Substance Abuse

Online Course #975 or #175 - 10 Contact Hours

©2009 National Center of Continuing Education, Inc.

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Table of Contents …Review Part 1 …Part 3 …Independent Analysis …Evaluation

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Amphetamines

Amphetamines are potentially addictive drugs that belong to the class of drugs known as stimulants, along with cocaine, caffeine, and others. The amphetamines were first synthesized in the 1920s for use as decongestants and later discovered to be helpful in treating narcolepsy, a rare disorder that causes an uncontrollable desire to sleep. They were effective medications for appetite control, and were good hangover cures as well. Because of their stimulating effects, they became widely sought by students, housewives, athletes, military personnel, truck drivers, and anyone who needed a boost to reduce fatigue, prolong wakefulness, or just get through a bad day. Initially sold over the counter and in inhalers, they were eventually highly regulated with prescriptions required for their use; this in turn led to increased illegal manufacturing of the drug. Amphetamine and its variants, methamphetamine and dextroamphetamine, are so similar in their effects that lab analysis may be the only way to differentiate among them; methamphetamine, however, has more pronounced effects on the central nervous system.
Methamphetamine is commonly known as "speed," "meth," and "chalk" or, in its smokeable form, as "ice," "crystal," "crank," or "glass." It is a white, odorless, bitter-tasting crystalline powder that easily dissolves in water or alcohol. Like amphetamine, it causes increased activity, decreased appetite, and a general sense of well-being. The effects of methamphetamine can last 6 to 8 hours or more. After the initial "rush," there is typically a state of high agitation that in some individuals can lead to violent behavior.
Methamphetamine can be made easily in clandestine settings with relatively inexpensive over-the-counter ingredients; many such as drain cleaner, battery acid, and antifreeze are extremely dangerous. The rapid proliferation of so-called "basement" laboratories for the production of methamphetamine has led to a widespread problem in many communities in the U.S. Methamphetamine abuse has long been reported as the dominant drug problem in portions of Southern California, but has become a substantial drug problem in other sections of the West and Southwest as well and continues to spread to other areas of the country, including both rural and urban sections of the South and Midwest. Its use was traditionally associated with white, male, blue-collar workers, but it is being used by ever more diverse population groups that change over time and differ by geographic area.
Methamphetamine comes in many forms and can be smoked, snorted, orally ingested, or injected. (See Figure 3).

The drug alters moods in different ways, depending on how it is taken. Immediately after smoking the drug or injecting it intravenously, the user experiences an intense rush or "flash" that lasts only a few minutes and is described as extremely pleasurable. Snorting or oral ingestion produces euphoria - a high but not an intense rush. Snorting produces effects within 3 to 5 minutes, and oral ingestion produces effects within 15 to 20 minutes.
As with similar stimulants, methamphetamine most often is used in a "binge and crash" pattern. Because tolerance for methamphetamine occurs within minutes - meaning that the pleasurable effects disappear even before the drug concentration in the blood falls significantly - users try to maintain the high by binging on the drug. In the 1980s, "ice," a smokeable form of methamphetamine, came into use. Ice is a large, usually clear crystal of high purity that is smoked in a glass pipe like crack cocaine. The smoke is odorless, leaves a residue that can be re-smoked, and produces effects that may continue for 12 hours or more.
Methamphetamine acts on the pleasure circuit in the brain by altering the levels of certain neurotransmitters present in the synapse. Methamphetamine is chemically similar to dopamine and another neurotransmitter, norepinephrine. It produces its effects by causing dopamine and norepinephrine to be released into the synapse in several areas of the brain, including the nucleus accumbens, prefrontal cortex, and the striatum, a brain area involved in movement. Specifically, methamphetamine enters nerve terminals by passing directly through nerve cell membranes. It is also carried into the nerve terminals by transporter molecules that normally carry dopamine or norepinephrine from the synapse back into the nerve terminal. Once in the nerve terminal, methamphetamine enters dopamine and norepinephrine containing vesicles and causes the release of these neurotransmitters. Enzymes in the cell normally break down excess dopamine and norepinephrine, but methamphetamine blocks this process. The excess neurotransmitters are then carried by transporter molecules out of the neuron and into the synapse. Once in the synapse, the significantly higher than normal concentration of dopamine causes feelings of pleasure and euphoria. The excess norepinephrine may be responsible for the alertness and anti-fatigue effects of methamphetamine.
Long-term methamphetamine abuse results in many damaging effects, including addiction. Addiction is a chronic, relapsing disease, characterized by compulsive drug-seeking and drug use, which is accompanied by functional and molecular changes in the brain. In addition to being addicted to methamphetamine, chronic methamphetamine abusers exhibit symptoms that can include anxiety, confusion, and insomnia. They also can display a number of psychotic features, including paranoia, auditory and visual hallucinations, mood disturbances, and delusions (for example, the sensation of insects creeping on the skin, called "formication"). The paranoia can result in homicidal as well as suicidal thoughts, and out-of-control rages that can be coupled with extremely violent behavior.
With chronic use, tolerance for methamphetamine can develop. In an effort to intensify the desired effects, users may take higher doses of the drug, take it more frequently, or change their method of drug intake. In some cases, abusers forego food and sleep while indulging in a form of binging known as a "run," injecting as much as a gram of the drug every 2 to 3 hours over several days until the user runs out of the drug or is too disorganized to continue. Although there are no physical manifestations of a withdrawal syndrome when methamphetamine use is stopped, there are several symptoms that occur when a chronic user stops taking the drug. These include depression, anxiety, fatigue, paranoia, aggression, and an intense craving for the drug.
Methamphetamine can also affect the brain in other ways, causing cerebral edema, brain hemorrhage, and hallucinations. Moreover, some of the effects of methamphetamine on the brain appear to be long lasting and even permanent. Recent research has shown that even three years after chronic methamphetamine users have discontinued use of the drug, there remains a reduction in their ability to transport dopamine back into neurons. Researchers have reported that as many as 50 percent of the dopamine-producing cells in the brain can be damaged after prolonged exposure to relatively low levels of methamphetamine. This is highly significant because dopamine has a major role in many brain functions, including experiences of pleasure, mood, and movement. In these same studies, researchers found similarities in the damage to the dopamine system of methamphetamine users to that seen in patients with Parkinson's disease. Researchers also have found that serotonin-containing nerve cells may be damaged even more extensively. Whether this toxicity is related to the psychosis seen in some long-term methamphetamine abusers is still an open question.
Methamphetamine can cause a variety of cardiovascular problems. These include rapid heart rate, irregular heartbeat, increased blood pressure, and irreversible, stroke-like damage to the small blood vessels of the brain. Hyperthermia and convulsions occur with methamphetamine overdose, and if not treated immediately can result in death.
Chronic methamphetamine abuse can result in inflammation of the heart lining, and among users who inject the drug, damaged blood vessels and skin abscesses. Methamphetamine abusers also can have episodes of violent behavior, paranoia, anxiety, confusion, and insomnia. Heavy users also show progressive social and occupational deterioration. Psychotic symptoms can sometimes persist for months or years after use has ceased.
A common method of illegal methamphetamine production uses lead acetate as a reagent; therefore, production errors may result in methamphetamine contaminated with lead. There have been documented cases of acute lead poisoning in intravenous methamphetamine abusers.
Fetal exposure to methamphetamine also is a significant problem in the United States. At present, research indicates that methamphetamine abuse during pregnancy may result in prenatal complications, increased rates of premature delivery, and altered neonatal behavioral patterns, such as abnormal reflexes and extreme irritability. Methamphetamine abuse during pregnancy may also be linked to congenital deformities.

Treatment
There are some established protocols that emergency room physicians use to treat individuals who have had a methamphetamine overdose. Because hyperthermia and convulsions are common and often fatal complications of such overdoses, emergency room treatment focuses on the immediate physical symptoms. Overdose patients are cooled off in ice baths, and anticonvulsant drugs may also be administered. Acute methamphetamine intoxication can often be handled by observation in a safe, quiet environment. In cases of extreme excitement or panic, treatment with antianxiety agents such as benzodiazepines has been helpful, and in cases of methamphetamine-induced psychoses, short-term use of neuroleptics has proven successful.
At this time the most effective treatments for methamphetamine addiction are cognitive behavioral interventions. These approaches are designed to help modify the patient's thinking, expectancies, and behaviors, and to increase skills in coping with various life stressors. Methamphetamine recovery support groups also appear to be effective adjuncts to behavioral interventions that can lead to long-term drug-free recovery. There are currently no particular pharmacological treatments for dependence on amphetamine or amphetamine-like drugs such as methamphetamine. The current pharmacological approach is borrowed from experience with treatment of cocaine dependence. Unfortunately, this approach has not met with much success since no single agent has proven efficacious in controlled clinical studies. Antidepressant medications can be helpful in combating the depressive symptoms frequently seen in newly abstinent methamphetamine users.

Abuse of Medications for ADHD
The medications used for treatment of ADHD are primarily stimulants. While these drugs are safe and effective when used properly, they have a high potential for abuse; like other stimulants, they can lead to marked tolerance and psychological dependence, and can cause medical problems leading to serious illness or even death.
The most well known of the ADHD medications is methylphenidate (MPH, Ritalin, and the sustained release preparations Concerta and Metadate). A mild central nervous stimulant, its mechanism of action is not entirely understood. However, it appears to activate the arousal systems in the brainstem and cortex to produce its stimulant effects. While MPH appears to target the same neuroreceptors as cocaine, it does not affect all the same components of the pleasure circuit throughout the brain.
MPH can be abused orally, or tablets can be crushed and either snorted or dissolved in water and injected. The pattern of abuse is characterized by an escalation in dose, frequent episodes of binge use followed by severe depression, and an overpowering desire to continue the use of this drug despite serious, adverse medical and social consequences. Typical of other CNS stimulants, high doses of MPH often produce agitation, tremors, euphoria, tachycardia, palpitations, and hypertension. Psychotic episodes, paranoid delusions, hallucinations, and bizarre behavioral characteristics similar to amphetamine-like toxic effects have been associated with MPH abuse.
Unlike amphetamine, methamphetamine, and cocaine, where illicit manufacturing and smuggling into the United States account for the vast majority of available drugs for abuse, pharmaceutical products diverted from legitimate channels are the only sources of MPH. It is important to note that many schools have more MPH stored for daytime dosing of students than is available in some pharmacies, and many families have supplies stored in kitchen or bathroom cabinets.
Information from DEA case files and state law enforcement services indicates that MPH is sought after by a wide range of individuals, from adolescents to street addicts. Even though the lack of clandestine production, regulatory controls, and predominant use in the treatment of ADHD in children have historically limited the illegal use of this drug, non-prescription use is on the rise. Recent reports of MPH misuse/abuse among adolescents and young adults are particularly disturbing, since this group has the freest access to this drug. Reports from numerous states and local municipalities indicate that adolescents are giving and selling their MPH medication to friends and classmates. Anecdotal reports from students and faculty on college campuses indicate that MPH is being used as a study aid in the same manner that amphetamine was used on campuses in the 1960s. Ritalin abuse is increasingly observed among elementary students, and newspaper reports suggest that it is "as easy to get as candy."
Since its approval for treatment of ADHD in 1996, Adderall, a mixture of four amphetamine salts, has become one of the most widely prescribed medications in the United States. It, too, has marked abuse potential.

Heroin and the Opiates

Opiates are powerful drugs derived from the poppy plant that have been used for centuries to relieve pain. They include opium, heroin, morphine, and codeine. Even centuries after their discovery, opiates are still the most effective pain relievers. Although heroin has no medicinal use, the other opiates, such as morphine and codeine, are used to relieve pain related to illnesses (for example, cancer) and medical and dental procedures. When used as directed by a physician, opiates are safe and generally do not produce addiction. But opiates also possess very strong reinforcing properties and can quickly trigger addiction when used improperly.
The brain produces endorphins that activate opioid receptors located throughout the brain and body. Research indicates that endorphins are involved in many functions, including respiration, nausea, vomiting, pain modulation, and hormonal regulation. Two important effects produced by the naturally occurring endorphins and opiate drugs alike are pleasure (or reward) and pain relief.
Like cocaine and other abused drugs, opiates activate the brain's reward system. Because of its chemical structure, heroin penetrates the brain more quickly than other opiates, which is probably why many addicts prefer heroin. When a person injects, sniffs, or orally ingests heroin, the drug travels through the bloodstream, across the blood brain barrier, and into the brain. Once in the brain, heroin is rapidly converted to morphine, which then activates opiate receptors located throughout the brain, including the ventral tegmental area, nucleus accumbens and cerebral cortex within the reward system. Research suggests that stimulation of opioid receptors by morphine results in feelings of reward and activates the pleasure circuit by causing greater amounts of dopamine to be released within the nucleus accumbens. This excessive release of dopamine and overstimulation of the reward system can lead to addiction.
Opiates also act directly on the respiratory center in the brainstem causing a slowdown in activity, resulting in a decrease in respiratory rate. Excessive amounts of an opiate, like heroin, can cause the respiratory centers to shut down breathing altogether. When someone overdoses on heroin, it is the action of heroin in the brainstem respiratory centers that can cause the person to stop breathing and die.
Heroin, the most abused and rapidly acting of the opiates, is an illegal, highly addictive drug. It is processed from morphine, the naturally occurring substance extracted from the seedpod of certain varieties of poppy plants. It is typically sold as a white or brownish powder or as the black sticky substance known on the streets as "black tar heroin." Although purer heroin is becoming more common, most street heroin is "cut" with other drugs or with substances such as sugar, starch, powdered milk, or quinine. Street heroin can also be cut with strychnine or other poisons. Because heroin abusers do not know the actual strength of the drug or its true contents, they are at risk of overdose or death. Heroin also poses special problems because of the transmission of HIV and other diseases that can occur from sharing needles or other injection equipment.
According to the 1998 National Household Survey on Drug Abuse, which may actually underestimate illicit opiate (heroin) use, an estimated 2.4 million people had used heroin at some time in their lives, and nearly 130,000 of them reported using it within the month preceding the survey. The survey report estimated that there were 81,000 new heroin users in 1997. A large proportion of these recent new users were smoking, snorting, or sniffing heroin, and most (87 percent) were under age 26. In 1992, only 61 percent were younger than 26.
The Drug Abuse Warning Network (DAWN), which collects data on drug-related hospital emergency department (ED) episodes from 21 metropolitan areas, estimates a 158% increase in ED episodes involving heroin among 18 to 25 year olds from 1992 to 1999. National Institute on Drug Abuse's (NIDA) Community Epidemiology Work Group (CEWG), which provides information about the nature and pattern of drug use, reported in its December 2000 publication that heroin use continues to trend upward, especially among younger populations. It is often used in combination with cocaine, either concurrently or sequentially. In Washington, D.C. in 1999-2000, for example, nearly three-fifths of primary heroin addicts in treatment reported cocaine/crack as a secondary drug. Heroin was mentioned most often as the primary cause of drug-related death in Baltimore, Seattle, Boston, Philadelphia, San Diego, Los Angeles, Phoenix, and San Francisco.
Heroin is usually injected, sniffed/snorted, or smoked. This causes an intense euphoria, or rush, that lasts only briefly and is followed by a few hours of relaxed contentment. A typical heroin abuser may inject up to four times a day. Intravenous injection provides the greatest intensity and most rapid onset of euphoria (7 to 8 seconds), while intramuscular injection produces a relatively slow onset of euphoria (5 to 8 minutes). When heroin is sniffed or smoked, peak effects are usually felt within 10 to 15 minutes. The intensity of the rush is a function of how much drug is taken and how rapidly the drug enters the brain and binds to the natural opioid receptors. With heroin, the rush is usually accompanied by a warm flushing of the skin, dry mouth, and a heavy feeling in the extremities, and may be accompanied by nausea, vomiting, and severe itching. Although smoking and sniffing heroin do not produce a "rush" as quickly or as intensely as intravenous injection, NIDA researchers have confirmed that all three forms of heroin use are addictive.
Injection continues to be the predominant method of heroin use among addicted users seeking treatment; however, researchers have observed a shift in heroin use patterns, from injection to sniffing and smoking. In fact, sniffing/snorting heroin is now the most widely reported means of taking heroin among users admitted for drug treatment in Newark, Chicago, and New York. With the shift in heroin abuse patterns comes an even more diverse group of users. Users over 30 years of age continue to be one of the largest user groups in most national data. However, younger and more affluent and discriminating users across the country are being lured by high-purity heroin, at a lower cost, that can be sniffed or smoked instead of injected.
One of the most detrimental long-term effects of heroin is addiction itself, characterized by compulsive drug seeking and use, and by neurochemical and molecular changes in the brain. Heroin also produces profound degrees of tolerance and physical dependence. As with abusers of any addictive drug, heroin abusers gradually spend more and more time and energy obtaining and using the drug. Once they are addicted, the heroin abusers' primary purpose in life becomes seeking and using drugs. Heroin literally changes their brains into drug-seeking machines.
Physical dependence develops with higher doses of the drug. With physical dependence, the body adapts to the presence of the drug and withdrawal symptoms occur if use is reduced abruptly. Withdrawal may occur within a few hours after the last time the drug is taken. Symptoms of withdrawal include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps ("cold turkey"), and leg movements. Major withdrawal symptoms peak between 24 and 48 hours after the last dose of heroin and subside after about a week. However, some people have shown persistent withdrawal signs for many months. Heroin withdrawal is never fatal to otherwise healthy adults, but it can cause death to the fetus of a pregnant addict.
Physical dependence and the emergence of withdrawal symptoms were once believed to be the key features of heroin addiction. It is now known, however, that craving and relapse can occur weeks and months after withdrawal symptoms are long gone. Interestingly, patients with chronic pain who need opiates to function (sometimes over extended periods) have few if any problems forgoing opiates after their pain is resolved by other means. This may be because the patient in pain is simply seeking relief of pain and not the rush sought by the addict.
Medical consequences of chronic heroin abuse include scarred and/or collapsed veins, bacterial infections of the blood vessels and heart valves, abscesses (boils) and other soft-tissue infections, and liver or kidney disease. Lung complications (including various types of pneumonia and tuberculosis) may result from the poor health condition of the abuser as well as from heroin's depressant effects on respiration. Many of the additives in street heroin may include substances that do not readily dissolve, thus clogging the blood vessels that lead to the lungs, liver, kidneys, or brain, and causing infection or even death of small patches of cells in vital organs. Immune reactions to these or other contaminants can cause arthritis or other rheumatologic problems. Of course, sharing of injection equipment or fluids can lead to some of the most severe consequences of heroin abuse: infections with hepatitis B and C, HIV, and a host of other blood-borne viruses, which drug abusers can then pass on to their sexual partners and children.

Treatment
A variety of effective treatments are available for heroin addiction. Treatment tends to be more effective when heroin abuse is identified early, and detoxification is the first step. The treatments that follow vary depending on the individual, but methadone, a synthetic opiate that blocks the effects of heroin and eliminates withdrawal symptoms, has a proven record of success. Other pharmaceutical approaches, like LAAM (levo-alpha-acetylmethadol) and buprenorphine, and many behavioral therapies also are used for treating heroin addiction.

Detoxification
The primary objective of detoxification is to relieve withdrawal symptoms while patients adjust to a drug-free state. Not in itself a treatment for addiction, detoxification is a useful step only when it leads into long-term treatment that is either drug-free (residential or outpatient) or uses medications as part of the treatment. The best documented drug-free treatments are the therapeutic community residential programs lasting at least 3 to 6 months.

Methadone programs
Methadone treatment has been used effectively and safely to treat opioid addiction for more than 30 years. Properly prescribed methadone is not intoxicating or sedating, and its effects do not interfere with ordinary activities such as driving a car. The medication is taken orally, once a day, and it suppresses narcotic withdrawal for 24 to 36 hours. Patients on methadone remain able to perceive pain and have emotional reactions. Most important, methadone relieves the craving associated with heroin addiction; craving is a major reason for relapse. Among methadone patients, it has been found that normal street doses of heroin are ineffective at producing euphoria, thus making the use of heroin more easily extinguishable.
Also, methadone is medically safe even when used continuously for 10 years or more. Combined with behavioral therapies or counseling and other supportive services, methadone enables patients to stop using heroin (and other opiates) and return to more stable and productive lives. Methadone dosages must be carefully monitored in patients who are receiving antiviral therapy for HIV infection, however, to avoid potential medication interactions.

Levo-alpha-acetylmethadol (LAAM ) and other medications
LAAM, like methadone, is a synthetic opiate that can be used to treat heroin addiction. LAAM can block the effects of heroin for up to 72 hours with minimal side effects when taken orally. In 1993 the Food and Drug Administration approved the use of LAAM for treating patients addicted to heroin. Its long duration of action permits dosing just three times per week, thereby eliminating the need for daily dosing and take-home doses for weekends. LAAM is increasingly available in clinics that already dispense methadone.
Naloxone (Narcan) and naltrexone (Trexan) are medications that also block the effects of morphine, heroin, and other opiates. As opiate antagonists, they are especially useful as antidotes. Naltrexone has long-lasting effects, ranging from 1 to 3 days, depending on the dose. Naltrexone blocks the pleasurable effects of heroin and is useful in treating some highly motivated individuals. Naltrexone has also been found to be successful in preventing relapse by former opiate addicts released from prison on parole.
Another medication, buprenorphine, has been approved for treatment of heroin addiction in Europe and is being evaluated in the United States. (An injectable form is already available here as an analgesic.) Buprenorphine is a particularly attractive treatment because, compared to other medications such as methadone, it causes weaker opiate effects and is less likely to cause overdose problems. Buprenorphine also produces a lower level of physical dependence, so patients who discontinue the medication generally have fewer withdrawal symptoms than do those who stop taking methadone. Because of these advantages, buprenorphine may be appropriate for use in a wider variety of treatment settings than the currently available medications. Several other medications with potential for treating heroin overdose or addiction are currently under investigation by NIDA.

Behavioral therapies
Although behavioral and pharmacologic treatments can be extremely useful when employed alone, integrating both types of treatments will ultimately be most effective. There are many behavioral treatments available for heroin addiction in both residential and outpatient settings: the important task is to match the treatment approach to the particular needs of the patient. Contingency management therapy, for example, uses a voucher-based system, where patients earn points based on negative drug tests that they can exchange for items that encourage healthy living. Cognitive-behavioral interventions are designed to help modify the patient's thinking, expectations, and behaviors and to increase skills in coping with various life stressors. Both behavioral and pharmacological treatments help to restore a degree of normalcy to brain function and behavior, with increased employment rates and lower risk of HIV and other diseases and criminal behavior.

Opioid Analogs and Relatives

Drug analogs are chemical compounds that are similar to other drugs in their effects but differ slightly in their chemical structure. Some analogs are produced by pharmaceutical companies for legitimate medical reasons. Other analogs, sometimes referred to as "designer" drugs, can be produced in illegal laboratories and are often more dangerous and potent than the original drug. Two of the most commonly known opioid analogs are fentanyl and meperidine (Demerol).
Fentanyl was introduced under the brand name "Sublimaze" in 1968 by a Belgian pharmaceutical company as a synthetic narcotic to be used as an analgesic in surgical procedures because of its minimal effects on the heart. Soon thereafter, an analog version called China White began to appear: users ended up in emergency rooms with classic overdose symptoms that responded to opiate antagonists like Narcan, but there were no traces of opiates in their symptoms. Fentanyl is particularly dangerous because it is 50 times more potent than heroin and can rapidly stop respiration. This is not a problem during surgical procedures because machines are used to help patients breathe. On the street, however, users have been found dead with the needle used to inject the drug still in their arms.
A particularly tragic story is associated with attempts to create an effective analog of Demerol for street use. The substance, called MPTP after its molecular components, turned out to be a potent neurotoxin, producing a serious and irreversible Parkinson's-like syndrome in users. Despite all treatment efforts, most of those affected remain unable to move or speak.
A semisynthetic narcotic, oxycodone (Percodan), has been widely used for years, often in combination with aspirin or acetaminophen. Synthesized from thebaine, an opium derivative, it is more potent than codeine and has a higher dependence potential. Street use was limited, however, due to its tendency to make the user's ears ring. Recently, a time-release version of the venerable Percodan was introduced; OxyContin, as it was called, was widely heralded as a significant improvement over available palliative medications, because its time-release mechanism afforded significant, sustained relief for people in severe pain. It has been prescribed primarily for patients diagnosed with terminal cancer, recovering from major surgery, or suffering from debilitating migraine headaches.
Unfortunately, street users of the drug, attracted to its euphoric high that is similar to that of heroin, have created an epidemic of OxyContin abuse. The pills are crushed into powder to overcome the sustained release; the drug is then snorted or diluted and injected into the user's veins. Dosage control is thus minimal, and hundreds of people have died from overdose. According to the U.S. Justice Department's National Drug Intelligence Center, the drug was initially most popular in parts of Ohio, Pennsylvania, West Virginia, Maryland and Maine; particularly in rural areas and small towns where resources for dealing with drug problems are limited, but its popularity is rapidly spreading across the country.

Hallucinogens

Hallucinogens are drugs that cause hallucinations - altered states of perception and profound distortions of reality. They can cause users to hear voices, see images, and feel sensations that do not exist; they also can produce rapid, intense emotional swings. Hallucinogenic drugs have played a role in human life for thousands of years. Cultures from the tropics to the arctic have used plants to induce states of detachment from reality and to precipitate "visions" thought to provide mystical insight. Historically, hallucinogenic plants were used largely for social and religious ritual, and their availability was limited by the climate and soil conditions they require. After the development of LSD, a synthetic compound that can be manufactured anywhere, abuse of hallucinogens became more widespread, and from the 1960s it increased dramatically. All LSD manufactured in this country is intended for illegal use, since LSD has no accepted medical use in the United States.
Hallucinogens include natural substances, such as mescaline and psilocybin that come from plants (cactus and mushrooms, respectively), and chemically manufactured ones, such as LSD and MDMA (ecstasy). LSD is manufactured from lysergic acid, which is found in ergot, a fungus that grows on rye and other grains. MDMA is a synthetic mind-altering drug with hallucinogenic properties. Although not a true hallucinogen in the pharmacological sense, PCP causes many of the same effects as hallucinogens and so is often included with this group of drugs.
Hallucinogens disrupt the interaction of nerve cells and the neurotransmitter serotonin. Distributed throughout the brain and spinal cord, the serotonin system is involved in the control of behavioral, perceptual, and regulatory systems, including mood, hunger, body temperature, sexual behavior, muscle control, and sensory perception. Researchers are not certain that brain chemistry permanently changes from hallucinogen use, but some people who use them appear to develop chronic mental disorders. PCP and MDMA are both addicting, whereas LSD, psilocybin, and mescaline are not.

LSD
LSD (an abbreviation of the German words for "lysergic acid diethylamide") is the drug most commonly identified with the term "hallucinogen" and the most widely used in this class of drugs. LSD, also familiar as "acid," is a clear or white, odorless, water-soluble material synthesized from lysergic acid, a compound derived from a rye fungus. LSD is the most potent mood- and perception-altering drug known: oral doses as small as 30 micrograms can produce effects that last 6 to 12 hours.
LSD is initially produced in crystalline form. The pure crystal can then be crushed to powder and mixed with binding agents to produce tablets known as "microdots" or thin squares of gelatin called "window panes"; more commonly, it is dissolved, diluted, and applied to paper or other materials. The most common form of LSD is called "blotter acid" - sheets of paper soaked in LSD and perforated into 1/4-inch square individual dosage units. Variations in manufacturing and the presence of contaminants can produce LSD in colors ranging from clear or white, in its purest form, to tan or even black. Even uncontaminated LSD begins to degrade and discolor soon after it is manufactured, and drug distributors often apply LSD to colored paper, making it difficult for a buyer to determine the drug's purity or age.
LSD's effects typically begin within 30 to 90 minutes after ingestion and may last as long as 12 hours. Users refer to LSD and other hallucinogenic experiences as "trips" and to the acute adverse experiences as "bad trips;" the drug's effects are unpredictable and may vary with the amount ingested and the user's personality, mood, expectations, and surroundings. Users of LSD may experience some physiological effects, such as increased blood pressure and heart rate, dizziness, loss of appetite, dry mouth, sweating, nausea, numbness, and tremors; but the drug's major effects are emotional and sensory. The user's emotions may shift rapidly through a range from fear to euphoria, with transitions so rapid that the user may seem to experience several emotions simultaneously.
LSD also has dramatic effects on the senses. Colors, smells, sounds, and other sensations seem highly intensified. In some cases, sensory perceptions may blend in a phenomenon known as synesthesia, in which a person seems to hear or feel colors and see sounds. Hallucinations distort or transform shapes and movements, and they may give rise to a perception that time is moving very slowly or that the user's body is changing shape. On some "trips", users experience sensations that are enjoyable and mentally stimulating and that produce a sense of heightened understanding. Bad trips, however, include terrifying thoughts and nightmarish feelings of anxiety and despair that include fears of insanity, death, or losing control.
LSD users quickly develop a high degree of tolerance for the drug's effects: after repeated use, they need increasingly larger doses to produce similar effects. LSD use also produces tolerance for other hallucinogenic drugs such as psilocybin and mescaline, but not for drugs such as marijuana, amphetamines, and PCP, which do not act directly on the same serotonin receptors affected by LSD. Tolerance for LSD is lost if the user stops taking the drug for several days, and there is no evidence that LSD produces physical withdrawal symptoms when chronic use is stopped.
Long-term effects of LSD use can include persistent psychosis and hallucinogen persisting perception disorder (HPPD), more commonly referred to as "flashbacks." The causes of these effects, which in some users occur after a single experience with the drug, are not known. The acute effects of LSD can be described as drug-induced psychosis: a distortion or disorganization of a person's capacity to recognize reality, think rationally, or communicate with others. Some LSD users experience devastating psychological effects that persist after the trip has ended, however, producing a long-lasting psychotic-like state. LSD-induced persistent psychosis may include dramatic mood swings from mania to profound depression, vivid visual disturbances, and hallucinations. These effects may last for years and can affect people who have no history or other symptoms of psychological disorder.
Other former LSD users report experiences known colloquially as "flashbacks" and called "HPPD" by physicians. These episodes are spontaneous, repeated, sometimes continuous recurrences of some of the sensory distortions originally produced by LSD. The experience may include hallucinations, but it most commonly consists of visual disturbances such as seeing false motion on the edges of the field of vision, bright or colored flashes, and halos or trails attached to moving objects. This condition is typically persistent and in some cases remains unchanged for years after individuals have stopped using the drug. Because HPPD symptoms may be mistaken for those of other neurological disorders such as stroke or brain tumors, sufferers may consult a variety of clinicians before the disorder is accurately diagnosed. There is no established treatment for HPPD, although some antidepressant drugs may reduce the symptoms. Psychotherapy may help patients adjust to the confusion associated with visual distraction and to minimize the fear, expressed by some, that they are suffering from ongoing brain damage or psychiatric disorder.
The precise mechanism by which LSD alters perceptions is still unclear. Evidence from laboratory studies suggests that LSD, like the hallucinogenic plants, binds to and activates certain groups of serotonin receptors designated the 5-HT2 receptors. Normally, serotonin binds to and activates its receptors and then is taken back up into the neuron that released it. In contrast, LSD binds very tightly to the serotonin receptor, causing a greater than normal activation of the receptor. LSD's effects are most prominent in two brain regions: the cerebral cortex, an area involved in mood, cognition, and perception; and the locus ceruleus, which receives sensory signals from all areas of the body and has been described as the brain's "novelty detector" for important external stimuli.

Street Names for Hallucinogens and Dissociative Drugs

LSD

• acid
• blotter
• dots
• microdot
• pane
• paper acid
• sugar
• sugar cubes
• trip
• window glass
• window pane
• Zen

Ketamine

• bump
• cat Valium
• green
• honey oil
• jet
• K
• purple
• Special K
• special la coke
• super acid
• super C
• vitamin K

PCP

• angel
• angel dust
• boat
• dummy dust
• love boat
• peace
• supergrass
• zombie

PCP and Other Dissociative Drugs

PCP (phencyclidine), developed in the 1950s as an intravenous surgical anesthetic, is classified as a dissociative drug rather than a true hallucinogen: its sedative and anesthetic effects are trance-like, and patients experience a feeling of being "out of body" and detached from their environment. At low to moderate doses, PCP causes altered perception of body image, but rarely produces visual hallucinations. PCP can also create effects that mimic the primary symptoms of schizophrenia, such as delusions and mental turmoil.
PCP was used in veterinary medicine but was never approved for human use because of problems that arose during clinical studies, including delirium and extreme agitation experienced by patients emerging from anesthesia. Over the years PCP has developed a reputation as a dynamite drug, for its ability to transform an otherwise docile person into a raging maniac, explosive and extremely dangerous. In a study of 1000 episodes of PCP intoxication, unpredictable outbursts leading to shootings, stabbings, grotesque murders, and self-inflicted injuries occurred in 35% of the cases. Another 32% of the users displayed bizarre behaviors, including wandering about nude in public, lying down in the middle of a busy street, or driving 10 mph on the freeway.
During the 1960s, PCP in pill form became widely abused, but the surge in illicit use receded rapidly as users became dissatisfied with the long delay between taking the drug and feeling its effects, and with the unpredictable and often violent behavior associated with its use. Powdered PCP - known as "ozone," "rocket fuel," "love boat," "hog," "embalming fluid," or "superweed" - appeared in the 1970s. In powdered form, the drug is sprinkled on marijuana, tobacco, or parsley, then smoked, and the onset of effects is rapid. Users sometimes ingest PCP by snorting the powder. Normally a white crystalline powder, PCP is sometimes colored with water-soluble or alcohol-soluble dyes.
When snorted or smoked, PCP rapidly passes to the brain to disrupt the functioning of sites known as NMDA (N-methyl-D-aspartate) receptor complexes, which are receptors for the neurotransmitter glutamate. Glutamate receptors play a major role in the perception of pain; in cognition, including learning and memory; and in emotion. In the brain, PCP also alters the actions of dopamine, a neurotransmitter responsible for the euphoria and "rush" associated with many abused drugs. PCP's effects are unpredictable. Typically, they are felt within minutes of ingestion and last for several hours, but some users report feeling the drug's effects for days. One drug-taking episode may produce feelings of detachment from reality, including distortions of space, time, and body image; another may produce hallucinations, panic, and fear. Some users report feelings of invulnerability and exaggerated strength. PCP users may become severely disoriented, violent, or suicidal.
At low PCP doses (5 mg or less), physical effects include shallow, rapid breathing, increased blood pressure and heart rate, and elevated temperature. Doses of 10 mg or more can cause dangerous changes in blood pressure, heart rate, and respiration, often accompanied by nausea, blurred vision, dizziness, and decreased awareness of pain. Muscle contractions may cause uncoordinated movements and bizarre postures. When severe, the muscle contractions can result in bone fracture or in kidney damage or failure as a consequence of muscle cells breaking down. Very high doses of PCP can cause convulsions, coma, hyperthermia, and death. Repeated use of PCP can result in addiction, and recent research suggests that repeated or prolonged use of PCP can cause withdrawal syndrome when drug use is stopped. Symptoms such as memory loss, speech problems, and depression may persist for as long as a year after a chronic user stops taking PCP.
Ketamine ("K," "Special K," "cat Valium") is another dissociative anesthetic. It was developed in 1963 to replace PCP and is currently manufactured as an injectable liquid to be used in human anesthesia and veterinary medicine. Much of the ketamine sold on the street has been diverted from veterinarians' offices. In illicit use ketamine is generally evaporated to form a powder that is snorted, smoked with marijuana or tobacco products, or compressed into pills. In some cities (Boston, New Orleans, and Minneapolis/St. Paul, for example), ketamine is reportedly being injected intramuscularly.
Ketamine's chemical structure and mechanism of action are similar to those of PCP, and its effects are similar, but ketamine is much less potent than PCP with effects of much shorter duration. Users report sensations ranging from a pleasant feeling of floating to being separated from their bodies. Some ketamine experiences involve a terrifying feeling of almost complete sensory detachment that is likened to a near-death experience. These experiences, similar to a "bad trip" on LSD, are called the "K-hole." Low-dose intoxication from ketamine results in impaired attention, learning ability, and memory. At higher doses, ketamine can cause delirium, amnesia, impaired motor function, high blood pressure, depression, and potentially fatal respiratory problems.
Ketamine is odorless and tasteless, so it can be added to beverages without being detected, and it induces amnesia. Because of these properties, the drug is sometimes given to unsuspecting victims and used in the commission of sexual assaults referred to as "drug rape."
Dextromethorphan (sometimes called "DXM" or "robo") is a cough-suppressing ingredient in a variety of over-the-counter cold and cough medications. Like PCP and ketamine, dextromethorphan acts as an NMDA receptor antagonist. The most common source of abused dextromethorphan is "extra-strength" cough syrup, which typically contains 3 milligrams of the drug per milliliter of syrup. At the doses recommended for treating coughs (1/6 to 1/3 ounce of medication, containing 15 mg to 30 mg dextromethorphan), the drug is safe and effective. At much higher doses (4 or more ounces), dextromethorphan produces dissociative effects similar to those of PCP and ketamine. The effects vary with dose, and dextromethorphan users describe a set of distinct dose-dependent "plateaus" ranging from a mild stimulant effect with distorted visual perceptions at low (approximately 2-ounce) doses to a sense of complete dissociation from one's body at doses of 10 ounces or more. The effects typically last for 6 hours. Over-the-counter medications that contain dextromethorphan often contain antihistamine and decongestant ingredients as well, and high doses of these mixtures can seriously increase risks associated with dextromethorphan abuse.

Club Drugs

"Club drugs" is a collective term for some very dangerous substances that are increasingly popular among young adults who attend all-night dance parties called raves or trances, dance clubs, and bars. Included in the term are a wide variety of drugs with a wide variety of sources, pharmacological agents, and potential contaminants, making it difficult to predict toxicity, symptoms, and consequences of use. In this category along with methamphetamine and the hallucinogens LSD and ketamine, are MDMA, the CNS depressant GHB, and the benzodiazepine Rohypnol.
MDMA (Ecstasy) is a synthetic, psychoactive drug with both stimulant and hallucinogenic properties. Other street names for MDMA include Adam, XTC, hug, beans, and love drug. MDMA was first synthesized and patented in 1914 by Merck, a German drug company, for use as an appetite suppressant but was never marketed. In the 1970s, the drug was given to psychotherapy patients because it helped them open up and talk about their feelings. This practice was stopped in 1986 when animal studies showed that Ecstasy could cause brain damage. Ecstasy gained national attention during the 1980s when it was touted as the new LSD, and now is widely considered the drug of choice at club parties. In a survey taken in 2000, 8.2% of 12th graders, 5.4% of 10th graders and 3.1% of 8th graders reported that they had used MDMA at least once within the year.
MDMA is usually taken orally in tablet or capsule form. Its effects last approximately 3 to 6 hours, though confusion, depression, sleep problems, anxiety, and paranoia have been reported to occur weeks after the drug is taken. MDMA can produce a significant increase in heart rate and blood pressure and a sense of alertness like that associated with amphetamine use. The stimulant effects of MDMA, which enable users to dance for extended periods, may also lead to dehydration, hypertension, and heart or kidney failure.
Users report that Ecstasy lowers their inhibitions and relaxes them. MDMA is also said to increase awareness and feelings of pleasure and to give people energy. Unlike the drug LSD, low doses of MDMA do not cause people to hallucinate. However, some people report side effects after taking MDMA such as headaches, chills, eye twitching, jaw clenching, blurred vision and nausea. MDMA can cause confusion, hallucinations, depression, sleep problems, drug craving, severe anxiety, and paranoia. In addition, in high doses it can cause a sharp increase in body temperature (malignant hyperthermia) leading to muscle breakdown and kidney and cardiovascular system failure.
Recent data suggest that MDMA may be toxic to the brain. Its chemical structure (3-4 methylenedioxymethamphetamine, "MDMA") is similar to methamphetamine, methylenedioxymethamphetamine (MDA), and mescaline. Like the hallucinogens, MDMA causes serotonin to be released from neurons in greater amounts than normal. Once released, this serotonin can excessively activate serotonin receptors. Scientists have shown that MDMA causes excess dopamine to be released from dopamine-containing neurons as well. Particularly alarming is research in animals that has demonstrated that MDMA can damage and destroy serotonin containing neurons. A recent study of the brain scans of people who had used Ecstasy an average of 200 times over five years found visible brain damage, although the behavior of these people appeared normal; in fact, those who used the drug more often had more brain damage than less frequent users. Positron emission tomography (PET) demonstrated a 20-60% reduction in healthy serotonin cells in the drug users, potentially limiting their abilities to remember and to learn. Given the widespread role of serotonin as a neurotransmitter, additional studies are being conducted to gauge Ecstasy's effect on mood, memory, cognition, and behaviors such as eating and sleeping.
GHB (gamma hydroxybutyrate) is a central nervous system depressant that can relax or sedate the body. Street names for the drug include Grievous Bodily Harm, G, Liquid Ecstasy, and Georgia Home Boy. It is usually abused either for its intoxicating/sedative/ euphoriant properties or for its growth hormone-releasing effects, which can build muscles. GHB can be produced in clear liquid, white powder, tablet, and capsule forms, and it is often used in combination with alcohol, making it even more dangerous. GHB is often manufactured in homes with recipes and ingredients found and purchased on the Internet; these ingredients are found in a number of dietary supplements available in health food stores and gymnasiums to induce sleep, build muscles, and enhance sexual performance.
The drug is used predominantly by adolescents and young adults, often when they attend nightclubs and raves. GHB's intoxicating effects begin 10 to 20 minutes after the drug is taken, and typically last up to 4 hours, depending on the dosage. At lower doses, GHB can relieve anxiety and produce relaxation; however, as the dose increases, the sedative effects may result in sleep and eventual coma or death. Overdose of GHB can occur rather quickly, and the signs are similar to those of other sedatives: drowsiness, nausea, vomiting, headache, loss of consciousness, loss of reflexes, and impaired breathing. GHB is cleared from the body relatively quickly, so it is sometimes difficult to detect in emergency rooms and other treatment facilities. GHB has been increasingly involved in poisonings, overdoses, "date rapes," and fatalities.
Rohypnol (flunitrazepam) belongs to the class of drugs known as benzodiazepines. It is not approved for prescription use in the United States, although it is approved in Europe and is used in more than 60 countries as a treatment for insomnia, as a sedative, and as a pre-surgery anesthetic. Street names for the drug include Roofies, Rophies, Roche, and the Forget-Me Pill. It is usually taken orally, although there are reports that it can be ground up and snorted. Rohypnol is tasteless and odorless, and it dissolves easily in carbonated beverages. The sedative and toxic effects are aggravated by concurrent use of alcohol but, even without alcohol, a dose of Rohypnol as small as 1 mg can impair a victim for 8 to 12 hours.
Adverse effects associated with Rohypnol include decreased blood pressure, drowsiness, visual disturbances, dizziness, confusion, gastrointestinal disturbances, and urinary retention. The drug can cause profound anterograde amnesia, so that individuals may not remember events they experienced while under the effects of the drug. This may be why one of the street names for Rohypnol is "the forget-me pill," and it reportedly has been used in sexual assaults.

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