQJ Education, Inc. courses to ensure dosage recommendations and treatments are precise and agree with the highest standards of practice. +RZHYHU DV D UHVXOW RI DFFXPXODWLQJ FOLQLFDO H[SHULHQFH DQG FRQWLQXLQJ ODERUDWRU\ VWXGLHV GRVDJH VFKHGXOHV DQGRU WUHDWPHQW UHFRPmendations are often altered or discontinued. In all cases the advice of a physician should be sought and followed concerning initiating or GLVFRQWLQXLQJDOOPHGLFDWLRQVRUWUHDWPHQWV7KHSODQQHU V DXWKRU V DQGRUHGLWRU V RIHDFKFRXUVHKDYHDWWHVWHGWRQRFRQÁLFWRILQWHUHVW QRUELDVRQWKHVXEMHFW7KH1DWLRQDO&HQWHURI&RQWLQXLQJ(GXFDWLRQ,QFGRHVQRWDFFHSWFRPPHUFLDOVXSSRUWRQDQ\FRXUVHQRUGRWKH\ HQGRUVHDQ\SURGXFWVWKDWPD\EHPHQWLRQHGLQWKHFRXUVH$Q\RIIODEHOXVHIRUPHGLFDWLRQVPHQWLRQHGLQDFRXUVHLVLGHQWLÀHGDVVXFK No part of this publication may be reproduced stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the prior written permission of the publisher. Payment Form:LQVLGHEDFNFRYHU‡Toll free number:‡Fax number:

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A second epidemic in cocaine use began in WKH8QLWHG6WDWHVLQWKHVDQGSHDNHGLQWKH PLGWRODWHVDJDLQWKHGUXJZDVDWÀUVW considered relatively harmless. Even middle class America began to use this chic drug in the ZRUNSODFHLWZDVVHHQDVDTXLFNSLFNPHXS D OLWWOH ´SHUNLHUµ WKDQ FRIIHH ´&UDFNµ D QHZ DQGLQH[SHQVLYHIRUPRIIUHHEDVHFRFDLQHZLWK PDJQLÀHGHIIHFWVKLWWKHPDUNHWVLQWKHV and soon was widespread in poorer neighborKRRGV%\WKHODWHVWKHFRFDLQHDQGFUDFN epidemic had subsided somewhat, however, as heroin regained popularity among illicit drug users. A growing group of new middle-class KHURLQXVHUVHPHUJHGLQWKHVDVDSRWHQW powdered heroin became available. Throughout WKLV SHULRG PDULMXDQD UHWDLQHG LWV UROH DV WKH gateway to other drug use. After over a decade RI GHFUHDVLQJ XVH PDULMXDQD VPRNLQJ EHJDQ DQXSZDUGWUHQGRQFHPRUHLQWKHHDUO\V especially among teenagers. 'HVSLWHLQFUHDVHGSXEOLFRXWFU\DQGDQLQWHQVLÀFDWLRQRIWKHJRYHUQPHQW·VZDURQGUXJVLW DSSHDUVWKDWGUXJDEXVHZLOOUHPDLQDVLJQLÀFDQW public health concern for the foreseeable future. In this course we will outline the neuroanatomy and neurophysiology of drug use, abuse, and adGLFWLRQUHYLHZWKHPRVWFRPPRQFODVVHVRIGUXJV RIDEXVHDQGVXPPDUL]HFXUUHQWDSSURDFKHVWR treatment and prevention.

Understanding Drug Abuse and Addiction Many people do not understand why individuals become addicted to drugs or how drugs change the brain to foster compulsive drug abuse. 7KH\PLVWDNHQO\YLHZGUXJDEXVHDQGDGGLFWLRQ as strictly a social problem and may characterL]HWKRVHZKRWDNHGUXJVDVPRUDOO\ZHDN2QH very common belief is that drug abusers should EHDEOHWRMXVWVWRSWDNLQJGUXJVLIWKH\DUHRQO\ willing to change their behavior. What people RIWHQXQGHUHVWLPDWHLVWKHFRPSOH[LW\RIGUXJ DGGLFWLRQ³WKDWLWLVDGLVHDVHWKDWLPSDFWVWKH brain and because of that, stopping drug abuse is not simply a matter of willpower. Through VFLHQWLÀFDGYDQFHVZHQRZNQRZPXFKPRUH DERXWKRZH[DFWO\GUXJVZRUNLQWKHEUDLQDQG ZHDOVRNQRZWKDWGUXJDGGLFWLRQFDQEHVXFFHVVfully treated to help people stop abusing drugs and resume their productive lives. 'UXJDEXVHDQGDGGLFWLRQDUHDPDMRUEXUGHQ to society. Estimates of the total overall costs of VXEVWDQFHDEXVHLQWKH8QLWHG6WDWHV³LQFOXGLQJ health- and crime-related costs as well as losses LQSURGXFWLYLW\³H[FHHGKDOIDWULOOLRQGROODUV DQQXDOO\ 7KLV LQFOXGHV DSSUR[LPDWHO\  ELOOLRQIRULOOLFLWGUXJVELOOLRQIRUWREDFFR DQGELOOLRQIRUDOFRKRO6WDJJHULQJDVWKHVH numbers are, however, they do not fully describe WKH EUHDGWK RI GHOHWHULRXV SXEOLF KHDOWK³DQG VDIHW\³LPSOLFDWLRQV ZKLFK LQFOXGH IDPLO\ disintegration, loss of employment, failure in Page 52

Substance Abuse

school, domestic violence, child abuse, and other crimes.

Use, Abuse and Dependence 0RVWH[SHUWVLQDGGLFWLRQPHGLFLQHGLIIHUHQWLate use, abuse, and dependence or addiction, and they are often seen as representing a continuum RIVHYHULW\LQDVVHVVLQJDSHUVRQ·VGUXJSURElem. Substance use is simply the ingestion of a chemically active agent such as a prescription or illicit drug, alcohol or tobacco. Substance abuse suggests a maladaptive pattern of substance use OHDGLQJ WR VLJQLÀFDQW GLIÀFXOWLHV LQ PHHWLQJ PDMRUUROHREOLJDWLRQVDWKRPHZRUNRUVFKRRO XVHLQVLWXDWLRQVLQZKLFKLWLVSK\VLFDOO\KD]DUGRXV VXFKDVGULYLQJ RUFRQWLQXHGXVHGHVSLWH related social and interpersonal problems, or legal problems. Dependence implies a cluster of cognitive, behavioral, and physical symptoms which indicate that the individual continues to use the substance despite the presence of VLJQLÀFDQW VXEVWDQFHUHODWHG SUREOHPV 7KH person develops a tolerance for the substance and requires progressively larger amounts to elicit the effects desired. Also, the person will H[SHULHQFHSK\VLFDODQGSV\FKRORJLFDOVLJQVDQG symptoms of withdrawal if the substance is not used. Addiction typically refers to a compulsive and maladaptive dependence on the substance, resulting in adverse psychological, physical, HFRQRPLFVRFLDODQGOHJDOUDPLÀFDWLRQV

Neurobiology in Brief The brain consists of several large regions, HDFKUHVSRQVLEOHIRUVSHFLÀFDFWLYLWLHVYLWDOIRU living. (Figure 1) The cerebral cortex, which is divided into right and left hemispheres, encompasses about two-thirds of the brain mass

and lies over and around most of the remaining structures of the brain. It is the most highly developed part of the human brain and is responsible IRU WKLQNLQJ SHUFHLYLQJ DQG SURGXFLQJ DQG XQGHUVWDQGLQJ ODQJXDJH 7KH FHUHEUDO FRUWH[ can be divided into areas with each having a VSHFLÀFIXQFWLRQVXFKDVYLVLRQKHDULQJWRXFK movement, or smell. Other areas are critical for WKLQNLQJDQGUHDVRQLQJ$OWKRXJKPDQ\IXQFtions, such as touch, are found in both the right and left cerebral hemispheres, some functions are found predominantly in only one hemisphere. )RUH[DPSOHLQPRVWSHRSOHODQJXDJHDELOLWLHV DUHORFDOL]HGLQWKHOHIWKHPLVSKHUH(YHQVRWKH FRUWH[PRVWRIWHQDFWVDVDXQLWLQSURFHVVLQJIRU FRPSOH[WDVNVDQGG\VIXQFWLRQLQDQ\RQHDUHD can affect the operation of the brain as a whole. The brainstem is the part of the brain that connects the brain and the spinal cord. It controls basic functions such as heart rate, respiration, appetite and sleep. The cerebellum, a prominent structure located above the brainstem, coordiQDWHVWKHEUDLQ·VSURFHVVHVIRUVNLOOHGUHSHWLWLYH movements and for maintaining balance and posture. It has also been implicated in higher OHYHOFRJQLWLYHIXQFWLRQVWKDWUHTXLUHFRPSOH[ motor activities. The diencephalon, which is also located beneath the cerebral hemispheres, contains the thalamus and hypothalamus. The thalamus is involved in sensory perception and regulation of motor functions (i.e., movement). It connects DUHDV RI WKH FHUHEUDO FRUWH[ WKDW DUH LQYROYHG in sensory perception and motor control with other parts of the brain and spinal cord that also have a role in sensation and movement. The hypothalamus is a very small but important FRPSRQHQWRIWKHGLHQFHSKDORQ,WSOD\VDPDMRU role in regulating hormone production, body

Brain Structures Cerebrum

Thalamus

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Cerebellum Hypothalamus Amygdala

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Brainstem

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temperature, and many other vital activities. On top of the brainstem and buried under the FRUWH[ WKHUH LV D VHW RI PRUH SULPLWLYH EUDLQ structures called the limbic system. The limbic system structures are involved in many of our emotions and motivations, particularly those that are related to survival, such as fear, anger, and WKHSOHDVXUHGHULYHGIURPDFWLYLWLHVOLNHHDWLQJ DQG VH[ 7ZR ODUJH OLPELF V\VWHP VWUXFWXUHV called the amygdala and hippocampus are also involved in memory. One of the reasons that GUXJVRIDEXVHFDQH[HUWVXFKSRZHUIXOFRQWURO over our behavior is that they act directly on the more primitive brainstem and limbic structures, ZKLFKFDQRYHUULGHWKHFRUWH[LQFRQWUROOLQJRXU behavior. In effect, they eliminate the most human part of our brain from its role in behavior control. The brain is made up of billions of nerve cells, each containing three important parts: a FHQWUDOFHOOERG\VKRUWÀEHUVFDOOHGGHQGULWHV that receive messages from other neurons and UHOD\WKHPWRWKHFHOOERG\DQGDQD[RQDORQJ VLQJOH ÀEHU WKDW WUDQVPLWV PHVVDJHV IURP WKH cell body to the dendrites of other neurons, or to body tissues such as muscles. Although most neurons contain all three parts, there is much GLYHUVLW\LQWKHVKDSHVDQGVL]HVRIQHXURQVDV ZHOODVWKHLUD[RQVDQGGHQGULWHV 7KHWUDQVIHURIDPHVVDJHIURPWKHD[RQRI one nerve cell to the dendrites of another is NQRZQDVQHXURWUDQVPLVVLRQ$OWKRXJK D[RQV DQG GHQGULWHV DUH ORFDWHG H[WUHPHO\ FORVH WR each other, the transmission of a message from DQD[RQWRDGHQGULWHGRHVQRWRFFXUWKURXJK direct contact. Instead, communication between nerve cells occurs mainly through the release of chemical substances into the space, or synapse, EHWZHHQWKHD[RQDQGGHQGULWHV:KHQQHXURQV communicate, a message, traveling as an electriFDOLPSXOVHPRYHVGRZQDQD[RQDQGWRZDUGWKH synapse. There it triggers the release of molecules FDOOHGQHXURWUDQVPLWWHUVIURPWKHD[RQLQWRWKH synapse. The neurotransmitters then diffuse across the synapse and bind to special receptor molecules located within the cell membranes of WKHGHQGULWHVRIWKHDGMDFHQWQHUYHFHOO7KLVLQ turn, stimulates or inhibits an electrical response LQWKHUHFHLYLQJQHXURQ·VGHQGULWHV There are many different types of neurotransmitters, each of which has a precise role to play in the functioning of the brain. Generally, each neurotransmitter can only bind to a very VSHFLÀFPDWFKLQJUHFHSWRU7KHUHIRUHZKHQD QHXURWUDQVPLWWHUFRXSOHVWRDUHFHSWRULWLVOLNH ÀWWLQJDNH\LQWRDORFN7KLVFRXSOLQJWKHQVWDUWV a whole cascade of events at both the surface of the dendrite of the receiving nerve cell and inside the cell. In this manner, the message carried by the neurotransmitter is received and processed by the receiving nerve cell. Once this has occurred, the neurotransmitter is inactivated E\EHLQJHLWKHUEURNHQGRZQE\DQHQ]\PHRU UHDEVRUEHGEDFNLQWRWKHQHUYHFHOOWKDWUHOHDVHG

LW7KHUHDEVRUSWLRQ DOVRNQRZQDVUHXSWDNH  a surface down to the nanogram, level is now requires the action of transporter molecules, available to businesses, schools and private ZKLFKUHVLGHLQWKHFHOOPHPEUDQHVRIWKHD[RQV companies. The narcotics that can be detected WKDWUHOHDVHWKHQHXURWUDQVPLWWHUV7KH\SLFNXS E\'UXJ:LSHDUH&RFDLQH&DQQDELV2SLDWHV VSHFLÀFQHXURWUDQVPLWWHUVIURPWKHV\QDSVHDQG (Heroin), and Amphetamine/Metamphetamines. 8VHGLQWKH8QLWHG6WDWHVE\URXJKO\ FDUU\WKHPEDFNDFURVVWKHFHOOPHPEUDQHDQG LQWR WKH D[RQ7KH QHXURWUDQVPLWWHUV DUH WKHQ national, state and local law enforcement and JRYHUQPHQWDJHQFLHVVLQFHWKHPLG·VWKLV available for reuse. Pleasure is a very powerful biological force DGYDQFHG WHFKQRORJ\ SURGXFHV ÀHOG UHOLDEOH IRUVXUYLYDO/LIHVXVWDLQLQJDFWLYLWLHVVXFKDV results in less than two minutes. )LUVW XVHG LQ (XURSH 'UXJ:LSH GLIIHUHQWLHDWLQJ DFWLYDWH D FLUFXLW RI VSHFLDOL]HG QHUYH cells devoted to producing and regulating ates itself from other drug detection products pleasure. One important set of these nerve cells, currently available by testing for the raw drug, which uses a chemical neurotransmitter called VRWKDWWUDIÀFNLQJUHVLGXHFDQQRZEHGHWHFWHG dopamine, sits at the very top of the brainstem as well as the sweat deposited from impaired in the ventral tegmental area (VTA). These XVHUV'UXJ:LSHWHFKQRORJ\XWLOL]HVSDWHQWHG dopamine-containing neurons relay messages biosensors to detect and identify the various DERXW SOHDVXUH WKURXJK WKHLU QHUYH ÀEHUV WR drug types, the patterns and the location of illegal nerve cells in a limbic system structure called the GUXJXVHDQGWUDIÀFNLQJ,WLVQRWQRUPDOO\XVHG QXFOHXVDFFXPEHQV6WLOORWKHUÀEHUVUHDFKWRD to pinpoint individual usage. $´VRSKLVWLFDWHGODERQDVWLFNµURXJKO\WKH related part of the frontal region of the cerebral FRUWH[ 6R WKH SOHDVXUH FLUFXLW ZKLFK LVNQRZQDVWKHPHVROLPELFGRSDPLQH Government Studies Reveal system, spans the survival-oriented brainstem, the emotion-oriented limbic Alarming Data V\VWHPDQGWKHIURQWDOFHUHEUDOFRUWH[ All drugs that are addicting can actiDrug abusers on average: YDWH WKH EUDLQ·V SOHDVXUH FLUFXLW 'UXJ addiction is a biological, pathological ‡ FRVW WKHLU HPSOR\HU  WR  process that alters the way in which the DQQXDOO\ pleasure center, as well as other parts of ‡ FRVWFRPSDQLHVSHUFHQWPRUHLQPHGLthe brain, functions. Almost all drugs that FDOFRVWVDQGEHQHÀWVDQG FKDQJHWKHZD\WKHEUDLQZRUNVGRVRE\ ‡ DUHDEVHQWXSWRWLPHVPRUHRIWHQDQG affecting chemical neurotransmission. are one third less productive. 6RPHGUXJVOLNHKHURLQDQG/6'PLPLF the effects of a natural neurotransmitA    recently  released  Department  of   WHU 2WKHUV OLNH 3&3 EORFN UHFHSWRUV Health  and  Human  Services  report  stated   and thereby prevent neuronal messages that  44%  of  drug  users  work  for  small   IURPJHWWLQJWKURXJK6WLOORWKHUVOLNH companies.  Same  study  found  that  7.7%   cocaine, interfere with the molecules of  workers  between  the  ages  of  18  and  49   that are responsible for transporting used  illegal  drugs  in  the  previous  month.   QHXURWUDQVPLWWHUVEDFNLQWRWKHQHXURQV Furthermore,  young,  white,  undereducated   that released them. (Figure 2) Finally, males  are  the  most  likely  to  use  drugs.   some drugs, such as methamphetamine, act by causing neurotransmitters to be ‡ 'UXJXVLQJHPSOR\HHVDUHPRUHOLNHO\ released in greater amounts than normal. WREHLQYROYHGLQZRUNSODFHDFFLGHQWVDQG Prolonged drug use changes the brain WLPHVPRUHOLNHO\WRÀOHZRUNHUFRPSHQVDin fundamental and long-lasting ways. tion claims. 7KHVHORQJODVWLQJFKDQJHVDUHDPDMRU ‡ RIDOOZRUNHUV·FRPSHQVDWLRQ component of the addiction itself. It is as claims are related to substance abuse. WKRXJKWKHUHLVDÀJXUDWLYH´VZLWFKµLQ ‡ 6XEVWDQFHDEXVHLVWKHWKLUGOHDGLQJFDXVH WKHEUDLQWKDW´ÁLSVµDWVRPHSRLQWGXURIZRUNSODFHYLROHQFH LQJDQLQGLYLGXDO·VGUXJXVH7KHSRLQW ‡ 6XEVWDQFHDEXVHUVDUHWLPHVPRUHOLNHO\WR DWZKLFKWKLV´ÁLSµRFFXUVYDULHVIURP XVHPHGLFDOEHQHÀWVWKDQRWKHUHPSOR\HHV individual to individual, but the effect ‡ 'UXJXVHUVDUHDEVHQWIURPWKHZRUNSODFH of this change is the transformation of a DQDYHUDJHRIGD\VSHUPRQWKGXHWRGUXJ drug abuser to a drug addict. use. ‡ :KLOHDWZRUNVXEVWDQFHDEXVHUVDUH Using Technology for less productive and cost their employers Drug Detection DQQXDOO\ 'UXJ:LSH D SDWHQWHG WHFKQRORJ\ that can instantly detect and identify WKHPDMRUW\SHVRILOOHJDOQDUFRWLFVRQ

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VL]HRIDSHQ'UXJ:LSHTXLFNO\SLFNVXSWKH invisible residue of illegal narcotics with a single ´ZDQGOLNHµPRWLRQ'UXJ:LSHLVDQHIIHFWLYH tool for businesses to combat employee theft, LQFUHDVH SURGXFWLYLW\ DQG UHGXFH ZRUNPHQ compensation claims. :KLOHVRPHPD\WKLQNWKDWGUXJWHVWLQJFRXOG deter potential employees from choosing a FRPSDQ\WRZRUNIRULWLVEHOLHYHGWREHMXVW WKHRSSRVLWHGXHWRWKHEHQHÀWVRIDGUXJIUHH ZRUNSODFHWRERWKWKHHPSOR\HUDQGWKHHPployee. Our research indicates that a drug-free ZRUNSODFHKDVDGLVWLQFWDGYDQWDJHLQKLULQJDQG retaining employees. These tests are a positive, SURDFWLYH ZD\ WR GHWHU ZRUNSODFH GUXJ DEXVH DQGWUDIÀFNLQJDQGWKH\LQVXUHWKHFRQÀGHQFH RI HPSOR\HHV WKDW WKH\ DUH ZRUNLQJ LQ D VDIH environment. It is a win-win situation for all as LWLPSURYHVZRUNSODFHPRUDOORZHUVLQVXUDQFH premiums, increases quality and productivity, lowers self-insured costs and reduces liability.

Commonly Abused Substances Marijuana 0DULMXDQDKDVDVVXPHGDXQLTXHSODFHLQRXU FXOWXUHDQGLVORRNHGXSRQEHQLJQO\E\VRPH DQGZLWKKRUURUE\RWKHUV0DQ\SHRSOHVPRNH PDULMXDQDQRZDQGWKHQSHUKDSVFRPELQLQJLW ZLWK DOFRKRO WR ´PHOORZ RXWµ DQG WKDW LV WKH H[WHQWRIWKHLUGUXJXVH)RURWKHUVKRZHYHU HVSHFLDOO\WHHQDJHUVPDULMXDQDLVDPDMRUJDWHZD\H[SHULHQFHLQWRWKHGUXJZRUOG0DULMXDQD is the most commonly abused illicit drug in the United States. 0DULMXDQDLVPDGHIURPWKHGULHGOHDYHVDQG ÁRZHUVRIWKH,QGLDQKHPSSODQWFDQQDELVVDWLYD It has been cultivated worldwide and used as a GUXJ IRU FHQWXULHV7KH SRWHQF\ RI PDULMXDQD depends on the method of preparation, with KDVKLVKDQGJDQMDPXFKPRUHSRZHUIXOWKDQWKH unprocessed form. Although cannabinoids are XVXDOO\VPRNHGWKH\FDQDOVREHHDWHQGUXQNDV WHDRUUDUHO\LQMHFWHGLQWUDYHQRXVO\7KHDFWLYH LQJUHGLHQWRIPDULMXDQDGHOWDWHWUDK\GURFDQQDELQRO 7+& ELQGVWRDQGDFWLYDWHVVSHFLÀF neuroreceptors, called cannabinoid receptors, located throughout the brain in areas that control memory, thought, concentration, time and depth perception, and coordinated movement. THC generally affects these functions negatively, by decreasing the activity of the neurons in each DUHD0DULMXDQDKDVEHHQVKRZQWRVWLPXODWHWKH dopamine pathway from the ventral tegmental area to the nucleus accumbens, within the pleasure center of the brain, leading to feelings of HXSKRULDUHOD[DWLRQDQGKHLJKWHQHGVHQVDWLRQ 7KH7+&FRQWHQWRIPDULMXDQDLVFXUUHQWO\KLJKHU WKDQWKDWRIWKHPDULMXDQDXVHGLQSDVWGHFDGHV Many potential adverse effects that were reported may be understated when compared with the effects of current street preparations. Page 54

Substance Abuse

3HDN SODVPD OHYHOV RI 7+& DUH QRUPDOO\ DFKLHYHGZLWKLQPLQXWHVRIVPRNLQJPDULMXDQDDQGLQWR[LFDWLRQODVWVDSSUR[LPDWHO\WZR WRWKUHHKRXUV%HFDXVHRILWVKLJKOLSLGVROXELOLW\ THC accumulates in fatty tissues, leading to its ORQJKDOIOLIHDQGUHODWHGHIIHFWV)RUH[DPSOHWKH GLVUXSWLYHHIIHFWWKDWPDULMXDQDKDVRQFRRUGLQDWLRQPD\ODVWIRUPRUHWKDQKRXUVZKLFKLV IDUEH\RQGWKHSHULRGRIVXEMHFWLYHLQWR[LFDWLRQ Many investigations using animals and some studies of humans suggest that reproductive abnormalities may occur with the use of mariMXDQD0DWHUQDOH[SRVXUHWRPDULMXDQDGXULQJ SUHJQDQF\PD\UHGXFHWKHVL]HRIWKHIHWXVDQG WKHELUWKZHLJKW$IROGLQFUHDVHLQWKHULVN RIQRQO\PSKREODVWLFOHXNHPLDLQFKLOGUHQZKRVH PRWKHUVXVHGPDULMXDQDEHIRUHRUGXULQJJHVWDtion has also been reported. 6RPH SDWLHQWV ZLWK SUHH[LVWLQJ PHGLFDO FRQGLWLRQVZKRXVHPDULMXDQDPD\EHDWSDUWLFXODUULVN)RUH[DPSOHDOWKRXJK7+&DFXWHO\ increases the respiratory rate and the diameter RIEURQFKLDODLUZD\VFKURQLFXVHRIPDULMXDQD results in epithelial damage to the trachea and PDMRUEURQFKLDQGGHFUHDVHGDLUZD\GLDPHWHU 0DULMXDQDVPRNHGRHVQRWFRQWDLQQLFRWLQHEXW GRHVKDYHDVLJQLÀFDQWO\KLJKHUWDUFRQWHQWWKDQ FLJDUHWWHV LW FRQWDLQV PDQ\ FDUFLQRJHQV DQG XQOLNHPRVWFLJDUHWWHVLVVPRNHGXQÀOWHUHG A serious but often neglected adverse effect RI PDULMXDQD LV WKH ULVN RI LQIHFWLRQ FKURQLF XVH RI PDULMXDQD PD\ OHDG WR LPSDLUPHQW RI LPSRUWDQWSXOPRQDU\GHIHQVHV$OVRPDULMXDQD can be contaminated with microorganisms such as aspergillus and salmonella, as well as fecal PDWWHU7KHULVNRILQIHFWLRQPD\EHRISDUWLFXODU FRQFHUQLQSDWLHQWVZKRKDYH+,9RU$,'6RU other compromise of the immune system. )RUPDQ\\HDUVLWKDVEHHQNQRZQWKDW7+& acts on cannabinoid receptors in the brain. It ZDV K\SRWKHVL]HG WKDWVLQFH WKH QRUPDOEUDLQ has these receptors, there must also be a substance produced by the brain itself that acts on WKHVH UHFHSWRUV )LQDOO\ LQ  DIWHU \HDUV of research, scientists discovered a substance produced by the brain that activates the THC receptors and has many of the same physiological effects as THC. The scientists named WKHVXEVWDQFHDQDQGDPLGHIURPD6DQVNULWZRUG PHDQLQJ¶EOLVV·7KHGLVFRYHU\RIDQDQGDPLGH opened whole new avenues of research. It now appears that anandamide and dopamine act in opposite ways to control movements in an area RIWKHEUDLQFDOOHGWKHGRUVDOVWULDWXP'RSDPLQH stimulates movements by acting in this area, and anandamide normally inhibits the action of dopamine. The discovery of anandamide may lead to a greater understanding of certain health problems and ultimately to more effective treatments. It may be particularly useful in treating diseases related to imbalances of dopamine in the brain, LQFOXGLQJ3DUNLQVRQ·VGLVHDVH:KHQPDGHV\Q-

thetically and given orally, THC can be used to treat nausea associated with chemotherapy and VWLPXODWHDSSHWLWHLQ$,'6ZDVWLQJV\QGURPH,W may also be useful for other conditions, including JODXFRPD1RZWKDWWKHEUDLQ·VRZQ7+&OLNH VXEVWDQFHKDVEHHQLGHQWLÀHGUHVHDUFKHUVPD\ soon be able to uncover the mechanisms underlying the therapeutic effects of THC, leading to the development of more effective and safer treatments for a variety of conditions.

Marijuana use rises The use of illicit drugs among Americans LQFUHDVHGEHWZHHQDQGDFFRUGLQJWR a national survey conducted by the Substance Abuse and Mental Health Services AdministraWLRQ 6$0+6$   7KH 1DWLRQDO 6XUYH\ RQ'UXJ8VHDQG+HDOWK 16'8+ VKRZVWKH overall rate of current illicit drug use in the United 6WDWHVURVHIURPSHUFHQWRIWKHSRSXODWLRQ DJHG  DQG ROGHU LQ  WR  SHUFHQW LQ 7KLVULVHLQRYHUDOOGUXJXVHZDVGULYHQLQ ODUJHSDUWE\LQFUHDVHVLQPDULMXDQDXVH)ODWRU increasing trends of substance use were reported DPRQJ\RXWK WR\HDUROGV $GGLWLRQDOO\ WKHOHYHORI\RXWKSHUFHLYLQJJUHDWULVNRIKDUP DVVRFLDWHG ZLWK VPRNLQJ PDULMXDQD RQFH RU WZLFHDZHHNGURSSHGIURPSHUFHQWLQ WRSHUFHQWLQPDUNLQJWKHÀUVWWLPH VLQFHWKDWOHVVWKDQKDOIRI\RXQJSHRSOH SHUFHLYHGJUHDWKDUPLQIUHTXHQWPDULMXDQDXVH ´7KHVHUHVXOWVDUHDZDNHXSFDOOWRWKHQDWLRQµ said SAMHSA Administrator Pamela S. Hyde, -'´2XUVWUDWHJLHVRIWKHSDVWDSSHDUWRKDYH VWDOOHGRXWZLWKJHQHUDWLRQ¶QH[W·3DUHQWVDQG caregivers, teachers, coaches, faith and comPXQLW\OHDGHUVPXVWÀQGFUHGLEOHQHZZD\VWR communicate with our youth about the dangers of substance abuse.” ´7RGD\·VÀQGLQJVDUHGLVDSSRLQWLQJEXWQRW surprising, because eroding attitudes and perceptions of harm about drug use over the past two \HDUVKDYHVHUYHGDVZDUQLQJVLJQVIRUH[DFWO\ ZKDW ZH VHH WRGD\µ %XW RXU HIIRUWV PXVW EH UHLQIRUFHGDQGVXSSRUWHGE\WKHPHVVDJHVNLGV get from their parents.

Synthetic Marijuana $UHODWLYHO\QHZGUXJRQWKHPDUNHWDFFRUGLQJ WRD86'HSDUWPHQWRI-XVWLFH'UXJ$OHUW:DWFK .DOVRNQRZQDV´6SLFHµRU´6SDFHµLVSURPRWHGDVDOHJDODOWHUQDWLYHWRPDULMXDQDZKLFK ZKHQVPRNHGFUHDWHVWKHVDPHKDOOXFLQRJHQLF affects but adds many adverse reactions for its XVHU VXFK DV WUHPRUV VHL]XUHV K\SHUWHQVLRQ tachycardia, numbness, tingling, vomiting, panic DWWDFNVDQGDJLWDWLRQ $QDWWUDFWLRQIRUSRWHQWLDOXVHUVLVWKHGUXJ·V inability to be detected in random drug screenings for THC. 6ROGLQVPRNHVKRSV´.µLVDEUDQGQDPHIRU WKHV\QWKHWLFKDOOXFLQRJHQPDUNHWHGXQGHUWKH QDPHVRI´VSLFHµ´VSDFHµ´KXVKµ´VDOYLDµDQG

‹1DWLRQDO&HQWHURI&RQWLQXLQJ(GXFDWLRQ,QF‡32%R[/DNHZD\7;

Medical Marijuana: States Going ‘TO POT’? ,WDSSHDUVWKDWPDULMXDQDLVJRLQJPDLQVWUHDP And the Federal Government is beginning to JRZLWKWKHÁRZ,IWKHVWDWHSHUPLWVWKHXVHRI PHGLFDOPDULMXDQDWKH9$V\VWHPZLOOQRORQJHU refuse to continue to treat the patient. As of July 7KH'HSDUWPHQWRI9HWHUDQV$IIDLUVZLOO formally allow patients treated at its hospitals DQGFOLQLFVWRXVHPHGLFDOPDULMXDQDLQVWDWHV ZKHUHLWLVOHJDODSROLF\FODULÀFDWLRQWKDWYHWerans have sought for several years. $GHSDUWPHQWGLUHFWLYHUHVROYHVWKHFRQÁLFW in veterans facilities between federal law, which RXWODZVPDULMXDQDDQGWKHVWDWHVWKDWDOORZ medicinal use of the drug, effectively deferring to the states. The policy will NOT permit department docWRUVWRSUHVFULEHPDULMXDQD%XWLWZLOODGGUHVV the concern of many patients who use the drug that they could lose access to their prescription pain medication if caught. Under department rules, veterans can be denied pain medications if they are found to be using illegal drugs. Until QRZWKHGHSDUWPHQWKDGQRZULWWHQH[FHSWLRQ IRUPHGLFDOPDULMXDQD The new, written policy applies only to vetHUDQVXVLQJPHGLFDOPDULMXDQDLQVWDWHVZKHUH LWLVOHJDO'RFWRUVPD\VWLOOPRGLI\DYHWHUDQ·V WUHDWPHQWSODQLIWKHYHWHUDQLVXVLQJPDULMXDQDRU decide not to prescribe pain medicine altogether LIWKHUHLVDULVNRIDGUXJLQWHUDFWLRQ%XWWKDW decision will be made on a case-by-case basis, QRWDVEODQNHWSROLF\

Treatment ,GHQWLI\LQJSDWLHQWVZLWKDPDULMXDQDUHODWHG GLVRUGHUFDQEHGLIÀFXOWEHFDXVHDEXVHDQGDVsociated problems commonly develop slowly. 2IWHQSDWLHQWVGRQRWUHFRJQL]HWKDWWKH\KDYHD SUREOHPLIWKH\GRWKH\DUHSHUKDSVPRUHOLNHO\ to continue their drug use while intensifying their

efforts to hide it from family, physicians and other DXWKRULW\ÀJXUHV$OWKRXJKPDULMXDQDDEXVHLQ adolescents and young adults is of particular FRQFHUQLWVKRXOGQRWEHRYHUORRNHGLQRWKHU SDWLHQWJURXSV)RUH[DPSOHSHUVRQVZLWKFHUWDLQ psychiatric disorders (such as bipolar disorder and post-traumatic stress disorder), those who are under severe emotional distress, and those who have chronic pain might be at increased ULVN 8OWLPDWHO\ SDWLHQWV ZKR QHHG WUHDWPHQW ZLOOEHLGHQWLÀHGWKURXJKGLUHFWGLVFORVXUHRI PDULMXDQDUHODWHG SUREOHPV E\ WKH SDWLHQW D SRVLWLYHXULQHGUXJVFUHHQRULGHQWLÀFDWLRQE\ legal, school or employment authorities. Researchers at the U.S. National Institute on 'UXJ$EXVH 1,'$ KDYHGLVFRYHUHGDZD\WR EORFN WKH HIIHFWV RI 7+& RQ WKH FDQQDELQRLG UHFHSWRUVWKXVPLQLPL]LQJWKHKLJKH[SHULHQFHG E\PDULMXDQDXVHUV7KHVHOHFWLYHFDQQDELQRLG &%UHFHSWRUDQWDJRQLVWULPRQDEDQWFKHPLFDOO\ EORFNV WKH UHFHSWRUV DQG WKXV HOLPLQDWHV WKH LQWR[LFDWLRQDVVRFLDWHGZLWKVPRNLQJPDULMXDQD 6XEMHFWVJLYHQWKHKLJKHVWGRVHRIULPRQDEDQW  PJ  UHSRUWHG D  UHGXFWLRQ LQ KRZ ´KLJKµ WKH\ IHOW FRPSDUHG ZLWK WKH FRQWURO JURXS 7KH WUHDWPHQW JURXS DOVR KDG D  smaller increase in heart rate, one of the primary SK\VLFDOHIIHFWVRIPDULMXDQD/HDGUHVHDUFKHU 'U0DULO\Q+XHVWLVRI1,'$VDLGWKHÀQGLQJV help point the way toward possible treatment IRUSHRSOHDGGLFWHGWRPDULMXDQD´,W·VFHUWDLQO\ an issue that is still a little controversial,” she VDLG ´%XW WKHUH·V EHHQ VRPH EHDXWLIXO ZRUN VKRZLQJ WKDW PDULMXDQD LV DGGLFWLYH DQG WKDW DQXPEHURISHRSOHZKRXWLOL]HWKHGUXJRQD chronic basis have developed dependence and KDYHDYHU\GLIÀFXOWWLPHVWRSSLQJWDNLQJWKH GUXJµ %\ EORFNLQJ WKH EUDLQ·V FDQQDELQRLG receptors, rimonabant may also prove useful in WUHDWLQJREHVLW\FLJDUHWWHVPRNLQJDQGGLVHDVHV VXFKDVVFKL]RSKUHQLDDQGLPSURYLQJPHPRU\

generally dilute it with such inert substances as cornstarch, talcum powder, or sugar, or with such active drugs as procaine (a chemically-related local anesthetic) or with such other stimulants as amphetamines.

“Short

Cocaine Cocaine, a powerfully addictive stimulant, LV RQH RI WKH ROGHVW NQRZQ GUXJV 7KH SXUH chemical, cocaine hydrochloride, has been an DEXVHGVXEVWDQFHIRUPRUHWKDQ\HDUVDQG coca leaves, the source of cocaine, have been ingested for thousands of years. Cocaine was ODEHOHGWKHGUXJRIWKHVDQG·VEHFDXVH RILWVH[WHQVLYHSRSXODULW\DQGXVHGXULQJWKLV period. There are basically two chemical forms RIFRFDLQHWKHK\GURFKORULGHVDOWDQGWKH´IUHHbase.” The hydrochloride salt, or powdered form of cocaine, dissolves in water and, when DEXVHGFDQEHWDNHQLQWUDYHQRXVO\RULQKDOHG Freebase refers to a compound that has not been QHXWUDOL]HGE\DQDFLGWRPDNHWKHK\GURFKORULGH VDOW7KHIUHHEDVHIRUPRIFRFDLQHLVVPRNHDEOH Cocaine is generally sold on the street as a ÀQHZKLWHFU\VWDOOLQHSRZGHUNQRZQDV´FRNHµ ´&µ´VQRZµ´ÁDNHµRU´EORZµ6WUHHWGHDOHUV

Payment Form:LQVLGHEDFNFRYHU‡Toll free number:‡Fax number:

  term  effects  of  

cocaine  include  constricted  

blood  vessels;;  dilated  pupils;;  



´ODYDµDOOZKLFKFRQWDLQWKHFKHPLFDO-:+ The euphoric feeling does not come cheap. 3ULFLQJ RXW DW DSSUR[LPDWHO\  IRU WZR JUDPVDQGIRUIRXUJUDPVZLWKSULFHV DGMXVWHGDFFRUGLQJWRSRWHQF\ Currently, there is no regulation deeming a minimum age to purchase the product, however, PDQ\VWRUHVUHTXLUHLGHQWLÀFDWLRQIURPSRWHQWLDO EX\HUVWKDWDUHDWOHDVW\HDUVROG´
&  increased  temperature,  heart   rate,  &  blood  pressure.

&UDFN RUURFN LVWKHVWUHHWQDPHJLYHQWR the freebase form of cocaine that has been processed from the powdered cocaine hydrochloride IRUPWRVPDOOFOXPSVRIVPRNDEOHVXEVWDQFH &UDFN FRFDLQH LV SURFHVVHG ZLWK DPPRQLD RU EDNLQJVRGDDQGZDWHUDQGKHDWHGWRUHPRYH WKHK\GURFKORULGH7KHWHUP´FUDFNµUHIHUVWR WKH FUDFNOLQJ VRXQG KHDUG ZKHQ WKH PL[WXUH LVVPRNHG%HFDXVHFUDFNLVVPRNHGWKHXVHU H[SHULHQFHVDKLJKLQOHVVWKDQVHFRQGV7KLV rather immediate euphoric effect is one of the UHDVRQVWKDWFUDFNKDVEHFRPHHQRUPRXVO\SRSXODUDQRWKHUUHDVRQLVWKDWFUDFNLVLQH[SHQVLYH both to produce and to buy. The principal routes of cocaine administration are oral, intranasal, intravenous, and inhalation. The slang terms for these routes are, respectively, ´FKHZLQJµ ´VQRUWLQJµ ´PDLQOLQLQJµ ´LQMHFWLQJµ DQG ´VPRNLQJµ LQFOXGLQJ IUHHEDVH DQG FUDFNFRFDLQH 6QRUWLQJLVWKHSURFHVVRILQKDOLQJ cocaine powder through the nostrils, where it is absorbed into the bloodstream through the nasal WLVVXHV,QMHFWLQJUHOHDVHVWKHGUXJGLUHFWO\LQWR the bloodstream, and heightens the intensity of LWVHIIHFWV6PRNLQJLQYROYHVWKHLQKDODWLRQRI FRFDLQHYDSRURUVPRNHLQWRWKHOXQJVZKHUH absorption into the bloodstream is as rapid as E\LQMHFWLRQ7KHGUXJFDQDOVREHUXEEHGRQWR mucous tissues. Some users combine cocaine SRZGHURUFUDFNZLWKKHURLQLQD´VSHHGEDOOµ Cocaine use ranges from occasional use to repeated or compulsive use, with a variety of SDWWHUQV EHWZHHQ WKHVH H[WUHPHV7KHUH LV QR safe way to use cocaine. Any route of adminisWUDWLRQFDQOHDGWRDEVRUSWLRQRIWR[LFDPRXQWV of cocaine, leading to acute cardiovascular or cerebrovascular emergencies that could result in sudden death. Repeated cocaine use by any route of administration can produce addiction and other adverse health consequences. Cocaine acts on the pleasure circuit within the brain to prevent reabsorption of the neurotransmitter dopamine after its release from nerve cells. Normally, the neurons that are part of the pleasure circuit release dopamine, which then crosses the synapse to stimulate another Substance Abuse

Page 55

neuron in the pleasure circuit. Once this has EHHQDFFRPSOLVKHGWKHGRSDPLQHLVSLFNHGXS E\DWUDQVSRUWHUPROHFXOHDQGFDUULHGEDFNLQWR the original neuron. However, because cocaine binds to the dopamine transporter molecule, it prevents the reabsorption of dopamine. This causes a buildup of dopamine in the synapse, which results in strong feelings of pleasure DQGHYHQHXSKRULD7KHH[FHVVGRSDPLQHWKDW accumulates in the synapse causes the neurons that have dopamine receptors to decrease the QXPEHURIUHFHSWRUVWKH\PDNH7KLVLVFDOOHG down regulation. When cocaine is no longer WDNHQDQGGRSDPLQHOHYHOVUHWXUQWRWKHLUQRUPDO (i.e., lower) concentration, the smaller number of dopamine receptors that are available for WKHQHXURWUDQVPLWWHUWRELQGWRLVLQVXIÀFLHQWWR fully activate nerve cells. This results in a drug ´FUDYLQJµZKLFKFRPSHOVWKHDGGLFWWRJHWWKH OHYHORIGRSDPLQHEDFNXSE\WDNLQJFRFDLQH Cocaine also binds to the transporters for other neurotransmitters, including serotonin and norHSLQHSKULQHDQGEORFNVWKHLUUHXSWDNH6FLHQWLVWVDUHVWLOOXQVXUHRIWKHHIIHFWVRIFRFDLQH·V interaction with these other neurotransmitters. &RFDLQHKDVDOVREHHQIRXQGWRVSHFLÀFDOO\ DIIHFWWKHSUHIURQWDOFRUWH[DQGDP\JGDODZKLFK are involved in aspects of memory and emotional learning. Researchers believe that a neural netZRUN LQYROYLQJ WKHVH EUDLQ UHJLRQV UHDFWV WR environmental cues and activates drug-related memories, and this in turn triggers biochemical changes that result in cocaine craving. &RFDLQH·VHIIHFWVDSSHDUDOPRVWLPPHGLDWHO\ after a single dose, and disappear within a few PLQXWHVWRKRXUV,IWDNHQLQVPDOODPRXQWV  PJRUOHVV FRFDLQHW\SLFDOO\PDNHVWKHXVHUIHHO euphoric, sociable, and mentally alert, especially to the sensations of sight, sound, and touch. It can also temporarily decrease the need for food and sleep. Some users say that the drug helps them to perform certain physical and intellectual WDVNVPRUHTXLFNO\ZKLOHRWKHUVH[SHULHQFHWKH opposite effect.

“Long term

use  may  

lead  to  tolerance,  &  addicts  report  



they  eventually  are  unable  to   achieve  as  much  pleasure  as  they   GLGIURPWKHLU¿UVWH[SHULHQFH

7KHGXUDWLRQRIFRFDLQH·VLPPHGLDWHHIIHFWV depends upon the route of administration. The faster the absorption, the more intense the high, and the shorter the duration of action. The high IURPVQRUWLQJIRUH[DPSOHLVUHODWLYHO\VORZLQ RQVHWDQGPD\ODVWWRPLQXWHVZKLOHWKDW Page 56

Substance Abuse

IURPVPRNLQJPD\ODVWRQO\WRPLQXWHV 3HUVRQV ZKR LQMHFW FRFDLQH KDYH SXQFWXUH Short-term physiological effects of cocaine PDUNV DQG ´WUDFNVµ PRVW FRPPRQO\ LQ WKHLU LQFOXGHFRQVWULFWHGEORRGYHVVHOVGLODWHGSXSLOV IRUHDUPV,QWUDYHQRXVFRFDLQHXVHUVPD\H[SHULand increased temperature, heart rate, and blood ence an allergic reaction to the drug or to some SUHVVXUH/DUJHDPRXQWV VHYHUDOKXQGUHGPLO- additive, resulting, in the most severe cases, in OLJUDPVRUPRUH LQWHQVLI\WKHXVHU·VKLJKEXW death. Cocaine abusers, especially those who PD\ DOVR OHDG WR EL]DUUH HUUDWLF DQG YLROHQW LQMHFWDUHDWLQFUHDVHGULVNIRUFRQWUDFWLQJVXFK EHKDYLRU7KHVHXVHUVPD\H[SHULHQFHWUHPRUV LQIHFWLRXVGLVHDVHVDV+,9$,'6DQGKHSDWLWLV vertigo, muscle twitches, paranoia, or, with re- Research has also shown that drug use can interSHDWHGGRVHVDWR[LFUHDFWLRQFORVHO\UHVHPEOLQJ IHUHZLWKMXGJPHQWDERXWULVNWDNLQJEHKDYLRUV amphetamine poisoning. Some users of cocaine and can potentially lead to reduced precautions report feelings of restlessness, irritability, and DERXW KDYLQJ VH[ WKH VKDULQJ RI QHHGOHV DQG DQ[LHW\,QUDUHLQVWDQFHVVXGGHQGHDWKFDQRF- LQMHFWLRQSDUDSKHUQDOLDDQGWKHWUDGLQJRIVH[ FXURQWKHÀUVWXVHRIFRFDLQHRUXQH[SHFWHGO\ for drugs, by both men and women. thereafter, perhaps the result of cardiac arrest or VHL]XUHVIROORZHGE\UHVSLUDWRU\DUUHVW Added Danger: Cocaethylene /RQJWHUP XVH PD\ OHDG WR WROHUDQFH DQG 3RO\GUXJXVH³XVHRIPRUHWKDQRQHGUXJ³LV many addicts report that they eventually are common among substance abusers. When people unable to achieve as much pleasure as they did consume two or more psychoactive drugs togethIURP WKHLU ÀUVW H[SHULHQFH 6RPH XVHUV ZLOO er, such as cocaine and alcohol, they compound repeatedly increase their doses in an attempt to WKHGDQJHUHDFKGUXJSRVHVDQGXQNQRZLQJO\ intensify and prolong the euphoric effects. While tolerance can occur, users can also become more SHUIRUPDFRPSOH[FKHPLFDOH[SHULPHQWZLWKLQ VHQVLWLYHWRWKHGUXJ·VDQHVWKHWLFDQGFRQYXOVDQW their bodies. Researchers have found that the HIIHFWVZLWKRXWLQFUHDVLQJWKHGRVHWDNHQWKLV human liver combines cocaine and alcohol to PD\H[SODLQVRPHRIWKHGHDWKVWKDWRFFXUDIWHU produce a third substance, cocaethylene, which DSSDUHQWO\ORZGRVHVRIFRFDLQH%LQJHXVHRI LQWHQVLÀHVFRFDLQH·VHXSKRULFHIIHFWV&RFDHWKFRFDLQHGXULQJZKLFKWKHGUXJLVWDNHQUHSHDW- \OHQHLVDVVRFLDWHGZLWKDJUHDWHUULVNRIVXGGHQ edly and at increasingly high doses, leads to a death than cocaine alone. 7KHIXOOH[WHQWRIWKHHIIHFWVRISUHQDWDOGUXJ state of increasing irritability, restlessness, and H[SRVXUHRQDFKLOGLVQRWFRPSOHWHO\NQRZQ paranoia. This may result in a full-blown paranoid psychosis, in which the individual loses EXW PDQ\ VFLHQWLÀF VWXGLHV KDYH GRFXPHQWHG WRXFK ZLWK UHDOLW\ DQG H[SHULHQFHV DXGLWRU\ that babies born to mothers who abuse cocaine during pregnancy are often prematurely delivhallucinations. Cocaine use has been associated with severe ered, have low birth weights and smaller head medical complications, including cardiovascular circumferences, and are often shorter in length. effects such as disturbances in heart rhythm and ,QIDFW´FUDFNEDELHVµRUEDELHVERUQWRPRWKHUV KHDUWDWWDFNVLQFUHDVHGEORRGSUHVVXUHDQGERG\ who used cocaine while pregnant, were written WHPSHUDWXUHFKHVWSDLQDQGUHVSLUDWRU\IDLOXUH off by many a decade ago as a lost generation. QHXURORJLFDO HIIHFWV LQFOXGLQJ VHL]XUH KHDG- They were predicted to suffer from severe, irDFKHVVWURNHVDQGFRPDDQGJDVWURLQWHVWLQDO reversible brain damage, resulting in reduced complications, including Cocaine’s Effect on Neurotransmission abdominal pain and nauVHD %HFDXVH FRFDLQH KDV a tendency to decrease Transmitting Neuron IRRGLQWDNHPDQ\FKURQLF Vesicles FRFDLQH XVHUV FDQ H[SHULContaining ence significant weight Dopamine loss and malnourishment. 'LIIHUHQWURXWHVRIFRFDLQH administration can produce different adverse effects. Dopamine Regularly snorting co- Dopamine Transoprter Transporter Dopamine Dopamine FDLQHIRUH[DPSOHFDQOHDG Functioning Functioning Transporter Transoprter Normally to loss of sense of smell, Normally Blocked Blocked Synapse by Cocaine Cocaine by nosebleeds, problems with Synapse swallowing, hoarseness, and an overall irritation of the nasal septum, which can in turn lead to a chroniDopamine Dopamine FDOO\LQÁDPHGUXQQ\QRVH Receptors Receptors Ingested cocaine can cause Cocaine Figure 2 Cocaine Receiving Neuron severe bowel gangrene, due © NCCE, Inc. WRUHGXFHGEORRGÁRZ ‹1DWLRQDO&HQWHURI&RQWLQXLQJ(GXFDWLRQ,QF‡32%R[/DNHZD\7;

LQWHOOLJHQFHDQGVRFLDOVNLOOV,WZDVODWHUIRXQG WKDWWKLVZDVDJURVVH[DJJHUDWLRQ0RVWFUDFN H[SRVHG EDELHV DSSHDU WR UHFRYHU IDLUO\ ZHOO However, the fact that most of these children appear normal should not be over-interpreted as a positive sign. Using more sophisticated technoloJLHVVFLHQWLVWVDUHQRZÀQGLQJWKDWH[SRVXUHWR cocaine during fetal development may lead to VXEWOHEXWVLJQLÀFDQWGHÀFLWVODWHUHVSHFLDOO\ with behaviors that are crucial to success in the FODVVURRP VXFK DV EORFNLQJ RXW GLVWUDFWLRQV and concentrating for long periods of time.

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Health/Behavioral Effects 7KH PDLQ SV\FKRDFWLYH LQJUHGLHQWV LQ NKDW are cathine and cathinone, chemicals that are structurally similar to, but less potent than, amphetamine, yet result in similar psychomotor VWLPXODQWHIIHFWV&KHZLQJNKDWOHDYHVLQGXFHV a state of euphoria and elation as well as feelings of increased alertness and arousal. The user also H[SHULHQFHVDQLQFUHDVHLQEORRGSUHVVXUHDQG heart rate. The effects begin to subside after DERXW  PLQXWHV WR  KRXUV EXW FDQ ODVW  KRXUV$WWKHHQGRIDNKDWVHVVLRQWKHXVHUPD\ H[SHULHQFHDGHSUHVVLYHPRRGLUULWDELOLW\ORVV RIDSSHWLWHDQGGLIÀFXOW\VOHHSLQJ There are a number of adverse physical effects that have been associated with heavy or ORQJWHUPXVHRINKDWLQFOXGLQJWRRWKGHFD\DQG SHULRGRQWDO GLVHDVH JDVWURLQWHVWLQDO GLVRUGHUV VXFK DV FRQVWLSDWLRQ XOFHUV LQÁDPPDWLRQ RI WKHVWRPDFKDQGLQFUHDVHGULVNRIXSSHUJDVWURLQWHVWLQDOWXPRUVDQGFDUGLRYDVFXODUGLVRUGHUV such as irregular heartbeat, decreased blood ÁRZDQGP\RFDUGLDOLQIDUFWLRQ7KHUHLVDOVR FRQVLVWHQWHSLGHPLRORJLFHYLGHQFHIRUDZHDN DVVRFLDWLRQEHWZHHQFKURQLFNKDWXVHDQGPHQWDO GLVRUGHUV$OWKRXJKWKHUHLVQRHYLGHQFHWKDWNKDW XVHFDXVHVPHQWDOLOOQHVVFKHZLQJNKDWOHDYHV may worsen symptoms in patients who have SUHH[LVWLQJSV\FKLDWULFFRQGLWLRQV ,WLVXQFOHDUZKHWKHUNKDWFDXVHVWROHUDQFH physical dependency, addiction, or withdrawal, but nightmares and slight trembling have been reported several days after ceasing to chew. ,WLVHVWLPDWHGWKDWPLOOLRQSHRSOHZRUOGZLGHFKHZNKDW,WLVFRPPRQO\IRXQGLQWKH southwestern part of the Arabian Peninsula and in East Africa, where it has been used for centuries as part of an established cultural tradiWLRQ,QRQHODUJHVWXG\LQ
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GUDLQ FOHDQHU EDWWHU\ DFLG DQG DQWLIUHH]H DUH H[WUHPHO\ GDQJHURXV 7KH UDSLG SUROLIHUDWLRQ RI VRFDOOHG ´EDVHPHQWµ ODERUDWRULHV IRU WKH production of methamphetamine has led to a widespread problem in many communities in the U.S. Methamphetamine abuse has long been reported as the dominant drug problem in portions of Southern California, but has become a substantial drug problem in other sections of the West and Southwest as well and continues to spread to other areas of the country, including both rural and urban sections of the South and Midwest. Its use was traditionally associated with ZKLWHPDOHEOXHFROODUZRUNHUVEXWLWLVEHLQJ used by ever more diverse population groups that change over time and differ by geographic area. Methamphetamine comes in many forms and FDQEHVPRNHGVQRUWHGRUDOO\LQJHVWHGRULQMHFWHG7KHGUXJDOWHUVPRRGVLQGLIIHUHQWZD\V GHSHQGLQJRQKRZLWLVWDNHQ,PPHGLDWHO\DIWHU VPRNLQJWKHGUXJRULQMHFWLQJLWLQWUDYHQRXVO\ WKHXVHUH[SHULHQFHVDQLQWHQVHUXVKRU´ÁDVKµ that lasts only a few minutes and is described as H[WUHPHO\SOHDVXUDEOH6QRUWLQJRURUDOLQJHVWLRQ SURGXFHVHXSKRULD³DKLJKEXWQRWDQLQWHQVH UXVK 6QRUWLQJ SURGXFHV HIIHFWV ZLWKLQ  WR  minutes, and oral ingestion produces effects ZLWKLQWRPLQXWHV As with similar stimulants, methamphetamine PRVWRIWHQLVXVHGLQD´ELQJHDQGFUDVKµSDWWHUQ %HFDXVHWROHUDQFHIRUPHWKDPSKHWDPLQHRFFXUV within minutes – meaning that the pleasurable effects disappear even before the drug concentraWLRQLQWKHEORRGIDOOVVLJQLÀFDQWO\²XVHUVWU\WR maintain the high by binging on the drug. In the V´LFHµD´VPRNHDEOHµIRUPRIPHWKDPphetamine, came into use. Ice is a large, usually FOHDU FU\VWDO RI KLJK SXULW\ WKDW LV VPRNHG LQ DJODVVSLSHOLNHFUDFNFRFDLQH7KHVPRNHLV RGRUOHVVOHDYHVDUHVLGXHWKDWFDQEHUHVPRNHG DQGSURGXFHVHIIHFWVWKDWPD\FRQWLQXHIRU hours or more. Methamphetamine acts on the pleasure circuit in the brain by altering the levels of certain neurotransmitters present in the synapse. Methamphetamine is chemically similar to dopamine and another neurotransmitter, norepinephrine. It produces its effects by causing dopamine and norepinephrine to be released into the synapse in several areas of the brain, including the nucleus DFFXPEHQVSUHIURQWDOFRUWH[DQGWKHVWULDWXP DEUDLQDUHDLQYROYHGLQPRYHPHQW6SHFLÀFDOO\ methamphetamine enters nerve terminals by passing directly through nerve cell membranes. It is also carried into the nerve terminals by transporter molecules that normally carry dopamine RUQRUHSLQHSKULQHIURPWKHV\QDSVHEDFNLQWR the nerve terminal. Once in the nerve terminal, methamphetamine enters dopamine and norepinephrine containing vesicles and causes the reOHDVHRIWKHVHQHXURWUDQVPLWWHUV(Q]\PHVLQWKH FHOOQRUPDOO\EUHDNGRZQH[FHVVGRSDPLQHDQG QRUHSLQHSKULQHEXWPHWKDPSKHWDPLQHEORFNV WKLVSURFHVV7KHH[FHVVQHXURWUDQVPLWWHUVDUH Substance Abuse

Page 57

then carried by transporter molecules out of the neuron and into the synapse. Once in the synapse, WKHVLJQLÀFDQWO\KLJKHUWKDQQRUPDOFRQFHQWUDtion of dopamine causes feelings of pleasure DQGHXSKRULD7KHH[FHVVQRUHSLQHSKULQHPD\ be responsible for the alertness and anti-fatigue effects of methamphetamine. /RQJWHUP PHWKDPSKHWDPLQH DEXVH UHVXOWV in many damaging effects, including addiction. Addiction is a chronic, relapsing disease, FKDUDFWHUL]HGE\FRPSXOVLYHGUXJVHHNLQJDQG drug use, which is accompanied by functional and molecular changes in the brain. In addition to being addicted to methamphetamine, chronic PHWKDPSKHWDPLQH DEXVHUV H[KLELW V\PSWRPV WKDWFDQLQFOXGHDQ[LHW\FRQIXVLRQDQGLQVRPnia. They also can display a number of psychotic features, including paranoia, auditory and visual hallucinations, mood disturbances, and delusions IRUH[DPSOHWKHVHQVDWLRQRILQVHFWVFUHHSLQJRQ WKHVNLQFDOOHG´IRUPLFDWLRQµ 7KHSDUDQRLDFDQ result in homicidal as well as suicidal thoughts, and out-of-control rages that can be coupled with H[WUHPHO\YLROHQWEHKDYLRU With chronic use, tolerance for methamphetamine can develop. In an effort to intensify the GHVLUHGHIIHFWVXVHUVPD\WDNHKLJKHUGRVHVRI WKHGUXJWDNHLWPRUHIUHTXHQWO\RUFKDQJHWKHLU PHWKRGRIGUXJLQWDNH,QVRPHFDVHVDEXVHUV forego food and sleep while indulging in a form RIELQJLQJNQRZQDVD´UXQµLQMHFWLQJDVPXFK DVDJUDPRIWKHGUXJHYHU\WRKRXUVRYHU several days until the user runs out of the drug RU LV WRR GLVRUJDQL]HG WR FRQWLQXH $OWKRXJK there are no physical manifestations of a withdrawal syndrome when methamphetamine use is stopped, there are several symptoms that occur ZKHQDFKURQLFXVHUVWRSVWDNLQJWKHGUXJ7KHVH LQFOXGHGHSUHVVLRQDQ[LHW\IDWLJXHSDUDQRLD aggression, and an intense craving for the drug. Methamphetamine can also affect the brain in other ways, causing cerebral edema, brain hemorrhage, and hallucinations. Moreover, some of the effects of methamphetamine on the brain appear to be long lasting and even permanent. Recent research has shown that even three years after chronic methamphetamine users have discontinued use of the drug, there remains a reduction in their ability to transport GRSDPLQHEDFNLQWRQHXURQV5HVHDUFKHUVKDYH UHSRUWHG WKDW DV PDQ\ DV  SHUFHQW RI WKH dopamine-producing cells in the brain can be GDPDJHGDIWHUSURORQJHGH[SRVXUHWRUHODWLYHO\ low levels of methamphetamine. This is highly VLJQLÀFDQWEHFDXVHGRSDPLQHKDVDPDMRUUROH LQPDQ\EUDLQIXQFWLRQVLQFOXGLQJH[SHULHQFHV of pleasure, mood, and movement. In these same studies, researchers found similarities in the damage to the dopamine system of methamphetamine users to that seen in patients with 3DUNLQVRQ·VGLVHDVH5HVHDUFKHUVDOVRKDYHIRXQG that serotonin-containing nerve cells may be GDPDJHGHYHQPRUHH[WHQVLYHO\:KHWKHUWKLV

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Substance Abuse

WR[LFLW\LVUHODWHGWRWKHSV\FKRVLVVHHQLQVRPH long-term methamphetamine abusers is still an open question. Methamphetamine can cause a variety of cardiovascular problems. These include rapid heart rate, irregular heartbeat, increased blood presVXUHDQGLUUHYHUVLEOHVWURNHOLNHGDPDJHWRWKH small blood vessels of the brain. Hyperthermia and convulsions occur with methamphetamine overdose, and if not treated immediately can result in death. Chronic methamphetamine abuse can result LQLQÁDPPDWLRQRIWKHKHDUWOLQLQJDQGDPRQJ XVHUVZKRLQMHFWWKHGUXJGDPDJHGEORRGYHVVHOV DQGVNLQDEVFHVVHV0HWKDPSKHWDPLQHDEXVHUV also can have episodes of violent behavior, SDUDQRLD DQ[LHW\ FRQIXVLRQ DQG LQVRPQLD Heavy users also show progressive social and occupational deterioration. Psychotic symptoms can sometimes persist for months or years after use has ceased. A common method of illegal methamphetamine production uses lead acetate as a reDJHQWWKHUHIRUHSURGXFWLRQHUURUVPD\UHVXOW in methamphetamine contaminated with lead. There have been documented cases of acute lead poisoning in intravenous methamphetamine abusers. )HWDOH[SRVXUHWRPHWKDPSKHWDPLQHDOVRLVD VLJQLÀFDQWSUREOHPLQWKH8QLWHG6WDWHV$WSUHVent, research indicates that methamphetamine abuse during pregnancy may result in prenatal complications, increased rates of premature delivery, and altered neonatal behavioral patterns, VXFKDVDEQRUPDOUHÁH[HVDQGH[WUHPHLUULWDELOity. Methamphetamine abuse during pregnancy PD\DOVREHOLQNHGWRFRQJHQLWDOGHIRUPLWLHV

Treatment There are some established protocols that emergency room physicians use to treat individuals who have had a methamphetamine RYHUGRVH %HFDXVH K\SHUWKHUPLD DQG FRQYXOsions are common and often fatal complications of such overdoses, emergency room treatment focuses on the immediate physical symptoms. Overdose patients are cooled off in ice baths, and anticonvulsant drugs may also be adminisWHUHG$FXWHPHWKDPSKHWDPLQHLQWR[LFDWLRQFDQ often be handled by observation in a safe, quiet HQYLURQPHQW,QFDVHVRIH[WUHPHH[FLWHPHQWRU SDQLFWUHDWPHQWZLWKDQWLDQ[LHW\DJHQWVVXFKDV EHQ]RGLD]HSLQHVKDVEHHQKHOSIXODQGLQFDVHV of methamphetamine-induced psychoses, shortterm use of neuroleptics has proven successful. At this time the most effective treatments for methamphetamine addiction are cognitive behavioral interventions. These approaches are GHVLJQHGWRKHOSPRGLI\WKHSDWLHQW·VWKLQNLQJ H[SHFWDQFLHV DQG EHKDYLRUV DQG WR LQFUHDVH VNLOOVLQFRSLQJZLWKYDULRXVOLIHVWUHVVRUV7KH 0DWUL[0RGHODSURYHQHIIHFWLYHWUHDWPHQWIRU PHWKDPSKHWDPLQHDGGLFWLRQFRQVLVWVRID

ZHHNLQWHUYHQWLRQWKDWLQFOXGHVLQWHQVLYHJURXS and individual therapy to promote the behavioral changes needed to remain off drugs, prevent relapse, and establish a new lifestyle unrelated to drugs. When applied to methamphetamine DEXVHUVWKH0DWUL[0RGHOKDVEHHQVKRZQWR VLJQLÀFDQWO\UHGXFHGUXJXVH )LJXUHWRULJKW  0RWLYDWLRQDO ,QFHQWLYHV IRU (QKDQFLQJ 'UXJ $EXVH5HFRYHU\ 0,('$5 DQLQFHQWLYHEDVHG method for cocaine and methamphetamine abstinence, is another treatment program that has UHFHQWO\GHPRQVWUDWHGHIÀFDF\LQPHWKDPSKHWDPLQHDEXVHUVWKURXJK1,'$·V1DWLRQDO'UXJ $EXVH &OLQLFDO7ULDOV 1HWZRUN 0HWKDPSKHWamine recovery support groups also appear to EHHIIHFWLYHDGMXQFWVWREHKDYLRUDOLQWHUYHQWLRQV that can lead to long-term drug-free recovery. Antidepressant medications can be helpful in combating the depressive symptoms frequently seen in newly abstinent methamphetamine users.

Abuse of Medications for ADHD 7KHPHGLFDWLRQVXVHGIRUWUHDWPHQWRI$'+' are primarily stimulants. While these drugs are safe and effective when used properly, they have DKLJKSRWHQWLDOIRUDEXVHOLNHRWKHUVWLPXODQWV WKH\FDQOHDGWRPDUNHGWROHUDQFHDQGSV\FKRlogical dependence, and can cause medical problems leading to serious illness or even death. 7KHPRVWZHOONQRZQRIWKH$'+'PHGLFDtions include amphetamines (e.g., Adderall®, a PL[RIDPSKHWDPLQHVDOWV DQGPHWK\OSKHQLGDWH HJ03+5LWDOLQDQG&RQFHUWD³DIRUPXODtion that releases medication in the body over a period of time). These medications have a SDUDGR[LFDOO\FDOPLQJDQG´IRFXVLQJµHIIHFWRQ LQGLYLGXDOVZLWK$'+'5HVHDUFKHUVVSHFXODWH that because methylphenidate, a mild central QHUYRXV VWLPXODQW DPSOLÀHV WKH UHOHDVH RI dopamine, thus improving attention and focus in individuals who have dopamine signals that DUHZHDN,WDOVRDFWVE\DFWLYDWLQJWKHDURXVDO V\VWHPVLQWKHEUDLQVWHPDQGFRUWH[WRSURGXFH its stimulant effects. While MPH appears to target the same neuroreceptors as cocaine, it does not affect all the same components of the pleasure circuit throughout the brain. MPH can be abused orally, or tablets can be crushed and either snorted or dissolved in water DQGLQMHFWHG7KHSDWWHUQRIDEXVHLVFKDUDFWHUL]HG by an escalation in dose, frequent episodes of binge use followed by severe depression, and an overpowering desire to continue the use of this drug despite serious, adverse medical and social consequences. Typical of other CNS stimulants, high doses of MPH often produce agitation, tremors, euphoria, tachycardia, palpitations, and hypertension. Psychotic episodes, paranoid GHOXVLRQVKDOOXFLQDWLRQVDQGEL]DUUHEHKDYLRUDO FKDUDFWHULVWLFVVLPLODUWRDPSKHWDPLQHOLNHWR[LF effects have been associated with MPH abuse.

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8QOLNH DPSKHWDPLQH PHWKDPSKHWDPLQH and cocaine, where illicit manufacturing and smuggling into the United States account for WKHYDVWPDMRULW\RIDYDLODEOHGUXJVIRUDEXVH pharmaceutical products diverted from legitimate channels are the only sources of MPH. It is important to note that many schools have more MPH stored for daytime dosing of students than is available in some pharmacies, and PDQ\IDPLOLHVKDYHVXSSOLHVVWRUHGLQNLWFKHQ or bathroom cabinets. ,QIRUPDWLRQ IURP '($ FDVH ÀOHV DQG VWDWH law enforcement services indicates that MPH is sought after by a wide range of individuals, from adolescents to street addicts. Even though WKHODFNRIFODQGHVWLQHSURGXFWLRQUHJXODWRU\ controls, and predominant use in the treatment RI$'+'LQFKLOGUHQKDYHKLVWRULFDOO\OLPLWHG the illegal use of this drug, non-prescription use is on the rise. Recent reports of MPH misuse/ abuse among adolescents and young adults are particularly disturbing, since this group has the freest access to this drug. Reports from numerous states and local municipalities indicate that adolescents are giving and selling their MPH medication to friends and classmates. Anecdotal reports from students and faculty on college campuses indicate that MPH is being used as a study aid in the same manner that amphetamine ZDVXVHGRQFDPSXVHVLQWKHV5LWDOLQDEXVH is increasingly observed among elementary students, and newspaper reports suggest that it LV´DVHDV\WRJHWDVFDQG\µ

Heroin and the Opiates Opiates are powerful drugs derived from the poppy plant that have been used for centuries to relieve pain. They include opium, heroin, morphine, and codeine. Even centuries after their discovery, opiates are still the most effective pain relievers. Although heroin has no medicinal use, the other opiates, such as morphine and codeine, are used to relieve pain related to illnesses (for H[DPSOHFDQFHU DQGPHGLFDODQGGHQWDOSURcedures. When used as directed by a physician, opiates are safe and generally do not produce DGGLFWLRQ%XWRSLDWHVDOVRSRVVHVVYHU\VWURQJ UHLQIRUFLQJSURSHUWLHVDQGFDQTXLFNO\WULJJHU addiction when used improperly. The brain produces endorphins that activate opioid receptors located throughout the brain and body. Research indicates that endorphins are involved in many functions, including respiration, nausea, vomiting, pain modulation, and hormonal regulation. Two important effects produced by the naturally occurring endorphins DQGRSLDWHGUXJVDOLNHDUHSOHDVXUH RUUHZDUG  and pain relief. /LNHFRFDLQHDQGRWKHUDEXVHGGUXJVRSLDWHV DFWLYDWHWKHEUDLQ·VUHZDUGV\VWHP%HFDXVHRI its chemical structure, heroin penetrates the EUDLQ PRUH TXLFNO\ WKDQ RWKHU RSLDWHV ZKLFK

is probably why many addicts prefer heroin. :KHQDSHUVRQLQMHFWVVQLIIVRURUDOO\LQJHVWV heroin, the drug travels through the bloodstream, across the blood brain barrier, and into the brain. Once in the brain, heroin is rapidly converted to morphine, which then activates opiate receptors located throughout the brain, including the ventral tegmental area, nucleus accumbens DQGFHUHEUDOFRUWH[ZLWKLQWKHUHZDUGV\VWHP Research suggests that stimulation of opioid receptors by morphine results in feelings of reward and activates the pleasure circuit by causing greater amounts of dopamine to be released ZLWKLQWKHQXFOHXVDFFXPEHQV7KLVH[FHVVLYH release of dopamine and over stimulation of the reward system can lead to addiction. Opiates also act directly on the respiratory center in the brainstem causing a slowdown in activity, resulting in a decrease in respiratory UDWH([FHVVLYHDPRXQWVRIDQRSLDWHOLNHKHURLQ can cause the respiratory centers to shut down breathing altogether. When someone overdoses on heroin, it is the action of heroin in the brainstem respiratory centers that can cause the person to stop breathing and die. Heroin, the most abused and rapidly acting of the opiates, is an illegal, highly addictive drug. It is processed from morphine, the naturally ocFXUULQJVXEVWDQFHH[WUDFWHGIURPWKHVHHGSRGRI certain varieties of poppy plants. It is typically sold as a white or brownish powder or as the EODFNVWLFN\VXEVWDQFHNQRZQRQWKHVWUHHWVDV ´EODFN WDU KHURLQµ $OWKRXJK SXUHU KHURLQ LV becoming more common, most street heroin is ´FXWµZLWKRWKHUGUXJVRUZLWKVXEVWDQFHVVXFK DV VXJDU VWDUFK SRZGHUHG PLON RU TXLQLQH Street heroin can also be cut with strychnine or RWKHUSRLVRQV%HFDXVHKHURLQDEXVHUVGRQRW NQRZWKHDFWXDOVWUHQJWKRIWKHGUXJRULWVWUXH FRQWHQWVWKH\DUHDWULVNRIRYHUGRVHRUGHDWK Heroin also poses special problems because of the transmission of HIV and other diseases that FDQRFFXUIURPVKDULQJQHHGOHVRURWKHULQMHFtion equipment. +HURLQ LV XVXDOO\ LQMHFWHG VQLIIHGVQRUWHG RUVPRNHG7KLVFDXVHVDQLQWHQVHHXSKRULDRU UXVKWKDWODVWVRQO\EULHÁ\DQGLVIROORZHGE\ DIHZKRXUVRIUHOD[HGFRQWHQWPHQW$W\SLFDO KHURLQDEXVHUPD\LQMHFWXSWRIRXUWLPHVDGD\ ,QWUDYHQRXVLQMHFWLRQSURYLGHVWKHJUHDWHVWLQWHQVLW\DQGPRVWUDSLGRQVHWRIHXSKRULD WR VHFRQGV ZKLOHLQWUDPXVFXODULQMHFWLRQSURGXFHV DUHODWLYHO\VORZRQVHWRIHXSKRULD WRPLQXWHV :KHQKHURLQLVVQLIIHGRUVPRNHGSHDN HIIHFWVDUHXVXDOO\IHOWZLWKLQWRPLQXWHV The intensity of the rush is a function of how PXFKGUXJLVWDNHQDQGKRZUDSLGO\WKHGUXJ enters the brain and binds to the natural opioid receptors. With heroin, the rush is usually acFRPSDQLHGE\DZDUPÁXVKLQJRIWKHVNLQGU\ PRXWKDQGDKHDY\IHHOLQJLQWKHH[WUHPLWLHV and may be accompanied by nausea, vomiting, DQGVHYHUHLWFKLQJ$OWKRXJKVPRNLQJDQGVQLII-

Payment Form:LQVLGHEDFNFRYHU‡Toll free number:‡Fax number:

LQJKHURLQGRQRWSURGXFHD´UXVKµDVTXLFNO\ RUDVLQWHQVHO\DVLQWUDYHQRXVLQMHFWLRQ1,'$ UHVHDUFKHUVKDYHFRQÀUPHGWKDWDOOWKUHHIRUPV of heroin use are addictive. ,QMHFWLRQ FRQWLQXHV WR EH WKH SUHGRPLQDQW method of heroin use among addicted users VHHNLQJ WUHDWPHQW KRZHYHU UHVHDUFKHUV KDYH observed a shift in heroin use patterns, from LQMHFWLRQ WR VQLIÀQJ DQG VPRNLQJ ,Q IDFW VQLIÀQJVQRUWLQJKHURLQLVQRZWKHPRVWZLGHO\ UHSRUWHGPHDQVRIWDNLQJKHURLQDPRQJXVHUV DGPLWWHGIRUGUXJWUHDWPHQWLQ1HZDUN&KLFDJR DQG1HZ
Substance Abuse

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bacterial infections of the blood vessels and heart valves, abscesses (boils) and other softWLVVXH LQIHFWLRQV DQG OLYHU RU NLGQH\ GLVHDVH /XQJFRPSOLFDWLRQV LQFOXGLQJYDULRXVW\SHVRI pneumonia and tuberculosis) may result from the poor health condition of the abuser as well DVIURPKHURLQ·VGHSUHVVDQWHIIHFWVRQUHVSLUDtion. Many of the additives in street heroin may include substances that do not readily dissolve, thus clogging the blood vessels that lead to WKHOXQJVOLYHUNLGQH\VRUEUDLQDQGFDXVLQJ infection or even death of small patches of cells in vital organs. Immune reactions to these or other contaminants can cause arthritis or other rheumatologic problems. Of course, sharing of LQMHFWLRQHTXLSPHQWRUÁXLGVFDQOHDGWRVRPHRI the most severe consequences of heroin abuse: LQIHFWLRQVZLWKKHSDWLWLV%DQG&+,9DQGD host of other blood-borne viruses, which drug DEXVHUVFDQWKHQSDVVRQWRWKHLUVH[XDOSDUWQHUV and children.

Treatment A variety of effective treatments are available for heroin addiction. Treatment tends to be more HIIHFWLYHZKHQKHURLQDEXVHLVLGHQWLÀHGHDUO\ DQGGHWR[LÀFDWLRQLVWKHÀUVWVWHS7KHWUHDWPHQWV that follow vary depending on the individual, EXWPHWKDGRQHDV\QWKHWLFRSLDWHWKDWEORFNV the effects of heroin and eliminates withdrawal symptoms, has a proven record of success. 3KDUPDFHXWLFDO DSSURDFKHV OLNH PHWKDGRQH 1DOWUH[RQH 1DOR[RQH DQG EXSUHQRUSKLQH DUH used to treat heroin addiction. There are also many effective behavioral treatments available IRU KHURLQ DGGLFWLRQ³XVXDOO\ LQ FRPELQDWLRQ with medication. These can be delivered in UHVLGHQWLDORURXWSDWLHQWVHWWLQJV([DPSOHVDUH LQGLYLGXDO RU JURXS FRXQVHOLQJ FRQWLQJHQF\ management, which uses a voucher-based sysWHPZKHUHSDWLHQWVHDUQ´SRLQWVµEDVHGRQQHJDWLYHGUXJWHVWV³WKHVHSRLQWVFDQEHH[FKDQJHG IRU LWHPV WKDW HQFRXUDJH KHDOWK\ OLYLQJ DQG cognitive-behavioral therapy, designed to help PRGLI\DSDWLHQW·VH[SHFWDWLRQVDQGEHKDYLRUV UHODWHGWRGUXJDEXVHDQGWRLQFUHDVHVNLOOVLQ coping with various life stressors.

'HWR[LÀFDWLRQ 7KHSULPDU\REMHFWLYHRIGHWR[LÀFDWLRQLVWR relieve withdrawal symptoms while patients DGMXVWWRDGUXJIUHHVWDWH1RWLQLWVHOIDWUHDWPHQWIRUDGGLFWLRQGHWR[LÀFDWLRQLVDXVHIXOVWHS only when it leads into long-term treatment that is either drug-free (residential or outpatient) or uses medications as part of the treatment. The best documented drug-free treatments are the therapeutic community residential programs ODVWLQJDWOHDVWWRPRQWKV

Treatment programs Methadone treatment has been used effectively and safely to treat opioid addiction for more than Page 60

Substance Abuse

\HDUV3URSHUO\SUHVFULEHGPHWKDGRQHLVQRW LQWR[LFDWLQJRUVHGDWLQJDQGLWVHIIHFWVGRQRW interfere with ordinary activities such as driving DFDU7KHPHGLFDWLRQLVWDNHQRUDOO\RQFHDGD\ DQGLWVXSSUHVVHVQDUFRWLFZLWKGUDZDOIRUWR  KRXUV 3DWLHQWV RQ PHWKDGRQH UHPDLQ DEOH to perceive pain and have emotional reactions. Most important, methadone relieves the craving DVVRFLDWHGZLWKKHURLQDGGLFWLRQFUDYLQJLVD PDMRU UHDVRQ IRU UHODSVH $PRQJ PHWKDGRQH patients, it has been found that normal street doses of heroin are ineffective at producing HXSKRULDWKXVPDNLQJWKHXVHRIKHURLQPRUH HDVLO\H[WLQJXLVKDEOH Also, methadone is medically safe even ZKHQXVHGFRQWLQXRXVO\IRU\HDUVRUPRUH Combined with behavioral therapies or counseling and other supportive services, methadone enables patients to stop using heroin (and other opiates) and return to more stable and productive lives. Methadone dosages must be carefully monitored in patients who are receiving antiviral therapy for HIV infection, however, to avoid potential medication interactions.

Other Medications Buprenorphine is a more recently approved treatment for heroin addiction (and other opiates). Compared with methadone, buprenorphine SURGXFHVOHVVULVNIRURYHUGRVHDQGZLWKGUDZDO effects and produces a lower level of physical dependence, so patients who discontinue the medication generally have fewer withdrawal V\PSWRPVWKDQWKRVHZKRVWRSWDNLQJPHWKDdone. The development of buprenorphine and LWV DXWKRUL]HG XVH LQ SK\VLFLDQV· RIÀFHV JLYH opiate-addicted patients more medical options DQGH[WHQGWKHUHDFKRIDGGLFWLRQPHGLFDWLRQ Its accessibility may even prompt attempts to obtain treatment earlier. However, not all patients UHVSRQG WR EXSUHQRUSKLQH³VRPH FRQWLQXH WR require treatment with methadone. Naltrexone (Trexan) is approved for treating KHURLQDGGLFWLRQEXWKDVQRWEHHQZLGHO\XWLOL]HG due to poor patient compliance. This medication EORFNVRSLRLGVIURPELQGLQJWRWKHLUUHFHSWRUV and thus prevents an addicted individual from IHHOLQJWKHHIIHFWVRIWKHGUXJ1DOWUH[RQHDVD treatment for opioid addiction is usually prescribed in outpatient medical settings, although initiation of the treatment often begins after PHGLFDOGHWR[LÀFDWLRQLQDUHVLGHQWLDOVHWWLQJ To prevent withdrawal symptoms, individuals PXVW EH PHGLFDOO\ GHWR[LÀHG DQG RSLRLGIUHH IRUVHYHUDOGD\VEHIRUHWDNLQJQDOWUH[RQH1DOWUH[RQHKDVDOVREHHQIRXQGWREHVXFFHVVIXO in preventing relapse by former opiate addicts released from prison on parole. Naloxone (Narcan) is a shorter-acting opioid UHFHSWRUEORFNHUXVHGWRWUHDWFDVHVRIRYHUGRVH As opiate antagonists, they are especially useful as antidotes. For pregnant heroin abusers, methadone

maintenance combined with prenatal care and a comprehensive drug treatment program can improve many of the detrimental maternal and neonatal outcomes associated with untreated heroin abuse. Preliminary evidence suggests that buprenorphine may also be a safe and effective treatment during pregnancy, although infants H[SRVHGWRHLWKHUPHWKDGRQHRUEXSUHQRUSKLQH prenatally may still require treatment for withdrawal symptoms. For women who do not want or are not able to receive pharmacotherapy for WKHLUKHURLQDGGLFWLRQGHWR[LÀFDWLRQIURPRSLates during pregnancy can be accomplished with PHGLFDOVXSHUYLVLRQDOWKRXJKSRWHQWLDOULVNVWR WKHIHWXVDQGWKHOLNHOLKRRGRIUHODSVHWRKHURLQ use should be considered. Other medications with potential for treating heroin overdose/addiction are currently under LQYHVWLJDWLRQE\1,'$

Behavioral therapies Although behavioral and pharmacologic treatPHQWVFDQEHH[WUHPHO\XVHIXOZKHQHPSOR\HG alone, integrating both types of treatments will ultimately be most effective. There are many behavioral treatments available for heroin addiction in both residential and outpatient settings: WKH LPSRUWDQW WDVN LV WR PDWFK WKH WUHDWPHQW approach to the particular needs of the patient. &RQWLQJHQF\PDQDJHPHQWWKHUDS\IRUH[DPSOH uses a voucher-based system, where patients earn points based on negative drug tests that they FDQH[FKDQJHIRULWHPVWKDWHQFRXUDJHKHDOWK\ living. Cognitive-behavioral interventions are GHVLJQHGWRKHOSPRGLI\WKHSDWLHQW·VWKLQNLQJ H[SHFWDWLRQV DQG EHKDYLRUV DQG WR LQFUHDVH VNLOOVLQFRSLQJZLWKYDULRXVOLIHVWUHVVRUV%RWK behavioral and pharmacological treatments help to restore a degree of normalcy to brain function and behavior, with increased employment rates DQGORZHUULVNRI+,9DQGRWKHUGLVHDVHVDQG criminal behavior.

Opioid Analogs and Relatives 'UXJDQDORJVDUHFKHPLFDOFRPSRXQGVWKDWDUH similar to other drugs in their effects but differ slightly in their chemical structure. Some analogs are produced by pharmaceutical companies for legitimate medical reasons. Other analogs, VRPHWLPHVUHIHUUHGWRDV´GHVLJQHUµGUXJVFDQ be produced in illegal laboratories and are often more dangerous and potent than the original GUXJ7ZRRIWKHPRVWFRPPRQO\NQRZQRSLRLG DQDORJVDUHIHQWDQ\ODQGPHSHULGLQH 'HPHURO  Fentanyl was introduced under the brand name ´6XEOLPD]HµLQE\D%HOJLDQSKDUPDFHXWLcal company as a synthetic narcotic to be used as an analgesic in surgical procedures because of its minimal effects on the heart. Soon thereafter, an analog version called China White began to appear: users ended up in emergency rooms with classic overdose symptoms that responded to RSLDWHDQWDJRQLVWVOLNH1DUFDQEXWWKHUHZHUH

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no traces of opiates in their symptoms. Fentanyl LVSDUWLFXODUO\GDQJHURXVEHFDXVHLWLVWLPHV more potent than heroin and can rapidly stop respiration. This is not a problem during surgical procedures because machines are used to help patients breathe. On the street, however, users have been found dead with the needle used to LQMHFWWKHGUXJVWLOOLQWKHLUDUPV A particularly tragic story is associated with attempts to create an effective analog of 'HPHURO IRU VWUHHW XVH7KH VXEVWDQFH FDOOHG MPTP after its molecular components, turned RXWWREHDSRWHQWQHXURWR[LQSURGXFLQJDVHULRXVDQGLUUHYHUVLEOH3DUNLQVRQ·VOLNHV\QGURPH LQXVHUV'HVSLWHDOOWUHDWPHQWHIIRUWVPRVWRI WKRVHDIIHFWHGUHPDLQXQDEOHWRPRYHRUVSHDN $ VHPLV\QWKHWLF QDUFRWLF R[\FRGRQH 3HUcodan), has been widely used for years, often in combination with aspirin or acetaminophen. 6\QWKHVL]HGIURPWKHEDLQHDQRSLXPGHULYDWLYH it is more potent than codeine and has a higher dependence potential. Street use was limited GXHWRLWVWHQGHQF\WRPDNHWKHXVHU·VHDUVULQJ Recently, a time-release version of the venerable 3HUFRGDQZDVLQWURGXFHG2[\&RQWLQDVLWLV FDOOHGZDVZLGHO\KHUDOGHGDVDVLJQLÀFDQWLPprovement over available palliative medications, because its time-release mechanism afforded VLJQLÀFDQWVXVWDLQHGUHOLHIIRUSHRSOHLQVHYHUH pain. It has been prescribed primarily for patients diagnosed with terminal cancer, recovering from PDMRU VXUJHU\ RU VXIIHULQJ IURP GHELOLWDWLQJ migraine headaches. Unfortunately, street users of the drug, attracted to its euphoric high that is similar to that of heroin, have created an epidemic of 2[\&RQWLQ DEXVH 7KH SLOOV DUH FUXVKHG LQWR SRZGHUWRRYHUFRPHWKHVXVWDLQHGUHOHDVHWKH GUXJLVWKHQVQRUWHGRUGLOXWHGDQGLQMHFWHGLQWR WKHXVHU·VYHLQV'RVDJHFRQWUROLVWKXVPLQLPDO and hundreds of people have died from overdose.

Hallucinogens Hallucinogens are drugs that cause hallucinations – altered states of perception and profound distortions of reality. They can cause users to hear voices, see images, and feel sensations that GRQRWH[LVWWKH\DOVRFDQSURGXFHUDSLGLQWHQVH emotional swings. Hallucinogenic drugs have played a role in human life for thousands of years. Cultures from the tropics to the arctic have used plants to induce states of detachment from reality DQGWRSUHFLSLWDWH´YLVLRQVµWKRXJKWWRSURYLGH mystical insight. Historically, hallucinogenic plants were used largely for social and religious ritual, and their availability was limited by the climate and soil conditions they require. After WKHGHYHORSPHQWRI/6'DV\QWKHWLFFRPSRXQG that can be manufactured anywhere, abuse of hallucinogens became more widespread, and IURP WKH V LW LQFUHDVHG GUDPDWLFDOO\$OO /6'PDQXIDFWXUHGLQWKLVFRXQWU\LVLQWHQGHGIRU LOOHJDOXVHVLQFH/6'KDVQRDFFHSWHGPHGLFDO

use in the United States. Hallucinogens include natural substances, such as mescaline and psilocybin that come from plants (cactus and mushrooms, respectively), and FKHPLFDOO\PDQXIDFWXUHGRQHVVXFKDV/6'DQG 0'0$ HFVWDV\ /6'LVPDQXIDFWXUHGIURP lysergic acid, which is found in ergot, a fungus WKDWJURZVRQU\HDQGRWKHUJUDLQV0'0$LVD synthetic mind-altering drug with hallucinogenic properties. Although not a true hallucinogen in the pharmacological sense, PCP causes many of the same effects as hallucinogens and so is often included with this group of drugs. Hallucinogens disrupt the interaction of nerve FHOOVDQGWKHQHXURWUDQVPLWWHUVHURWRQLQ'LVWULEuted throughout the brain and spinal cord, the serotonin system is involved in the control of behavioral, perceptual, and regulatory systems, including mood, hunger, body temperature, VH[XDO EHKDYLRU PXVFOH FRQWURO DQG VHQVRU\ perception. Researchers are not certain that brain chemistry permanently changes from hallucinogen use, but some people who use them appear to develop chronic mental disorders. PCP DQG0'0$DUHERWKDGGLFWLQJZKHUHDV/6' psilocybin, and mescaline are not.

LSD LSD (an abbreviation of the German words IRU ´O\VHUJLF DFLG GLHWK\ODPLGHµ  LV WKH GUXJ PRVWFRPPRQO\LGHQWLÀHGZLWKWKHWHUP´KDOlucinogen” and the most widely used in this FODVVRIGUXJV/6'DOVRIDPLOLDUDV´DFLGµLV a clear or white, odorless, water-soluble mateULDOV\QWKHVL]HGIURPO\VHUJLFDFLGDFRPSRXQG GHULYHGIURPDU\HIXQJXV/6'LVWKHPRVWSRWHQW PRRGDQGSHUFHSWLRQDOWHULQJGUXJNQRZQRUDO GRVHVDVVPDOODVPLFURJUDPVFDQSURGXFH HIIHFWVWKDWODVWWRKRXUV /6'LVLQLWLDOO\SURGXFHGLQFU\VWDOOLQHIRUP The pure crystal can then be crushed to powder DQGPL[HGZLWKELQGLQJDJHQWVWRSURGXFHWDEOHWV NQRZQDV´PLFURGRWVµRUWKLQVTXDUHVRIJHODWLQ FDOOHG´ZLQGRZSDQHVµPRUHFRPPRQO\LWLV dissolved, diluted, and applied to paper or other PDWHULDOV7KHPRVWFRPPRQIRUPRI/6'LV FDOOHG´EORWWHUDFLGµ²VKHHWVRISDSHUVRDNHGLQ /6'DQGSHUIRUDWHGLQWRLQFKVTXDUHLQGLvidual dosage units. Variations in manufacturing and the presence of contaminants can produce /6' LQ FRORUV UDQJLQJ IURP FOHDU RU ZKLWH LQLWVSXUHVWIRUPWRWDQRUHYHQEODFN(YHQ XQFRQWDPLQDWHG /6' EHJLQV WR GHJUDGH DQG discolor soon after it is manufactured, and drug GLVWULEXWRUVRIWHQDSSO\/6'WRFRORUHGSDSHU PDNLQJLWGLIÀFXOWIRUDEX\HUWRGHWHUPLQHWKH GUXJ·VSXULW\RUDJH /6'·VHIIHFWVW\SLFDOO\EHJLQZLWKLQWR minutes after ingestion and may last as long as KRXUV8VHUVUHIHUWR/6'DQGRWKHUKDOOXFLQRJHQLFH[SHULHQFHVDV´WULSVµDQGWRWKHDFXWH DGYHUVHH[SHULHQFHVDV´EDGWULSVµWKHGUXJ·V effects are unpredictable and may vary with WKHDPRXQWLQJHVWHGDQGWKHXVHU·VSHUVRQDOLW\

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Cactus…

Source of Mescaline PRRGH[SHFWDWLRQVDQGVXUURXQGLQJV8VHUVRI /6'PD\H[SHULHQFHVRPHSK\VLRORJLFDOHIIHFWV such as increased blood pressure and heart rate, GL]]LQHVVORVVRIDSSHWLWHGU\PRXWKVZHDWLQJ QDXVHDQXPEQHVVDQGWUHPRUVEXWWKHGUXJ·V PDMRU HIIHFWV DUH HPRWLRQDO DQG VHQVRU\7KH XVHU·V HPRWLRQV PD\ VKLIW UDSLGO\ WKURXJK D range from fear to euphoria, with transitions VRUDSLGWKDWWKHXVHUPD\VHHPWRH[SHULHQFH several emotions simultaneously. /6'DOVRKDVGUDPDWLFHIIHFWVRQWKHVHQVHV Colors, smells, sounds, and other sensations VHHPKLJKO\LQWHQVLÀHG,QVRPHFDVHVVHQVRU\ SHUFHSWLRQVPD\EOHQGLQDSKHQRPHQRQNQRZQ as synesthesia, in which a person seems to hear or feel colors and see sounds. Hallucinations distort or transform shapes and movements, and they may give rise to a perception that time is PRYLQJYHU\VORZO\RUWKDWWKHXVHU·VERG\LV FKDQJLQJVKDSH2QVRPH´WULSVµXVHUVH[SHULHQFHVHQVDWLRQVWKDWDUHHQMR\DEOHDQGPHQWDOO\ stimulating and that produce a sense of heightHQHGXQGHUVWDQGLQJ%DGWULSVKRZHYHULQFOXGH terrifying thoughts and nightmarish feelings of DQ[LHW\DQGGHVSDLUWKDWLQFOXGHIHDUVRILQVDQLW\ death, or losing control.

Mushrooms…

Source of Psilocybin Substance Abuse

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Street Names for Hallucinogens and Dissociative Drugs LSD ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡

acid blotter dots microdot pane paper acid sugar sugar cubes trip window glass window pane ]HQ

Ketamine ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡

bump cat Valium green honey oil MHW K purple special K VSHFLDOODFRNH super acid super C vitamin K

PCP ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡

angel angel dust boat dummy dust love boat peace supergrass ]RPELH

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nightshade angeltrumpet CIA drug MLPVRQZHHG Substance Abuse

/6'XVHUVTXLFNO\GHYHORSDKLJKGHJUHHRI WROHUDQFHIRUWKHGUXJ·VHIIHFWVDIWHUUHSHDWHG use, they need increasingly larger doses to SURGXFHVLPLODUHIIHFWV/6'XVHDOVRSURGXFHV tolerance for other hallucinogenic drugs such as psilocybin and mescaline, but not for drugs such DVPDULMXDQDDPSKHWDPLQHVDQG3&3ZKLFKGR not act directly on the same serotonin receptors DIIHFWHGE\/6'7ROHUDQFHIRU/6'LVORVWLI WKHXVHUVWRSVWDNLQJWKHGUXJIRUVHYHUDOGD\V DQG WKHUH LV QR HYLGHQFH WKDW /6' SURGXFHV physical withdrawal symptoms when chronic use is stopped. /RQJWHUP HIIHFWV RI /6' XVH FDQ LQFOXGH persistent psychosis and hallucinogen persisting SHUFHSWLRQGLVRUGHU +33' PRUHFRPPRQO\ UHIHUUHGWRDV´ÁDVKEDFNVµ7KHFDXVHVRIWKHVH effects, which in some users occur after a single H[SHULHQFHZLWKWKHGUXJDUHQRWNQRZQ7KH DFXWHHIIHFWVRI/6'FDQEHGHVFULEHGDVGUXJLQGXFHGSV\FKRVLVDGLVWRUWLRQRUGLVRUJDQL]DWLRQ RIDSHUVRQ·VFDSDFLW\WRUHFRJQL]HUHDOLW\WKLQN rationally, or communicate with others. Some /6'XVHUVH[SHULHQFHGHYDVWDWLQJSV\FKRORJLcal effects that persist after the trip has ended, KRZHYHUSURGXFLQJDORQJODVWLQJSV\FKRWLFOLNH VWDWH /6'LQGXFHG SHUVLVWHQW SV\FKRVLV PD\ include dramatic mood swings from mania to profound depression, vivid visual disturbances, and hallucinations. These effects may last for years and can affect people who have no history or other symptoms of psychological disorder. 2WKHUIRUPHU/6'XVHUVUHSRUWH[SHULHQFHV NQRZQFROORTXLDOO\DV´ÁDVKEDFNVµDQGFDOOHG ´+33'µ E\ SK\VLFLDQV 7KHVH HSLVRGHV DUH spontaneous, repeated, sometimes continuous recurrences of some of the sensory distortions RULJLQDOO\ SURGXFHG E\ /6' 7KH H[SHULHQFH may include hallucinations, but it most commonly consists of visual disturbances such as VHHLQJIDOVHPRWLRQRQWKHHGJHVRIWKHÀHOGRI YLVLRQEULJKWRUFRORUHGÁDVKHVDQGKDORVRU WUDLOVDWWDFKHGWRPRYLQJREMHFWV7KLVFRQGLtion is typically persistent and in some cases remains unchanged for years after individuals KDYH VWRSSHG XVLQJ WKH GUXJ %HFDXVH +33' V\PSWRPVPD\EHPLVWDNHQIRUWKRVHRIRWKHU QHXURORJLFDOGLVRUGHUVVXFKDVVWURNHRUEUDLQ tumors, sufferers may consult a variety of clinicians before the disorder is accurately diagnosed. 7KHUH LV QR HVWDEOLVKHG WUHDWPHQW IRU +33' although some antidepressant drugs may reduce the symptoms. Psychotherapy may help patients DGMXVWWRWKHFRQIXVLRQDVVRFLDWHGZLWKYLVXDO GLVWUDFWLRQDQGWRPLQLPL]HWKHIHDUH[SUHVVHG by some, that they are suffering from ongoing brain damage or psychiatric disorder. 7KHSUHFLVHPHFKDQLVPE\ZKLFK/6'DOWHUV perceptions is still unclear. Evidence from laboUDWRU\VWXGLHVVXJJHVWWKDW/6'OLNHWKHKDOOXcinogenic plants, binds to and activates certain groups of serotonin receptors designated the +7UHFHSWRUV1RUPDOO\VHURWRQLQELQGVWR

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PCP and Other Dissociative Drugs PCP 3&3 SKHQF\FOLGLQH GHYHORSHGLQWKHV as an intravenous surgical anesthetic, is clasVLÀHGDVDGLVVRFLDWLYHGUXJUDWKHUWKDQDWUXH hallucinogen: its sedative and anesthetic effects DUHWUDQFHOLNHDQGSDWLHQWVH[SHULHQFHDIHHOLQJRIEHLQJ´RXWRIERG\µDQGGHWDFKHGIURP their environment. At low to moderate doses, PCP causes altered perception of body image, but rarely produces visual hallucinations. PCP can also create effects that mimic the primary V\PSWRPVRIVFKL]RSKUHQLDVXFKDVGHOXVLRQV and mental turmoil. PCP was used in veterinary medicine but was never approved for human use because of problems that arose during clinical studies, LQFOXGLQJGHOLULXPDQGH[WUHPHDJLWDWLRQH[SHrienced by patients emerging from anesthesia. Over the years PCP has developed a reputation as a dynamite drug, for its ability to transform an otherwise docile person into a raging maniac, H[SORVLYHDQGH[WUHPHO\GDQJHURXV,QDVWXG\ RIHSLVRGHVRI3&3LQWR[LFDWLRQXQSUHGLFWable outbursts leading to shootings, stabbings, JURWHVTXH PXUGHUV DQG VHOILQÁLFWHG LQMXULHV RFFXUUHGLQRIWKHFDVHV$QRWKHURI WKHXVHUVGLVSOD\HGEL]DUUHEHKDYLRUVLQFOXGLQJ wandering about nude in public, lying down in WKHPLGGOHRIDEXV\VWUHHWRUGULYLQJPSK on the freeway. 'XULQJWKHV3&3LQSLOOIRUPEHFDPH widely abused, but the surge in illicit use receded UDSLGO\DVXVHUVEHFDPHGLVVDWLVÀHGZLWKWKHORQJ GHOD\EHWZHHQWDNLQJWKHGUXJDQGIHHOLQJLWVHIfects, and with the unpredictable and often violent behavior associated with its use. Powdered PCP ²NQRZQDV´R]RQHµ´URFNHWIXHOµ´ORYHERDWµ ´KRJµ´HPEDOPLQJÁXLGµRU´VXSHUZHHGµ²DSSHDUHGLQWKHV,QSRZGHUHGIRUPWKHGUXJ LVVSULQNOHGRQPDULMXDQDWREDFFRRUSDUVOH\ WKHQVPRNHGDQGWKHRQVHWRIHIIHFWVLVUDSLG Users sometimes ingest PCP by snorting the powder. Normally a white crystalline powder, PCP is sometimes colored with water-soluble or alcohol-soluble dyes. :KHQVQRUWHGRUVPRNHG3&3UDSLGO\SDVVHV to the brain to disrupt the functioning of sites

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NQRZQ DV 10'$ 1PHWK\O'DVSDUWDWH  UHFHSWRUFRPSOH[HVZKLFKDUHUHFHSWRUVIRUWKH neurotransmitter glutamate. Glutamate receptors SOD\DPDMRUUROHLQWKHSHUFHSWLRQRISDLQLQ FRJQLWLRQLQFOXGLQJOHDUQLQJDQGPHPRU\DQGLQ emotion. In the brain, PCP also alters the actions of dopamine, a neurotransmitter responsible for WKHHXSKRULDDQG´UXVKµDVVRFLDWHGZLWKPDQ\ DEXVHGGUXJV3&3·VHIIHFWVDUHXQSUHGLFWDEOH Typically, they are felt within minutes of ingestion and last for several hours, but some users UHSRUWIHHOLQJWKHGUXJ·VHIIHFWVIRUGD\V2QH GUXJWDNLQJ HSLVRGH PD\ SURGXFH IHHOLQJV RI detachment from reality, including distortions RIVSDFHWLPHDQGERG\LPDJHDQRWKHUPD\ produce hallucinations, panic, and fear. Some users report feelings of invulnerability and H[DJJHUDWHGVWUHQJWK3&3XVHUVPD\EHFRPH severely disoriented, violent, or suicidal. $WORZ3&3GRVHV PJRUOHVV SK\VLFDOHIfects include shallow, rapid breathing, increased blood pressure and heart rate, and elevated WHPSHUDWXUH'RVHVRIPJRUPRUHFDQFDXVH dangerous changes in blood pressure, heart rate, and respiration, often accompanied by nausea, EOXUUHGYLVLRQGL]]LQHVVDQGGHFUHDVHGDZDUHness of pain. Muscle contractions may cause XQFRRUGLQDWHGPRYHPHQWVDQGEL]DUUHSRVWXUHV When severe, the muscle contractions can result LQERQHIUDFWXUHRULQNLGQH\GDPDJHRUIDLOXUH DVDFRQVHTXHQFHRIPXVFOHFHOOVEUHDNLQJGRZQ Very high doses of PCP can cause convulsions, coma, hyperthermia, and death. Repeated use of PCP can result in addiction, and recent research suggests that repeated or prolonged use of PCP can cause withdrawal syndrome when drug use is stopped. Symptoms such as memory loss, speech problems, and depression may persist for as long DVD\HDUDIWHUDFKURQLFXVHUVWRSVWDNLQJ3&3

Ketamine ´.µ´6SHFLDO.µ´FDW9DOLXPµ LVDQRWKHU GLVVRFLDWLYHDQHVWKHWLF,WZDVGHYHORSHGLQ to replace PCP and is currently manufactured DVDQLQMHFWDEOHOLTXLGWREHXVHGLQKXPDQDQesthesia and veterinary medicine. Much of the NHWDPLQHVROGRQWKHVWUHHWKDVEHHQGLYHUWHG IURPYHWHULQDULDQV·RIÀFHV,QLOOLFLWXVHNHWDPLQH is generally evaporated to form a powder that LVVQRUWHGVPRNHGZLWKPDULMXDQDRUWREDFFR products, or compressed into pills. In some citLHV %RVWRQ1HZ2UOHDQVDQG0LQQHDSROLV6W 3DXOIRUH[DPSOH NHWDPLQHLVUHSRUWHGO\EHLQJ LQMHFWHGLQWUDPXVFXODUO\ .HWDPLQH·VFKHPLFDOVWUXFWXUHDQGPHFKDQLVP of action are similar to those of PCP, and its HIIHFWVDUHVLPLODUEXWNHWDPLQHLVPXFKOHVV potent than PCP with effects of much shorter duration. Users report sensations ranging from DSOHDVDQWIHHOLQJRIÁRDWLQJWREHLQJVHSDUDWHG IURPWKHLUERGLHV6RPHNHWDPLQHH[SHULHQFHV involve a terrifying feeling of almost complete VHQVRU\ GHWDFKPHQW WKDW LV OLNHQHG WR D QHDU

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Club Drugs ´&OXE GUXJVµ LV D FROOHFWLYH WHUP IRU VRPH very dangerous substances that are increasingly popular among young adults who attend all-night dance parties called raves or trances, dance clubs, and bars. Included in the term are a wide variety of drugs with a wide variety of sources, pharmacological agents, and potential FRQWDPLQDQWV PDNLQJ LW GLIÀFXOW WR SUHGLFW WR[LFLW\V\PSWRPVDQGFRQVHTXHQFHVRIXVH In this category along with methamphetamine DQGWKHKDOOXFLQRJHQV/6'DQGNHWDPLQHDUH 0'0$ WKH &16 GHSUHVVDQW *+% DQG WKH EHQ]RGLD]HSLQH5RK\SQRO

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hallucinate. However, some people report side HIIHFWVDIWHUWDNLQJ0'0$VXFKDVKHDGDFKHV FKLOOVH\HWZLWFKLQJMDZFOHQFKLQJEOXUUHGYLVLRQDQGQDXVHD0'0$FDQFDXVHFRQIXVLRQ hallucinations, depression, sleep problems, drug FUDYLQJVHYHUHDQ[LHW\DQGSDUDQRLD,QDGGLtion, in high doses it can cause a sharp increase in body temperature (malignant hyperthermia) OHDGLQJWRPXVFOHEUHDNGRZQDQGNLGQH\DQG cardiovascular system failure. 5HFHQW GDWD VXJJHVW WKDW 0'0$ PD\ EH WR[LF WR WKH EUDLQ ,WV FKHPLFDO VWUXFWXUH  PHWK\OHQHGLR[\PHWKDPSKHWDPLQH´0'0$µ  is similar to methamphetamine, methylHQHGLR[\PHWKDPSKHWDPLQH 0'$  DQG PHVFDOLQH /LNH WKH KDOOXFLQRJHQV 0'0$ causes serotonin to be released from neurons in greater amounts than normal. Once released, WKLVVHURWRQLQFDQH[FHVVLYHO\DFWLYDWHVHURWRQLQ UHFHSWRUV6FLHQWLVWVKDYHVKRZQWKDW0'0$ FDXVHV H[FHVV GRSDPLQH WR EH UHOHDVHG IURP dopamine-containing neurons as well. Particularly alarming is research in animals that has GHPRQVWUDWHG WKDW 0'0$ FDQ GDPDJH DQG destroy serotonin containing neurons. A recent study of the brain scans of people who had XVHG(FVWDV\DQDYHUDJHRIWLPHVRYHUÀYH years found visible brain damage, although the EHKDYLRURIWKHVHSHRSOHDSSHDUHGQRUPDOLQIDFW those who used the drug more often had more brain damage than less frequent users. Positron HPLVVLRQWRPRJUDSK\ 3(7 GHPRQVWUDWHGD UHGXFWLRQLQKHDOWK\VHURWRQLQFHOOVLQWKH drug users, potentially limiting their abilities to remember and to learn. Given the widespread role of serotonin as a neurotransmitter, additional VWXGLHVDUHEHLQJFRQGXFWHGWRJDXJH(FVWDV\·V effect on mood, memory, cognition, and behaviors such as eating and sleeping.

GHB *+% *DPPD K\GUR[\EXW\UDWH ´;\UHPµ  is a central nervous system depressant that can UHOD[RUVHGDWHWKHERG\,WZDVDSSURYHGE\WKH )'$IRUWKHWUHDWPHQWRIQDUFROHSV\ZLWKVHYHUH restrictions and patient registry monitoring. Street names for the drug include Grievous %RGLO\+DUP*/LTXLG(FVWDV\DQG*HRUJLD +RPH %R\ ,W LV XVXDOO\ DEXVHG HLWKHU IRU LWV LQWR[LFDWLQJVHGDWLYH HXSKRULF SURSHUWLHV RU for its growth hormone-releasing effects, which FDQ EXLOG PXVFOHV *+% FDQ EH SURGXFHG LQ clear liquid, white powder, tablet, and capsule forms, and it is often used in combination with DOFRKROPDNLQJLWHYHQPRUHGDQJHURXV*+% is often manufactured in homes with recipes and LQJUHGLHQWVIRXQGDQGSXUFKDVHGRQWKH,QWHUQHW these ingredients are found in a number of dietary supplements available in health food stores and gymnasiums to induce sleep, build muscles, and HQKDQFHVH[XDOSHUIRUPDQFH The drug is used predominantly by adolescents and young adults, often when they attend Substance Abuse

Page 63

QLJKWFOXEVDQGUDYHV*+%·VLQWR[LFDWLQJHIIHFWV EHJLQWRPLQXWHVDIWHUWKHGUXJLVWDNHQ DQGW\SLFDOO\ODVWXSWRKRXUVGHSHQGLQJRQ WKHGRVDJH$WORZHUGRVHV*+%FDQUHOLHYH DQ[LHW\DQGSURGXFHUHOD[DWLRQKRZHYHUDVWKH dose increases, the sedative effects may result in sleep and eventual coma or death. Overdose of *+%FDQRFFXUUDWKHUTXLFNO\DQGWKHVLJQVDUH similar to those of other sedatives: drowsiness, nausea, vomiting, headache, loss of consciousQHVVORVVRIUHÁH[HVDQGLPSDLUHGEUHDWKLQJ *+%LVFOHDUHGIURPWKHERG\UHODWLYHO\TXLFNO\ VRLWLVVRPHWLPHVGLIÀFXOWWRGHWHFWLQHPHUJHQF\ URRPVDQGRWKHUWUHDWPHQWIDFLOLWLHV*+%KDV been increasingly involved in poisonings, overGRVHV´GDWHUDSHVµDQGIDWDOLWLHV

Rohypnol 5RK\SQRO ÁXQLWUD]HSDP EHORQJVWRWKHFODVV RIGUXJVNQRZQDVEHQ]RGLD]HSLQHV,WLVQRWDSproved for prescription use in the United States and its importation is banned. It is approved in (XURSHDQGXVHGLQPRUHWKDQFRXQWULHVDVD treatment for insomnia, as a sedative, and as a pre-surgery anesthetic. 6WUHHW QDPHV IRU WKH GUXJ LQFOXGH 5RRÀHV Rophies, Roche, and the Forget-Me Pill. It is XVXDOO\WDNHQRUDOO\DOWKRXJKWKHUHDUHUHSRUWV that it can be ground up and snorted. Rohypnol is tasteless and odorless, and it dissolves easily in carbonated beverages. The sedative and WR[LFHIIHFWVDUHDJJUDYDWHGE\FRQFXUUHQWXVH of alcohol but, even without alcohol, a dose of Rohypnol as small as 1 mg can impair a victim IRUWRKRXUV Adverse effects associated with Rohypnol include decreased blood pressure, drowsiness, YLVXDOGLVWXUEDQFHVGL]]LQHVVFRQIXVLRQJDVtrointestinal disturbances, and urinary retention. The drug can cause profound anterograde amnesia, so that individuals may not remember HYHQWVWKH\H[SHULHQFHGZKLOHXQGHUWKHHIIHFWV of the drug. This may be why one of the street QDPHVIRU5RK\SQROLV´WKHIRUJHWPHSLOOµDQG LWUHSRUWHGO\KDVEHHQXVHGLQVH[XDODVVDXOWV

Date Rape Drugs $FFRUGLQJWRWKH$PHULFDQ$FDGHP\RI([perts in Traumatic Stress, there continues to be an escalating problem of drug-assisted rape. This increase in prevalence and incidence led to the SDVVDJHRIWKH'UXJLQGXFHG5DSH3UHYHQWLRQ DQG3XQLVKPHQW$FW  7KLVODZSURYLGHV IRUXSWR\HDUVLQSULVRQDQGÀQHVIRUDQ\one who intends to commit a violent crime by covertly distributing a controlled substance to DQXQNQRZLQJLQGLYLGXDO Other substances historically associated with drug-assisted rape include amphetamines, barbiturates, opiates, and chloral hydrate and DOFRKROD´0LFNH\)LQQµ Current substances now commonly used as ´NQRFNRXWµGUXJVWKDWPD\UHQGHUDZRPDQLQFDPage 64

Substance Abuse

SDEOHRIUHVLVWLQJDQDWWDFNDUH*+%5RK\SQRO .HWDPLQHDQG'DWXUD'DWXUDLVDQDQWLFKROLQHUJLFDQGKDOOXFLQRJHQLFVXEVWDQFHPDGHRIUHÀQHG VFRSRODPLQH,WLVXVHGIRUPRWLRQVLFNQHVVDQG DVDQDGMXQFWWRDQHVWKHVLDSURGXFLQJVHGDWLRQ DQGDPQHVLD2QVHWLVZLWKLQPLQXWHVZLWK HIIHFWVODVWLQJXSWRGD\V2QFHLQJHVWHGRU LQKDOHGRQHH[SHULHQFHVVXEPLVVLYHEHKDYLRU hypnosis, hallucinations and confusion. Serious side effects include an anticholinergic syndrome OHDGLQJWRFRPDVHL]XUHVDQGGHDWK7UHDWPHQW of overdose includes airway management and administration of physostigmine for severe anticholinergic effects.

Inhalants Inhalants are volatile substances that produce chemical vapors that can be inhaled to induce a psychoactive, or mind-altering, effect. Although other abused substances can be inhaled, the WHUP´LQKDODQWVµLVXVHGWRGHVFULEHDYDULHW\ of substances whose main common characWHULVWLFLVWKDWWKH\DUHUDUHO\LIHYHUWDNHQE\ DQ\URXWHRWKHUWKDQLQKDODWLRQ7KLVGHÀQLWLRQ encompasses a broad range of chemicals found in hundreds of different products that may have GLIIHUHQWSKDUPDFRORJLFDOHIIHFWV )LJXUHRQ the following page) As a result, precise categori]DWLRQRILQKDODQWVLVGLIÀFXOW2QHFODVVLÀFDWLRQ system lists four general categories of inhalants, volatile solvents, aerosol, gases, and nitrites, based on the form in which they are often found in household, industrial, and medical products. Volatile solventsDUHOLTXLGVWKDWYDSRUL]HDW room temperatures. They are found in a multitude RILQH[SHQVLYHHDVLO\DYDLODEOHSURGXFWVXVHG for common household and industrial purposes. These include paint thinners and removers, GU\FOHDQLQJÁXLGVGHJUHDVHUVJDVROLQHJOXHV FRUUHFWLRQÁXLGVDQGIHOWWLSPDUNHUÁXLGV Aerosols are sprays that contain propellants and solvents. They include spray paints, deodorants and hair sprays, vegetable oil sprays for FRRNLQJDQGIDEULFSURWHFWRUVSUD\V Gases include medical anesthetics as well as gases used in household or commercial products. Medical anesthetic gases include ether, FKORURIRUPKDORWKDQHDQGQLWURXVR[LGHFRPPRQO\FDOOHG´ODXJKLQJJDVµ1LWURXVR[LGHLV the most abused of these gases and can be found in whipped cream dispensers and products that boost octane levels in racing cars. Household or commercial products containing gases also LQFOXGH EXWDQH OLJKWHUV SURSDQH WDQNV DQG refrigerants. Nitrites often are considered a special class of LQKDODQWV8QOLNHPRVWRWKHULQKDODQWVZKLFKDFW directly on the central nervous system, nitrites DFWSULPDULO\WRGLODWHEORRGYHVVHOVDQGUHOD[WKH muscles. And while other inhalants are used to DOWHUPRRGQLWULWHVDUHXVHGSULPDULO\DVVH[XDO HQKDQFHUV1LWULWHVLQFOXGHF\FORKH[\OQLWULWH isoamyl (amyl) nitrite, and isobutyl (butyl) ni-

WULWH&\FORKH[\OQLWULWHLVIRXQGLQURRPGHRGRUL]HUV$P\OQLWULWHLVXVHGLQFHUWDLQGLDJQRVWLF procedures and is prescribed to some patients for heart pain. Illegally diverted ampules of amyl QLWULWHDUHFDOOHG´SRSSHUVµRU´VQDSSHUVµRQWKH VWUHHW%XW\OQLWULWHLVDQLOOHJDOVXEVWDQFHWKDW LVRIWHQSDFNDJHGDQGVROGLQVPDOOERWWOHVDOVR UHIHUUHGWRDV´SRSSHUVµ Inhalants, particularly volatile solvents, JDVHVDQGDHURVROVDUHRIWHQDPRQJWKHÀUVW drugs that young children use. They also are one of the few substances abused more by younger children than by older ones. One national survey LQGLFDWHVWKDWDERXWSHUFHQWRI86FKLOGUHQ have tried inhalants by the time they reach fourth grade. Current statistics revealed lifetime use of LQKDODQWVZDVUHSRUWHGE\SHUFHQWRIWK JUDGHUVSHUFHQWRIWKJUDGHUVDQG SHUFHQWRIWKJUDGHUVLQ ,QYHVWLJDWRUVDUHFRQFHUQHGWKDWSHUFHLYHGULVN associated with inhalant use has been in decline for several years, which may leave young people open to renewed interest. Abuse can also become FKURQLFDQGH[WHQGLQWRDGXOWKRRG Generally, inhalant abusers will abuse any available substance. However, effects produced by individual inhalants vary, and some individuals will go out of their way to obtain their IDYRULWHLQKDODQW)RUH[DPSOHLQFHUWDLQSDUWVRI WKHFRXQWU\´7H[DVVKRHVKLQHµDVKRHVKLQLQJ spray containing the chemical toluene, is a local favorite. Silver and gold spray paints, which contain more toluene than other spray colors, also are popular inhalants. 'DWD IURP QDWLRQDO DQG VWDWH VXUYH\V VXJJHVWVLQKDODQWDEXVHUHDFKHVLWVSHDNDWVRPH point during the seventh through ninth grades. Gender differences in inhalant abuse have been LGHQWLÀHGDWGLIIHUHQWSRLQWVLQFKLOGKRRG2QH study indicates inhalant abuse is higher for boys WKDQJLUOVLQJUDGHVWKURXJKRFFXUVDWVLPLODU UDWHVLQJUDGHVWKURXJKZKHQRYHUDOOXVH is highest, and becomes more prevalent again DPRQJ ER\V LQ JUDGHV  WKURXJK  3HRSOH who abuse inhalants are found in both urban and rural settings. Research on factors contributing to inhalant abuse suggests that adverse socioeconomic conditions, rather than racial or cultural factors per se, may account for most reported racial and ethnic differences in rates of inhalant abuse. Poverty, a history of childhood abuse, poor grades, and dropping out of school all are associated with inhalant abuse. Inhalants can be breathed in through the nose or the mouth in a variety of ways, such as: x´6QLIÀQJµRU´VQRUWLQJµIXPHVIURP  FRQWDLQHUV x Spraying aerosols directly into the  QRVHRUPRXWK x´%DJJLQJµRUVQLIÀQJRULQKDOLQJ fumes from substances sprayed or

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Complications of Commonly Abused Inhalants amyl nitrite, butyl nitrite ´SRSSHUVµ´YLGHRKHDGFOHDQHUµ VXGGHQVQLIÀQJGHDWKV\QGURPH VXSSUHVVHGLPPXQRORJLFIXQFWLRQLQMXU\ WRUHGEORRGFHOOV LQWHUIHULQJZLWKR[\JHQ supply to vital tissues) benzene (found in gasoline) ERQHPDUURZLQMXU\LPSDLUHG LPPXQRORJLFIXQFWLRQLQFUHDVHGULVNRI OHXNHPLDUHSURGXFWLYHV\VWHPWR[LFLW\ butane, propane IRXQGLQOLJKWHUÁXLGKDLUDQGSDLQW sprays) VXGGHQVQLIÀQJGHDWKV\QGURPHYLD FDUGLDFHIIHFWVVHULRXVEXUQLQMXULHV EHFDXVHRIÁDPPDELOLW\ freon (used as a refrigerant and aerosol propellant) VXGGHQVQLIÀQJGHDWKV\QGURPH respiratory obstruction and death (from VXGGHQFRROLQJFROGLQMXU\WRDLUZD\V  liver damage



 GHSRVLWHGLQVLGHDSODVWLFRUSDSHUEDJ  x´+XIÀQJµIURPDQLQKDODQWVRDNHGUDJ VWXIIHGLQWKHPRXWKDQG

 

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 R[LGH Inhaled chemicals are rapidly absorbed through the lungs into the bloodstream and TXLFNO\GLVWULEXWHGWRWKHEUDLQDQGRWKHURUJDQV :LWKLQPLQXWHVRILQKDODWLRQWKHXVHUH[SHULHQFHVLQWR[LFDWLRQDORQJZLWKRWKHUHIIHFWVVLPLODUWR WKRVHSURGXFHGE\DOFRKRO$OFRKROOLNHHIIHFWV may include slurred speech, an inability to coorGLQDWHPRYHPHQWVHXSKRULDDQGGL]]LQHVV,Q DGGLWLRQXVHUVPD\H[SHULHQFHOLJKWKHDGHGQHVV KDOOXFLQDWLRQVDQGGHOXVLRQVVXFKDVWKLQNLQJ WKH\FDQÁ\%HFDXVHLQWR[LFDWLRQODVWVRQO\D IHZPLQXWHVDEXVHUVIUHTXHQWO\VHHNWRSURORQJ the high by continuing to inhale repeatedly over the course of several hours, a very dangerous practice. With successive inhalations, abusers can suffer loss of consciousness and death. At the least, they will feel less inhibited and less in control. After heavy use of inhalants, abusers PD\IHHOGURZV\IRUVHYHUDOKRXUVDQGH[SHULHQFH a lingering headache. Many brain systems may be involved in the DQHVWKHWLFLQWR[LFDWLQJDQGUHLQIRUFLQJHIIHFWV of different inhalants. Nearly all abused inhalants (other than nitrites) produce a pleasurable effect

methylene chloride (found in paint thinners and removers, degreasers) UHGXFWLRQRIR[\JHQFDUU\LQJFDSDFLW\RI blood, changes to the heart muscle and heartbeat nitrous oxide (“laughing gas”), hexane GHDWKIURPODFNRIR[\JHQWRWKHEUDLQ altered perception and motor coordination, ORVVRIVHQVDWLRQOLPEVSDVPVEODFNRXWV caused by blood pressure changes, depression of heart muscle functioning toluene (found in gasoline, paint thinners and UHPRYHUVFRUUHFWLRQÁXLG brain damage (loss of brain tissue mass, impaired cognition, gait disturbances, loss of coordination, loss of equilibrium, limb spasm hearing and vision loss), liver and NLGQH\GDPDJH trichloroethylene (found in spot removers, degreasers) VXGGHQVQLIÀQJGHDWKV\QGURPHFLUUKRVLV of the liver, reproductive complications, hearing and vision damage

Figure 3

by depressing the CNS. Evidence from animal studies suggests that a number of commonly abused volatile solvents and anesthetic gases have neurobehavioral effects and mechanisms of action similar to those produced by CNS depressants, which include alcohol and medications such as sedatives and anesthetics. A recent study indicates that toluene, a solvent found in many commonly abused inhalants including airplane glue, paint sprays, and paint and nail SROLVKUHPRYHUVDFWLYDWHVWKHEUDLQ·VGRSDPLQH system. The dopamine system has been shown to play a role in the rewarding effects of many drugs of abuse. Nitrites, in contrast, dilate and UHOD[EORRGYHVVHOVUDWKHUWKDQDFWLQJDVDQHVthetic agents. The chemicals found in solvents, aerosol sprays, and gases can produce a variety of additional effects during or shortly after use. 7KHVHHIIHFWVDUHUHODWHGWRLQKDODQWLQWR[LFDWLRQ and may include belligerence, apathy, impaired MXGJPHQWDQGLPSDLUHGIXQFWLRQLQJLQZRUNRU VRFLDOVLWXDWLRQV'L]]LQHVVGURZVLQHVVVOXUUHG VSHHFK OHWKDUJ\ GHSUHVVHG UHÁH[HV JHQHUDO PXVFOH ZHDNQHVV DQG VWXSRU DUH RWKHU SRVVLEOHHIIHFWV)RUH[DPSOHUHVHDUFKVKRZVWKDW toluene can produce headache, euphoria, giddy feelings, and inability to coordinate movements. ([SRVXUH WR KLJK GRVHV FDQ FDXVH FRQIXVLRQ and delirium. Nausea and vomiting are other common side effects.

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Inhaled nitrites dilate blood vessels, increase heart rate, and produce a sensation of heat and H[FLWHPHQW WKDW FDQ ODVW IRU VHYHUDO PLQXWHV 2WKHUHIIHFWVFDQLQFOXGHÁXVKGL]]LQHVVDQG headache. A strong desire to continue using inhalants has been reported among many individuals, particularly those who abuse inhalants for prolonged periods over many days. Compulsive use and a mild withdrawal syndrome can occur with long-term inhalant abuse. Additional symptoms H[KLELWHGE\ORQJWHUPLQKDODQWDEXVHUVLQFOXGH ZHLJKW ORVV PXVFOH ZHDNQHVV GLVRULHQWDWLRQ LQDWWHQWLYHQHVVODFNRIFRRUGLQDWLRQLUULWDELOLW\ and depression. ,QKDODQWDEXVHUVULVNDQDUUD\RIGHYDVWDWLQJ PHGLFDO FRQVHTXHQFHV 3URORQJHG VQLIÀQJ RI the highly concentrated chemicals in solvents or aerosol sprays can induce irregular and rapid heart rhythms and lead to heart failure and death within minutes of a session of prolonged sniffLQJ7KLVV\QGURPHNQRZQDV´VXGGHQVQLIÀQJ death,” can result from a single session of inhalant use by an otherwise healthy young person. 6XGGHQVQLIÀQJGHDWKLVSDUWLFXODUO\DVVRFLated with the abuse of butane, propane, and chemicals in aerosols. Inhalant abuse also can cause death by: 

     

x$VSK\[LDWLRQIURPUHSHDWHGLQKDOD tions, which lead to high concentrations of inhaled fumes displacing the available  R[\JHQLQWKHOXQJV x6XIIRFDWLRQIURPEORFNLQJDLUIURPHQWHU ing the lungs when inhaling fumes  IURPDSODVWLFEDJSODFHGRYHUWKHKHDG x&KRNLQJIURPLQKDODWLRQRIYRPLWDIWHU  LQKDODQWXVHRU x)DWDOLQMXU\IURPDFFLGHQWVLQFOXGLQJ motor vehicle fatalities, suffered while  LQWR[LFDWHG

%RWKDQLPDOUHVHDUFKDQGKXPDQSDWKRORJLFDO studies indicate that chronic abuse of volatile solvents such as toluene damages the protective VKHDWKDURXQGFHUWDLQQHUYHÀEHUVLQWKHEUDLQ DQGSHULSKHUDOQHUYRXVV\VWHP7KLVH[WHQVLYH GHVWUXFWLRQRIQHUYHÀEHUVLVFOLQLFDOO\VLPLODU to that seen with neurological diseases such as PXOWLSOH VFOHURVLV 7KH QHXURWR[LF HIIHFWV RI prolonged inhalant abuse include damage to parts of the brain involved in controlling cognition, movement, vision, and hearing. Cognitive abnormalities can range from mild impairment to severe dementia. Other effects can include GLIÀFXOW\ FRRUGLQDWLQJ PRYHPHQW VSDVWLFLW\ and loss of feeling, hearing, and vision. ,QKDODQWV DOVR DUH KLJKO\ WR[LF WR RWKHU RUJDQV&KURQLFH[SRVXUHFDQSURGXFHVLJQLÀFDQW GDPDJHWRWKHKHDUWOXQJVOLYHUDQGNLGQH\V Although some inhalant-induced damage to the nervous and other organ systems may be at least partially reversible when inhalant abuse is

Substance Abuse

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stopped, many syndromes caused by repeated or prolonged abuse are irreversible. Abuse of inhalants during pregnancy may SODFHLQIDQWVDQGFKLOGUHQDWLQFUHDVHGULVNRI developmental problems. Animal studies designed to simulate human patterns of inhalant DEXVHVXJJHVWWKDWSUHQDWDOH[SRVXUHWRWROXHQH or trichloroethylene (TCE) can result in reduced ELUWKZHLJKWVNHOHWDODEQRUPDOLWLHVDQGGHOD\HG neurobehavioral development. A number of case reports note abnormalities in newborns of mothers who chronically abuse solvents, and there is evidence of subsequent developmental impairment in some of these children. However, no well-controlled, prospective VWXG\ RI WKH HIIHFWV RI SUHQDWDO H[SRVXUH WR inhalants in humans has been conducted, and LW LV QRW SRVVLEOH WR OLQN SUHQDWDO H[SRVXUH RI DVSHFLÀFFKHPLFDOWRDVSHFLÀFELUWKGHIHFWRU developmental problem. As noted previously, nitrites are mainly abused by older adolescents and adults, typically to HQKDQFHVH[XDOIXQFWLRQDQGSOHDVXUH5HVHDUFK VKRZVWKDWDEXVHRIWKHVHGUXJVLQWKLVFRQWH[W LVDVVRFLDWHGZLWKXQVDIHVH[XDOSUDFWLFHVWKDW JUHDWO\ LQFUHDVH WKH ULVN RI FRQWUDFWLQJ DQG spreading such infectious diseases as HIV/ $,'6DQGKHSDWLWLV5HFHQWUHVHDUFKDOVRUDLVHV WKHSRVVLELOLW\WKDWWKHUHPD\EHDOLQNEHWZHHQ abuse of nitrite inhalants and the development and progression of infectious diseases and tumors. The research indicates that inhaling nitrites depletes many cells in the immune system and LPSDLUVLPPXQHV\VWHPPHFKDQLVPVWKDWÀJKW infectious diseases. A recent study found that HYHQDUHODWLYHO\VPDOOQXPEHURIH[SRVXUHVWR butyl nitrite can produce dramatic increases in tumor incidence and growth rates in animals.

Steroids ´$QDEROLF VWHURLGVµ LV WKH IDPLOLDU QDPH for synthetic substances related to the male VH[KRUPRQHV DQGURJHQV 7KH\SURPRWHWKH JURZWKRIVNHOHWDOPXVFOH DQDEROLFHIIHFWV DQG WKHGHYHORSPHQWRIPDOHVH[XDOFKDUDFWHULVWLFV (androgenic effects), among other effects. AnaEROLFVWHURLGVZHUHGHYHORSHGLQWKHODWHV primarily to treat hypogonadism, a condition in ZKLFKWKHWHVWHVGRQRWSURGXFHVXIÀFLHQWWHVtosterone for normal growth, development, and VH[XDOIXQFWLRQLQJ7KHSULPDU\PHGLFDOXVHVRI these compounds are to treat delayed puberty, some types of impotence, and wasting of the body caused by HIV infection or other diseases. 'XULQJWKHVVFLHQWLVWVGLVFRYHUHGWKDW anabolic steroids could facilitate the growth of VNHOHWDOPXVFOHLQODERUDWRU\DQLPDOVZKLFKOHG WRXVHRIWKHFRPSRXQGVÀUVWE\ERG\EXLOGHUV and weightlifters and then by athletes in other sports. Steroid abuse has become so widespread in athletics that it often affects the outcome of VSRUWVFRQWHVWV0RUHWKDQGLIIHUHQWDQDEROLF steroids have been developed, but they require Page 66

Substance Abuse

a prescription to be used legally in the United States. Most steroids that are used illegally are smuggled in from other countries, illegally GLYHUWHGIURP86SKDUPDFLHVRUV\QWKHVL]HG in clandestine laboratories. In the United States, supplements such as '+($ GHK\GURHSLDQGURVWHURQH  DQG $QGUR (androstenedione) can be purchased legally without a prescription through many commercial sources including health food stores. They are often referred to as dietary supplements, although they are not food products. They are RIWHQWDNHQEHFDXVHWKHXVHUEHOLHYHVWKH\KDYH muscle-building effects. Steroidal supplements can be converted into testosterone or a similar compound in the body. :KHWKHU VXFK FRQYHUVLRQ SURGXFHV VXIÀFLHQW quantities of testosterone to promote muscle growth or whether the supplements themselves SURPRWH PXVFOH JURZWK LV XQNQRZQ 5HFHQW evidence suggests that steroid abuse among adolescents is on the rise. It has been estimated WKDWKXQGUHGVRIWKRXVDQGVRISHRSOHDJHG and older abuse anabolic steroids at least once a year. Among both adolescents and adults, steroid abuse is higher among males than females. However, steroid abuse is growing most rapidly among young women. . Two of the main reasons people give for abusing steroids is to enhance sports performance and improve physical appearance. Among competitive bodybuilders, steroid abuse has been estimated to be very high. Among other athletes, the incidence of abuse probably varies GHSHQGLQJRQWKHVSHFLÀFVSRUW$QRWKHUUHDVRQ SHRSOH JLYH IRU WDNLQJ VWHURLGV LV WR LQFUHDVH WKHLUPXVFOHVL]HDQGRUUHGXFHWKHLUERG\IDW This group includes some people who have a behavioral syndrome (muscle dysmorphia) in which a person has a distorted image of his or KHUERG\0HQZLWKWKLVFRQGLWLRQWKLQNWKDWWKH\ ORRNVPDOODQGZHDNHYHQLIWKH\DUHODUJHDQG muscular. Similarly, women with the syndrome WKLQNWKDWWKH\ORRNIDWDQGÁDEE\HYHQWKRXJK they are actually lean and muscular. Some people who abuse steroids to boost PXVFOHVL]HPD\KDYHH[SHULHQFHGSK\VLFDORU VH[XDO DEXVH DQG DUH WU\LQJ WR LQFUHDVH WKHLU PXVFOHVL]HWRSURWHFWWKHPVHOYHV,QRQHVHULHV RILQWHUYLHZVZLWKPDOHZHLJKWOLIWHUVSHUFHQW who abused steroids reported memories of childKRRGSK\VLFDORUVH[XDODEXVHFRPSDUHGZLWK none who did not abuse steroids. In a study of women weightlifters, twice as many of those who had been raped reported using anabolic steroids and/or another purported muscle-building drug, compared to those who had not been raped. Moreover, almost all of those who had been UDSHGUHSRUWHGWKDWWKH\PDUNHGO\LQFUHDVHGWKHLU ERG\EXLOGLQJ DFWLYLWLHV DIWHU WKH DWWDFN 7KH\ believed that being bigger and stronger would GLVFRXUDJHIXUWKHUDWWDFNVEHFDXVHPHQZRXOG ÀQGWKHPHLWKHULQWLPLGDWLQJRUXQDWWUDFWLYH Finally, some adolescents abuse steroids as

SDUWRIDSDWWHUQRIKLJKULVNEHKDYLRUV7KHVH DGROHVFHQWVDOVRWDNHULVNVVXFKDVGULQNLQJDQG driving, carrying a gun, not wearing a helmet on a motorcycle, and abusing other illicit drugs. While conditions such as muscle dysmorphia, a KLVWRU\RISK\VLFDORUVH[XDODEXVHRUDKLVWRU\ RIHQJDJLQJLQKLJKULVNEHKDYLRUVPD\LQFUHDVH WKHULVNRILQLWLDWLQJRUFRQWLQXLQJVWHURLGDEXVH researchers agree that most steroid abusers are psychologically normal when they start abusing the drugs. 6RPHDQDEROLFVWHURLGVDUHWDNHQRUDOO\RWKHUV DUHLQMHFWHGLQWUDPXVFXODUO\DQGVWLOORWKHUVDUH provided in gels or creams that are rubbed on WKHVNLQ'RVHVWDNHQE\DEXVHUVFDQEHWR WLPHVKLJKHUWKDQWKHGRVHVXVHGIRUPHGLFDOFRQGLWLRQV6WHURLGDEXVHUVW\SLFDOO\´VWDFNµ WKHGUXJVPHDQLQJWKDWWKH\WDNHWZRRUPRUH GLIIHUHQWDQDEROLFVWHURLGVPL[LQJRUDODQGRU LQMHFWDEOHW\SHVDQGVRPHWLPHVHYHQLQFOXGLQJ compounds that are designed for veterinary use. $EXVHUVWKLQNWKDWWKHGLIIHUHQWVWHURLGVLQWHUDFW WRSURGXFHDQHIIHFWRQPXVFOHVL]HWKDWLVJUHDWHU than the effects of each drug individually, a theory WKDWKDVQRWEHHQWHVWHGVFLHQWLÀFDOO\ 2IWHQ VWHURLG DEXVHUV DOVR´S\UDPLGµWKHLU GRVHVLQF\FOHVRIWRZHHNV$WWKHEHJLQQLQJ of a cycle, the person starts with low doses of the GUXJVEHLQJVWDFNHGDQGWKHQVORZO\LQFUHDVHVWKH doses. In the second half of the cycle, the doses DUHVORZO\GHFUHDVHGWR]HUR7KLVLVVRPHWLPHV followed by a second cycle in which the person continues to train but without drugs. Abusers believe that pyramiding allows the body time WR DGMXVW WR WKH KLJK GRVHV DQG WKH GUXJIUHH F\FOHDOORZVWKHERG\·VKRUPRQDOV\VWHPWLPH WRUHFXSHUDWH$VZLWKVWDFNLQJWKHSHUFHLYHG EHQHÀWV RI S\UDPLGLQJ DQG F\FOLQJ KDYH QRW EHHQVXEVWDQWLDWHGVFLHQWLÀFDOO\ Anabolic steroid abuse has been associated with a wide range of adverse side effects. One VWXG\IRXQGWKDWH[SRVLQJPDOHPLFHIRURQHÀIWK of their lifespan to steroid doses comparable to WKRVH WDNHQ E\ KXPDQ DWKOHWHV FDXVHG D KLJK percentage of premature deaths. It is clear, KRZHYHUWKDWVWHURLGDEXVHKDVPDUNHGHIIHFWV on a number of body systems.

Hormonal System Steroid abuse disrupts the normal production of hormones in the male body, causing both reversible and irreversible changes. Changes that can be reversed include reduced sperm SURGXFWLRQDQGVKULQNLQJRIWKHWHVWLFOHV WHVticular atrophy). Irreversible changes include male-pattern baldness and breast development (gynecomastia). In one study of male bodybuilders, more than half had testicular atrophy, and more than half had gynecomastia. In the female ERG\DQDEROLFVWHURLGVFDXVHPDVFXOLQL]DWLRQ %UHDVWVL]HDQGERG\IDWGHFUHDVHWKHVNLQEHcomes coarse, the clitoris enlarges, and the voice GHHSHQV :RPHQ PD\ H[SHULHQFH H[FHVVLYH growth of body hair but lose scalp hair. With

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continued administration of steroids, some of these effects are irreversible.

Musculoskeletal System 5LVLQJ OHYHOV RI WHVWRVWHURQH DQG RWKHU VH[ hormones normally trigger the growth spurt that occurs during puberty and adolescence. Subsequently, when these hormones reach certain levels, they signal the bones to stop growing, ORFNLQJDSHUVRQLQWRKLVRUKHUPD[LPXPKHLJKW :KHQDFKLOGRUDGROHVFHQWWDNHVDQDEROLFVWHURLGVWKHUHVXOWLQJDUWLÀFLDOO\KLJKVH[KRUPRQH levels can signal the bones to stop growing sooner than they normally would have done.

Cardiovascular System Steroid abuse has been associated with carGLRYDVFXODU GLVHDVHV LQFOXGLQJ KHDUW DWWDFNV DQGVWURNHVHYHQLQDWKOHWHV\RXQJHUWKDQ Steroids contribute to the development of cardiovascular problems, partly by changing the levels of lipoproteins that carry cholesterol in the blood. Steroids, particularly the oral types, increase the level of low-density lipoprotein /'/ DQGGHFUHDVHWKH OHYHO RI KLJKGHQVLW\ OLSRSURWHLQ +'/  +LJK /'/ DQG ORZ +'/ OHYHOV LQFUHDVH WKH ULVN RI DWKHURVFOHURVLV D condition in which fatty substances are deposited LQVLGHDUWHULHVDQGGLVUXSWEORRGÁRZ6WHURLGV DOVRLQFUHDVHWKHULVNWKDWEORRGFORWVZLOOIRUP in blood vessels, potentially disrupting blood ÁRZDQGGDPDJLQJWKHKHDUWPXVFOHVRWKDWLW does not pump blood effectively, or increasing WKHULVNRIVWURNH

Other Effects Steroid abuse has been associated with liver tumors and a rare condition called peliosis hepaWLWLVLQZKLFKEORRGÀOOHGF\VWVIRUPLQWKHOLYHU %RWKWKHWXPRUVDQGWKHF\VWVVRPHWLPHVUXSWXUH causing internal bleeding. Steroid abuse can also FDXVHDFQHF\VWVDQGRLO\KDLUDQGVNLQ 0DQ\ DEXVHUV ZKR LQMHFW DQDEROLF VWHURLGV XVH QRQVWHULOH LQMHFWLRQ WHFKQLTXHV RU VKDUH contaminated needles with other abusers. In addition, some steroid preparations are manufactured illegally under non-sterile conditions. 7KHVHIDFWRUVSXWDEXVHUVDWULVNIRUDFTXLULQJ life-threatening viral infections, such as HIV DQGKHSDWLWLV%DQG&$EXVHUVDOVRFDQGHYHORS infective endocarditis, a bacterial illness that FDXVHVDSRWHQWLDOO\IDWDOLQÁDPPDWLRQRI WKH LQQHU OLQLQJ RI WKH KHDUW %DFWHULDO LQIHFWLRQV also can cause pain and abscess formation at LQMHFWLRQVLWHV Case reports and small studies indicate that anabolic steroids, particularly in high doses, increase irritability and aggression. Some steroid abusers report that they have committed DJJUHVVLYH DFWV VXFK DV SK\VLFDO ÀJKWLQJ committing armed robbery, or using force to obtain something. Some abusers also report that they have committed property crimes, such as

stealing from a store, damaging or destroying RWKHUV·SURSHUW\RUEUHDNLQJLQWRDKRXVHRUD building. Abusers who have committed aggressive acts or property crimes generally report that they engage in these behaviors more often when WKH\WDNHVWHURLGVWKDQZKHQWKH\DUHGUXJIUHH Some researchers, however, have suggested that steroid abusers may commit aggressive acts and SURSHUW\FULPHVQRWEHFDXVHRIVWHURLGV·GLUHFW effects on the brain but because the abusers have EHHQDIIHFWHGE\H[WHQVLYHPHGLDDWWHQWLRQWRWKH OLQNEHWZHHQVWHURLGVDQGDJJUHVVLRQ$FFRUGLQJ to this theory, the abusers are using this possible OLQNDVDQH[FXVHWRFRPPLWDJJUHVVLYHDFWVDQG property crimes. One way to distinguish between these two possibilities is to administer either high steroid GRVHVRUSODFHERIRUGD\VRUZHHNVWRKXPDQ YROXQWHHUVDQGWKHQDVNWKHSHRSOHWRUHSRUWRQ their behavioral symptoms. To date, four such studies have been conducted. In three, high steroid doses did produce greater feelings of irULWDELOLW\DQGDJJUHVVLRQWKDQGLGSODFHEREXWLQ one study, the drugs did not have that effect. One SRVVLEOHH[SODQDWLRQDFFRUGLQJWRUHVHDUFKHUVLV that some but not all anabolic steroids increase irritability and aggression. Anabolic steroids have been reported to cause other behavioral effects, including euphoria, LQFUHDVHGHQHUJ\VH[XDODURXVDOPRRGVZLQJV distractibility, forgetfulness, and confusion. In the studies in which researchers administered high steroid doses to volunteers, a minority of the volunteers developed behavioral symptoms WKDWZHUHVRH[WUHPHDVWRGLVUXSWWKHLUDELOLW\ WRIXQFWLRQLQWKHLUMREVRULQVRFLHW\,QDIHZ FDVHVWKHYROXQWHHUV·EHKDYLRUSUHVHQWHGDWKUHDW WRWKHPVHOYHVDQGRWKHUV,QVXPPDU\WKHH[WHQW to which steroid abuse contributes to violence DQGEHKDYLRUDOGLVRUGHUVLVXQNQRZQ$VZLWK the health complications of steroid abuse, the SUHYDOHQFH RI H[WUHPH FDVHV RI YLROHQFH DQG behavioral disorders seems to be low, but it may EHXQGHUUHSRUWHGRUXQGHUUHFRJQL]HG An undetermined percentage of steroid abusers become addicted to the drugs, as evidenced E\WKHLUFRQWLQXLQJWRWDNHVWHURLGVLQVSLWHRI physical problems, negative effects on social relations, or nervousness and irritability. Also, they spend large amounts of time and money REWDLQLQJWKHGUXJVDQGH[SHULHQFHZLWKGUDZDO symptoms such as mood swings, fatigue, restOHVVQHVVORVVRIDSSHWLWHLQVRPQLDUHGXFHGVH[ GULYHDQGWKHGHVLUHWRWDNHPRUHVWHURLGV7KH most dangerous of the withdrawal symptoms is depression, because it sometimes leads to suicide attempts. Untreated, some depressive symptoms associated with anabolic steroid withdrawal have EHHQNQRZQWRSHUVLVWIRUD\HDURUPRUHDIWHU WKHDEXVHUVWRSVWDNLQJWKHGUXJV Few studies of treatments for anabolic steroid DEXVHKDYHEHHQFRQGXFWHG&XUUHQWNQRZOHGJH LVEDVHGODUJHO\RQWKHH[SHULHQFHVRIDVPDOO QXPEHURI SK\VLFLDQV ZKR KDYHZRUNHG ZLWK

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patients undergoing steroid withdrawal. The physicians have found that supportive therapy LVVXIÀFLHQWLQVRPHFDVHV3DWLHQWVDUHHGXFDWHG DERXWZKDWWKH\PD\H[SHULHQFHGXULQJZLWKdrawal and are evaluated for suicidal thoughts. If symptoms are severe or prolonged, medications RUKRVSLWDOL]DWLRQPD\EHQHHGHG Some medications that have been used for treating steroid withdrawal restore the hormonal system after its disruption by steroid abuse. 2WKHU PHGLFDWLRQV WDUJHW VSHFLÀF ZLWKGUDZDO V\PSWRPVIRUH[DPSOHDQWLGHSUHVVDQWVWRWUHDW depression, and analgesics for headaches and PXVFOHDQGMRLQWSDLQ6RPHSDWLHQWVUHTXLUHDVsistance beyond simple treatment of withdrawal symptoms and are also treated with behavioral therapies.

Prescription and Over-theCounter Medications Prescription medications such as pain relievers, central nervous system (CNS) depressants WUDQTXLOL]HUVDQGVHGDWLYHV DQGVWLPXODQWVDUH KLJKO\EHQHÀFLDOWUHDWPHQWVIRUDYDULHW\RIKHDOWK conditions. Pain relievers enable individuals with FKURQLFSDLQWROHDGSURGXFWLYHOLYHVWUDQTXLOL]HUVFDQUHGXFHDQ[LHW\DQGKHOSSDWLHQWVZLWK VOHHSGLVRUGHUVDQGVWLPXODQWVKHOSSHRSOHZLWK DWWHQWLRQGHÀFLWK\SHUDFWLYLW\GLVRUGHU $'+'  IRFXV WKHLU DWWHQWLRQ 0RVW SHRSOH ZKR WDNH prescription medications use them responsibly. %XWZKHQDEXVHG³WKDWLVWDNHQE\VRPHRQH other than the patient for whom the medication ZDVSUHVFULEHGRUWDNHQLQDPDQQHURUGRVDJH RWKHUWKDQZKDWZDVSUHVFULEHG³SUHVFULSWLRQ medications can produce serious adverse health effects, including addiction. Patients, health care professionals, and pharmacists all have roles in preventing the abuse of and addiction to prescription medications. For H[DPSOHSDWLHQWVVKRXOGIROORZWKHGLUHFWLRQV IRU XVH FDUHIXOO\ OHDUQ ZKDW HIIHFWV DQG VLGH HIIHFWVWKHPHGLFDWLRQFRXOGKDYHDQGLQIRUP WKHLUGRFWRUSKDUPDFLVWZKHWKHUWKH\DUHWDNLQJ other medications [including over-the-counter (OTC) medications or health supplements], since these could potentially interact with the prescribed medication. The patient should read all information provided by the pharmacist. Physicians and other health care providers should screen for past or current substance abuse in the SDWLHQW GXULQJ URXWLQH H[DPLQDWLRQ LQFOXGLQJ DVNLQJTXHVWLRQVDERXWZKDWRWKHUPHGLFDWLRQV WKHSDWLHQWLVWDNLQJDQGZK\3URYLGHUVVKRXOG note any rapid increases in the amount of a PHGLFDWLRQQHHGHGRUIUHTXHQWUHTXHVWVIRUUHÀOOV before the quantity prescribed should have been ÀQLVKHGDVWKHVHPD\EHLQGLFDWRUVRIDEXVH Similarly, some OTC medications, such as FRXJK DQG FROG PHGLFLQHV FRQWDLQLQJ GH[WURPHWKRUSKDQKDYHEHQHÀFLDOHIIHFWVZKHQWDNHQ DVUHFRPPHQGHGEXWWKH\FDQDOVREHDEXVHG Substance Abuse

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and lead to serious adverse health consequences. Parents should be aware of the potential for abuse of these medications, especially when consumed in large quantities, which should signal concern and the possible need for intervention. Although almost all prescription drugs can be misused, there are three classes of prescription drugs that are most commonly abused: Opioids are commonly prescribed because of their effective analgesic, or pain-relieving, properties. Medications that fall within this class, sometimes referred to as narcotics, include morphine, codeine, and related drugs. 0RUSKLQHIRUH[DPSOHLVRIWHQXVHGEHIRUHRU after surgery to alleviate severe pain. Codeine, EHFDXVHLWLVOHVVHIÀFDFLRXVWKDQPRUSKLQHLV XVHGIRUPLOGHUSDLQ2WKHUH[DPSOHVRIRSLRLGV that can be prescribed to alleviate pain include R[\FRGRQH 3HUFRGDQRU2[\&RQWLQVHHVHFWLRQ RQ2SLDWHV SURSR[\SKHQH 'DUYRQ K\GURFRGRQH 9LFRGLQ DQGK\GURPRUSKRQH 'LODXGLG  DVZHOODVPHSHULGLQH 'HPHURO ZKLFKLVXVHG less often because of its side effects. In addition to their pain-relieving properties, some of these GUXJVIRUH[DPSOHFRGHLQHDQGGLSKHQR[\ODWH /RPRWLO  FDQ EH XVHG WR UHOLHYH FRXJKV DQG diarrhea. Chronic use of opioids can result in tolerance IRUWKHGUXJVZKLFKPHDQVWKDWXVHUVPXVWWDNH higher doses to achieve the same initial effects. /RQJWHUPXVHDOVRFDQOHDGWRSK\VLFDOGHSHQdence and addiction, the body adapts to the presence of the drug, and withdrawal symptoms RFFXULIXVHLVUHGXFHGRUVWRSSHG)LQDOO\WDNing a large single dose of an opioid could cause severe respiratory depression that can lead to death. Opioids are safe to use with other drugs RQO\XQGHUDSK\VLFLDQ·VVXSHUYLVLRQ7\SLFDOO\ they should not be used with other substances that depress the central nervous system, such as alcohol, antihistamines, barbiturates, ben]RGLD]HSLQHVRUJHQHUDODQHVWKHWLFVDVVXFKD FRPELQDWLRQLQFUHDVHVWKHULVNRIOLIHWKUHDWHQLQJ respiratory depression. CNS Depressants are substances that can slow QRUPDOEUDLQIXQFWLRQ%HFDXVHRIWKLVSURSHUW\ some CNS depressants are useful in the treatment RIDQ[LHW\DQGVOHHSGLVRUGHUV%DUELWXUDWHVVXFK as mephobarbital (Mebaral) and pentobarbital VRGLXP 1HPEXWDO DUHXVHGWRWUHDWDQ[LHW\ WHQVLRQDQGVOHHSGLVRUGHUV%HQ]RGLD]HSLQHV VXFK DV GLD]HSDP 9DOLXP  FKORUGLD]HSR[LGH +&O /LEULXP  DQG DOSUD]RODP ;DQD[  FDQ EHSUHVFULEHGWRWUHDWDQ[LHW\DFXWHVWUHVVUHDFWLRQV DQG SDQLF DWWDFNV WKH PRUH VHGDWLQJ EHQ]RGLD]HSLQHV VXFK DV WULD]RODP +DOFLRQ  DQGHVWD]RODP 3UR6RP FDQEHSUHVFULEHGIRU short-term treatment of sleep disorders. In higher doses, some CNS depressants can also be used as general anesthetics. Most CNS depressants ZRUNLQWKHEUDLQE\LQFUHDVLQJWKHDFWLYLW\RI WKHQHXURWUDQVPLWWHU*$%$ 'HVSLWHWKHLUPDQ\EHQHÀFLDOHIIHFWVEDUELWXUDWHVDQGEHQ]RGLD]HSLQHVKDYHWKHSRWHQWLDO Page 68

Substance Abuse

for abuse and should be used only as prescribed. 'XULQJWKHÀUVWIHZGD\VRIWDNLQJDSUHVFULEHG CNS depressant, a person usually feels sleepy and uncoordinated, but as the body becomes accustomed to the effects of the drug, these feelings begin to disappear. If one uses these drugs long term, the body will develop tolerance for the drugs, and larger doses will be needed to achieve the same initial effects. In addition, continued use can lead to physical dependence and, when XVHLVUHGXFHGRUVWRSSHGZLWKGUDZDO%HFDXVH DOO&16GHSUHVVDQWVZRUNE\VORZLQJWKHEUDLQ·V DFWLYLW\ZKHQDQLQGLYLGXDOVWRSVWDNLQJWKHP WKHEUDLQ·VDFWLYLW\FDQUHERXQGDQGUDFHRXWRI FRQWUROSRVVLEO\OHDGLQJWRVHL]XUHVDQGRWKHU harmful consequences. Although withdrawal IURPEHQ]RGLD]HSLQHVFDQEHSUREOHPDWLFLWLV rarely life threatening, whereas withdrawal from prolonged use of other CNS depressants can have life-threatening complications. Therefore, VRPHRQHZKRLVWKLQNLQJDERXWGLVFRQWLQXLQJ CNS depressant therapy or who is suffering ZLWKGUDZDOIURPD&16GHSUHVVDQWVKRXOGVSHDN ZLWKDSK\VLFLDQRUVHHNPHGLFDOWUHDWPHQW CNS depressants should be used with other PHGLFDWLRQVRQO\XQGHUDSK\VLFLDQ·VVXSHUYLsion. Typically, they should not be combined with any other medication or substance that causes CNS depression, including prescription pain medicines, some over-the-counter cold and allergy medications, or alcohol. Using CNS depressants with these other substances, particularly alcohol, can slow breathing, or slow both the heart and respiration, and possibly lead to death. Stimulants DPSKHWDPLQHV>$GGHUDOO'H[edrine] and methylphenidate [Concerta, Ritalin]) increase alertness, attention, and energy. They also increase blood pressure and heart rate, constrict blood vessels, increase blood glucose, and open up the pathways of the respiratory system. Historically, stimulants were prescribed to treat asthma and other respiratory problems, obesity, neurological disorders, and a variety of other ailments. As their potential for abuse and addiction became apparent, the prescribing of stimulants by physicians began to wane. Now, stimulants are prescribed for treating only a few health FRQGLWLRQV PRVW QRWDEO\ $'+' QDUFROHSV\ and, in some instances, depression that has not responded to other treatments. They have chemical structures that are similar WR NH\ EUDLQ QHXURWUDQVPLWWHUV FDOOHG PRQRamines, which include norepinephrine and dopamine. Stimulants increase the amount of these chemicals in the brain. This, in turn, increases blood pressure and heart rate, constricts blood vessels, increases blood glucose, and opens up the pathways of the respiratory system. In addition, the increase in dopamine is associated with a sense of euphoria that can accompany the use of these drugs. The consequences of stimulant abuse can be dangerous. Although their use PD\QRWOHDGWRSK\VLFDOGHSHQGHQFHDQGULVN

of withdrawal, stimulants can be addictive in that individuals begin to use them compulsively. 7DNLQJKLJKGRVHVRIVRPHVWLPXODQWVUHSHDWHGO\ over a short time can lead to feelings of hostility RUSDUDQRLD$GGLWLRQDOO\WDNLQJKLJKGRVHVRID stimulant may result in dangerously high body temperatures and an irregular heartbeat. There is also the potential for cardiovascular failure RUOHWKDOVHL]XUHV Stimulants should be used with other medicaWLRQVRQO\ZKHQWKHSDWLHQWLVXQGHUDSK\VLFLDQ·V VXSHUYLVLRQ)RUH[DPSOHDVWLPXODQWPD\EH SUHVFULEHGWRDSDWLHQWWDNLQJDQDQWLGHSUHVVDQW However, healthcare providers and patients should be mindful that antidepressants enhance the effects of a stimulant. Patients also should be DZDUHWKDWVWLPXODQWVVKRXOGQRWEHPL[HGZLWK over-the-counter cold medicines that contain decongestants, as this combination may cause blood pressure to become dangerously high or lead to irregular heart rhythms. Dextromethorphan (sometimes called ´';0µ RU ´URERµ  LV D FRXJKVXSSUHVVLQJ ingredient in a variety of over-the-counter cold DQGFRXJKPHGLFDWLRQV/LNH3&3DQGNHWDPLQH GH[WURPHWKRUSKDQDFWVDVDQ10'$UHFHSWRU antagonist. The most common source of abused GH[WURPHWKRUSKDQ LV ´H[WUDVWUHQJWKµ FRXJK V\UXS ZKLFK W\SLFDOO\ FRQWDLQV  PLOOLJUDPV of the drug per milliliter of syrup. At the doses UHFRPPHQGHG IRU WUHDWLQJ FRXJKV  WR  RXQFHRIPHGLFDWLRQFRQWDLQLQJPJWRPJ GH[WURPHWKRUSKDQ WKHGUXJLVVDIHDQGHIIHFWLYH$WPXFKKLJKHUGRVHV RUPRUHRXQFHV  GH[WURPHWKRUSKDQSURGXFHVGLVVRFLDWLYHHIIHFWV VLPLODUWRWKRVHRI3&3DQGNHWDPLQH7KHHIIHFWV YDU\ ZLWK GRVH DQG GH[WURPHWKRUSKDQ users describe a set of distinct dose-dependent ´SODWHDXVµUDQJLQJIURPDPLOGVWLPXODQWHIIHFW ZLWKGLVWRUWHGYLVXDOSHUFHSWLRQVDWORZ DSSUR[LPDWHO\RXQFH GRVHVWRDVHQVHRIFRPSOHWH GLVVRFLDWLRQ IURP RQH·V ERG\ DW GRVHV RI  RXQFHVRUPRUH7KHHIIHFWVW\SLFDOO\ODVWIRU hours. Over-the-counter medications that contain GH[WURPHWKRUSKDQRIWHQFRQWDLQDQWLKLVWDPLQH and decongestant ingredients as well, and high GRVHVRIWKHVHPL[WXUHVFDQVHULRXVO\LQFUHDVH ULVNVDVVRFLDWHGZLWKGH[WURPHWKRUSKDQDEXVH

Management of Drug Overdose %HFDXVHVRPDQ\LOOLFLWGUXJVDUHDEXVHGLQ combination, management of an overdose can be H[WUHPHO\FRPSOH[7UHDWPHQWRIHDFKPXVWEH individual, and only general treatment guidelines are offered here. Symptomatic and supportive care is the basis IRUWUHDWPHQWRIDGUXJRYHUGRVHWKHSULPDU\ goal is to insure adequate vital functions. 1. Pat ient a ssessment is c r it ica l to determine the adequacy of respiratory and cardiac function. Note the LQWHJULW\ RI UHÁH[HV FRUQHDO SXSLO gag and deep tendon.)

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,I WKH SDWLHQW LV DV\PSWRPatic because he has not absorbed D VXIÀFLHQW TXDQWLW\ RI WKH    GUXJ vomiting may be induced. This must not be done if there is central nervous system depression, however. Activated charcoal powder may be given, or gastric lavage performed. If the patient demonstrates decreased consciousness during the procedure, however, he should be intubated before the lavage is started. ,IWKHSDWLHQW·VOHYHORIFRQVFLRXVQHVV is decreased, all treatment should be directed toward maintaining cardiac and respiratory function. Provide ventilation by mouth-to-mouth, use of an Ambubag, or respirator until WKHSDWLHQWLVR[\JHQDWHG,QWXEDWLRQ and suction, plus monitoring of blood gases, follow management of the emergency. $GHTXDWHK\GUDWLRQVKRXOGEHPDLQtained with IV fluids, and central venous pressure should be monitored. ,QVHUWLQGZHOOLQJXULQDU\FDWKHWHUDQG monitor output. *DVWULFODYDJHVKRXOGEHSHUIRUPHG only after vital functions are adequate and supportive measures to maintain them have been implemented. 6SHFLÀFDQWLGRWHVIRUGUXJRYHUGRVHV are few and should only be used with GHÀQLWHLQGLFDWLRQV1HYHUXVHWKHP prophylactically. 8QQHFHVVDU\GUXJVVKRXOGEHDYRLGHG CNS stimulants are not advised as WKH\PD\UHVXOWLQVHL]XUHV6XSSRUWive care is most important now. &RQWLQXHGFDUHZLWKFORVHPRQLWRUing of vital functions may be needed IRUDQH[WHQGHGSHULRGRIWLPH&RPD may persist for days. 2EVHUYH FDUHIXOO\ IRU WKH FRPPRQ complication of aspiration: pneumonia and subsequent infection. Initial aspiration fluids should be VDYHG IRU WR[LFRORJLFDO DQDO\VLV DV VKRXOG WKH ÀUVW XULQH VDPSOH 7KLV may have an important effect upon treatment. ,IWKHSDWLHQWVXUYLYHVEHVXUHKHLV referred for counseling and follow-up care.

6R ZKDW LV WKH QH[W VWHS WR JDLQLQJ VRPH ground in this cycle of addiction?

Treatment Approaches for Addiction 'UXJDGGLFWLRQLVDFRPSOH[LOOQHVVFKDUDFWHUL]HGE\LQWHQVHDQGDWWLPHVXQFRQWUROODEOH drug craving, along with compulsive drug

VHHNLQJDQGXVHWKDWSHUVLVWHYHQLQWKHIDFHRI devastating consequences. While the path to drug addiction begins with the voluntary act RI WDNLQJ GUXJV RYHU WLPH D SHUVRQ·V DELOLW\ to choose not to do so becomes compromised, DQGVHHNLQJDQGFRQVXPLQJWKHGUXJEHFRPHV compulsive. This behavior results largely from WKHHIIHFWVRISURORQJHGGUXJH[SRVXUHRQEUDLQ functioning. Addiction is a brain disease that affects multiple brain circuits, including those involved in reward and motivation, learning and memory, and inhibitory control over behavior. %HFDXVH GUXJ DEXVH DQG DGGLFWLRQ KDYH VR many dimensions and disrupt so many aspects RIDQLQGLYLGXDO·VOLIHWUHDWPHQWLVQRWVLPSOH Effective treatment programs typically incorporate many components, each directed to a particular aspect of the illness and its consequences. Addiction treatment must help the individual stop using drugs, maintain a drug-free lifestyle, and achieve productive functioning LQWKHIDPLO\DWZRUNDQGLQVRFLHW\%HFDXVH addiction is typically a chronic disease, people cannot simply stop using drugs for a few days and be cured. Most patients require long-term or repeated episodes of care to achieve the ultimate goal of sustained abstinence and recovery of their lives.

Key Principles of Effective Treatment 6FLHQWLÀFUHVHDUFKVLQFHWKHPLG²VVKRZV that treatment can help patients addicted to drugs stop using, avoid relapse, and successIXOO\UHFRYHUWKHLUOLYHV%DVHGRQWKLVUHVHDUFK NH\SULQFLSOHVKDYHHPHUJHGWKDWVKRXOGIRUP the basis of any effective treatment programs:

plan must be assessed continually and  PRGLÀHGDVQHFHVVDU\WRHQVXUHWKDWLW meets his or her changing needs. xMany drug–addicted individuals also have other mental disorders. x0HGLFDOO\DVVLVWHGGHWR[LÀFDWLRQLV  RQO\WKHÀUVWVWDJHRIDGGLFWLRQWUHDW ment and by itself does little to change long–term drug abuse. xTreatment does not need to be voluntary to be effective. x'UXJXVHGXULQJWUHDWPHQWPXVWEH monitored continuously, as lapses dur ing treatment do occur. 

xTreatment programs should assess  SDWLHQWVIRUWKHSUHVHQFHRI+,9$,'6  KHSDWLWLV%DQG&WXEHUFXORVLVDQG other infectious diseases as well as  SURYLGHWDUJHWHGULVN²UHGXFWLRQFRXQ seling to help patients modify or change behaviors that place them at



 ULVNRIFRQWUDFWLQJRUVSUHDGLQJLQIHF tious diseases.

Effective Treatment Approaches

xRemaining in treatment for an ad

Medication and behavioral therapy, especially when combined, are important elements of an overall therapeutic process that often begins ZLWK GHWR[LÀFDWLRQ IROORZHG E\ WUHDWPHQW and relapse prevention. Easing withdrawal symptoms can be important in the initiation of WUHDWPHQWSUHYHQWLQJUHODSVHLVQHFHVVDU\IRU maintaining its effects. And sometimes, as with other chronic conditions, episodes of relapse may require a return to prior treatment components. $FRQWLQXXPRIFDUHWKDWLQFOXGHVDFXVWRPL]HG WUHDWPHQWUHJLPHQ³DGGUHVVLQJDOODVSHFWVRIDQ LQGLYLGXDO·VOLIHLQFOXGLQJPHGLFDODQGPHQWDO KHDOWK VHUYLFHV³DQG IROORZ²XS RSWLRQV HJ community – or family-based recovery support V\VWHPV FDQEHFUXFLDOWRDSHUVRQ·VVXFFHVVLQ achieving and maintaining a drug–free lifestyle.

equate period of time is critical.

Medications

x$GGLFWLRQLVDFRPSOH[EXWWUHDWDEOH disease that affects brain function and behavior. xNo single treatment is appropriate for everyone. xTreatment needs to be readily available. xEffective treatment attends to multiple  QHHGVRIWKHLQGLYLGXDOQRWMXVWKLVRU her drug abuse.

x&RXQVHOLQJ³LQGLYLGXDODQGRU  JURXS³DQGRWKHUEHKDYLRUDOWKHUDSLHV are the most commonly used forms of drug abuse treatment. xMedications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. x$QLQGLYLGXDO·VWUHDWPHQWDQGVHUYLFHV

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Medications can be used to help with different aspects of the treatment process. Withdrawal. Medications offer help in suppressing withdrawal symptoms during GHWR[LÀFDWLRQ+RZHYHUPHGLFDOO\DVVLVWHGGHWR[LÀFDWLRQLVQRWLQLWVHOI´WUHDWPHQWµ³LWLVRQO\ WKHÀUVWVWHSLQWKHWUHDWPHQWSURFHVV3DWLHQWV who go through medically assisted withdrawal but do not receive any further treatment show drug abuse patterns similar to those who were never treated.

Substance Abuse

Page 69

Treatment. Medications can be used to help reestablish normal brain function and to prevent relapse and diminish cravings. Currently, there are medications available for opioids (heroin, morphine), and are developing others for treating stimulant (cocaine, methamphetamine) and FDQQDELV PDULMXDQD  DGGLFWLRQ 0RVW SHRSOH with severe addiction problems, however, are polydrug users (users of more than one drug) and will require treatment for all of the substances that they abuse. ‡2SLRLGV Methadone, buprenorphine and, IRUVRPHLQGLYLGXDOVQDOWUH[RQHDUHHIIHFWLYH medications for the treatment of opiate addiction. Acting on the same targets in the brain as heroin and morphine, methadone and buprenorphine suppress withdrawal symptoms and relieve cravLQJV1DOWUH[RQHZRUNVE\EORFNLQJWKHHIIHFWV of heroin or other opioids at their receptor sites and should only be used in patients who have DOUHDG\ EHHQ GHWR[LÀHG %HFDXVH RI FRPSOLDQFH LVVXHV QDOWUH[RQH LV QRW DV ZLGHO\ XVHG as the other medications. All medications help SDWLHQWVGLVHQJDJHIURPGUXJVHHNLQJDQGUHODWHG criminal behavior and become more receptive to behavioral treatments.

Behavioral Treatments %HKDYLRUDO WUHDWPHQWV KHOS SDWLHQWV HQJDJH in the treatment process, modify their attitudes and behaviors related to drug abuse, and increase KHDOWK\ OLIH VNLOOV 7KHVH WUHDWPHQWV FDQ DOVR enhance the effectiveness of medications and help people stay in treatment longer. Treatment for drug abuse and addiction can be delivered in many different settings using a variety of behavioral approaches. Outpatient behavioral treatment encompasses a wide variety of programs for patients who visit a clinic at regular intervals. Most of the programs involve individual or group drug counseling. Some programs also offer other forms of behavioral treatment such as: ‡&RJQLWLYH²EHKDYLRUDOWKHUDS\ZKLFKVHHNV WRKHOSSDWLHQWVUHFRJQL]HDYRLGDQGFRSHZLWK WKHVLWXDWLRQVLQZKLFKWKH\DUHPRVWOLNHO\WR abuse drugs. ‡ 0XOWLGLPHQVLRQDO IDPLO\ WKHUDS\, which was developed for adolescents with drug abuse SUREOHPV³DVZHOODVWKHLUIDPLOLHV³DGGUHVVHV DUDQJHRILQÁXHQFHVRQWKHLUGUXJDEXVHSDWterns and is designed to improve overall family functioning. ‡0RWLYDWLRQDOLQWHUYLHZLQJZKLFKFDSLWDOL]HV on the readiness of individuals to change their behavior and enter treatment. ‡0RWLYDWLRQDOLQFHQWLYHV (contingency management), which uses positive reinforcement to encourage abstinence from drugs. ‡5HVLGHQWLDOWUHDWPHQW programs can also be

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Substance Abuse

very effective, especially for those with more VHYHUHSUREOHPV)RUH[DPSOHWKHUDSHXWLFFRPmunities (TCs) are highly structured programs in which patients remain at a residence, typiFDOO\IRUWRPRQWKV7&VGLIIHUIURPRWKHU treatment approaches principally in their use of WKH FRPPXQLW\³WUHDWPHQW VWDII DQG WKRVH LQ UHFRYHU\³DVDNH\DJHQWRIFKDQJHWRLQÁXHQFH patient attitudes, perceptions, and behaviors associated with drug use. Patients in TCs may include those with relatively long histories of drug addiction, involvement in serious criminal activities, and seriously impaired social functioning. TCs are now also being designed to accommodate the needs of women who are pregnant or have children. 7KHIRFXVRIWKH7&LVRQWKHUHVRFLDOL]DWLRQRI the patient to a drug-free, crime–free lifestyle.

Treatment Within the Criminal Justice System

5LVNIDFWRUVLQFOXGHFKDRWLFKRPHHQYLURQments, particularly in which parents abuse VXEVWDQFHVRUVXIIHUIURPPHQWDOLOOQHVVHV ineffective parenting, especially with FKLOGUHQ ZLWK GLIÀFXOW WHPSHUDPHQWV RU FRQGXFWGLVRUGHUVODFNRIPXWXDODWWDFKPHQWVDQGQXUWXULQJLQDSSURSULDWHO\VK\ RU DJJUHVVLYH EHKDYLRU LQ WKH FODVVURRP IDLOXUHLQVFKRROSHUIRUPDQFHSRRUVRFLDO FRSLQJVNLOOVDIÀOLDWLRQVZLWKGHYLDQWSHHUV RUSHHUVGLVSOD\LQJGHYLDQWEHKDYLRUVDQG perceptions of approval of drug-using beKDYLRUVLQIDPLO\ZRUNVFKRROSHHUDQG community environments. 

xPrevention programs may target a variety of drugs of abuse, such as tobacco, DOFRKROLQKDODQWVDQGPDULMXDQDRUPD\ target a single area of drug abuse such as the misuse of prescription drugs.



xPrevention programs should include genHUDOOLIHVNLOOVWUDLQLQJDQGWUDLQLQJLQVNLOOV to resist drugs when offered, strengthen personal attitudes and commitments against drug use, and increase social competency (e.g., in communications, peer relationVKLSVVHOIHIÀFDF\ DVVHUWLYHQHVV 

7UHDWPHQW LQ D FULPLQDO MXVWLFH VHWWLQJ FDQ VXFFHHG LQ SUHYHQWLQJ DQ RIIHQGHU·V UHWXUQ WR criminal behavior, particularly when treatment FRQWLQXHVDVWKHSHUVRQWUDQVLWLRQVEDFNLQWRWKH community. Studies show that treatment does not need to be voluntary to be effective.

Prevention Is The Key ,QPRUHWKDQ\HDUVRIGUXJDEXVHUHVHDUFK 1,'$ KDV LGHQWLÀHG LPSRUWDQW SULQFLSOHV IRU prevention programs in the family, school, and FRPPXQLW\1,'$VXSSRUWHGUHVHDUFKHUVKDYH tested these principles in long-term drug abuse prevention programs and have found them to be effective. It should be noted that healthcare professionals are often in a unique position to LQÁXHQFH DQG LPSOHPHQW ERWK WKH SUHYHQWLRQ and treatment of drug abuse. Effective intervention for prevention can occur during one-to-one interactions with patients DV ZHOO DV LQ WKH FRQWH[W RI FRPPXQLW\ ZLGH programs. Prevention programs should be designed to HQKDQFH´SURWHFWLYHIDFWRUVµDQGPRYHWRZDUG UHYHUVLQJRUUHGXFLQJNQRZQ´ULVNIDFWRUVµ3URtective factors are those associated with reduced SRWHQWLDOIRUGUXJXVH5LVNIDFWRUVDUHWKRVHWKDW PDNHWKHSRWHQWLDOIRUGUXJXVHPRUHOLNHO\ 1. Protective factors include strong and SRVLWLYHERQGVZLWKLQDSURVRFLDOIDPLO\ SDUHQWDOPRQLWRULQJFOHDUUXOHVRIFRQGXFW that are consistently enforced within the IDPLO\LQYROYHPHQWRISDUHQWVLQWKHOLYHV RIWKHLUFKLOGUHQVXFFHVVLQVFKRROSHUIRUPDQFHVWURQJERQGVZLWKRWKHUSURVRFLDO institutions, such as school and religious RUJDQL]DWLRQVDQGDGRSWLRQRIFRQYHQWLRQDO norms about drug use.

 

xPrevention programs for children and adolescents should include developmentally appropriate interactive methods, such as peer discussion groups and group problem VROYLQJDQGGHFLVLRQPDNLQJUDWKHUWKDQ didactic teaching techniques alone.



x Prevention programs should include SDUHQWV·RUFDUHJLYHUV·FRPSRQHQWVWKDWWUDLQ them to use appropriate parenting strategies, reinforce what the children are learning about drugs and their harmful effects, and open opportunities for family discussions about the use of legal and illegal substances and family policies about their use.



x Prevention programs should be longterm (throughout the school career), with repeat interventions to reinforce the original SUHYHQWLRQ JRDOV )RU H[DPSOH VFKRRO based efforts directed at elementary and middle school students should include booster sessions to help with the critical transitions such as from middle to high school.



x Family-focused prevention efforts have a greater impact than strategies that focus on parents only or children only.



x Community programs that include media campaigns and policy changes, such as new regulations that restrict access to

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alcohol, tobacco, or other drugs, are more effective when they are accompanied by school and family interventions. 









 

x Community programs need to strengthen norms against drug use in all drug abuse prevention settings, including the family, WKH VFKRRO WKH ZRUNSODFH DQG WKH FRPmunity. x Schools offer opportunities to reach all populations and also serve as important setWLQJVIRUVSHFLÀFVXESRSXODWLRQVDWULVNIRU drug abuse, such as children with behavior problems or learning disabilities and those who are potential dropouts. x Prevention programming should be DGDSWHGWRDGGUHVVWKHVSHFLÀFQDWXUHRIWKH drug abuse problem in the local community. x 7KHKLJKHUWKHOHYHORIULVNRIWKHWDUJHW population, the more intensive the prevention effort must be and the earlier it must begin. x Prevention programs should be ageVSHFLÀFGHYHORSPHQWDOO\DSSURSULDWHDQG culturally sensitive. xEffective prevention programs are costeffective. For every $1 spent on drug use SUHYHQWLRQ FRPPXQLWLHV FDQ VDYH  WR LQFRVWVIRUGUXJDEXVHWUHDWPHQWDQG counseling.

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Or do we focus on the users? What can we GRWRVWRSVRPHRQHIURPWDNLQJWKHÀUVWKLWRQD MRLQWSRSSLQJKLVÀUVWSLOOVWLFNLQJWKDWQHHGOH into his arm? There are no easy answers, but one thing does seem clear: comprehensive, patientcentered treatment and prevention programs may represent our best hope for a brighter, drug-free future for us all. 7KH1DWLRQDO,QVWLWXWHRQ'UXJ$EXVH 1,'$  SXEOLVKHVDVHULHVRIH[FHOOHQW5HVHDUFK5HSRUWV on the various drugs of abuse, many of which ZHUHH[FHUSWHGLQWKHSUHSDUDWLRQRIWKLVFRXUVH$ list of available Reports may be obtained at www. QLGDQLKJRY5HVHDUFK5HSRUWV5HVHDUFK,QGH[ html, or by contacting the National ClearingKRXVHRQ$OFRKRODQG'UXJ,QIRUPDWLRQ32 %R[5RFNYLOOH0'

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0RQURH7´$GGUHVVLQJVXEVWDQFHDEXVHDPRQJ nursing students: development of a prototype alternative-to-dismissal policy.” J Nurs Educ0D\  S 6LPPRQV6´7HHQVDQGSUHVFULSWLRQGUXJVD potentially dangerous combination.” Nursing0D\  S 6LUF\5$6WRMDQRVNL$´$'+'WUHDWPHQWDQG WKHULVNRIVXEVWDQFHDEXVHµNurse Pract, $SU  S 6PLWK&6´6XEVWDQFHDEXVHFKURQLFVRUURZ and mothering loss: relapse triggers among female victims of child abuse.” J Pediatr Nurs2FW  S :DWVRQ'6´7KHFRGHRIVLOHQFHµAORN J, 1RY  S

Additional Sources of Useful Information: $UQVWHLQ3´,VP\SDWLHQWGUXJVHHNLQJRULQ need of pain relief?” Nursing0D\   S %XUURZ6DQFKH]--/RSH]$/6ODJOH&3 ´3HUFHLYHGFRPSHWHQFHLQDGGUHVVLQJ student substance abuse: a national survey of middle school counselors.” J Sch Health, 0D\  S &RQQHUV%XUURZ1$-RKQVRQ%:KLWHVLGH 0DQVHOO/´0DWHUQDOVXEVWDQFHDEXVHDQG FKLOGUHQ·VH[SRVXUHWRYLROHQFHµJ Pediatr Nurs 2FW  S )ODVNHUXG-+´&XOWXUDOFRQWH[WDQGWUHDWPHQW for substance-related disorders: an invitation.” Issues Ment Health NurV$SU   S )URVFK'  ´9$(DVLQJ5XOHVIRU8VHUVRI0HGLFDO0DULMXDQDµ1<7LPHV [Online], Available:http://www.nytimes. FRPKHDOWKSROLF\YHWHUDQV KWPO"SDJHZDQWHG  BU  SDJHZDQW *RQ]DOH]*XDUGD502UWHJD-9DVTXH](3 HWDO´/DPDQFKDQHJUDVXEVWDQFHDEXVH YLROHQFHDQGVH[XDOULVNVDPRQJ+LVSDQLF males.” West J Nurs Re )HE   S /HIHEYUH/0LGPHU'%R\G-$HWDO´3DUticipant perception of an integrated program for substance abuse in pregnancy.” J Obstet Gynecol Neonatal NurV-DQ   S /RQGRQ)´3V\FKRHGXFDWLRQ3DWLHQWHGXFDWLRQ gets respect.” Home Healthc Nurse, Apr   S

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0DULMXDQDFUHDWHVIHHOLQJVRIHXSKRULDUHOD[ ation, and heightened sensation by: A. stimulating the dopamine pathway within the pleasure circuit %FDXVLQJFDVFDGHVRIVHURWRQLQWREH released into the brain C. increasing the activity level of neurons throughout the brain 'FDXVLQJWKHEUDLQWRFUHDWHPRUHFDQ nabinoid receptors

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$UHODWLYHO\QHZGUXJRQWKHPDUNHWNQRZQ  DV6SLFHRU.LVDV\QWKHWLFIRUPRI $PDULMXDQD %FRFDLQH C. heroin '.HWDPLQH $GYHUVHSK\VLFDOHIIHFWVRIPDULMXDQDXVH include: A. chronic diarrhea %ORVVRIDSSHWLWH C. headache 'LWFK\VFDO\VNLQ ,QDGGLWLRQWRDGROHVFHQWVDQG\RXQJDGXOWV SHUVRQVDWKLJKULVNIRUGHYHORSPHQWRI PDULMXDQDDEXVHLQFOXGHWKRVH A. diagnosed with post-traumatic stress disorder %VXEMHFWHGWRFKURQLFORZOHYHOVRIVWUHVV &HQJDJHGLQKLJKULVNRFFXSDWLRQV 'DOORIWKHDERYH ,QFRPSDULVRQWRSRZGHUFRFDLQH´FUDFNµ is: $PRUHOLNHO\WREHLQMHFWHGRULQKDOHG %SUHIHUUHGIRUWKHVORZVWHDG\HXSKRULD it produces  &XQOLNHO\WRSURGXFHDGGLFWLRQRURWKHU health consequences 'OHVVH[SHQVLYHWRSURGXFHDQGWREX\

5HVHDUFKKDVLQGLFDWHGWKDW´FUDFNEDELHVµ whose mothers used cocaine during their pregnancy: A. suffered severe brain damage leading to UHGXFHGLQWHOOLJHQFHDQGODFNRIVRFLDOVNLOOV %DUHOLNHO\WRKDYHUHGXFHGOLIHH[SHFWDQF\ &PD\KDYHGLIÀFXOW\FRQFHQWUDWLQJZKHQ they reach school age  'VKRXOGH[SHFWQRLOOHIIHFWVIURPWKH  FRFDLQHH[SRVXUH  7UHDWPHQW RI LQGLYLGXDOV IRU FRFDLQH DGdiction is complicated by the fact that they: A. may have sustained permanent biologi cal changes in their brains %RIWHQXVHPXOWLSOHGUXJVLQDGGLWLRQWR cocaine C. present with a wide variety of psycho logical and social issues 'DOORIWKHDERYH 0RVWRIWKHPHWKDPSKHWDPLQHXVHGLQWKH United States is: A. imported from Asia and South America %PDQXIDFWXUHGLQVPDOOFODQGHVWLQH ODERUDWRULHVIURPLQH[SHQVLYHHDV\WRREtain materials &GLYHUWHGIURPSKDUPDF\VWRFNVLQWHQGHG for legitimate medical use  'VPXJJOHGLQIURP(XURSHZKHUHLWLV legal

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2UDOLQJHVWLRQRIPHWKDPSKHWDPLQHSURGXFduces: A. an immediate, intensely pleasurable rush that lasts for about three minutes %DQRWLFHDEOHKLJKZLWKLQÀIWHHQWR twenty minutes of the dose  &PDUNHGDJLWDWLRQDQGSDUDQRLDLQPRVW users  'IHHOLQJVRIDOHUWQHVVDQGZHOOEHLQJWKDW can last for days  /RQJWHUP DEXVHUV RI PHWKDPSKHWDPLQH PD\H[SHULHQFH´IRUPLFDWLRQµZKLFKLV $JUDGXDOGHIRUPLW\RIWKHIDFHDQGQHFN %HQJDJLQJLQLOOLFLWVH[LQH[FKDQJHIRU drugs C. the sensation of insects crawling on  RQH·VVNLQ 'H[FHVVSURGXFWLRQRIPXFXV &KURQLFXVHRIPHWKDPSKHWDPLQHOHDGVWR A. chronic somnolence and fatigue %GDPDJHWRGRSDPLQHSURGXFLQJFHOOV in the brain C. clear physical manifestations of withdrawal 'DQLUUHYHUVLEOHSV\FKRWLFVWDWH (PHUJHQF\URRPWUHDWPHQWRIDPSKHWDPLQH overdose should focus on: A. immediate physical symptoms of hyperthermia or convulsions %DGPLQLVWUDWLRQRISURSK\ODFWLFGRVHVRI narcoleptics for possible psychosis  &XVHRIEHQ]RGLD]HSLQHVWRFDOPWKHSDWLHQW  'VHGDWLRQDQGREVHUYDWLRQ $WWKLVWLPHWKHPRVWHIIHFWLYHWUHDWPHQWV for methamphetamine abuse are: A. antidepressants  %DQ[LRO\WLFVFRPELQHGZLWKJURXSDQG family counseling C. cognitive and behavioral interventions 'VWHSUHFRYHU\VXSSRUWSURJUDPV $EXVHRI5LWDOLQDQGRWKHUPHGLFDWLRQVXVHG WRWUHDW$'+'KDVEHHQGRFXPHQWHGDPRQJ A. elementary school children %PLGGOHDQGKLJKVFKRROVWXGHQWV C. street addicts 'DOORIWKHDERYH  7ZR LPSRUWDQW HIIHFWV SURGXFHG E\ WKH naturally occurring endorphins and opiate GUXJVDOLNHDUH A. enhanced alertness and energy %SOHDVXUHDQGSDLQUHOLHI &HXSKRULDDQGUHOD[DWLRQ 'FRQÀGHQFHDQGVRFLDELOLW\

 'HDWK IURP D KHURLQ RYHUGRVH LV XVXDOO\ due to: $DVSK\[LDWLRQIURPDVSLUDWLRQRIVWRP ach contents %VHYHUHFDUGLDFDUUK\WKPLD &XQFRQWUROOHGVHL]XUHV 'WREUDLQVWHPPHGLDWHGUHVSLUDWRU\DUUHVW +HURLQLVSUHIHUUHGRYHURWKHURSLDWHVE\ most street users because it: A. enters the brain and produces its ef IHFWVPRUHTXLFNO\  %LVPRUHSUHGLFWDEOHLQLWVVWUHQJWK duration, and effects C. can be obtained more easily 'LVOHVVOLNHO\WRFDXVHDGGLFWLRQ 6\PSWRPVRIKHURLQZLWKGUDZDOLQFOXGHDOO RIWKHIROORZLQJH[FHSW A. muscle and bone pain %´FROGWXUNH\µ C. somnolence and stupor 'GLDUUKHDDQGYRPLWLQJ 0HGLFDWLRQVWKDWPD\EHXVHGWRWUHDWKHURLQ addiction include: A. buprenorphine %GLD]HSDP C. meperidine 'SKHQF\FOLGLQH %XSUHQRUSKLQHLVDQDWWUDFWLYHWUHDWPHQWIRU heroin addiction because it $SURGXFHVOHVVULVNIRURYHUGRVHDQG withdrawl: %LVOHVVH[SHQVLYHWKDQDOWHUQDWLYHPHGL cations &KDVDSURYHQWUDFNUHFRUGLQWKH8QLWHG States 'DOORIWKHDERYH  7KH RSLDWH DQDORJ GUXJ 0373 FDXVHV LWV users to develop: A. decreased tolerance for heroin, with  LQFUHDVHGULVNIRURYHUGRVH %FOXEELQJRIWKHÀQJHUVDQGWRHV &3DUNLQVRQOLNHLPPRELOLW\  'KHDUWDUUK\WKPLDVDQGUHVSLUDWRU\SURE lems  :KLFK RI WKH IROORZLQJ KDOOXFLQRJHQV LV considered to be addictive? $/6' %0'0$ C. mescaline 'SVLORF\ELQ

 /6' XVHUV PD\ H[SHULHQFH V\QHVWKHVLD ZKLFKLVGHÀQHGDV $IHHOLQJWKDWRQH·VERG\LVFKDQJLQJVKDSH %SHUFHLYLQJRQHVHOIDVKHDULQJFRORUVRU seeing sounds  &H[SHULHQFLQJVHYHUDOHPRWLRQVVLPXOWD neously 'IHDULQJGHDWKRUORVVRIFRQWURO 5HVHDUFKDQGFOLQLFDOHYLGHQFHLQGLFDWHWKDW /6'LQGXFHGSHUVLVWHQWSV\FKRVLV $PD\UHVXOWLQPDUNHGEOXQWLQJRIDIIHFW %LQFOXGHVYLYLGYLVXDOGLVWXUEDQFHVDQG hallucinations C. usually occurs after prolonged, regular  /6'XVH  'RQO\DIIHFWVSHUVRQVZLWKDKLVWRU\RI psychological problems

$GRVHRIPJRUOHVVRI3&3LVOLNHO\WR produce A. slow, labored breathing %HOHYDWHGEORRGSUHVVXUH C. hypothermia 'LQVHQVLWLYLW\WRSDLQ $QRYHUGRVHRIGH[WURPHWKRUSKDQIRXQGLQ over the counter cough and cold remedies, is OLNHO\WRSURGXFH A. distorted visual perceptions %IHHOLQJVRIGLVVRFLDWLRQ &NHWDPLQHOLNHHIIHFWV 'DOORIWKHDERYH 7KHVWUHHWQDPHV$GDPKXJDQGEHDQVUHIHU to the club drug $0'0$ %/6' &NHWDPLQH 'PHWKDPSKHWDPLQH  5HFHQW VWXGLHV KDYH LQGLFDWHG WKDW XVH RI Ecstasy may result in $VLJQLÀFDQWUHGXFWLRQRIVHURWRQLQSUR ducing brain cells %ELUWKGHIHFWVLQFKLOGUHQRIFKURQLFXVHUV C. persistent symptoms of paranoia and disorientation 'DOORIWKHDERYH $OORIWKHIROORZLQJGUXJVKDYHEHHQIUH TXHQWO\LPSOLFDWHGLQ´GUXJUDSHµH[FHSW $NHWDPLQH %*+% C. rohypnol '/6'

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Substance Abuse

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1LWULWHVDUHFRQVLGHUHGWREHDVSHFLDOFODVV of inhalants because they: A. act on the blood vessels and muscles rather than the brain %DUHQRWDYDLODEOHLQDQ\FRPPHUFLDO products C. are used primarily by children and younger adolescents 'DFWDVPRRGHQKDQFHUV

 ,QWXEDWLRQ RI WKH GUXJ RYHUGRVH SDWLHQW should occur: A. immediately upon admission as a precautionary measure %XSRQFRPSOHWLRQRIJDVWULFODYDJH &ZKHQHYHUWKHSDWLHQW·VOHYHORIFRQ sciousness begins to decline  'DIWHUDGPLQLVWUDWLRQRIVSHFLÀFGUXJ antidotes

'DWDIURPQDWLRQDODQGVWDWHVXUYH\VLQGLcate that inhalant abuse: $UHDFKHVLWVSHDNGXULQJWKDQGWK grade  %LVFRQVLVWHQWO\PRUHFRPPRQDPRQJ boys than girls &YHU\UDUHO\H[WHQGVLQWRDGXOWKRRG  'LVDVVRFLDWHGZLWKSRRUJUDGHVDQG school dropouts

.H\SULQFLSOHVIRUHIIHFWLYHWUHDWPHQWSURJUDPVLQFOXGHDOORIWKHIROORZLQJH[FHSW A. Treatment needs to be available and readily accessible. %7KHWUHDWPHQWSODQVKRXOGEHPRGLÀHG as necessary to meet multiple needs. C. Adequate duration of treatment is critical for success.  '7UHDWPHQWVKRXOGIRFXVRQWKHGUXJ abuse rather than related psychosocial issues.

0RVWLQKDODQWVSURGXFHWKHLUHIIHFWVE\ A. depressing the central nervous system %DFWLQJDV&16VWLPXODQWV &ELQGLQJWRRSLDWHUHFHSWRUVLQWKHEUDLQ·V pleasure circuit  'DOWHULQJJOXFRVHPHWDEROLVPLQWKHEUDLQ '+($DQG$QGURWDNHQIRUWKHLUPXVFOH building effects, are available A. for legal purchase in health food stores %E\SUHVFULSWLRQRQO\ C. by mail or Internet order from foreign sources only 'RQO\IURPLOOHJDOPDQXIDFWXUHUV 6WHURLGDEXVHLVKLJKHUDPRQJ A. elementary and middle school-age boys %PDOHVWKDQIHPDOHV C. professional athletes 'PLGGOHDJHDQGROGHUPHQ  2QH RI WKH PDLQ UHDVRQV SHRSOH JLYH IRU using steroids is to: A. improve their performance in sports  %FRXQWHUWKHVLGHHIIHFWVRIFDUGLRYDVFXODU medications C. slow the aging process 'HQKDQFHVH[XDODURXVDODQGSHUIRUPDQFH  7KH PRVW FRPPRQO\ DEXVHG FODVVHV RI prescription drugs include all of the folORZLQJH[FHSW A. opioids %VWLPXODQWV C. anticonvulsants '&16GHSUHVVDQWV

 $ FXVWRPL]HG WUHDWPHQW UHJLPHQ LQFOXGHVBBBBBBWR DVVLVW LQ PDLQWDLQLQJ D drug-free lifestyle. A. options to return to prior treatment %PHGLFDODQGPHQWDOKHDOWKVHUYLFHV C. follow-up options (recovery support systems) 'DOORIWKHDERYH  2XWSDWLHQW EHKDYLRUDO WUHDWPHQW HQFRPpasses: A. cognitive-behavioral therapy  %PXOWLGLPHQVLRQDOIDPLO\ therapy C. motivational interviewing and incentives 'DOORIWKHDERYHWUHDWPHQWV 3UHYHQWLRQSURJUDPVGHVLJQHGZLWK´3URWHFtive factors” are associated with reduced potential for drug use and include: A. strong and positive family bonds %FOHDUDQGFRQVLVWHQWUXOHVRIFRQGXFW C. acceptance of conventional norms regarding drug abuse 'DOORIWKHDERYH (IIHFWLYHGUXJDEXVHSUHYHQWLRQSURJUDPV are: $YHU\H[SHQVLYHEXWQHFHVVDU\WR prevent human suffering  %GLVDSSHDULQJGXHWRFRPSHWLQJFODLPVRQ WKHVKULQNLQJKHDOWKFDUHGROODU C. cost effective in reducing community   H[SHQGLWXUHVIRUGUXJWUHDWPHQWDQG counseling 'LQFUHDVLQJO\VHHQDVWKHUHVSRQVLELOLW\ of the private sector ~ End Test ~

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