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 - Management of Drug Abuse (B8)

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APPROACHES TO THE MANAGEMENT OF DRUG ABUSE

The management of drug abuse in adolescents is complex and requires the cooperation of a multidisciplinary team or a residential treatment center.

Tasks for Health Care Providers

  • Be informed of current drugs of abuse and their pharmacology
  • Understand one's own limitations and use community resources as needed
  • Be aware of available community resources for emergency medical services, crisis intervention and residential treatment programs
  • Develop relationships with emergency departments at local hospitals on identification and referral of adolescents at high risk of substance abuse
  • Become familiar with laws related to drug abuse
  • Be able to manage acute drug ingestion
  • Provide drug education to schools, youth organizations, adolescents, and parents.
  • Provide supportive counseling to the adolescent
  • Identify the child or adolescent at high risk of chemical dependency and to intervene appropriately

History Taking

In taking the adolescent's history, the health-care provider should keep the following points in mind:

  • Be supportive, nonthreatening, nonjudgemental, and honest.
  • If an adolescent is under the influence of mood-altering chemicals, do not attempt or expect to get an accurate history.
  • Assess level of chemical used, what drugs are used, their frequency and route of administration, associated life problems, level of chemical dependency, family history of chemical dependency, peer drug use and stress factors in family, school or elsewhere.

In performing the physical examination look for evidence of malnutrition, infection, blood pressure changes, pulse changes, temperature changes, skin rashes or needle tracks, eye changes including pupil size and reactivity and also for cardiopulmonary changes.

The following list of common eye signs to determine the use of various drugs.

  • Marijuana
    • Normal-sized pupil
    • Slow or no reaction of pupil to light
    • Nonconvergence
    • Conjunctival injection
    • Glazing of cornea
    • Horizontal nystagmus
    • Swollen eyelids
    • Watering
  • Heroin
    • Constricted pupil
    • Nonreactive pupil
    • Ptosis
    • Glazing of cornea
    • Decreased corneal reflex
    • Swollen eyelids
  • Alcohol/benzodiazepines
    • Normal-sized pupil
    • Slow or no reaction of pupil to light
    • Nystagmus
    • Redness of conjuctiva
    • Glazing of cornea
    • Nonconvergence
  • Cocaine/amphetamine
    • Dilated pupil
    • Slow or no reaction of pupil to light
    • Decreased corneal reflex
  • Phencyclidine (PCP)
    • Normal-sized pupil
    • Slow or no reaction of pupil to light
    • Vertical and horizontal nystagmus
    • Retracted upper eyelid
    • Decreased corneal reflex
    • Swollen eyelids
  • Amphetamines
    • Dilated pupils
    • Nonreactive pupil
  • Barbiturates
    • Lateral nystagmus

Diagnostic clues by drug class

  • Sympathomimetics: Delusions, paranoia, restlessness, agitation, tachycardia, hypertension, hyperpyrexia, diaphoresis, mydriasis and hyperreflexia, dry mouth, diarrhea, sweating
  • Sedative-hypnotics: Respiratory depression, miosis and lateral nystagmus, drowsiness, lethargy, coma, hypotension, and fluctuating levels of consciousness with glutethimide; mydriasis with barbiturates
  • Hallucinogens: Bizarre behavior, psychosis, hallucinations
  • Opiates: Coma, hypotension, bradycardia, hypothermia, hyporeflexia, miotic pupils, depressed respiration, coma, needle marks
  • Phenothiazines: Miosis, hypotension, tremors, extrapyramidal movements, cardiac arrhythmias
  • Anticholinergics (e.g., tricyclics, antidepressants, jimsonweed): Delirium with mumbling speech, tachycardia, dry flushed skin, dilated pupils, myoclonus, decreased bowel sounds, hypotension, arrhythmias, increased QRS-complex duration, choreoathetoid movements, urinary retention ("mad as a hatter, blind as a bat, red as a beet, hot as a hare, and dry as a bone")
  • Cholinergics (e.g., Amanita muscaria mushrooms): SLUDGE = salivation, lacrimation, urination, defecation, gastrointestinal upset, and emesis; also bronchorrea, miosis, confusion, seizures, or coma
  • Gamma Hydroxybutyric Acid (GHB) Sedation progressing to coma associated with seizure like activity. Respiratory depression to point of apnea with intermittent periods of violent agitation. Bradycardia, ectopy and conduction blocks are common
  • Serotonin syndrome Fever, increased muscle tone (rigidity), hyperreflexia, sinus tachycardia, hypertension, diaphoresis and altered mental status. Serotonin syndrome is caused by drug-induced excess of intrasynaptic 5-hydroxytryptamine. Aside from SSRIs, the syndrome can be caused by amphetamines, cocaine and LSD.

Drug screening

The technology for drug screening and identification has greatly expanded in recent years. Inexpensive, reliable, and rapid tests are currently available. However, drug testing can provide reliable and useful information in the diagnosis and management of substance abuse in adolescents and is the only objective test to evaluate chemical abuse and dependency. However, false-positive and false-negative results do occur and positive results on screening tests should be confirmed with more specific tests. There are also many ethical dilemmas regarding drug testing and confidentiality issues.

Website regarding drug screening:

For urine collection: Drug Testing Procedures Handbook (U.S. Department of Transportation publication No. S/N 050-000-00538-1). Available from the Superintendent of Documents, U.S. Government Printing Office, PO . Box 371954 , Pittsburgh , PA 15250 .

Management

Details of basic principles are laid out by the National Institute on Drug Abuse and are available at: http://www.nida.nih.gov/DrugsofAbuse.html

Important principles include:

  • No single treatment is appropriate for all individuals.
  • Treatment needs to be readily available to avoid losing interested individuals.
  • Effective treatment attends to multiple needs of the individual , not just his or her drug use.
  • At different times during treatment, a patient may develop a need for medical services, family therapy, vocational rehabilitation, and social and legal services.
  • Treatment must be continued for an adequate time period , which varies on individual need, but most patients need at least 3 months for significant improvement.
  • Individual and/or group counseling and other behavioral therapies are critical components of effective treatment for addiction.
  • Medications are an important element of treatment for many patients , especially when combined with counseling and other behavioral therapies.
  • Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way.
  • Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use.
  • Treatment does not need to be voluntary to be effective.
  • Possible drug use during treatment must be monitored continuously.
  • 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 them or others at risk of infection.
  • Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment.

Names by Drug: (More complete list by drugs in alphabetic order can also be found at http://www.nida.nih.gov/drugpages/)

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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.