CHAPTER 319
Drug Use and Abuse
Drugs are an integral part of everyday life for many people—legitimately and illegitmately—and drug use among adolescents remains high (see page 1758).
The legality and social acceptance of a particular drug often depend on what it is used for, what its effects are, and who is using it. For example, many abused drugs have legitimate medical uses:
Amphetamines: To treat attention-deficit/hyperactivity disorder
Barbiturates and benzodiazepines: To treat anxiety and insomnia
Cocaine: To numb surfaces of the body (as a topical anesthetic)
Ketamine: To provide anesthesia
Marijuana: To treat nausea due to advanced cancer
Opioids: To relieve pain and provide anesthesia
However, use of these drugs for pleasure is illegal and dangerous. Legality and social acceptance of a drug often vary among different societies or countries. Legality and acceptance may also change within a society or country over time, as happened with alcohol in the United States.
Many drugs, some legal and some not, alter the mind. Some mind-altering (psychoactive) drugs affect brain function each time they are used, regardless of how much is used. Others affect brain function only if a large amount is used or if the drug is used continually. Some drugs affect the brain in such a way that people want or feel a need to use the drug again and again (craving). Some cause symptoms, such as euphoria (a high).
Narcotics are often thought of when drug abuse is discussed. This term refers to drugs that cause loss of feeling, a sense of numbness, and drowsiness. The term often refers specifically to opioids (drugs that bind to opiate receptors on cells). However, the term narcotics is also used in a broader (and inaccurate) sense to include any drug that is illegal or used illegitimately.
Did You Know…
Some people who abuse drugs are not dependent on them.
Definitions
Different terms are used to indicate the problems caused by using mind-altering drugs. However, doctors and other experts sometimes disagree about the exact meaning of these terms.
Tolerance: This term means that people need more and more of a drug to feel the effects originally produced by a smaller amount. People can develop tremendous tolerance to drugs such as opioids and alcohol.
Intoxication: This term refers to the immediate and temporary effects of a specific drug. When people are intoxicated, mental function and judgment are impaired, and mood may be altered. Depending on the drug, people may feel a sense of excitement, an exaggerated feeling of well-being, or euphoria, or they may feel more calm, relaxed, and sleepy. Many drugs impair physical functioning, with decreased coordination, leading to falls and vehicle crashes. Some drugs trigger aggressive behavior, leading to fighting. As larger amounts of the drug are used, adverse effects become more obvious (called an overdose), with serious complications and risk of death.
Drug Dependence: Drug dependence refers to factors that make it difficult for a person to stop taking a drug. These factors include craving and withdrawal. Drug dependence may be psychologic or physical.
Psychologic dependence refers to a compelling desire to repeat the experience of taking a mind-altering drug (craving) or to avoid the discontent of not using the drug (withdrawal). Desiring the drug experience may be the only obvious reason for compulsive use. Drugs that cause psychologic dependence often produce one or more of the following:
Reduced anxiety and tension
Elation, euphoria, or other pleasurable mood changes
Feelings of increased mental and physical ability
Feeling a temporary escape from reality
Altered perceptions of the environment (for example, auditory or visual hallucinations)
The intense desire and compulsion to use a drug lead to using it in larger amounts, more frequently, or over a longer period than at first intended. People who are psychologically dependent on a drug give up social and other activities because of drug use. They also continue to use the drug even though they know that the drug is physically harmful or interferes with other aspects of their life, including family and work.
Physical dependence means that stopping the drug results in unpleasant, sometimes painful physical symptoms (withdrawal). Symptoms occur because the body adapts to the continuous presence of a drug.
People going through withdrawal feel sick and may have various unpleasant symptoms depending on the drug involved. Withdrawal from some drugs (such as alcohol or barbiturates) can be serious and even life threatening.
How drug dependence develops is complex and unclear. It depends on interaction of the following:
Drug: Drugs vary in how likely they are to make people dependent on them.
User: The user’s personality, health, physical characteristics (including genetic makeup), and emotional circumstances affect whether the user is likely to become dependent. For example, the presence of constant pain may drive a person to use drugs inappropriately, as may emotional distress. However, research has not identified any clear-cut biochemical or physical differences in people to explain why some become dependent and others do not.
Cultural and social factors: Peer or group pressure and stress (for example, due to work or family obligations) may contribute to dependency, as may the mass media’s portrayal of prescription drugs as safely relieving all distress.
Drug Abuse: Drug abuse can be defined in terms of society’s disapproval and the effect the drug has on the person’s social and emotional well-being. Drug abuse may involve the following:
Using drugs, usually illegal drugs, recreationally (not for medical reasons)
Using mind-altering drugs to relieve medical problems or symptoms without a health care practitioner’s recommendation
Using drugs because of a strong psychologic or physical compulsion (dependence) to use them
Use of illegal drugs is often considered abuse largely because the drugs are illegal. But drugs that are abused are not necessarily illegal, and they may or may not alter the mind. They include prescription drugs, alcohol, and substances in products not considered drugs (such as glue or paint), as well as illegal drugs. People of all socioeconomic groups abuse drugs.
Some people who abuse drugs use an amount large enough or over a period long enough to threaten their quality of life, health, or safety or those of other people. But many people control their abuse of drugs so that it does not adversely affect their health or functioning, making the effects less obvious. Drug abuse does not necessarily include dependence.
Recreational Drug Use: The recreational use of drugs involves using drugs occasionally in relatively small doses and thus often without harm to users. That is, users do not develop tolerance or become physically dependent, and the drug does not physically harm them (at least in the short term). Drugs usually considered recreational include opium, alcohol, nicotine, marijuana, caffeine, hallucinogenic mushrooms, and cocaine.
Recreational drugs are usually taken by mouth or inhaled.
Drug Addiction: Drug addiction has no universally accepted definition. It is characterized by an intense craving for the drug and compulsive, uncontrolled use of the drug despite harm done to the user or other people. People who are addicted spend more and more time obtaining the drug, using the drug, or recovering from its effects. Thus, addiction usually interferes with the ability to work, study, or interact normally with family and friends. Because there is a risk of harm, addiction implies the need to stop drug use, regardless of whether the addict understands and agrees.
Addiction can involve illegal or legal drugs. However, obtaining and using an illegal drug is very different from obtaining and using a legal drug, which may involve simply going to the doctor, getting a prescription, and going to the pharmacy. Obtaining an illegal drug (or a legal drug used without medical need) may involve lying and stealing. For example, people may falsify symptoms to a doctor or visit several doctors with the same symptoms to obtain several prescriptions. When people with severe pain due to advanced cancer become dependent (psychologically and physically) on an opioid such as morphine, their ongoing need for that drug is not usually considered an addiction. However, when people become dependent on heroin, steal to get money to buy heroin, and lie to family members and friends, their behavior is considered an addiction.
At times, family members or friends may behave in ways that allow an addict to continue to use drugs or alcohol. These people are called enablers. They are considered codependents when their own needs are intertwined with perpetuating the addict’s use of the addictive substance. Enablers may call in sick for an addict or make excuses for the addict’s behavior. Enablers may plead with the addict to stop using drugs or alcohol but rarely do anything else to help the addict stop.
A pregnant addict exposes her fetus to the drugs she is using. Often, a pregnant addict does not admit to her doctor that she is using drugs or alcohol. The fetus may become dependent and may develop serious defects as a result of the mother’s drug use (see page 1708). Soon after delivery, the newborn can experience severe or even fatal withdrawal, particularly when the doctor is unaware of the mother’s addiction.
Methods of Use
Drugs may be swallowed, smoked, inhaled through the nose as a powder (snorted), or injected. When drugs are injected, their effects may occur more quickly, be stronger, or both.
Drugs may be injected into a vein (intravenously), a muscle (intramuscularly), or under the skin (sub-cutaneously). Veins in the arms are typically used for intravenous injections, but if these areas become too scarred, drugs may be injected into veins anywhere in the body, including those of the thigh, neck, or armpit.
Complications From Drug Injection: Injecting drugs has more risks than other methods. People are exposed not only to the side effects of the drug but also to problems related to injection itself, such as the following:
Adulterants: Adulterants are substances that are added to a drug to alter its physical qualities. They are usually added, without the user’s knowledge, to reduce costs or to make the drug easier to use. Thus, users do not know what they are injecting. In street drugs such as heroin and cocaine, adulterants may also be added to enhance mind-altering properties or
Other Drugs of Abuse
Drug abuse typically involves mind-altering drugs, but it may involve drugs taken for other purposes, usually losing weight or enhancing athletic performance. Taking these drugs without medical need and medical supervision can endanger the quality of life, health, or safety of the user. Using a drug this way is considered drug abuse. Anabolic steroids are probably the most commonly abused drugs in this group (see page 2090).
Growth Hormone
Growth hormone is produced by the pituitary gland to help the body control how proteins, carbohydrates, and fats are used to stimulate growth. Growth hormone is also manufactured as a drug and is sometimes given to children of small stature when their body is unable to make enough growth hormone. Some athletes abuse growth hormone because they believe it can increase muscle growth and strength while decreasing body fat.
Use of growth hormone without medical need over a long period can cause an increase in fat levels in the blood, diabetes, and an increase in heart size, which may result in heart failure.
Laboratory tests to identify growth hormone not made by the person’s own body are not routinely available.
Erythropoietin and Darbepoetin
Erythropoietin is a hormone produced by the kidneys. It stimulates bone marrow to produce red blood cells. Erythropoietin is also manufactured as a drug. Darbepoetin is a drug similar to erythropoietin. Both drugs are used to increase production of red blood cells in people with certain kinds of anemia. These drugs may be taken by athletes because they believe that with more red blood cells, more oxygen can get to their muscles, enabling them to perform better.
Using erythropoietin or darbepoetin without medical need may change the body’s regulation of red cell cell production, so that the number of red blood cells suddenly decreases when these drugs are stopped.
Diuretics
Diuretics are drugs that speed the elimination of salt and water by the kidneys. Diuretics are used to treat a variety of disorders, including high blood pressure and heart failure. However, some people, including athletes and people with eating disorders such as anorexia nervosa, take diuretics to help them lose weight quickly. Inappropriate use of diuretics may cause dehydration and severe deficiencies of electrolytes such as potassium. Such deficiencies can lead to severe illness or death.
Ipecac Syrup
Ipecac syrup is a drug that triggers vomiting. It is sometimes used to treat children who have swallowed chemicals or poisons. However, people with eating disorders such as anorexia nervosa often take ipecac syrup to help them lose weight. Inappropriate use of ipecac may cause diarrhea, severe deficiencies of electrolytes, weakness, irregular heart rhythms, and heart failure.
Laxatives
Laxatives are drugs that speed the passage of substances through the digestive tract and that are used to treat constipation. However, people who falsely believe they must have frequent bowel movements as part of being healthy often abuse laxatives. In addition, people with eating disorders such as anorexia nervosa sometimes take laxatives because they believe doing so can help them lose weight.
Laxatives used often and without medical need may cause dehydration and severe deficiencies of electrolytes. Regular use of laxatives can also interfere with absorption of other drugs, causing them to stop working. Inappropriate use of laxatives over a long period can damage the muscle layers of the large intestine. Severe constipation and other intestinal disorders (such as diverticulosis) may result.
to substitute for the drug. Quinine, a common heroin adulterant, can cause double vision, paralysis, and other symptoms of nerve injury, including Guillain-Barré syndrome (see page 828).
Fillers: Some people crush tablets of prescription drugs, dissolve them, and inject the solution intravenously. These people are injecting the fillers that tablets commonly contain (such as cellulose, talc, and cornstarch). Fillers can become trapped in the lungs, causing inflammation. Fillers can also damage heart valves, increasing the risk of infection there (endocarditis).
Bacteria and viruses: Injecting drugs with unsterilized needles, particularly needles used by someone else, can introduce bacteria and viruses into the body. As a result, abscesses may develop near the injection site, or bacteria or viruses may travel through the bloodstream to other parts of the body, such as the lungs, heart, brain, or bones, and cause infection. Infection of the heart valves (endocarditis—see page 386) is a common serious consequence of injecting drugs contaminated with bacteria or using dirty needles. Sharing needles can spread serious infections, such as hepatitis B and C and human immunodeficiency virus (HIV) infection.
Injuries due to needle use: Drug abuser’s elbow (myositis ossificans) is caused by repeated, inept needle punctures. The muscle around the elbow is replaced with scar tissue. Subcutaneous injections (those given under the skin, also called skin popping) can cause skin sores. Intravenous injections lead to scarring of veins (tracks), which makes the veins more and more difficult to inject and impairs blood flow.
Screening
Screening involves checking for drug abuse in people who do not necessarily have any symptoms of drug abuse. It may be done systematically or randomly in people such as the following:
Certain groups of people, such as students, athletes, and prisoners
People who are applying for or who already hold certain types of jobs (such as pilots or commercial truck drivers)
People who have been involved in motor vehicle or boating accidents or accidents at work
People who have attempted suicide by unclear means
People in a court-ordered treatment program for drug abuse or with terms of probation or parole requiring abstinence—to monitor compliance
People in a substance abuse treatment program— to detect continuing substance abuse and thus better plan treatment
Tricks of the Trade: Body Packing
To smuggle drugs across borders or other security checkpoints, people may voluntarily swallow packets filled with drugs. This tactic is called body packing.
Body packing often involves drugs with a high street value (primarily heroin or cocaine). The drugs may be placed in condoms or in packets wrapped in several layers of polyethylene or latex and sometimes covered with an outer layer of wax. After body packers (mules) swallow several packets, they typically take drugs to slow the movement of substances through the digestive tract until the packets can be retrieved.
If a packet tears, a drug overdose may occur, sometimes causing serious symptoms. Symptoms may include repeated seizures, high blood pressure, a very high body temperature, difficulty breathing, and coma. Packets may block or tear the intestine. If the intestine tears, its contents may leak into the abdominal cavity and cause infection—a disorder called peritonitis.
Body stuffing is similar to body packing. It occurs when people swallow drug packets to avoid being caught by law enforcement. Sometimes packets are hidden in the rectum or vagina. The amounts of drugs are smaller than those in body packing. But the drugs are usually less securely wrapped, so overdose is still a concern.
Typically, people have to give consent for screening except in certain circumstances, such as car accidents. Screening cannot determine how often a substance is used and thus cannot distinguish casual users from those with more serious problems. Also, drug screening targets only some substances and thus misses many others. Substances most commonly targeted include alcohol, marijuana, cocaine, opioids, amphetamines, phencyclidine, benzodiazepines, and barbiturates.
A sample of urine, blood, breath, saliva, sweat, or hair may be tested. Urine testing is most common because it is noninvasive, quick, inexpensive, and able to detect many drugs. It can detect drugs that were used within 1 to 4 days, sometimes longer, depending on the drug used. Hair testing is not as widely available but can detect some drugs if they were used in the previous 100 days. Health care practitioners may directly observe the collection of the sample and seal it so that they can be sure the sample has not been tampered with.
Diagnosis
Sometimes drug abuse is diagnosed when people go to a health care practitioner because they want help stopping use of the drug. Other people try to hide their drug use.
Practitioners may suspect problems with drug use when they notice changes in mood or behavior in a person. They may then do a thorough physical examination. Signs of drug abuse may be apparent. For example, repeatedly injecting drugs intravenously produces track marks. Track marks are lines of tiny, dark dots (needle punctures) surrounded by an area of darkened or discolored skin. Injecting drugs under the skin produces circular scars or ulcers. Addicts may claim other reasons for the marks, such as frequent blood donations, bug bites, or other injuries.
Health care practitioners also use other methods (such as questionnaires) to identify abuse of some drugs and other substances and to determine the extent of abuse and its effects. Urine and sometimes blood tests may be done to check for the presence of drugs.
If a drug use problem is identified, especially if the drugs are injected, people are thoroughly evaluated for hepatitis, HIV infection, and other infections common in people who use these drugs.
Treatment
Specific treatment depends on the drug being used, but it typically involves counseling and sometimes involves use of other drugs. Family support and support groups help people remain committed to stopping use of the drug.
Treatment of complications is the same as that for similar complications with other causes. For example, abscesses may be drained, and antibiotics may be used to treat infections.
Because sharing needles is a common cause of HIV infection, a harm-reduction movement was started. Its purpose is to reduce the harm of drug use in users who cannot stop. Thus, users are provided clean needles and syringes so they do not reuse other abusers’ needles. This strategy helps reduce the spread (and the cost to society) of HIV infection and hepatitis.
Alcohol
Genetics and personal characteristics may play a part in the development of alcohol use disorders.
Drinking too much alcohol may make people sleepy or aggressive, impair coordination and mental function, and interfere with work, family, and other activities.
Drinking too much alcohol for a long time can make people dependent on alcohol and damage the liver, brain, and heart.
Doctors may use questionnaires or determine the blood alcohol level to help identify people with an alcohol use disorder.
Immediate treatment may include assistance with breathing, fluids, thiamin, other vitamins, and, for withdrawal, benzodiazepines.
Detoxification and rehabilitation programs can help people with severe alcohol use disorders.
About 45 to 50% of adults currently drink alcohol, 20% are former drinkers, and 30 to 35% are lifetime abstainers. Drinking large amounts of alcohol (more than 2 to 6 drinks per day) for extended periods can damage a number of organs, especially the liver, heart, and brain. However, drinking a moderate amount of alcohol may reduce the risk of death from heart and blood vessel (cardiovascular) disorders. Nonetheless, drinking alcohol for this purpose is not recommended, especially when other safer, more effective preventive measures are available.
Alcohol Abuse: Most people do not consume enough alcohol or consume it often enough to impair their health or interfere with their activities. However, 7 to 10% of adults in the United States have a problem with alcohol use (alcohol use disorder). Disorders include at-risk drinking (defined solely by amount consumed), alcohol abuse, and alcohol dependence (the most severe alcohol use disorder). Alcoholism is an imprecise term. It typically refers to excessive drinking, unsuccessful attempts at stopping drinking, and continued drinking despite adverse social and occupational consequences. Men are 2 to 4 times more likely than women to become alcoholics.
CLASSIFYING ALCOHOL USE DISORDERS
| DISORDER | DESCRIPTION |
| At-risk drinking | Defined by the amount and frequency of drinking:
|
| Alcohol abuse | Drinking that does any of the following but without evidence of dependence:
|
| Alcohol dependence | Frequent consumption of large amounts of alcohol causing more than three of the following problems:
|
| *One drink is equivalent to 12 ounces of beer, 5 ounces of wine, or 1 1/2 ounces of liquor, such as whiskey. |
Generally, people who become alcoholics have been regularly using alcohol in excessive amounts for a long time and are dependent on alcohol. The amount of alcohol people consume on an average day before they develop alcohol problems varies widely. But it may be as little as 2 drinks per day for women and 3 drinks for men (one drink is equivalent to 12 ounces of beer, 5 ounces of wine, or 1 1/2 ounces of liquor, such as whiskey). Many people with alcohol problems are also binge drinkers—that is, men who drink 5 or more drinks and women who drink 4 or more drinks per occasion. Binge drinking may go on for many days, followed by drinking little or none for a few days. Binge drinking is a particular problem among younger people.
Did You Know…
Drinking very large amounts of alcohol can quickly cause death.
Alcoholism leads to many destructive behaviors. Drunkenness may disrupt family and social relationships. Married couples often divorce. Extreme absenteeism from work can lead to unemployment. Alcoholics often cannot control their behavior, tend to drive while drunk, and experience physical injury from falls, fights, or motor vehicle accidents. Some alcoholics become violent. Alcoholism in men is often associated with domestic violence against women (see page 1581).
Special Populations: Very young children who drink alcohol (typically accidentally) are at significant risk of very low blood sugar and coma. Women may be more sensitive to the effects of alcohol than men, even on a per-weight basis. Older people may be more sensitive than younger adults. Drinking during pregnancy increases the risk of fetal alcohol syndrome (see page 1641).
Although sensitivity to the effects of alcohol may vary, people of all ages are susceptible to alcohol use disorders. Increasingly, adolescents are having alcohol problems, with especially disastrous consequences (see page 1758). Those who start drinking at an early age (particularly the preteen years) are much more likely to become dependent on alcohol as adults.
Causes
Alcohol use disorders involve heredity to some extent. Blood relatives of alcoholics are more likely to have alcohol use disorders than people in the general population, and alcohol use disorders are more likely to develop in biologic children of alcoholics than in adopted children. Some research suggests that people at risk of alcoholism are less easily intoxicated than people who are not alcoholics. That is, their brains are less sensitive to the effects of alcohol. Blood relatives of alcoholics may have this trait.
Certain background and personality traits may predispose people to alcohol use disorders. Alcoholics frequently come from broken homes, and relationships with their parents are often disturbed. Alcoholics tend to feel isolated, lonely, shy, depressed, or hostile. They may act self-destructively and may be sexually immature. Whether such traits are the cause of alcoholism or the result is not certain.
Symptoms
Alcohol causes three basic types of problems:
Those that occur immediately when people drink too much at a particular time (intoxication and overdose)
Those that occur over a long period of time when people regularly consume excessive amounts
Those that occur when heavy, long-term use is stopped suddenly (withdrawal)
Immediate Effects: Alcohol has almost immediate effects because it is absorbed faster than it is processed (metabolized) and eliminated from the body. As a result, alcohol levels in the blood rise rapidly. Effects can occur within a few minutes of drinking.
Effects vary greatly from person to person. For example, people who drink regularly (2 or more drinks per day) are less affected by a given amount of alcohol than those who normally do not drink or who drink only socially, a phenomenon termed tolerance. People who have developed tolerance to alcohol may also be tolerant of other drugs that slow brain function, such as barbiturates and benzodiazepines.
Effects vary depending on the level of alcohol in the bloodstream, which is usually expressed in terms of milligrams per deciliter (1/10 liter) of blood, abbreviated mg/dL. Actual blood levels required to produce given symptoms vary greatly with tolerance, but in typical users who have not developed tolerance, the following symptoms are typical:
20 to 50 mg/dL: Tranquility, mild drowsiness, some decrease in fine motor coordination, and some impairment of driving ability
50 to 100 mg/dL: Impaired judgment and a further decrease in coordination
100 to 150 mg/dL: Unsteady gait, slurred speech, loss of behavioral inhibitions, and memory impairment
150 to 300 mg/dL: Delirium and lethargy (likely)
300 to 400 mg/dL: Often unconsciousness
≥ 400 mg/dL: Possibly fatal
EFFECTS OF PROLONGED ALCOHOL USE
| TYPE OF PROBLEM | EFFECTS |
| Nutritional | |
| Low folate (folic acid) levels | Anemia (fatigue, weakness, and light-headedness) |
| Birth defects | |
| Low iron levels | Anemia |
| Low niacin levels | Pellagra (skin damage, diarrhea, and depression) |
| Gastrointestinal | |
| Esophagus | Cancer |
| Inflammation (esophagitis) | |
| Stomach | Cancer |
| Inflammation (gastritis) | |
| Ulcers | |
| Liver | A bleeding tendency (coagulopathy) |
| Cancer | |
| Fatty liver | |
| Inflammation (hepatitis) | |
| Severe scarring (cirrhosis) | |
| Pancreas | Inflammation (pancreatitis) |
| Low blood sugar levels (hypoglycemia) | |
| Cardiovascular | |
| Heart | Disturbance of the heart’s rhythm (arrhythmia) |
| Heart failure | |
| Blood vessels | Atherosclerosis |
| High blood pressure | |
| Stroke | |
| Neurologic | |
| Brain | Confusion |
| Poor short-term memory (poor recall of recent events) | |
| Psychosis (loss of contact with reality) | |
| Reduced coordination | |
| Nerves | Deterioration of the nerves in arms and legs that control movements (reduced ability to walk) |
| Genitourinary | |
| Reproductive organs | Decreased sex drive |
| In men, enlarged breasts, smooth skin, and shrinking of the testes |
Vomiting is common with moderate to severe intoxication. Because people may be very drowsy, vomited material may enter the lungs (be aspirated), sometimes leading to pneumonia and death. Drinking large amounts can also cause low blood pressure and low blood sugar levels.
In most U.S. states, the legal definition of intoxication is a blood alcohol content (BAC) of 80 mg/dL or higher.
The effects of a particular blood level differ in chronic drinkers. Many seem unaffected and appear to function normally with relatively high levels (such as 300 to 400 mg/dL).
Long-Term Effects: Prolonged use of excessive amounts of alcohol damages many organs of the body, particularly the liver (alcoholic liver disease). Because people may not eat an adequate diet, they may also develop severe vitamin and other nutritional deficiencies.
Alcoholic liver disease includes liver inflammation (hepatitis), fatty liver, and cirrhosis (see page 222). An alcohol-damaged liver is less able to rid the body of toxic waste products, which can cause brain dysfunction (hepatic encephalopathy). People developing hepatic encephalopathy become dull, sleepy, stuporous, and confused and may lapse into a coma. Usually, they also have liver flap (asterixis): When the arms and hands are outstretched, the hands suddenly drop, then resume their original position. Liver flap resembles but is not a tremor. Hepatic coma is life threatening and needs to be treated immediately. With cirrhosis of the liver, pressure builds up in the blood vessels around the liver (portal hypertension—see page 217). These blood vessels can bleed heavily, causing people to vomit blood. This bleeding is a particular problem because the damaged liver does not produce enough of the substances that make blood clot.
Excessive alcohol use can cause inflammation of the pancreas (pancreatitis). People develop severe abdominal pain with vomiting.
Excessive alcohol use can damage the nerves and parts of the brain. People may develop a chronic tremor. Damage to the part of the brain that coordinates movement (cerebellum) can lead to poorly controlled movement of the arms and legs. It can also damage the lining (myelin sheath) of nerves in the brain, resulting in a rare disorder called Marchiafava-Bignami disease. People with this disorder become agitated, confused, and demented. Some develop seizures and go into a coma before dying.
Severe alcoholism can cause a severe deficiency of thiamin, a B vitamin. This deficiency can lead to Wernicke’s encephalopathy (see page 2088), which, if not promptly treated, may result in Korsakoff’s syndrome (see page 2089), coma, or even death.
Drinking alcohol may worsen existing depression, and alcoholics are more likely to become depressed than people who are not alcoholics. Because alcoholism, especially binge drinking, often causes deep feelings of remorse during dry periods, alcoholics are prone to suicide even when they are not drinking.
In pregnant women, alcohol use can cause severe problems in the developing fetus, including low birth weight, short body length, small head size, heart damage, muscle damage, and low intelligence or intellectual disability (mental retardation). These effects are called the fetal alcohol syndrome (see page 1641). Avoidance of alcohol is therefore recommended during pregnancy.
Withdrawal Symptoms: If people who drink continually for a period of time suddenly stop drinking, withdrawal symptoms are likely. For example, withdrawal can occur during hospitalization (for example, for elective surgery) because drinkers are unable to obtain alcohol.
Withdrawal symptoms vary from mild to severe. Severe untreated alcohol withdrawal can be fatal.
Mild withdrawal usually begins 12 to 24 hours after drinking stops. Mild symptoms include tremor, headache, weakness, sweating, and nausea. Some people have seizures (called alcoholic epilepsy or rum fits).
Alcoholic hallucinosis may occur in heavy drinkers who stop drinking. They hear voices that seem accusatory and threatening, causing apprehension and terror. Alcoholic hallucinosis may last for days and can be controlled with antipsychotic drugs, such as chlorpromazine or thioridazine.
Delirium tremens (DTs) is the most serious group of withdrawal symptoms. Usually, delirium tremens does not begin immediately. Rather, it appears about 48 to 72 hours after the drinking stops. People are initially anxious. Later, they become increasingly confused, do not sleep well, have frightening nightmares, sweat excessively, and become very depressed. The pulse rate tends to speed up. Fever typically develops. The episode may escalate to include fleeting hallucinations, illusions that arouse fear and restlessness, and disorientation with visual hallucinations that may be terrifying. Objects seen in dim light may be particularly terrifying, and the people become extremely confused. Their balance is impaired, sometimes making them think the floor is moving, the walls are falling, or the room is rotating. As the delirium progresses, a persistent tremor develops in the hands and sometimes extends to the head and body. Most people become severely uncoordinated. Delirium tremens can be fatal, particularly when untreated.
Diagnosis
Acute alcohol intoxication is usually apparent based on what people or their friends tell the doctor and on results of the physical examination. If it is not clear why a person is acting abnormally, doctors may do tests to rule out other possible causes of symptoms, such as low blood sugar or head injury. Tests may include tests to determine the amount of alcohol in the blood and the blood sugar level, urine tests for certain toxic substances, and computed tomography (CT) of the head. Doctors do not assume that simply because people have alcohol on their breath that nothing else could be wrong.
For legal purposes (for example, when people are in vehicle crashes or are acting abnormally at work), alcohol levels can be measured in the blood or estimated by measuring the amount in a sample of exhaled breath.
In people with a long-term alcohol use disorder, blood tests may be done to check for abnormalities in liver function and evidence of other organ damage. If symptoms are very severe, an imaging test such as CT may be done to rule out a brain injury or infection.
Screening for Alcohol Abuse: Some people may not know that their amount of drinking could be a problem. Others know but do not want to admit that they have an alcohol problem. Therefore, health care practitioners do not wait for people to ask for help. They may suspect an alcohol use disorder in people whose behavior changes inexplicably or whose behavior becomes self-destructive. They may also suspect an alcohol use disorder when medical problems, such as high blood pressure or stomach inflammation (gastritis), do not respond to usual treatment.
Many practitioners periodically screen people for alcohol-related problems by asking about their use of alcohol. Questions may include the following:
On average, how many days per week do you drink alcohol?
On a typical day when you drink, how many drinks do you have?
What is the maximum number of drinks you had on any given occasion in the past month?
If doctors suspect alcoholism, they may ask more specific questions about consequences of drinking, such as the following:
Have you ever felt you should cut down on your drinking?
Does criticism of your drinking annoy you?
Have you ever felt guilty about drinking?
Have you ever had an “eye opener” (a drink first thing in the morning) to steady your nerves or to get rid of a hangover?
Two or more “yes” answers to these questions indicate a probable alcohol problem.
Treatment
Treatment may occur in the following situations:
People come because they do not want to continue drinking.
People are brought in because they have symptoms related to high blood alcohol levels.
People come because they have intolerable withdrawal symptoms. However, alcoholics who develop withdrawal symptoms usually treat themselves by drinking.
Emergency Treatment: Emergency treatment is needed when very large amounts of alcohol or alcohol withdrawal causes severe symptoms.
There is no specific antidote for acute intoxication. Coffee and other home remedies do not reverse the effects of alcohol. However, if people are in a coma, they may need to have a tube inserted in their airway to keep them from choking on vomit and secretions. If their breathing is suppressed, they may need to be placed on a ventilator.
If needed to prevent or treat dehydration or low blood pressure, fluids are given intravenously, and thiamin is given to prevent Wernicke’s encephalopathy. Often, doctors also add magnesium (which helps the body process thiamin) and multivitamins (for possible vitamin deficiencies) to the fluids.
For withdrawal symptoms, doctors often prescribe a benzodiazepine (a mild sedative) for a few days. It reduces agitation and helps prevent some withdrawal symptoms, seizures, and delirium tremens. Because people can become dependent on benzodiazepines, these drugs are used for only a short time. Antipsychotic drugs are sometimes given to people with alcoholic hallucinosis.
Delirium tremens can be life threatening and is treated aggressively to control the high fever and severe agitation. People are treated in an intensive care unit if possible. Treatment usually includes the following:
High doses of benzodiazepines, given intravenously
High doses of vitamins (especially thiamin)
Fluids given intravenously
Drugs that lower fever (such as acetaminophen)
Drugs that control heart rate and blood pressure
Treatment of complications (such as pancreatitis, pneumonia, and seizures)
With such treatment, delirium tremens usually begins to clear within 12 to 24 hours of its beginning, but severe cases may last for 5 to 7 days. Most people do not remember events during severe withdrawal after it resolves.
After any urgent medical problems are resolved, further treatment depends on how severe the alcohol use disorder is. If people have not become dependent on alcohol, doctors may discuss the serious consequences of alcoholism with them, recommend ways to reduce or stop their drinking, and schedule follow-up visits to check on how well they are doing.
For people with more severe disorders, a detoxification and rehabilitation program should be started.
Detoxification and Rehabilitation: In the first phase, alcohol is completely withdrawn, and any withdrawal symptoms are treated. Then alcoholics have to learn ways to modify their behavior. Without help, most alcoholics relapse within a few days or weeks. Rehabilitation programs, which combine psychotherapy with medical supervision, can help.
Alcoholics Anonymous: A Path to Recovery
No approach has benefited so many alcoholics as effectively as Alcoholics Anonymous (AA). AA is an international fellowship of people who want to stop drinking. There are no dues or fees. The program operates on the basis of the “Twelve Steps,” which offers the alcoholic a new way of living without alcohol. Members of the fellowship typically work with a sponsor—a fellow member who is abstaining from alcohol use—who offers guidance and support. AA operates within a spiritual context but is not affiliated with any specific ideology or religious doctrine. However, alternative organizations, such as LifeRing Recovery (Secular Organizations for Sobriety), exist for those seeking a more secular approach.
AA helps its members in other ways as well. It provides a place where recovering alcoholics can socialize away from the tavern and with friends who do not drink and who are always available for support when the urge to start drinking again becomes strong. In meetings, alcoholics hear other people relate—to the entire group—how they are struggling every day to avoid taking a drink. By providing a means to help others, AA builds self-esteem and confidence formerly found only in drinking alcohol. Most metropolitan areas have many AA meetings available day and night, 7 days a week. Alcoholics are encouraged to try several different meetings and to attend those at which they feel most comfortable.
People are warned about how difficult stopping is. They are also taught ways to enhance the motivation to stop and to avoid situations that are likely to trigger drinking. Treatment is tailored to the individual. These programs also enlist the support of family members and friends. Self-help groups, such as Alcoholics Anonymous, can also help.
Sometimes certain drugs (disulfiram, naltrexone, and acamprosate) can help alcoholics avoid drinking alcohol. However, drugs can typically help only if people are motivated and cooperative and if the drugs are used as part of an ongoing intensive counseling regimen. Results vary.
Disulfiram deters drinking because it interferes with alcohol metabolism, causing acetaldehyde (a substance that results from the breakdown of alcohol) to build up in the bloodstream. Acetaldehyde makes people feel ill. It causes facial flushing, a throbbing headache, a rapid heart rate, rapid breathing, and sweating within 5 to 15 minutes after people drink alcohol. Nausea and vomiting may follow 30 to 60 minutes later. These uncomfortable and potentially dangerous reactions last 1 to 3 hours. The discomfort from drinking alcohol after taking disulfiram is so intense that few people risk drinking alcohol—even the small amount in some over-the-counter cough and cold preparations or some foods. Disulfiram must be taken every day. If people stop taking disulfiram, its effectiveness in treating alcohol dependence is limited. Pregnant women, people who have a serious illness, and older people should not use disulfiram.
Naltrexone alters the effects of alcohol on certain chemicals made by the brain (endorphins), which may be associated with alcohol craving and consumption. This drug is effective in most people who take it consistently. A long-acting form can be given by injection once a month. Naltrexone, unlike disulfiram, does not make people sick. Thus, people taking naltrexone can continue to drink. Naltrexone should not be taken by people who have hepatitis or certain other liver disorders.
WERNICKE’S ENCEPHALOPATHY
Wernicke’s encephalopathy causes confusion, eye problems, and loss of balance and results from thiamin deficiency.
Wernicke’s encephalopathy is caused by a severe deficiency of thiamin, a B vitamin (see page 923). In people who have only a small amount of thiamin stored in the body, it may be triggered by consuming carbohydrates.
Wernicke’s encephalopathy often develops in people with severe alcoholism because the long-term use of excess amounts of alcohol interferes with the absorption of thiamin. Also, alcoholics often do not consume an adequate diet and thus not enough thiamin. Wernicke’s encephalopathy may result from other conditions that cause prolonged undernutrition or vitamin deficiencies. These conditions include dialysis, severe vomiting, starvation, cancer, and AIDS.
Symptoms
Wernicke’s encephalopathy causes confusion, drowsiness, involuntary eye movements (nystagmus), partial paralysis of the eyes (ophthalmoplegia), and loss of balance. To maintain balance, people walk with their feet far apart and take slow, short steps.
Internal body processes may malfunction, causing tremor, agitation, a cold body temperature, a sudden and excessive decrease in blood pressure when people stand (orthostatic hypotension), and fainting. If untreated, Wernicke’s encephalopathy can lead to Korsakoff’s syndrome (see page 2089), coma, or death. The combination is called Wernicke-Korsakoff syndrome.
Diagnosis
Doctors suspect the diagnosis in people who have the characteristic symptoms and undernutrition or a thiamin deficiency, especially if they are alcoholics.
Tests, such as blood tests to measure blood sugar levels, a complete blood cell count, liver function tests, and imaging, are usually done to rule out other causes. Thiamin levels are not routinely measured.
Prognosis
The prognosis depends on how quickly the disorder is diagnosed and treated. Prompt treatment may correct all abnormalities. However, loss of balance and confusion may persist days to months. Without treatment, about 10 to 20% of people die.
Treatment
Thiamin is given immediately by injection into a vein or muscle. It is continued daily for at least 3 to 5 days. Magnesium, which helps the body process thiamin, is also given by injection or by mouth. Fluids and multivitamins are given, and if levels of electrolytes (such as potassium) are abnormal, they are corrected. Some people may require hospitalization.
People with Wernicke’s syndrome must stop drinking alcohol. Thiamin supplements, taken by mouth, may need to be continued after the initial treatment.
KORSAKOFF’S SYNDROME
Korsakoff’s syndrome (Korsakoff’s amnestic syndrome) causes memory loss for recent events, confusion, and apathy.
Korsakoff’s syndrome occurs in 80% of people with untreated Wernicke’s encephalopathy. Korsakoff’s syndrome is sometimes triggered by a severe bout of delirium tremens, whether Wernicke’s encephalopathy is present or not. Other causes include head injuries, stroke, bleeding within the brain, and, rarely, certain brain tumors.
People with Korsakoff’s syndrome lose memory for recent events. Memory is so poor that they often makes up stories, sometimes very convincingly, to try to cover up the inability to remember (called confabulation). They lose all sense of time. People become confused and apathetic and may not respond to events, even frightening ones. About 1 in 5 people with the syndrome do not completely recover. Some require care in an institution.
Doctors base the diagnosis on symptoms, particularly confabulation, in people with conditions that can cause Korsakoff’s syndrome.
Treatment consists of thiamin and fluids given intravenously. Thiamin supplements, taken by mouth, may need to be continued after the initial treatment.
Recovery depends on the cause. If the cause is a head injury or bleeding in the brain, people who are treated often improve. If the cause is Wernicke’s encephalopathy, the chances of recovery are worse: Only about 20% recover completely, and about 25% of people require institutional care. Improvement may take months and continue for up to 2 years or longer.
Amphetamines
Amphetamines increase alertness, enhance physical performance, and produce euphoria and a sense of well-being.
An overdose can cause extreme agitation, delirium, and a life-threatening heart attack or stroke.
Urine tests can detect most amphetamines.
For most people, treatment involves reassurance and a calm environment, but sedatives such as benzodiazepines may be needed.
Amphetamines include amphetamine and its many variants such as methamphetamine (speed or crystal meth) and methylenedioxymethamphetamine (MDMA, Ecstasy, or Adam). Methamphetamine is the most commonly used amphetamine in the United States. Use of MDMA is growing in popularity. Amphetamines are usually taken by mouth but can be snorted, smoked, or injected.
Because some amphetamines are widely used as treatment for attention-deficit/hyperactivity disorder, obesity, and narcolepsy, there is a ready supply that can be diverted to illegal use. Some amphetamines are not approved for medical use and are manufactured and used illegally.
Some amphetamine users are depressed and seek the mood-elevating effects of these stimulants to temporarily relieve the depression. Others use them during high-energy activities. Amphetamines cause more dopamine to be released in the brain. (Dopamine is a neurotransmitter, a substance that helps nerve cells communicate.) This effect is the likely cause of mood elevation. MDMA differs from other amphetamines in that it also interferes with the reuptake of serotonin (another neurotransmitter) in the brain. Amphetamine users frequently develop dependence.
Did You Know…
High doses of amphetamines may raise body temperature to dangerous levels.
Symptoms
Immediate Effects: Amphetamines increase alertness, reduce fatigue, heighten concentration, decrease appetite, and enhance physical performance. They may produce a feeling of well-being, euphoria, and loss of inhibitions. Also, people sweat profusely, and the pupils are dilated. High doses (overdose) increase blood pressure and heart rate. These increases may be life threatening. People may become extremely paranoid, violent, and out of control.
Binge usage (perhaps over several days) eventually causes extreme exhaustion and a need for sleep.
Complications: People may become delirious. Heart attacks have occurred, even in healthy young athletes. Blood pressure may become so high that a blood vessel in the brain ruptures, causing a stroke. Other effects include dizziness, nausea, vomiting, diarrhea, seizures, and a life-threatening high body temperature (hyperthermia).
Complications are more likely in the following situations:
When drugs such as MDMA are used in warm rooms with little ventilation
When the user is very active physically (for example, when dancing fast)
When the user sweats heavily and does not drink enough water to restore lost fluids, resulting in dehydration
Long-Term Effects: People who habitually use amphetamines rapidly develop tolerance as part of dependence. They need to use more and more to get the same effect. The amount ultimately used may be more than several times the original dose. Most people using very high doses become confused and psychotic because amphetamines can cause severe anxiety, paranoia, and a distorted sense of reality. Psychotic reactions include hearing and seeing things that are not there (auditory and visual hallucinations) and false beliefs (delusions), such as a feeling of having unlimited power (omnipotence) or of being persecuted (paranoia). Memory may be affected. Confusion, memory loss, and delusions may last for months. Although these effects can occur in any user, people with a mental health disorder, such as schizophrenia, are more vulnerable to them.
Users have a high rate of severe tooth decay affecting numerous teeth. The causes include decreased salivation, corrosive substances in the smoke, and poor oral hygiene—called meth mouth.
Withdrawal Symptoms: When an amphetamine is suddenly stopped, symptoms vary. People dependent on amphetamines become tired or sleepy—an effect that may last for 2 or 3 days after stopping the drug. As a result, they are more likely to be injured. Some people are extremely anxious and restless, and some, especially those with a tendency toward depression, become depressed when they stop. They may become suicidal but may lack the energy to attempt suicide for several days.
Diagnosis
Doctors base the diagnosis on symptoms in people known to have taken amphetamines. If the diagnosis is unclear, urine tests may be done, but the test usually does not detect MDMA. Other tests, such as electrocardiography, computed tomography, and blood tests, may be done to check for complications.
Treatment
For most people, treatment involves reassurance and a calm environment.
For people with severe symptoms such as high blood pressure, extreme agitation, or seizures, doctors usually give benzodiazepines (sedative drugs), such as lorazepam, intravenously. If blood pressure remains high, nitrates or other antihypertensive drugs are given intravenously.
Treatment may be needed to correct dehydration, hyperthermia, and other complications.
During drug withdrawal, long-term users may need to be hospitalized so that they can be observed for suicidal behavior. Antidepressants may be given if depression persists. Otherwise, no treatment is generally needed for people experiencing withdrawal.
Cognitive-behavioral therapy (a form of psychotherapy) helps some people stay free of amphetamines.
Anabolic Steroids
Users of anabolic steroids are often athletes who are looking to promote muscle growth and increase their strength and energy.
Anabolic steroids increase muscle size, but their use can also have many side effects, including mood swings, aggressive behavior, irritability, and acne.
These substances can be detected in urine for up to 6 months.
Treatment involves stopping use.
Anabolic steroids include the hormone testosterone and related drugs. Anabolic steroids have many physical effects, including promoting muscle growth and increasing strength and energy. Thus, these drugs are often used illegitimately to gain a competitive edge in sports. Users are often athletes, typically football players, wrestlers, or weight lifters, and most users are male. Anabolic steroids are used medically to treat low testosterone levels (hypogonadism) and sometimes to prevent muscles from wasting away in people who are confined to bed or who have severe burns, cancer, or AIDS.
The drugs may be taken by mouth, injected into a muscle, or applied to a skin as a gel or in a patch.
Athletes may take steroids for a certain period, stop, then start again several times a year. This process is called cycling. Athletes also often use many steroids at the same time (a practice called stacking), and they take them by different routes (by mouth, injection, or patch). They may also increase the dose through a cycle (called pyramiding). Pyramiding may result in very high doses. Cycling, stacking, and pyramiding are intended to enhance desired effects and minimize harmful effects, but little evidence supports these benefits.
At doses used to treat disorders, anabolic steroids cause few problems. However, athletes may take doses 10 to 50 times these doses.
Symptoms
Steroids increase muscle size. How much muscles increase depends directly on how much of the drug is taken.
Steroids have several psychologic effects (usually only with very high doses):
Wide and erratic mood swings
Irrational behavior
Increased aggressiveness (steroid or roid rage)
Irritability
Increased sex drive (libido) in men and sometimes in women
Depression
Increased acne is common in both sexes. Libido may increase or, less commonly, decrease. Aggressiveness and appetite may increase. In males, breast tissue may enlarge (gynecomastia), and testes may shrink and sperm count decrease. In females, masculinizing effects such as loss of head hair, excess body hair (hirsutism), an enlarged clitoris, and a deepened voice are common. Also, breast size may decrease, and tissues lining the vagina may thin and become less elastic (atrophy). Menstruation may change or stop. Gynecomastia in men and masculinizing effects in women may be irreversible.
In younger adolescents, steroids can interfere with the development of arm and leg bones.
Long-term use can cause production of excess red blood cells and abnormal levels of fats (lipids) in the blood. Low density lipoprotein (LDL)—the bad— cholesterol levels increase, and high density lipoprotein (HDL)—the good—cholesterol levels decrease.
Diagnosis
Urine tests are done to check for breakdown products of anabolic steroids. These products can be detected up to 6 months after use is stopped.
Prevention
Adolescents and young adults should be taught about the risks of taking steroids starting in middle school. Also, programs that teach alternative, healthy ways to increase muscle size and improve performance may be useful. Such programs emphasize good nutrition and weight training techniques.
Classifying the Abuse Potential of Prescription Drugs
Prescription drugs that can cause dependency are subject to restrictions dictated by United States government regulations. All prescription drugs regulated under the Controlled Substances Act are assigned a schedule or class number that determines how they may be prescribed:
Schedule I: Drugs are considered to have a high potential for abuse, no accepted medical use, and no acceptable safety data. Heroin is an example.
Schedule II: Drugs have a high potential for abuse but have some appropriate medical uses. Morphine is an example.
Schedules III, IV, and V: Drugs have progressively less potential for abuse and have accepted medical uses. Schedule V drugs have the least potential for abuse.
Treatment
The main treatment is stopping use. Although physical dependence does not occur, psychologic dependence, particularly in competitive bodybuilders, may exist. Gynecomastia may require surgical reduction.
Antianxiety and Sedative Drugs
Using prescription drugs to relieve anxiety or help with sleeping can cause dependence.
An overdose can cause drowsiness, confusion, and slowed respiration.
Stopping a drug after using it for a long time causes anxiety, irritability, and sleep problems.
If people become dependent on a drug, they are gradually weaned off the drug by reducing the dose.
Prescription drugs used to treat anxiety (antianxiety drugs) and induce sleep (sedatives or sleep aids) can cause dependence. These drugs include benzodiazepines (such as diazepam and lorazepam) and barbiturates. Each works in a different way, and each has a different potential for dependency and tolerance.
Severe or life-threatening symptoms are less likely with benzodiazepines than with barbiturates because for benzodiazepines, the difference between prescribed doses and dangerous doses (called the margin of safety) is large. People can take relatively large amounts of benzodiazepines without dying.
Most people dependent on antianxiety drugs and sedatives started out taking them for a medical reason. Dependency can develop within as little as 2 weeks of continual use.
Symptoms
Immediate Effects: Antianxiety drugs and sedatives decrease alertness and can result in slurred speech, poor coordination, confusion, and slowed breathing. These effects are magnified when people take alcohol. These drugs may make people alternately depressed and anxious. Some people experience memory loss, faulty judgment, a shortened attention span, and frightening shifts in their emotions. People may speak slowly and have difficulty thinking and understanding others. People may have involuntary eye movements (nystagmus).
In older people, symptoms may be more severe and may include dizziness, disorientation, delirium, and loss of balance. Falls may occur, resulting in broken bones, especially hip fractures.
Higher doses cause more severe symptoms, including stupor (people can be aroused only temporarily and with difficulty), very slow and shallow breathing, and, mainly with barbiturates, eventually death.
Withdrawal Symptoms: When withdrawal symptoms occur and how they progress vary from drug to drug and depend on the dose of the drug. Symptoms may begin within 12 to 24 hours.
People who have used sedatives for more than a few days often feel that they cannot sleep without them. When they stop the drugs, they may have mild withdrawal symptoms:
Anxiety and nervousness at bedtime
Poor sleep
Disturbing dreams
Irritability when they awaken
If high doses have been taken, abrupt withdrawal can produce a severe, frightening, and potentially life-threatening reaction, much like alcohol withdrawal. Seizures may occur after withdrawal.
Other effects include dehydration, delirium, insomnia, confusion, and frightening visual and auditory hallucinations (seeing and hearing things that are not there). Serious withdrawal reactions can occur with barbiturates and benzodiazepines. People are usually hospitalized during the withdrawal process because a severe reaction is possible.
Treatment
Emergency Treatment: People who have taken an overdose require immediate medical evaluation. An overdose of barbiturates is more dangerous than an overdose of benzodiazepines. If people who take a dangerous overdose of antianxiety drugs or sedatives have significant respiratory, heart, or blood pressure problems, they should be hospitalized, usually in an intensive care unit or another area where they can be monitored.
Benzodiazepines have an antidote, flumazenil, which can reverse a serious overdose.
Supportive care may include fluids given intravenously, drugs if blood pressure drops, and a ventilator.
Detoxification and Rehabilitation: People with mild withdrawal symptoms require social and psychologic support to help them overcome a strong urge to begin using the drug again to stop the feelings of anxiety.
People with severe withdrawal symptoms usually need to be treated in a hospital, sometimes in an intensive care unit, and be closely supervised. They are given low doses of the drug intravenously. The dose is decreased gradually over days or weeks and then stopped. Sometimes another similar drug that is easier to gradually withdraw is substituted. Even with the best treatment, people may not feel normal for a month or more.
Cocaine
Cocaine is a strong stimulant that increases alertness, causes euphoria, and makes people feel powerful.
High doses can cause serious, life-threatening disorders, such as a heart attack or stroke.
The diagnosis can be confirmed by urine tests.
Sedatives such as lorazepam given intravenously can relieve many symptoms.
People who stop using the drug must be closely supervised because they may be suicidal and they require much help to remain free of the drug.
Cocaine has effects similar to those of amphetamines. It may be snorted, injected directly into a vein, or heated and inhaled. When boiled with sodium bicarbonate, cocaine is converted into a freebase form called crack cocaine. Heating crack cocaine releases cocaine vapor that can be inhaled. Inhaling the vapor is usually referred to as smoking, but the crack is not actually burned. Crack cocaine acts almost as fast as cocaine injected intravenously.
Heavy regular users and people who inject the drug intravenously or smoke it are most likely to become dependent. Light occasional users and people who snort the drug nasally are less likely to become dependent. Cocaine may contain many fillers, adulterants, and contaminants, which, when injected, can cause complications such as infections.
Symptoms
Immediate Effects: Cocaine produces a sense of extreme alertness, euphoria, and great power when it is injected intravenously or inhaled. These feelings are less intense when cocaine is snorted. Because cocaine’s effects may last only a short time, users may inject, smoke, or snort it every 15 to 30 minutes. Binges, often over several days, lead to exhaustion and a need for sleep.
Complications: Acute cocaine toxicity can be fatal. Cocaine increases blood pressure and heart rate and narrows (constricts) blood vessels. Heart rhythm may be disturbed (called arrhythmias). Cocaine’s effects on the heart can cause chest pain, a heart attack (even in healthy young athletes), or sudden death. Cocaine can also cause kidney failure, stroke, and lung problems.
High doses (overdose) can impair judgment and cause tremors, extreme nervousness, seizures, hallucinations, insomnia, paranoid delusions, delirium, and violent behavior. People sweat profusely and the pupils are dilated. Very high doses can cause a life-threatening high body temperature (hyperthermia).
Long-Term Effects: Long-term users may develop tolerance, requiring more and more of the drug to get the same effects. Long-term use may damage the tissue separating the two halves of the nose (septum), causing sores (ulcerations) that may require surgery. Heavy use may impair mental function, including attention and memory.
If women use cocaine during pregnancy, the fetus is more likely to have problems. However, such women usually have many other risk factors for problems in the fetus, including tobacco and alcohol use, poor nutrition, and lack of prenatal care. Doctors now think that these other risk factors are more responsible for problems than the cocaine.
Withdrawal Symptoms: Withdrawal reactions include extreme fatigue and depression—the opposite of the drug’s effects. Appetite is increased, and people have trouble concentrating. Suicidal urges emerge when addicts stop taking the drug. After several days, when mental and physical strength has returned, addicts may attempt suicide.
Did You Know…
Using cocaine can cause sudden death.
Diagnosis
Doctors usually base the diagnosis on symptoms in people known to use the drug. Urine testing can detect evidence of the drug for 2 to 3 days after its use.
Treatment
Emergency Treatment: Cocaine is a very short-acting drug, so treatment of uncomfortable reactions is usually not necessary. People who are very agitated or delirious or who have seizures or high blood pressure are given benzodiazepines (sedatives), such as lorazepam, intravenously. Nitrates or other antihypertensive drugs may be given intravenously to lower blood pressure or heart rate. Hyperthermia may also need to be treated.
Detoxification and Rehabilitation: Stopping longterm cocaine use may require close supervision because people can become depressed and suicidal. Entering a hospital or a drug treatment center may be necessary. The most effective method of treating cocaine addiction is psychotherapy. Many self-help groups and cocaine hotlines are available to help people remain free of the drug.
Sometimes the mental health disorders common to cocaine addicts, such as depression, are treated with the appropriate drugs for those disorders.
Gamma Hydroxybutyrate
Gamma hydroxybutyrate (GHB or G) is taken by mouth. It is similar to ketamine or alcohol in its effects, but its effects last longer and GHB is much more dangerous.
Symptoms
GHB produces feelings of relaxation and tranquility. It may also cause fatigue and feelings of being uninhibited.
At higher doses, GHB may cause dizziness, loss of coordination, nausea, and vomiting. GHB can slow breathing and cause seizures and coma, sometimes leading to respiratory failure and death. Combining GHB and any other sedative, especially alcohol, is extremely dangerous. Most deaths have occurred when GHB was taken with alcohol.
Withdrawal symptoms occur if GHB is not taken for several days after previous frequent use.
Diagnosis and Treatment
No readily available tests can confirm the use of GHB.
Treatment is needed only for overdose. A ventilator may be needed if breathing is affected. Most people recover rapidly.
Hallucinogens
Hallucinogens distort and intensify sensations, but the actual effects can depend on the user’s mood and expectations.
The chief dangers are the psychologic effects and impaired judgment they cause.
A dark, quiet room and calm, nonthreatening talk can help users who are experiencing a bad trip.
Hallucinogens include LSD (lysergic acid diethylamide), psilocybin (mushroom), mescaline (peyote), dimethyl-tryptamine (DMT) and 2,5-dimethoxy-4-methylamphetamine (DOM or STP), an amphetamine derivative. Many new compounds are being synthesized, and the list of hallucinogens is growing.
These drugs may be taken various ways. LSD is taken by mouth using tablets or blotter paper. DMT can be smoked.
People may become psychologically dependent on hallucinogens, but physical dependence, which results in unpleasant symptoms (withdrawal) when the drug is stopped, is not typical.
Symptoms
Hallucinogens distort and intensify auditory and visual sensations. For example, people may feel as if they are seeing sounds and hearing colors. People feel as if they are not real (called depersonalization) or are detached from their environment (called dissociation). Many hallucinogens cause nausea and vomiting. LSD causes blurred vision, sweating, palpitations, and impaired coordination.
The actual effect can depend on the user’s mood and expectations when the drug is taken and the setting in which the drug is taken. For example, users who were depressed before the drug was taken are likely to feel sadder when the drug takes effect. The chief dangers of using these drugs are the psychologic effects and impaired judgment they cause, which can lead to dangerous decisions or accidents. For example, users may think they can fly and may even jump out a window to prove it.
The user’s ability to cope with the visual and auditory distortions also affects the experience—or “trip.” Inexperienced, frightened users are less able to cope than someone who is more experienced and not afraid of the trip. Users under the influence of a hallucinogen, usually LSD, can become extremely anxious and begin to panic, resulting in a bad trip. They may want to stop the trip, which is not possible.
Some users remain out of touch with reality (psychotic) for many days or longer after the drug’s effects have worn off. A prolonged psychosis is more likely in users with a preexisting mental health disorder.
Some people—especially long-term or repeated users of hallucinogens, particularly LSD—may experience flashbacks after they stop using the drugs. Flashbacks are similar to but generally less intense than the original experience. Typically, flashbacks disappear over 6 to 12 months but can recur as long as 5 years after the last use of LSD, especially in users who still have an anxiety or another mental health disorder.
Diagnosis and Treatment
Doctors usually base the diagnosis on symptoms. Tests are not available to confirm the use of many of these drugs.
Most users do not seek treatment. A quiet, dark room and calm, nonthreatening talk can help users who are having a bad trip. They need reassurance that the effects are caused by the drug and will end. If anxiety is severe, benzodiazepines (sedatives), such as lorazepam, may help. People who experience a prolonged psychosis may need mental health treatment.
Ketamine
Ketamine is a drug used for anesthesia. People who use it illicitly may snort it or inject it intravenously, into a muscle, or under the skin.
Symptoms
Ketamine reduces pain perception and causes giddiness and euphoria, which are often followed by bursts of anxiety. With high doses (overdose), users have a distorted perception of their body, the environment, and time. They feel scattered or as if they are not real (called depersonalization), and they feel detached from their environment (called dissociation).
At even higher doses, hallucinations and paranoid delusions may occur, and the sense of detachment from the world intensifies. Ketamine users often refer to these experiences as a k-hole. People may become combative. Coordination may be lost, and muscles tremble and jerk.
Very high doses may cause a life-threatening high body temperature (hyperthermia), a fast heart rate, very high blood pressure, seizures, and coma. Ketamine can also disrupt memory for several hours.
Diagnosis and Treatment
No test can rapidly confirm the presence of ketamine in the body.
Usually, reassurance and a quiet, nonthreatening environment help people recover. Benzodiazepines (sedatives) can be used to control seizures. Ketamine’s effects usually abate in about 30 minutes.
Marijuana
Marijuana produces a dreamy state, a sense of well-being, and distorted perceptions.
Stopping the drug causes only mild symptoms.
Marijuana can be detected in urine for days to weeks after it was used.
Treatment involves counseling, which is effective only when people are motivated to stop.
Marijuana (cannabis) use is widespread. Surveys of high school students have shown periodic variation in its use.
In the United States, marijuana is commonly smoked in the form of cigarettes (joints) made from the stems, leaves, and flowering tops of the dried plant (Cannabis sativa or Cannabis indica). Marijuana is also used as hashish, the pressed resin (tarry substance) of the plant. The active ingredient of marijuana is tetrahydrocannabinol (THC), which occurs in many variations. The most active variation is delta-9-THC. Dronabinol, a synthetic form of delta-9-THC, is used to relieve nausea and vomiting caused by chemotherapy drugs and to enhance appetite in people with AIDS.
Most people use marijuana intermittently and without developing noticeable social or psychologic dysfunction or dependence. However, some people become dependent on marijuana.
Symptoms
Marijuana slows brain activity, producing a dreamy state in which ideas seem disconnected and free-flowing. It is mildly psychedelic, causing time, color, and spatial perceptions to distort and be enhanced. Colors may seem brighter, sounds may seem louder, and appetite may be increased. Marijuana generally relieves tension and provides a sense of well-being. The sense of exaltation, excitement, and inner joy-ousness (a high) seems to be related to the setting in which the drug is taken—such as whether the smoker is alone or in a group and what the prevailing mood is. Coordination, reaction time, depth perception, and concentration may be impaired during marijuana use, so driving or operating heavy equipment is dangerous. Other effects include an increased heart rate, bloodshot eyes, and dry mouth. Effects usually last 4 to 6 hours after inhalation.
Some people, especially those who have not used marijuana before, experience anxiety or feel panicky or paranoid. If people have a psychosis (loss of contact with reality) such as schizophrenia, using marijuana may make symptoms worse or trigger new symptoms.
Complications: People who use large quantities of marijuana for a long time may develop breathing problems, such as bronchitis, wheezing, coughing, and increased phlegm. However, even daily smokers do not develop obstructive airway disease. There is no evidence of increased risk of head and neck or airway cancers, as there is with tobacco.
Pregnant women who use marijuana may have smaller babies than nonusers, but the effect seems small. Delta-9-THC passes into breast milk, but no harmful effects have been detected. Nonetheless, women who are pregnant or breastfeeding are advised not to use it.
Withdrawal Symptoms: Marijuana is eliminated from the body slowly over several weeks, so withdrawal symptoms tend to be mild. After a few weeks of heavy, frequent use, abruptly stopping causes symptoms that begin about 12 hours later and last up to 7 days. Symptoms include insomnia, irritability, depression, nausea, and loss of appetite.
Diagnosis and Treatment
A urine test can detect marijuana for several days or weeks after it is used, even in casual users. In regular users, the test may detect the drug for even longer while the drug is slowly released from body fat. Urine testing is an effective means of identifying marijuana use, but a positive result means only that a person has used marijuana. It does not prove that the user is currently impaired (intoxicated).
For people who want to stop using marijuana, counseling, behavior modification, and drug treatment programs may be helpful. However, success relies heavily on their motivation to stop and, for some users, on their willingness to disassociate from their social circle of regular users.
Nicotine
People who stop using nicotine may become irritable, anxious, and restless.
Smoking harms almost every organ in the body.
Counseling, behavior modification, nicotine replacement products, and certain drugs can help people quit.
Nicotine is the substance in tobacco (present in cigarettes, cigars, and pipe and chewing tobacco) that users become dependent on. It is also the active ingredient in some drug products used to help people quit smoking.
Most nicotine exposure is from smoking tobacco, although children may accidentally eat it (usually cigarettes or butts left in ashtrays or sometimes nicotine gum or patches). In the United States, about 45 million adults smoke, and smoking is the leading cause of death. About one half of current smokers will die prematurely of a disorder caused by smoking. Smoking is so deadly because smokers inhale hundreds of other substances, including ones that can cause cancer.
About 70% of smokers acknowledge that they desire to quit smoking but are unable to do so. Of people who quit, 90% do so on their own, but only about 3 to 4% successfully quit in any given year.
Symptoms
Immediate Effects: Nicotine, when obtained through smoking, usually has few noticeable effects. Some people experience flushing. People who handle large amounts of tobacco leaves may absorb nicotine through their skin and develop nausea, vomiting, diarrhea, sweating, and weakness. This illness has been termed green tobacco sickness. Children who eat tobacco products can develop similar symptoms, along with agitation and confusion, sometimes from as little as one cigarette. However, serious or fatal toxicity in children is uncommon, probably because the vomiting empties the stomach.
Long-Term Effects: Because smoking involves inhaling many harmful substances, it has many serious consequences. It harms nearly every organ in the body. Smoking increases the risk of coronary artery disease, lung cancer, chronic lung disorders, stroke, other cancers (such as bladder, esophageal, kidney, throat, and stomach cancers), and pneumonia. Smoking during pregnancy can cause problems such as preterm birth, a low birth weight, and sudden infant death syndrome.
Withdrawal Symptoms: Nicotine withdrawal may result in many unpleasant symptoms, including a craving for nicotine, irritability, anxiety, poor concentration, restlessness, trembling (tremor), depression, headaches, drowsiness, and stomach upset. Many people gain weight while trying to stop smoking. Withdrawal is most troublesome in severely dependent people.
Treatment
Emergency treatment is rarely required except for children who have eaten products that contain nicotine. Doctors usually give them activated charcoal by mouth to absorb any drug remaining in the gastrointestinal tract. Sometimes drugs such as diazepam are used.
Smoking Cessation: Most issues regarding nicotine use involve efforts to quit smoking. Most smokers who quit do so for health or economic reasons. People who want to quit smoking can get help from health care practitioners, who can provide advice and support and recommend ways to modify behavior. Other sources for help include the Internet and package inserts in nicotine replacement products.
Quitting smoking abruptly (cold turkey) is generally preferable to tapering off. Selection of a quit date is very helpful. The quit date may be random or on a special occasion (such as a holiday or anniversary). A stressful time, such as when a deadline (for example, a tax deadline) needs to be met, is not a good time to try to quit.
Behavior modification can help people change the habits that cue smoking during normal daily activities. These cues may be phone conversations, coffee breaks, meals, sexual activity, boredom, traffic problems, or other frustrations. People who recognize smoking cues may modify the cues (for example, taking a walk in place of a coffee break) or substitute another oral activity (such as sucking on candy, chewing on a toothpick, or chewing gum).
Substituting a nonsmoked version of nicotine for a time helps many people break the habit of smoking. Many nonprescription (over-the-counter) and prescription nicotine replacement products are available. They include nicotine chewing gum, a nicotine patch, nicotine nasal spray, and a nicotine inhaler. Using the patch with the gum or spray is more effective than any one product alone. These products have a few cautions:
People with jaw (temporomandibular) disorders should not use the gum.
People with severe skin sensitivity should not use the patch.
These products may have harmful effects in pregnant or breastfeeding women and in adolescents.
People who have had certain types of heart attacks recently should talk to their doctor before using one of these products.
Bupropion can be used with a nicotine replacement product. Together, they have a higher success rate than either alone. The results of both drugs are best when used with a behavior modification program.
A newer drug, varenicline, helps lessen craving and withdrawal symptoms and helps some people quit smoking. Nicotine replacement products and varenicline should not be used together.
If people who are depressed attempt to quit smoking, they should receive counseling. Bupropion is an antidepressant, making it particularly useful for people who are depressed or at risk of depression. Nortriptyline, another antidepressant, may be used instead.
Nicotine suppresses appetite and slightly increases the rate at which calories are burned. Thus, people who quit smoking often gain weight, which is particularly a concern among women. Exercise helps prevent weight gain and may reduce the craving for nicotine.
Support from family members and friends can help. Many U.S. states have telephone quitlines that can provide additional support for smokers trying to quit.
In the United States, about 20 million people try to quit each year. More than 90% of them return to smoking within days, weeks, or months. Receiving counseling or taking drugs improves the chances of success. About 20 to 30% of people who receive such help quit successfully. The more often people make a serious attempt to quit smoking, the more likely they are to ultimately succeed. Many people fail several times before they succeed.
Opioids
Opioids are used to relieve pain, but they also cause an exaggerated sense of well-being and, if used too much, dependence and addiction.
Taking too much of an opioid can be fatal, usually because breathing stops.
Urine tests can be done to check for opioids.
Treatment may involve stopping the drug abruptly, substituting another drug and gradually reducing its dose to nothing, or substituting another drug that is taken indefinitely.
Ongoing counseling and support are essential to controlling opioid addition.
Opioids have a legitimate medical use as powerful pain relievers (see page 642). They include codeine (which has a low potential for dependence), oxycodone (alone and in various combinations, such as oxycodone plus acetaminophen), meperidine, morphine, pentazocine, and hydromorphone. Methadone taken by mouth and fentanyl taken by a skin patch are used for chronic severe pain. Heroin, which is illegal in the United States but is used in very limited treatment applications in other countries, is one of the strongest opioids.
Opioids are common drugs of abuse because they are widely available and cause an exaggerated sense of well-being. People can become dependent on any opioid.
Although many people who use opioids to relieve pain for more than several days feel some symptoms of withdrawal when they stop, serious dependence and addiction rarely occur when opioid use is medically supervised.
Tolerance can develop after 2 to 3 days of continued opioid use. That is, people need more and more of a drug to feel the effects originally produced by a smaller amount. People may become more tolerant of some effects than of others. People who have developed tolerance may show few signs of drug use and function normally in their usual activities as long as they have access to drugs.
Did You Know…
Taking opioids to relieve the pain of an immediate injury, if supervised by a doctor, rarely leads to addiction.
Taking opioids during pregnancy can cause addiction in the fetus and withdrawal symptoms in the newborn.
Symptoms
Immediate Effects: Opioids are strong sedating drugs, causing people to become drowsy and quiet. Opioids may also cause euphoria. They dull pain and may enhance sexual pleasure. Other effects, such as constipation, nausea, vomiting, and itching, are less desirable. Opioids may cause confusion, especially in older people. In larger doses, they cause lethargy or sleep and may slow the heart rate and breathing rate.
The products that result from the breakdown (metabolism) of the opioid meperidine can cause seizures. When taken with certain other drugs, some opioids can cause a serious disorder called serotonin syndrome. This syndrome is characterized by confusion, tremors, involuntary muscle spasms or twitching, agitation, excessive sweating, and a high body temperature.
Taking too much of an opioid at once (overdose) is life threatening. Breathing becomes dangerously slow and shallow, and the lungs may fill with fluid. Blood pressure, heart rate, and body temperature may decrease, and pupils constrict (becoming like pinpoints). People may become unconscious or die, usually because breathing stops.
Long-Term Effects: Opioids themselves do not cause many long-term complications other than dependence. However, many complications can result from sharing needles with another person and from unknowingly injecting other substances with the opioid (see page 2080).
Withdrawal Symptoms: Withdrawal is uncomfortable but not life threatening. Symptoms can appear as early as 4 hours after opioid use stops and generally peak within 48 to 72 hours. They usually subside after about a week, although the time frame can vary considerably depending on which opioid is used. Each opioid is eliminated from the body at a different rate, which alters how quickly withdrawal progresses and stops. Withdrawal symptoms are worse in people who have used large doses for a long time.
At first, people feel anxious and crave the drug. Breathing becomes rapid, usually accompanied by yawning, perspiration, watery eyes, a runny nose, dilated pupils, and stomach cramps. Later, people may become hyperactive and agitated and have a heightened sense of alertness. Heart rate increases. Other symptoms include gooseflesh, tremors, muscle twitching, fever and chills, aching muscles, loss of appetite, and diarrhea.
Opioid use during pregnancy is especially serious because heroin and methadone easily cross the placenta into the fetus. Because babies born to addicted mothers have been exposed to the drugs their mothers have taken, they may quickly develop withdrawal symptoms, including tremors, high-pitched crying, jitters, seizures, and rapid breathing. If mothers take opioids immediately before labor and delivery, the baby’s breathing may be weak.
Diagnosis
Doctors base the diagnosis on symptoms and urine tests to check for the drug. Other tests may be done to check for complications.
Treatment
An opioid overdose requires emergency treatment. The ultimate and difficult goal of treatment is to help addicts control their addiction. Detoxification can help people get through the initial period of drug withdrawal, but further assistance is usually required to prevent people from returning to using drugs. Those who continually return to using opioids may require maintenance treatment.
Emergency Treatment: An opioid overdose is a medical emergency that must be treated quickly to prevent death. Breathing may require support, sometimes with a ventilator, if the overdose has suppressed breathing. A drug called naloxone is given intravenously as an antidote to the opioid, rapidly reversing all adverse effects. Because some people briefly become agitated and delirious before they become fully conscious, physical restraints may be applied for a short time. Because naloxone precipitates withdrawal symptoms in people who are dependent on opioids, it is used only when clearly necessary (as when breathing is weak).
People recovering from an overdose should be observed for several hours until the effects of naloxone have worn off to be sure that no adverse effects of the opioid remain. If people took an opioid with long-lasting effects (such as methadone or slow-release forms of other opioids), they are usually observed for a longer time.
If symptoms redevelop, people may be given another dose of naloxone, be admitted to the hospital, or both.
Detoxification: There are two basic approaches:
Stopping the opioid and allowing withdrawal to run its course (cold turkey detoxification)
Substituting a similar but less potent drug, then gradually decreasing the dose and stopping the drug
With detoxification, treatment is usually needed to lessen the symptoms of withdrawal. Clonidine usually provides some relief. However, clonidine may cause low blood pressure and drowsiness. Stopping clonidine may cause restlessness, insomnia, irritability, a fast heartbeat, and headaches. Sometimes drugs that block the effects of opioids, such as naltrexone, are needed to help people remain free of the opioid after they are fully detoxified.
Drugs that can be substituted, then stopped include methadone and buprenorphine. Methadone is an opioid that is taken by mouth. It blocks withdrawal symptoms and the craving for other opioids, especially heroin. Because methadone’s effects last much longer than those of other opioids, it can be taken less frequently, usually once a day. The dose can then be decreased slowly. Doctors can begin the substitution, but then the use of methadone must be supervised in a licensed methadone treatment program, usually at a clinic.
Buprenorphine is a partial opioid agonist. That means it has some of the effects of opioids but blocks some of the effects of opioids. It does not require supervision in a special program, and thus doctors who are trained in its use can prescribe it in their office. In many countries, buprenorphine has replaced methadone in detoxification programs.
Maintenance: For people who continually return to using opioids (called chronic, relapsing opioid addiction), another approach—called maintenance— is often preferred. It involves substituting a prescribed drug that the user takes for a long time. Methadone, buprenorphine, or naltrexone may be used.
Maintaining addicts with regular doses of one of these drugs for months or years enables them to be socially productive because they do not have to spend time getting the opioid and because the drugs used do not interfere with functioning the way that illicit drug use does. For some addicts, the treatment works. For many addicts, lifelong maintenance is necessary.
Methadone suppresses withdrawal symptoms and the craving for the opioid without making addicts overly drowsy or elated. However, addicts must appear regularly, up to once a day, at a clinic, where methadone is dispensed in the amount that prevents severe withdrawal symptoms from developing, minimizes craving, and supports daily functioning.
Buprenorphine is being used more and more because it can be prescribed by doctors in their office. Thus, addicts do not have to go to a special clinic.
Naltrexone is a drug that blocks the effects of opioids (opioid antagonist). Before starting naltrexone, people must be fully detoxified from opioids, or a severe withdrawal reaction can occur. Depending on the dose, naltrexone’s effects last from 24 to 72 hours. Thus, the drug can be taken once a day or as few as 3 times a week. Because this drug has no opioid effects, some addicts do not want to use it. This drug is most useful for addicts who are strongly motivated to remain free of opioids and who are not severely dependent on opioids.
Rehabilitation: Regardless of which approach is used, ongoing counseling and support is essential. Support may include specially trained doctors, nurses, counselors, opioid maintenance programs, family members, friends, and other people with the same addiction (support groups).
The therapeutic community concept emerged nearly 25 years ago in response to the problems of heroin addiction. Daytop Village and Phoenix House pioneered this nondrug approach. Addicts live in a communal, residential center for an extended period of time. These programs help addicts build new lives through training, education, and redirection. The programs have helped many people, but initial dropout rates are high. Questions about precisely how well these programs have worked and how widely they should be applied remain unanswered. Because these programs require a lot of resources to run, many people may be unable to afford them.
Phencyclidine
Phencyclidine (PCP or angel dust) is most often smoked after being sprinkled on plant material, such as parsley, mint leaves, tobacco, or marijuana. Occasionally, PCP is taken by mouth or injected.
Symptoms
PCP depresses brain function, and users usually become confused and disoriented shortly after taking the drug. They may not know where they are, who they are, or what time or day it is. They may go into a trance as if hypnotized. PCP users can be combative, and because they do not feel pain, they may continue fighting even when they are hit hard. Salivation, sweating, blood pressure, and heart rate also increase. Muscle tremors (shaking) are common.
High doses (overdose) can cause hallucinations, seizures, a life-threatening high body temperature (hyperthermia), coma, and possibly death. Long-term PCP use may damage the brain, kidneys, and muscles.
Treatment
When PCP users become agitated (as most do when brought for treatment), they are put in a quiet room and allowed to relax. Their blood pressure, heart rate, and breathing are monitored frequently. Soothing talk does not help. In fact, they may become even more agitated. If quiet surroundings do not calm agitated people, the doctor may give them a sedative such as lorazepam.
Common Products That Contain Solvent Inhalants
ADHESIVES
Airplane glue
Rubber cement
Polyvinyl chloride cement
AEROSOLS
Spray paint
Hair spray
SOLVENTS AND GASES
Nail polish remover
Paint remover
Paint thinner
Typing correction fluid and thinner
Fuel gas
Cigarette lighter fluid
Gasoline
CLEANING AGENTS
Dry cleaning fluid
Spot remover
Degreaser
Abused Inhalants With Medical Uses
Amyl nitrite: This inhalant widens (dilates) the arteries of the heart, allowing more oxygen to reach the heart muscle. Thus, it is used to relieve chest pain caused by coronary artery disease. Amyl nitrite is sold only by prescription.
Two closely related drugs, butyl nitrite and isobutyl nitrite, are not used medically. They can be sold legally for commercial purposes related to their use as air-fresheners, but other use is banned.
All three of these nitrite drugs briefly lower blood pressure, produce dizziness, and cause flushing, followed by a rapid heartbeat. These effects combined may produce a sense of excitement and euphoria. People also use these drugs because they believe that they enhance sexual pleasure. When used with sildenafil (used to treat erectile dysfunction), these nitrite drugs may greatly lower blood pressure, which can cause fainting, heart attack, or stroke.
Nitrous oxide: This gas (laughing gas) is used as an anesthetic. It is also used as a propellant in cans and dispensers of whipped cream. Nitrous oxide is sometimes abused because it produces a sense of euphoria and a pleasant dreamlike state. Prolonged exposure to nitrous oxide can cause numbness and weakness in the legs and arms, which can be permanent.
Solvent Inhalants
Adolescents use inhalants more frequently than cocaine or LSD but less frequently than marijuana or alcohol. In the United States, about 10% of adolescents have inhaled solvents. Inhalant use is particularly a problem among children aged 12 and younger. Inhalants are found in many common household products. Thus, children and adolescents can easily obtain them.
The product may be sprayed into a plastic bag and inhaled (bagging, sniffing, or snorting), or a cloth soaked with the product may be placed next to the nose or in the mouth (huffing).
Symptoms
Users rapidly become intoxicated. They may become dizzy, drowsy, and confused. Speech may be slurred. They may have difficulty standing and walking, resulting in an unsteady gait. Users may also become excited—but not because the solvents are stimulants. Later, perceptions and sense of reality may be distorted, resulting in illusions, hallucinations, and delusions. Users experience a euphoric, dreamy high, culminating in a short period of sleep. They may become delirious and confused, with mood swings. Thinking and coordination may be impaired. Intoxication can last anywhere from a few minutes to more than an hour.
Death can occur suddenly, even the first time one of these products is directly inhaled, because breathing becomes very slow and shallow or because heart rhythm is disturbed (called arrhythmia).
With chronic use, people become somewhat tolerant of the solvent’s effects. People may become psychologically dependent on solvents, with a strong urge to continue using the solvents. But physical dependence does not occur. That is, stopping the drug does not cause unpleasant symptoms (withdrawal).
Chronic use or exposure to solvents (including exposure in the workplace) can severely damage the brain, heart, kidneys, liver, and lungs. In addition, bone marrow may be damaged, impairing red blood cell production and causing anemia.
Treatment
Treating children and adolescents who use inhalants involves evaluating any organ damage. Education and counseling to improve mental health and social skills and to manage sociologic problems may help. Recovery rates from inhalant use are among the poorest for any mood-altering substance. However, most users stop by the end of adolescence.