Substance Abuse

Online Course #975 or #175 - 10 Contact Hours

©2010 National Center of Continuing Education, Inc.

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Table of Contents …Review Part 1 …Review Part 2 …Independent Analysis …Evaluation

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Inhalants

Inhalants are volatile substances that produce chemical vapors that can be inhaled to induce a psychoactive, or mind-altering, effect. Although other abused substances can be inhaled, the term "inhalants" is used to describe a variety of substances whose main common characteristic is that they are rarely, if ever, taken by any route other than inhalation. This definition encompasses a broad range of chemicals found in hundreds of different products that may have different pharmacological effects. (See Figure 4)

Figure 4

Brain images show marked atrophy (shrinkage) of brain tissue in a toluene abuser (B) compared to a nonabusing individual (A). Note the smaller size and the larger empty (dark) space within the toluene abuser's brain. (The white outer circle in each image is the skull.)

As a result, precise categorization of inhalants is difficult. One classification system lists four general categories of inhalants - volatile solvents, aerosol, gases, and nitrites - based on the form in which they are often found in household, industrial, and medical products.
Volatile solvents are liquids that vaporize at room temperatures. They are found in a multitude of inexpensive, easily available products used for common household and industrial purposes. These include paint thinners and removers, dry-cleaning fluids, degreasers, gasoline, glues, correction fluids, and felt-tip marker fluids.
Aerosols are sprays that contain propellants and solvents. They include spray paints, deodorants and hair sprays, vegetable oil sprays for cooking, and fabric protector sprays.
Gases include medical anesthetics as well as gases used in household or commercial products. Medical anesthetic gases include ether, chloroform, halothane, and nitrous oxide, commonly called "laughing gas." Nitrous oxide is the most abused of these gases and can be found in whipped cream dispensers and products that boost octane levels in racing cars. Household or commercial products containing gases also include butane lighters, propane tanks, and refrigerants.
Nitrites often are considered a special class of inhalants. Unlike most other inhalants, which act directly on the central nervous system, nitrites act primarily to dilate blood vessels and relax the muscles. And while other inhalants are used to alter mood, nitrites are used primarily as sexual enhancers. Nitrites include cyclohexyl nitrite, isoamyl (amyl) nitrite, and isobutyl (butyl) nitrite. Cyclohexyl nitrite is found in room deodorizers. Amyl nitrite is used in certain diagnostic procedures and is prescribed to some patients for heart pain. Illegally diverted ampules of amyl nitrite are called "poppers" or "snappers" on the street. Butyl nitrite is an illegal substance that is often packaged and sold in small bottles also referred to as "poppers."
Inhalants - particularly volatile solvents, gases, and aerosols - are often among the first drugs that young children use. One national survey indicates that about 6 percent of U.S. children have tried inhalants by the time they reach fourth grade. Inhalants also are one of the few substances abused more by younger children than by older ones. Nevertheless, inhalant abuse can become chronic and extend into adulthood.
Generally, inhalant abusers will abuse any available substance. However, effects produced by individual inhalants vary, and some individuals will go out of their way to obtain their favorite inhalant. For example, in certain parts of the country, "Texas shoe-shine," a shoe-shining spray containing the chemical toluene, is a local favorite. Silver and gold spray paints, which contain more toluene than other spray colors, also are popular inhalants.
Data from national and state surveys suggests inhalant abuse reaches its peak at some point during the seventh through ninth grades. Gender differences in inhalant abuse have been identified at different points in childhood. One study indicates inhalant abuse is higher for boys than girls in grades 4 through 6, occurs at similar rates in grades 7 through 9 - when overall use is highest - and becomes more prevalent again among boys in grades 10 through 12. People who abuse inhalants are found in both urban and rural settings. Research on factors contributing to inhalant abuse suggests that adverse socioeconomic conditions, rather than racial or cultural factors per se, may account for most reported racial and ethnic differences in rates of inhalant abuse. Poverty, a history of childhood abuse, poor grades, and dropping out of school all are associated with inhalant abuse.
Inhalants can be breathed in through the nose or the mouth in a variety of ways, such as:

• "Sniffing" or "snorting" fumes from containers;
• Spraying aerosols directly into the nose or mouth;
• "Bagging" or sniffing or inhaling fumes from substances sprayed or deposited inside a plastic or paper bag;
• "Huffing" from an inhalant-soaked rag stuffed in the mouth; and
• Inhaling from balloons filled with nitrous oxide.

Inhaled chemicals are rapidly absorbed through the lungs into the bloodstream and quickly distributed to the brain and other organs. Within minutes of inhalation, the user experiences intoxication along with other effects similar to those produced by alcohol. Alcohol-like effects may include slurred speech, an inability to coordinate movements, euphoria, and dizziness. In addition, users may experience lightheadedness, hallucinations, and delusions, such as thinking they can fly. Because intoxication lasts only a few minutes, abusers frequently seek to prolong the high by continuing to inhale repeatedly over the course of several hours, a very dangerous practice. With successive inhalations, abusers can suffer loss of consciousness and death. At the least, they will feel less inhibited and less in control. After heavy use of inhalants, abusers may feel drowsy for several hours and experience a lingering headache.
Many brain systems may be involved in the anesthetic, intoxicating, and reinforcing effects of different inhalants. Nearly all abused inhalants (other than nitrites) produce a pleasurable effect by depressing the CNS. Evidence from animal studies suggests that a number of commonly abused volatile solvents and anesthetic gases have neurobehavioral effects and mechanisms of action similar to those produced by CNS depressants, which include alcohol and medications such as sedatives and anesthetics. A recent study indicates that toluene, a solvent found in many commonly abused inhalants including airplane glue, paint sprays, and paint and nail polish removers, activates the brain 's dopamine system. The dopamine system has been shown to play a role in the rewarding effects of many drugs of abuse. Nitrites, in contrast, dilate and relax blood vessels rather than acting as anesthetic agents.
The chemicals found in solvents, aerosol sprays, and gases can produce a variety of additional effects during or shortly after use. These effects are related to inhalant intoxication and may include belligerence, apathy, impaired judgment, and impaired functioning in work or social situations. Dizziness, drowsiness, slurred speech, lethargy, depressed reflexes, general muscle weakness, and stupor are other possible effects. For example, research shows that toluene can produce headache, euphoria, giddy feelings, and inability to coordinate movements. Exposure to high doses can cause confusion and delirium. Nausea and vomiting are other common side effects.
Inhaled nitrites dilate blood vessels, increase heart rate, and produce a sensation of heat and excitement that can last for several minutes. Other effects can include flush, dizziness, and headache.
A strong need to continue using inhalants has been reported among many individuals, particularly those who abuse inhalants for prolonged periods over many days. Compulsive use and a mild withdrawal syndrome can occur with long-term inhalant abuse. Additional symptoms exhibited by long-term inhalant abusers include weight loss, muscle weakness, disorientation, inattentiveness, lack of coordination, irritability, and depression.
Inhalant abusers risk an array of devastating medical consequences. Prolonged sniffing of the highly concentrated chemicals in solvents or aerosol sprays can induce irregular and rapid heart rhythms and lead to heart failure and death within minutes of a session of prolonged sniffing. This syndrome, known as "sudden sniffing death," can result from a single session of inhalant use by an otherwise healthy young person. Sudden sniffing death is particularly associated with the abuse of butane, propane, and chemicals in aerosols. Inhalant abuse also can cause death by:

• Asphyxiation from repeated inhalations, which lead to high concentrations of inhaled fumes displacing the available oxygen in the lungs;
• Suffocation from blocking air from entering the lungs when inhaling fumes from a plastic bag placed over the head;
• Choking from inhalation of vomit after inhalant use; or
• Fatal injury from accidents, including motor vehicle fatalities, suffered while intoxicated.

Both animal research and human pathological studies indicate that chronic abuse of volatile solvents such as toluene damages the protective sheath around certain nerve fibers in the brain and peripheral nervous system. This extensive destruction of nerve fibers is clinically similar to that seen with neurological diseases such as multiple sclerosis. The neurotoxic effects of prolonged inhalant abuse include damage to parts of the brain involved in controlling cognition, movement, vision, and hearing. Cognitive abnormalities can range from mild impairment to severe dementia. Other effects can include difficulty coordinating movement, spasticity, and loss of feeling, hearing, and vision.
Inhalants also are highly toxic to other organs. Chronic exposure can produce significant damage to the heart, lungs, liver, and kidneys. Although some inhalant-induced damage to the nervous and other organ systems may be at least partially reversible when inhalant abuse is stopped, many syndromes caused by repeated or prolonged abuse are irreversible.
Abuse of inhalants during pregnancy may place infants and children at increased risk of developmental problems. Animal studies designed to simulate human patterns of inhalant abuse suggest that prenatal exposure to toluene or trichloroethylene (TCE) can result in reduced birth weight, skeletal abnormalities, and delayed neurobehavioral development. A number of case reports note abnormalities in newborns of mothers who chronically abuse solvents, and there is evidence of subsequent developmental impairment in some of these children. However, no well-controlled, prospective study of the effects of prenatal exposure to inhalants in humans has been conducted, and it is not possible to link prenatal exposure to a specific chemical to a specific birth defect or developmental problem.
As noted above, nitrites are mainly abused by older adolescents and adults, typically to enhance sexual function and pleasure. Research shows that abuse of these drugs in this context is associated with unsafe sexual practices that greatly increase the risk of contracting and spreading such infectious diseases as HIV/AIDS and hepatitis. Recent research also raises the possibility that there may be a link between abuse of nitrite inhalants and the development and progression of infectious diseases and tumors. The research indicates that inhaling nitrites depletes many cells in the immune system and impairs immune system mechanisms that fight infectious diseases. A recent study found that even a relatively small number of exposures to butyl nitrite can produce dramatic increases in tumor incidence and growth rates in animals.

Complications of Use of Commonly Abused Inhalants

sudden sniffing death syndrome, suppressed immunologic function, injury to red blood cells (interfering with oxygen supply to vital tissues)

benzene (found in gasoline)

bone marrow injury, impaired immunologic function, increased risk of leukemia, reproductive system toxicity

sudden sniffing death syndrome via cardiac effects, serious burn injuries (because of flammability)

freon (used as a refrigerant and aerosol propellant)

sudden sniffing death syndrome, respiratory obstruction and death (from sudden cooling/cold injury to airways), liver damage

reduction of oxygen-carrying capacity of blood, changes to the heart muscle and heartbeat

nitrous oxide ("laughing gas"), hexane

death from lack of oxygen to the brain, altered perception and motor coordination, loss of sensation, limb spasms, blackouts caused by blood pressure changes, depression of heart muscle functioning

toluene (found in gasoline, paint thinners and removers, correction fluid)

brain damage (loss of brain tissue mass, impaired cognition, gait disturbances, loss of coordination, loss of equilibrium, limb spasm hearing and vision loss), liver and kidney damage

sudden sniffing death syndrome, cirrhosis of the liver, reproductive complications, hearing and vision damage

Steroids

"Anabolic steroids" is the familiar name for synthetic substances related to the male sex hormones (androgens). They promote the growth of skeletal muscle (anabolic effects) and the development of male sexual characteristics (androgenic effects), among other effects. Anabolic steroids were developed in the late 1930s primarily to treat hypogonadism, a condition in which the testes do not produce sufficient testosterone for normal growth, development, and sexual functioning. The primary medical uses of these compounds are to treat delayed puberty, some types of impotence, and wasting of the body caused by HIV infection or other diseases.
During the 1930s, scientists discovered that anabolic steroids could facilitate the growth of skeletal muscle in laboratory animals, which led to use of the compounds first by bodybuilders and weightlifters and then by athletes in other sports. Steroid abuse has become so widespread in athletics that it often affects the outcome of sports contests. More than 100 different anabolic steroids have been developed, but they require a prescription to be used legally in the United States. Most steroids that are used illegally are smuggled in from other countries, illegally diverted from U.S. pharmacies, or synthesized in clandestine laboratories. In the United States, supplements such as DHEA (dehydroepiandrosterone) and Andro (androstenedione) can be purchased legally without a prescription through many commercial sources including health food stores. They are often referred to as dietary supplements, although they are not food products. They are often taken because the user believes they have anabolic effects.
Steroidal supplements can be converted into testosterone or a similar compound in the body. Whether such conversion produces sufficient quantities of testosterone to promote muscle growth or whether the supplements themselves promote muscle growth is unknown. Little is known about the side effects of steroidal supplements, but if large quantities of these compounds substantially increase testosterone levels in the body, they also are likely to produce the same side effects as anabolic steroids.
Recent evidence suggests that steroid abuse among adolescents is on the rise. The 1999 Monitoring the Future study, a NIDA-funded survey of drug abuse among adolescents in middle and high schools across the United States, estimated that 2.7 percent of 8th- and 10th-graders and 2.9 percent of 12th-graders had taken anabolic steroids at least once in their lives. For all three grades, the 1999 levels represent a significant increase from 1991: in that year, 1.9 percent of 8th-graders, 1.8 percent of 10th-graders, and 2.1 percent of 12th-graders reported that they had taken anabolic steroids at least once. Few data exist on the extent of steroid abuse by adults. It has been estimated that hundreds of thousands of people aged 18 and older abuse anabolic steroids at least once a year. Among both adolescents and adults, steroid abuse is higher among males than females. However, steroid abuse is growing most rapidly among young women.
One of the main reasons people give for abusing steroids is to improve their performance in sports. Among competitive bodybuilders, steroid abuse has been estimated to be very high. Among other athletes, the incidence of abuse probably varies depending on the specific sport. Another reason people give for taking steroids is to increase their muscle size and/or reduce their body fat. This group includes some people who have a behavioral syndrome (muscle dysmorphia) in which a person has a distorted image of his or her body. Men with this condition think that they look small and weak, even if they are large and muscular. Similarly, women with the syndrome think that they look fat and flabby, even though they are actually lean and muscular.
Some people who abuse steroids to boost muscle size may have experienced physical or sexual abuse, and are trying to increase their muscle size to protect themselves. In one series of interviews with male weightlifters, 25 percent who abused steroids reported memories of childhood physical or sexual abuse, compared with none who did not abuse steroids. In a study of women weightlifters, twice as many of those who had been raped reported using anabolic steroids and/or another purported muscle-building drug, compared to those who had not been raped. Moreover, almost all of those who had been raped reported that they markedly increased their bodybuilding activities after the attack. They believed that being bigger and stronger would discourage further attacks because men would find them either intimidating or unattractive.
Finally, some adolescents abuse steroids as part of a pattern of high-risk behaviors. These adolescents also take risks such as drinking and driving, carrying a gun, not wearing a helmet on a motorcycle, and abusing other illicit drugs. While conditions such as muscle dysmorphia, a history of physical or sexual abuse, or a history of engaging in high-risk behaviors may increase the risk of initiating or continuing steroid abuse, researchers agree that most steroid abusers are psychologically normal when they start abusing the drugs.
Some anabolic steroids are taken orally, others are injected intramuscularly, and still others are provided in gels or creams that are rubbed on the skin. Doses taken by abusers can be 10 to 100 times higher than the doses used for medical conditions. Steroid abusers typically "stack" the drugs, meaning that they take two or more different anabolic steroids, mixing oral and/or injectable types and sometimes even including compounds that are designed for veterinary use. Abusers think that the different steroids interact to produce an effect on muscle size that is greater than the effects of each drug individually, a theory that has not been tested scientifically.
Often, steroid abusers also "pyramid" their doses in cycles of 6 to 12 weeks. At the beginning of a cycle, the person starts with low doses of the drugs being stacked and then slowly increases the doses. In the second half of the cycle, the doses are slowly decreased to zero. This is sometimes followed by a second cycle in which the person continues to train but without drugs. Abusers believe that pyramiding allows the body time to adjust to the high doses and the drug-free cycle allows the body 's hormonal system time to recuperate. As with stacking, the perceived benefits of pyramiding and cycling have not been substantiated scientifically.
Anabolic steroid abuse has been associated with a wide range of adverse side effects ranging from some that are physically unattractive, such as acne and breast development in men, to others that are life threatening, such as heart attacks and liver cancer. Most are reversible if the abuser stops taking the drugs, but some are permanent. Most data on the long-term effects of anabolic steroids on humans comes from case reports rather than formal epidemiological studies. From the case reports, the incidence of life-threatening effects appears to be low, but serious adverse effects may be under-recognized or under-reported. Data from animal studies seem to support this possibility. One study found that exposing male mice for one-fifth of their lifespan to steroid doses comparable to those taken by human athletes caused a high percentage of premature deaths. It is clear, however, that steroid abuse has marked effects on a number of body systems.

Hormonal system
Steroid abuse disrupts the normal production of hormones in the male body, causing both reversible and irreversible changes. Changes that can be reversed include reduced sperm production and shrinking of the testicles (testicular atrophy). Irreversible changes include male-pattern baldness and breast development (gynecomastia). In one study of male bodybuilders, more than half had testicular atrophy, and more than half had gynecomastia. In the female body, anabolic steroids cause masculinization. Breast size and body fat decrease, the skin becomes coarse, the clitoris enlarges, and the voice deepens. Women may experience excessive growth of body hair but lose scalp hair. With continued administration of steroids, some of these effects are irreversible.

Musculoskeletal system
Rising levels of testosterone and other sex hormones normally trigger the growth spurt that occurs during puberty and adolescence. Subsequently, when these hormones reach certain levels, they signal the bones to stop growing, locking a person into his or her maximum height. When a child or adolescent takes anabolic steroids, the resulting artificially high sex hormone levels can signal the bones to stop growing sooner than they normally would have done.

Cardiovascular system
Steroid abuse has been associated with cardiovascular diseases, including heart attacks and strokes, even in athletes younger than 30. Steroids contribute to the development of cardiovascular problems, partly by changing the levels of lipoproteins that carry cholesterol in the blood. Steroids, particularly the oral types, increase the level of low-density lipoprotein (LDL) and decrease the level of high-density lipoprotein (HDL). High LDL and low HDL levels increase the risk of atherosclerosis, a condition in which fatty substances are deposited inside arteries and disrupt blood flow. Steroids also increase the risk that blood clots will form in blood vessels, potentially disrupting blood flow and damaging the heart muscle so that it does not pump blood effectively, or increasing the risk of stroke.

Other effects
Steroid abuse has been associated with liver tumors and a rare condition called peliosis hepatis, in which blood-filled cysts form in the liver. Both the tumors and the cysts sometimes rupture, causing internal bleeding. Steroid abuse can also cause acne, cysts, and oily hair and skin.
Many abusers who inject anabolic steroids use nonsterile injection techniques or share contaminated needles with other abusers. In addition, some steroid preparations are manufactured illegally under non-sterile conditions. These factors put abusers at risk for acquiring life-threatening viral infections, such as HIV and hepatitis B and C. Abusers also can develop infective endocarditis, a bacterial illness that causes a potentially fatal inflammation of the inner lining of the heart. Bacterial infections also can cause pain and abscess formation at injection sites.
Case reports and small studies indicate that anabolic steroids, particularly in high doses, increase irritability and aggression. Some steroid abusers report that they have committed aggressive acts, such as physical fighting, committing armed robbery, or using force to obtain something. Some abusers also report that they have committed property crimes, such as stealing from a store, damaging or destroying others ' property, or breaking into a house or a building. Abusers who have committed aggressive acts or property crimes generally report that they engage in these behaviors more often when they take steroids than when they are drug-free. Some researchers, however, have suggested that steroid abusers may commit aggressive acts and property crimes not because of steroids ' direct effects on the brain but because the abusers have been affected by extensive media attention to the link between steroids and aggression. According to this theory, the abusers are using this possible link as an excuse to commit aggressive acts and property crimes.
One way to distinguish between these two possibilities is to administer either high steroid doses or placebo for days or weeks to human volunteers and then ask the people to report on their behavioral symptoms. To date, four such studies have been conducted. In three, high steroid doses did produce greater feelings of irritability and aggression than did placebo; but in one study, the drugs did not have that effect. One possible explanation, according to researchers, is that some but not all anabolic steroids increase irritability and aggression.
Anabolic steroids have been reported to cause other behavioral effects, including euphoria, increased energy, sexual arousal, mood swings, distractibility, forgetfulness, and confusion. In the studies in which researchers administered high steroid doses to volunteers, a minority of the volunteers developed behavioral symptoms that were so extreme as to disrupt their ability to function in their jobs or in society. In a few cases, the volunteers ' behavior presented a threat to themselves and others. In summary, the extent to which steroid abuse contributes to violence and behavioral disorders is unknown. As with the health complications of steroid abuse, the prevalence of extreme cases of violence and behavioral disorders seems to be low, but it may be under-reported or under-recognized.
An undetermined percentage of steroid abusers become addicted to the drugs, as evidenced by their continuing to take steroids in spite of physical problems, negative effects on social relations, or nervousness and irritability. Also, they spend large amounts of time and money obtaining the drugs and experience withdrawal symptoms such as mood swings, fatigue, restlessness, loss of appetite, insomnia, reduced sex drive, and the desire to take more steroids. The most dangerous of the withdrawal symptoms is depression, because it sometimes leads to suicide attempts. Untreated, some depressive symptoms associated with anabolic steroid withdrawal have been known to persist for a year or more after the abuser stops taking the drugs.
Few studies of treatments for anabolic steroid abuse have been conducted. Current knowledge is based largely on the experiences of a small number of physicians who have worked with patients undergoing steroid withdrawal. The physicians have found that supportive therapy is sufficient in some cases. Patients are educated about what they may experience during withdrawal and are evaluated for suicidal thoughts. If symptoms are severe or prolonged, medications or hospitalization may be needed.
Some medications that have been used for treating steroid withdrawal restore the hormonal system after its disruption by steroid abuse. Other medications target specific withdrawal symptoms: for example, antidepressants to treat depression, and analgesics for headaches and muscle and joint pain. Some patients require assistance beyond simple treatment of withdrawal symptoms and are also treated with behavioral therapies.

Prescription Drug Abuse

Although almost all prescription drugs can be misused, there are three classes of prescription drugs that are most commonly abused:

• Opioids, which are most often prescribed to treat pain;
• CNS depressants, which are used to treat anxiety and sleep disorders;
• Stimulants, which are prescribed to treat the sleep disorder narcolepsy, attention-deficit hyperactivity disorder (ADHD), and obesity.

Opioids are commonly prescribed because of their effective analgesic, or pain-relieving, properties. Medications that fall within this class - sometimes referred to as narcotics - include morphine, codeine, and related drugs. Morphine, for example, is often used before or after surgery to alleviate severe pain. Codeine, because it is less efficacious than morphine, is used for milder pain. Other examples of opioids that can be prescribed to alleviate pain include oxycodone (Percodan or OxyContin - see section on Opiates), propoxyphene (Darvon), hydrocodone (Vicodin), and hydromorphone (Dilaudid), as well as meperidine (Demerol), which is used less often because of its side effects. In addition to their pain-relieving properties, some of these drugs - for example, codeine and diphenoxylate (Lomotil) - can be used to relieve coughs and diarrhea.
Chronic use of opioids can result in tolerance for the drugs, which means that users must take higher doses to achieve the same initial effects. Long-term use also can lead to physical dependence and addiction - the body adapts to the presence of the drug, and withdrawal symptoms occur if use is reduced or stopped. Finally, taking a large single dose of an opioid could cause severe respiratory depression that can lead to death. Opioids are safe to use with other drugs only under a physician 's supervision. Typically, they should not be used with other substances that depress the central nervous system, such as alcohol, antihistamines, barbiturates, benzodiazepines, or general anesthetics; as such a combination increases the risk of life-threatening respiratory depression.
CNS depressants are substances that can slow normal brain function. Because of this property, some CNS depressants are useful in the treatment of anxiety and sleep disorders. Barbiturates, such as mephobarbital (Mebaral) and pentobarbital sodium (Nembutal), are used to treat anxiety, tension, and sleep disorders. Benzodiazepines, such as diazepam (Valium), chlordiazepoxide HCl (Librium), and alprazolam (Xanax), can be prescribed to treat anxiety, acute stress reactions, and panic attacks; the more sedating benzodiazepines, such as triazolam (Halcion) and estazolam (ProSom) can be prescribed for short-term treatment of sleep disorders. In higher doses, some CNS depressants can also be used as general anesthetics. Most CNS depressants work in the brain by increasing the activity of the neurotransmitter GABA.
Despite their many beneficial effects, barbiturates and benzodiazepines have the potential for abuse and should be used only as prescribed. During the first few days of taking a prescribed CNS depressant, a person usually feels sleepy and uncoordinated, but as the body becomes accustomed to the effects of the drug, these feelings begin to disappear. If one uses these drugs long term, the body will develop tolerance for the drugs, and larger doses will be needed to achieve the same initial effects. In addition, continued use can lead to physical dependence and - when use is reduced or stopped - withdrawal. Because all CNS depressants work by slowing the brain 's activity, when an individual stops taking them, the brain 's activity can rebound and race out of control, possibly leading to seizures and other harmful consequences. Although withdrawal from benzodiazepines can be problematic, it is rarely life threatening, whereas withdrawal from prolonged use of other CNS depressants can have life-threatening complications. Therefore, someone who is thinking about discontinuing CNS depressant therapy or who is suffering withdrawal from a CNS depressant should speak with a physician or seek medical treatment.
CNS depressants should be used with other medications only under a physician 's supervision. Typically, they should not be combined with any other medication or substance that causes CNS depression, including prescription pain medicines, some over-the-counter cold and allergy medications, or alcohol. Using CNS depressants with these other substances - particularly alcohol - can slow breathing, or slow both the heart and respiration, and possibly lead to death.
As the name suggests, stimulants are a class of drugs that enhance brain activity - they cause an increase in alertness, attention, and energy that is accompanied by elevated blood pressure and increased heart rate and respiration. Stimulants were used historically to treat asthma and other respiratory problems, obesity, neurological disorders, and a variety of other ailments. But as their potential for abuse and addiction became apparent, the medical use of stimulants began to wane. Now, stimulants are prescribed for the treatment of only a few health conditions, including narcolepsy, attention-deficit hyperactivity disorder, and depression that has not responded to other treatments. Stimulants may be used as appetite suppressants for short-term treatment of obesity, and they also may be used for patients with asthma who do not respond to other medications.
Stimulants, such as dextroamphetamine (Dexedrine) and methylphenidate (Ritalin), have chemical structures that are similar to a family of key brain neurotransmitters called monoamines, which include norepinephrine and dopamine. Stimulants increase the amount of these chemicals in the brain. This, in turn, increases blood pressure and heart rate, constricts blood vessels, increases blood glucose, and opens up the pathways of the respiratory system. In addition, the increase in dopamine is associated with a sense of euphoria that can accompany the use of these drugs. The consequences of stimulant abuse can be dangerous. Although their use may not lead to physical dependence and risk of withdrawal, stimulants can be addictive in that individuals begin to use them compulsively. Taking high doses of some stimulants repeatedly over a short time can lead to feelings of hostility or paranoia. Additionally, taking high doses of a stimulant may result in dangerously high body temperatures and an irregular heartbeat. There is also the potential for cardiovascular failure or lethal seizures.
Stimulants should be used with other medications only when the patient is under a physician 's supervision. For example, a stimulant may be prescribed to a patient taking an antidepressant. However, healthcare providers and patients should be mindful that antidepressants enhance the effects of a stimulant. Patients also should be aware that stimulants should not be mixed with over-the-counter cold medicines that contain decongestants, as this combination may cause blood pressure to become dangerously high or lead to irregular heart rhythms.

Management of Drug Overdose

Because so many illicit drugs are abused in combination, management of an overdose can be extremely complex. Treatment of each must be individual, and only general treatment guidelines are offered here. Symptomatic and supportive care is the basis for treatment of a drug overdose; the primary goal is to insure adequate vital functions.

1. Patient assessment is critical to determine the adequacy of respiratory and cardiac function. Note the integrity of reflexes (corneal, pupil, gag and deep tendon.)
2. If the patient is asymptomatic because he has not absorbed a sufficient quantity of the drug, vomiting may be induced. This must not be done if there is central nervous system depression, however. Activated charcoal powder may be given, or gastric lavage performed. If the patient demonstrates decreased consciousness during the procedure, however, he should be intubated before the lavage is started.
3. If the patient 's level of consciousness is decreased, all treatment should be directed toward maintaining cardiac and respiratory function. Provide ventilation by mouth-to-mouth, use of an Ambu bag, or respirator until the patient is oxygenated. Intubation and suction, plus monitoring of blood gases, follow management of the emergency.
4. Adequate hydration should be maintained with IV fluids, and central venous pressure should be monitored.
5. Insert indwelling urinary catheter and monitor output.
6. Gastric lavage should be performed only after vital functions are adequate and supportive measures to maintain them have been implemented.
7. Specific antidotes for drug overdoses are few and should only be used with definite indications. Never use them prophylactically.
8. Unnecessary drugs should be avoided. CNS stimulants are not advised as they may result in seizures. Supportive care is most important now.
9. Continued care with close monitoring of vital functions may be needed for an extended period of time. Coma may persist for days.
10. Observe carefully for the common complication of aspiration: pneumonia and subsequent infection.
11. Initial aspiration fluids should be saved for toxicological analysis, as should the first urine sample. This may have an important effect upon treatment.
12. If the patient survives, be sure he is referred for counseling and follow-up care.

Principles of Effective Drug Addiction Treatment

In addition to the specific approaches to treatment of addiction to various drugs as described above, there are a number of general principles to be followed. The National Institute on Drug Abuse (NIDA) recommends the following as applicable to all treatment plans.

1. No single treatment is appropriate for all individuals. Matching treatment settings, interventions, and services to each individual 's particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society.
2. Treatment needs to be readily available. Because individuals who are addicted to drugs may be uncertain about entering treatment, taking advantage of opportunities when they are ready for treatment is crucial. Potential treatment applicants can be lost if treatment is not immediately available or is not readily accessible.
3. Effective treatment attends to multiple needs of the individual, not just his or her drug use. To be effective, treatment must address the individual 's drug use and any associated medical, psychological, social, vocational, and legal problems.
4. An individual 's treatment and services plan must be assessed continually and modified as necessary to ensure that the plan meets the person 's changing needs. A patient may require varying combinations of services and treatment components during the course of treatment and recovery. In addition to counseling or psychotherapy, a patient at times may require medication, other medical services, family therapy, parenting instruction, vocational rehabilitation, and social and legal services. It is critical that the treatment approach be appropriate to the individual 's age, gender, ethnicity, and culture.
5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness. The appropriate duration for an individual depends on his or her problems and needs. Research indicates that for most patients, the threshold of significant improvement is reached at about 3 months in treatment. After this threshold is reached, additional treatment can produce further progress toward recovery. Because people often leave treatment prematurely, programs should include strategies to engage and keep patients in treatment.
6. Counseling (individual and/or group) and other behavioral therapies are critical components of effective treatment for addiction. In therapy, patients address issues of motivation, build skills to resist drug use, replace drug-using activities with other constructive and rewarding activities, and improve problem-solving abilities. Behavioral therapy also facilitates interpersonal relationships and the individual 's ability to function in the family and community.
7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. Methadone and levo-alpha-acetylmethadol (LAAM) are very effective in helping individuals addicted to heroin or other opiates stabilize their lives and reduce their illicit drug use. Naltrexone is also an effective medication for some opiate addicts and some patients with co-occurring alcohol dependence. Antidepressants and anxiolytic medications can sometimes be helpful in treating symptoms of withdrawal. For patients with mental disorders, both behavioral treatments and medications can be critically important in achieving treatment goals.
8. Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way. Because addictive disorders and mental disorders often occur in the same individual, patients presenting for either condition should be assessed and treated for the co-occurrence of the other type of disorde.r
9. Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use. Medical detoxification safely manages the acute physical symptoms of withdrawal associated with stopping drug use. While detoxification alone is rarely sufficient to help addicts achieve long-term abstinence, for some individuals it is a strongly indicated precursor to effective drug addiction treatment.
10. Treatment does not need to be voluntary to be effective. Strong motivation can facilitate the treatment process. Sanctions or enticements in the family, employment setting, or criminal justice system can increase significantly both treatment entry and retention rates and the success of drug treatment interventions.
11. Possible drug use during treatment must be monitored continuously. Lapses to drug use can occur during treatment. The objective monitoring of a patient 's drug and alcohol use during treatment, such as through urinalysis or other tests, can help the patient withstand urges to use drugs. Such monitoring also can provide early evidence of drug use so that the individual 's treatment plan can be adjusted. Feedback to patients who test positive for illicit drug use is an important element of monitoring.
12. Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases, and counseling to help patients modify or change behaviors that place themselves or others at risk of infection. Counseling can help patients avoid high-risk behavior. Counseling also can help people who are already infected manage their illness.
13. Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug use can occur during or after successful treatment episodes. Addicted individuals may require prolonged treatment and multiple episodes of treatment to achieve long-term abstinence and fully restored functioning. Participation in self-help support programs during and following treatment often is helpful in maintaining abstinence.

Principles for Prevention Programs

In more than 20 years of drug abuse research, NIDA has identified important principles for prevention programs in the family, school, and community. NIDA-supported researchers have tested these principles in long-term drug abuse prevention programs and have found them to be effective. It should be noted that healthcare professionals are often in a unique position to influence and implement both the prevention and treatment of drug abuse. Effective intervention for prevention can occur during one-to-one interactions with patients as well as in the context of community wide programs.

• Prevention programs should be designed to enhance "protective factors" and move toward reversing or reducing known "risk factors." Protective factors are those associated with reduced potential for drug use. Risk factors are those that make the potential for drug use more likely:
  Protective factors include strong and positive bonds within a prosocial family; parental monitoring; clear rules of conduct that are consistently enforced within the family; involvement of parents in the lives of their children; success in school performance; strong bonds with other prosocial institutions, such as school and religious organizations; and adoption of conventional norms about drug use.
  Risk factors include chaotic home environments, particularly in which parents abuse substances or suffer from mental illnesses; ineffective parenting, especially with children with difficult temperaments or conduct disorders; lack of mutual attachments and nurturing; inappropriately shy or aggressive behavior in the classroom; failure in school performance; poor social coping skills; affiliations with deviant peers or peers displaying deviant behaviors; and perceptions of approval of drug-using behaviors in family, work, school, peer, and community environments.
• Prevention programs may target a variety of drugs of abuse, such as tobacco, alcohol, inhalants, and marijuana or may target a single area of drug abuse such as the misuse of prescription drugs.
• Prevention programs should include general life skills training and training in skills to resist drugs when offered, strengthen personal attitudes and commitments against drug use, and increase social competency (e.g., in communications, peer relationships, self-efficacy, and assertiveness).
• Prevention programs for children and adolescents should include developmentally appropriate interactive methods, such as peer discussion groups and group problem solving and decision making, rather than didactic teaching techniques alone.
• Prevention programs should include parents ' or caregivers ' components that train them to use appropriate parenting strategies, reinforce what the children are learning about drugs and their harmful effects, and open opportunities for family discussions about the use of legal and illegal substances and family policies about their use.
• Prevention programs should be long-term (throughout the school career), with repeat interventions to reinforce the original prevention goals. For example, school-based efforts directed at elementary and middle school students should include booster sessions to help with the critical transitions such as from middle to high school.
• Family-focused prevention efforts have a greater impact than strategies that focus on parents only or children only.
• Community programs that include media campaigns and policy changes, such as new regulations that restrict access to alcohol, tobacco, or other drugs, are more effective when they are accompanied by school and family interventions.
• Community programs need to strengthen norms against drug use in all drug abuse prevention settings, including the family, the school, the workplace and the community.
• Schools offer opportunities to reach all populations and also serve as important settings for specific subpopulations at risk for drug abuse, such as children with behavior problems or learning disabilities and those who are potential dropouts.
• Prevention programming should be adapted to address the specific nature of the drug abuse problem in the local community.
• The higher the level of risk of the target population, the more intensive the prevention effort must be and the earlier it must begin.
• Prevention programs should be age- specific, developmentally appropriate, and culturally sensitive.
• Effective prevention programs are cost- effective. For every $1 spent on drug use prevention, communities can save $4 to $5 in costs for drug abuse treatment and counseling.

One cannot be aware of the drug problem facing this country and its people without wondering about solutions. Should we barricade the borders to keep the smugglers out? Crack down even harder on clandestine chemists? Napalm growing plants in the fields of this and other countries? Is the answer to be found in stiffer sentences for dealers, more random urine testing, tougher laws?
Or do we focus on the users? What can we do to stop someone from taking the first hit on a joint, popping his first pill, sticking that needle into his arm? There are no easy answers, but one thing does seem clear: comprehensive, patient-centered treatment and prevention programs may represent our best hope for a brighter, drug-free future for us all.

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