Lawrence S. Neinstein, M.D., F.A.C.P.
Professor of Pediatrics and Medicine
USC Keck School of Medicine
Executive Director
University Park Health Center
Associate Dean of Student Affairs
   

 

 

Substance Abuse - Alcohol/Cigarette Use/Marijuana/Hallucinogens (B8)

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ALCOHOL

Alcohol is the most widely used drug by adolescents. Problems related to adolescents alcohol use include motor vehicle accidents secondary to driving under the influence and suicides and homicides that involve alcohol use. In addition, there is an increase of unprotected intercourse in those under the influence of alcohol and other drugs.

Factors contributing to Teenage Alcohol Use
Factors involved in adolescent alcohol use include:

  • Family and parental factors including genetics, extreme parenting styles, lack of perceived family support
  • Peer influence
  • Desire to attain adult status
  • Sexuality socialization
  • Psychological problems
  • Curiosity
  • Lack of religious involvement
  • Timing of sexual maturation: Earlier puberty is associated with a younger age at onset of both drinking and smoking among adolescent girls (Wilson et al., 1994).

Behavioral Clues to alcohol or drug abuse problems:

  • Changes in activity such as loss of interest in school, play, home, or work
  • Changes in sleeping patterns
  • Changes in eating patterns
  • Changes in personality: May be reflected in mood changes, fighting with friends and with family members, or truancy
  • Manifestations of depression, such as poor attention span, difficulties in concentrating, lack of interest, and boredom
  • Trouble with law enforcement
  • Multiple or frequent accident-related injuries
  • School failure
  • Blackouts

Screening Instruments

Determining the extent of alcohol abuse and diagnosing alcoholism in the adolescent is crucial. The HEADSS psychosocial profile can be helpful as can available screening tests such as the Michigan Alcoholism Screening Test (MAST) or the CAGE questionnaire. Screening instruments are reviewed in the NIAAA's Assessing Alcohol Problems, NIAAA Treatment Handbook Series 4. (NIAAA, 1995)

Treatment

Components of successful treatment of adolescent alcohol abuse and dependence include:

  • Accurate diagnosis and assessment:
  • Treatment of any primary psychiatric disturbances should they be identified.
  • Disease concept of recovery
  • Positive alternatives
  • Good support systems
  • Family involvement

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CIGARETTE SMOKING

The World Health Organization has estimated that by the year 2025, 500 million people worldwide will die of a tobacco-related disease. Smoking related deaths are almost 3 times the yearly deaths due to illegal drugs, homicide, alcohol, AIDS, suicide, and motor vehicle accidents combined . Over 80% of all cigarette smokers start before the age of 18 years and approximately 20% before their 13th birthday.

Prevalence data are available for US:

National Youth Tobacco Survey (sponsored by the American Legacy Foundation and the Centers for Disease Control and Prevention Foundation) http://www.cdc.gov/tobacco/data_statistics/surveys/NYTS/

Youth Risk Behavior Survey (sponsored by the Centers for Disease Control and Prevention) http://www.cdc.gov/nccdphp/dash/yrbs/

Monitoring the Future (sponsored by the University of Michigan Institute for Social Research and the National Institute of Drug Abuse)
http://www.monitoringthefuture.org/

Nicotine Addiction

Besides being a potent pesticide, nicotine is one of the most addictive substances known. Tobacco use by adolescents, which may have started primarily for psychosocial reasons, may over time become a serious drug addiction. Initial symptoms of nicotine dependence may occur in some teens within days to weeks of onset of use. Nicotine seems to function as a positive reinforcer through its actions on nicotinic acetylcholine receptors in the mesocorticolimbic dopamine pathway. Besides nicotine, cigarettes contain tar, a toxic compound as well as literally thousands of other chemicals, many poisonous and cancer causing, including ammonia, cadmium, carbon monoxide, cyanide, formaldehyde, nitrosamines, and polynuclear aromatic hydrocarbons.

Prevention and Treatment

Brief Practitioner Interventions

Although smoking onset and maintenance by adolescents are complex psychosocial and biological phenomena as noted above, research has demonstrated that 3-minute discussions of tobacco use (“brief interventions”) can have a significant impact on smoking prevention or smoking cessation.

Intensive smoking cessation interventions

More intensive smoking cessation interventions may be more effective in helping addicted smokers quit. These more intensive interventions may involve a medical clinician discussing health issues and prescribing pharmacotherapy, and a nonmedical clinician focusing on additional psychosocial or behavioral issues.

Anti-smoking messages

Anti-smoking message should be varied according to the smoking status of the patient and their age and developmental stage.

United State Public health Clinical Guidelines

The United States Public Health Service guidelines stress the 5 “Rs” for enhancing motivation to quit tobacco use. These 5 “Rs” are:

  • indicating why quitting is personally Relevant
  • Identifying the Risks of tobacco use
  • identifying the medical and psychosocial Rewards from quitting
  • identifying Roadblocks to quitting, and how to overcome them; and
  • Repeating the motivational intervention at every clinic visit.

The United States Public Health Service published a revised clinical practice guideline for treating tobacco use and dependence in 2000 utilizing the Five "A"s

  • Ask systematically about smoking at each visit
  • Advise all smokers to quite
  • Assess patient willingness to make a quit attempt
  • Assist the patient in stopping smoking. Set a quit date for a smoker has been shown to be an important and effective first step in smoking cessation. Pharmacotherapy including nicotine replacement products and bupriopion may be helpful.
  • Fifth, Arrange follow-up.

Educational materials

Resources include:

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MARIJUANA

Marijuana remains the most widely abused illicit drug in the United States and around the world. There remains significant controversy over the effects of the drug on physical and mental health. However, marijuana is no longer considered a benign drug. It has been shown to have negative effects on both physical and psychological health and is associated with the possible development of tolerance, dependence and a withdrawal syndrome.

The Drug

Marijuana is derived from the flowering tops and leaves of the plant Cannabis sativa. The resinous oil is extracted. The THC content is highest in the flowering tops and less in leaves, stems and seeds. Marijuana contains more than 60 cannabinoids but the major psychoactive ingredient appears to be delta-9-tetrahydrocannabinol (THC). Marijuana is usually smoked but may be eaten, brewed in tea or swollowed in a pill form. Marijuana appears to stimulate dopamine pathways in the brain.

THC is primarily metabolized in the liver through the cytochrome P450 system. Peak plasma levels of THC are reached within about 10 minutes of smoking marijuana. Effects last about two to three hours. The drug is fat-soluble and thus can accumulate for long periods in the body. Smoked marijuana has 5 to 10 times the bioavailability of the ingested drug.

Interpretation of the urine drug screen depends somewhat on the level detected.

Level <20 ng/mL: Considered negative

Level of 20-50 ng/mL: May not distinguish recent use in the occasional user from past use in long-term users

Level >50 ng/mL: May be detected in long-term users for up to 2 weeks after last use

Level >400 ng/mL: Indicates recent heavy use

Effects of intoxication include:

  • Physical reactions: Increase in heart rate, a reddening of the conjunctivae, dry mouth and throat, dilated pupils, sleepiness
  • Distortion of time sense
  • Auditory and visual enhancement or distortions
  • Impaired learning and cognitive functions
  • Increase in appetite
  • Low to moderate dose: Euphoria, time distortion, increased talking, and the reactions described above (item a)
  • High dose: Mood fluctuations, depersonalization, and hallucinations
  • Potential toxic reactions: Anxiety panic, organic brain syndrome, psychoses, delusions, hallucinations, and paranoia
  • Seizures: Marijuana may precipitate seizures in epileptic individuals.
  • Psychosis: Marijuana may precipitate psychotic episodes in schizophrenic individuals.

While marijuana can have affects on the cardiopulmonary, endocrine and other systems the most controversial has been the amotivational syndrome: This proposed syndrome consists of a state of passive withdrawal from usual work and recreational activities following heavy marijuana use.

Treatment

Treatment of marijuana use in the adolescent involves differentiation between the experimental or occasional use and the abuse of marijuana. After initially experimenting with marijuana, many adolescents do not use it again or use it very infrequently. However, physicians should not overlook the negative effects of marijuana use in adolescence. Frequent marijuana use can interfere with the cognitive, emotional, and social development of adolescence. Deterioration in school performance, family and social problems, accidents, and legal difficulties suggest the need for intervention and treatment.

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HALLUCINOGENS

The hallucinogen (“producer of hallucinations”) class of drugs includes LSD, peyote, mescaline, psilocybin, certain mushrooms, DMT (dimethyltryptamine), morning-glory seeds, STP (serenity-tranquility-peace pill), jimsonweed, and PCP (phencyclidine). The term hallucinogen is a misnomer since “prototypical hallucinogens” like LSD and mescaline at usual doses levels do not cause hallucinations (sensory perception changes without a corresponding environmental stimulus) but produce illusions (perceptural distortion of a real environmental stimulus) or distortions of perceived reality. True hallucinations do occur with the use of volatile solvents (e.g., gasoline). With the exception of the hallucinogenic amphetamines, physical withdrawal does not occur.

Types of Hallucinogens

The following is a sub-groupings of hallucinogens based on distinctive psychoactive effects and structure-activity relationship similarities:

  • Psychedelics - prominent hallucinations/synesthesias
  • Indolealkylamines – LSD, psilocybin (magic mushrooms), dimethyltryptamine (DMT), B-carbolines (harmaline)
  • Phenylalkylamines – Mescaline (peyote),
  • Entactogens – Structural similarities to psychedelics(mescaline) and amphetamines. Unique characteristics psychoactively include improved communication, empathy with others, and positive mood enhancement
  • Methylenedioxymethamphetamine (ecstasy, MDMA)
  • 4-methylenedioxyamphetamine (EVE)
  • PCP – Also a dissociative anesthetic
  • Marijuana

LSD

  • Most potent psychoactive drug.
  • Rapidly absorbed from the gastrointestinal tract, with onset of action in 30-40 minutes.
  • Half-life of 3 hours and is not detected on standard urine drug screens.
  • Tolerance develops rapidly but is short-lived.
  • Physiological effects: Include: Conjunctival injection, ataxia, increase in blood pressure, heart rate, and temperature, mydriasis, lacrimation, flushing and sweating, decrease in urine output, decrease in appetite, dry mouth, blurred vision, tremors and incoordination, and psychological effects such as depersonalization, loss of time sense and of the relationship between current impressions and past experience, loss of ego boundaries, decrease in judgment and visual and auditory illusions.
  • Symptoms of intoxication include: Anorexia, nausea, flushing, elevated temperature, dizziness, paresthesia, dilated pupils, hyperactive reflexes, tremor, labile affect, anxiety, body image changes, euphoria, floating feeling, illusions, restlessness, sleep disturbance, paranoia, and depersonalization, elevated blood pressure and tachycardia
  • Symptoms of overdose include: General (dry mouth, perspiration, elevated temperature, flushing), neurological (grand mal seizures, dilated pupils, hyperactive reflexes, tremor, dizziness, coma), psychiatric (toxic psychosis, suspiciousness, anxiety, body distortions, irritability delirium, illusions), cardiovascular (tachycardia, hypertension, circulatory collapse), gastrointestinal (anorexia, nausea, vomiting, abdominal cramps), coagulopathies, tolerance and psychological dependence; no physical dependence, bad trips, flashbacks and chronic adverse effects (psychosis, depression, and personality changes).

Treatment of a Bad Trip and of Overdose

  • Provide an appropriate setting that is peaceful and calm
  • Help to restore contact with reality.
  • Avoid the use of any medications, if possible.
  • Avoid discussing reasons for use of the drug or personal problems of the user during a bad trip.
  • Support respiration and circulation as needed.
  • Treat hyperthermia.
  • Treat seizures.
  • Treat hypertension.

Peyote and mescaline

  • Onset of action within 30 minutes to 2 hours after use
  • Effects last about 6 - 12 hours
  • Mescaline intensifies body sense, whereas LSD tends to have a stronger effect on the mind
  • Tolerance and psychological dependence can occur with mescaline, but no physical addiction occurs.

Psilocybin

Mushrooms containing psilocybin and psilocin produce effects similar to those of the other hallucinogens. Onset within 15 minutes, peak at 90 minutes, begin to wear off in about 2 - 3 hours, and disappear after about 5 - 6 hours.

DMT

DMT (dimethyltryptamine) is a natural constituent of the seeds of several plants found in the West Indies and South America . The drug has effects similar to those of other hallucinogens, except that the "trip" is short, lasting only 1 - 3 hours.

PCP

While declining in use in the 1980s, PCP again increased in use in adolescents in the 1990s. PCP was first introduced in the 1950s as a general anesthetic but because of significant side effects it was discontinued from use in 1965. Popularity increased in the 1970s and became a major drug of abuse. Until 1978 the drug was still legally manufactured as Semylan for veterinary anesthesia.

  • PCP is fat soluble and thus can remain in the body for prolonged periods
  • Its urinary excretion is highly dependent on urine pH, with significantly higher excretion rates at an acidic pH.
  • The half-life of PCP is 3 days
  • PCP is a dissociative anesthetic with analgesic, stimulant, depressant, and hallucinogenic properties.
  • PCP generally induces one of several clinical states:
  • Acute intoxication
  • Acute or prolonged delirium:
  • Schizophreniform psychosis
  • Mania
  • Depressive reactions
  • PCP may be packaged as a liquid, powder, tablet, leaf mixture, or rock crystal. It can be used intravenously, intramuscularly, or orally, or it can be snorted or smoked.
  • Dose ranges may vary tremendously from 0.1 mg to over 150 mg
  • Many street names including: angel dust, animal, dust, elephant tranquilizer, sherms, goon, cadillac, crystal, KJ crystal.
  • Clinical manifestations of PCP vary with dose, route used and experience of user.
  • Low dose includes: Blank stare, horizontal and vertical nystagmus, gait ataxis, increased blood pressure, increased deep tendon reflexes, decreased proprioception and sensations, miosis, diaphoresis, flushing and behavioral disorders.
  • Moderate doses include above changes plus myoclonus, fever, mutism, amnesia, anxiety and individual may be stuporous or extremely agitated or violent.
  • High doses include: Unresponsive, immobile state, arrhythmiass, muscle rigidity, decerebrate posturing, convulsions, miosis.
  • The diagnosis of PCP use should be suspected in all adolescents with a distorted thought process, especially when there is evidence of analgesia or nystagmus. Common symptoms include vertical and horizontal nystagmus, ataxia, increased blood pressure and reflexes, miotic but reactive pupils and disorientation with catatonic or agitated state.
  • Complications include seizures, hypertension, renal failure, psychosis and death.
  • Treatment involves reducing stimulation, removal of hazards, avoidance of medications if possible, acidification of urine, cardiopulmonary support and use of haloperidol for severe agitation and psychosis.

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Copyright (©) 2004-2013 Lawrence S. Neinstein, University of Southern California . All rights reserved. Republication or redistribution of the text, table, graphs and photos is expressly prohibited. The University of Southern California shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon.