Issuu on Google+

2011 Introduction to Drugs of Abuse with Assessment Strategies

Compiled and Edited by: Frances Hodgkins BSN, RN, PMHN-BC 8/14/2011


Drugs of Abuse and Assessment Strategies

2011

Welcome and Good Morning! Introduction to Drugs of Abuse and Assessment Strategies with

Ms. Frances Hodgkins BSN, RN, PMHN-BC

Ground Rules This session will be 2 hours in length A 10 min break will be given at the one hour mark, please be prompt in returning from break You may eat and drink in class Please silence your cell phones and no calls during class.

Chapter:

Questions and free discussion are welcomed and encouraged.

2


Drugs of Abuse and Assessment Strategies

2011

Table of Contents Welcome and Good Morning! .................................................................................................................................... 2 Introduction to Drugs of Abuse and Assessment Strategies ......................................................................................... 2 Table of Contents .......................................................................................................................................................... 3 You Know You're a Psychiatric Nurse When.................................................................................................................. 4 Drugs of Abuse and ....................................................................................................................................................... 6 Acute Effects/Health Risks ............................................................................................................................................. 6 History of Drug Abuse.................................................................................................................................................. 10 Causes of Drug Abuse .................................................................................................................................................. 11 Common Causes of Drug Abuse: .............................................................................................................................12 Signs of Drug Abuse ..................................................................................................................................................... 13 Drug Abuse Treatment ................................................................................................................................................ 13 Principles of Drug Addiction Treatment ...................................................................................................................... 14 Types of drugs ............................................................................................................................................................. 17 Alcohol Abuse ..........................................................................................................................................................17 Legal Drugs ..............................................................................................................................................................18 Recreational Drugs ..................................................................................................................................................18 Club Drugs ...............................................................................................................................................................19 Illicit Drugs ...............................................................................................................................................................19 Prescription Drug Abuse..........................................................................................................................................19 Marijuana Abuse .....................................................................................................................................................21 Methamphetamine Abuse ......................................................................................................................................22 Heroin Abuse ...........................................................................................................................................................23

Cocaine Abuse .........................................................................................................................................................26 Laboratory Testing ....................................................................................................................................................... 27

Chapter:

Ecstasy Abuse ..........................................................................................................................................................25

3


Drugs of Abuse and Assessment Strategies

2011

Confirmation of Positive Drug Screens....................................................................................................................29 Sample Collection ....................................................................................................................................................29 Drug Classes ............................................................................................................................................................29 Amphetamines: ...................................................................................................................................................29 Barbiturates: .......................................................................................................................................................30 Cocaine: ..............................................................................................................................................................30 Opiates: ...............................................................................................................................................................31 Benzodiazepines: ................................................................................................................................................31 Phencyclidine: .....................................................................................................................................................31 Cannabinoids: .....................................................................................................................................................32 DIAGNOSTIC STUDIES .................................................................................................................................................. 33 Pre-Screening: .........................................................................................................................................................33 Alcohol Use Disorder Identification Test (AUDIT) ...............................................................................................33 DAST (Drug Abuse Screening Test) .....................................................................................................................35 Fagerstrom Test Nicotine Dependence ..............................................................................................................36 MAST (Short Michigan Alcohol Screening Test) ..................................................................................................37 Addiction Severity Index (ASI) Assessment Tool: ................................................................................................37 DSM-IV Criteria for Substance Use Disorders .........................................................................................................37 Substance Abuse .................................................................................................................................................37 Substance Dependence ......................................................................................................................................38 Substance Use History and Physical Examination ....................................................................................................... 38 Nursing Diagnosis with Interventions .......................................................................................................................... 45 Overdoses and Withdrawal Syndromes ..................................................................................................................45 Recovery ..................................................................................................................................................................45 Suicide .....................................................................................................................................................................45 Nursing Priorities for IN-HOSPITAL Care...................................................................................................................... 45 Discharge Goals ........................................................................................................................................................... 45

Chapter:

References ................................................................................................................................................................... 47

4


Drugs of Abuse and Assessment Strategies

2011

You Know You're a Psychiatric Nurse When... (American Psychiatric Nurses Association, 2011)

...you are moved to tears and inspired by a patient's resilience and insight. ...you are not afraid to talk to the client/patient that the non-psych nurses are afraid to talk to. ...other nurses say, "I could never do that." ...you can do a suicide assessment on the med/surg floor without batting an eyelash. ...holistic and integrated practice becomes 'second nature'...like breathing out and breathing in! ...you reach in your pocket for keys when you are opening doors at home‌ ...your spouse formulates psychiatric diagnoses for strangers in restaurants. ...your young son, in response to your telling him something he did "made mommy mad" states "but mommy, I can't MAKE you mad. Only you can control your feelings. If you are mad it's because you choose to be!" Oh my....and it's a true story. ...you never give up on the repeat admissions because you believe in miracles.

...you listen a lot more than you speak, but your words can change the direction of someone else's life. ...your husband uses the phrase 'acting out' to describe the cats' behavior! ...you start diagnosing your pet dogs based on their behavior. ...you wish you could order Ativan as a pizza topping. ...you see a disheveled person talking to himself and you think-aww-there goes one of my peeps. ...you see a pair of scissors on a counter top in a public place and wonder why in the world they would leave them out for ANYONE to grab! ...you can use the word "milieu" several times in one day.

Chapter: You Know You're a Psychiatric Nurse When...

...you care enough to give your very best.

5


Drugs of Abuse and Assessment Strategies

2011

Drugs of Abuse and

Chapter: Drugs of Abuse and

Acute Effects/Health Risks

6


Drugs of Abuse and Assessment Strategies

Substances: Examples of Commercial Category and Name and Street Names

2011

DEA Schedule*/ How Administered**

Acute Effects/Health Risks

Tobacco Nicotine

Found in cigarettes, cigars, bidis, and smokeless tobacco (snuff, spit tobacco, chew)

Not scheduled/smoked, snorted, chewed

Increased blood pressure, and heart rate/chronic lung disease; cardiovascular disease; stroke; cancers of the mouth, pharynx, larynx, esophagus, stomach, pancreas, cervix, kidney, bladder, and acute myeloid leukemia; adverse pregnancy outcomes; addiction

Found in liquor, beer, and wine

Not scheduled/swallowed In low doses, euphoria, mild stimulation, relaxation, lowered inhibitions; in higher doses, drowsiness, slurred speech, nausea, emotional volatility, loss of coordination, visual distortions, impaired memory, sexual dysfunction, loss of consciousness/increased risk of injuries, violence, fetal damage (in pregnant women); depression; neurologic deficits; hypertension; liver and heart disease; addiction; fatal overdose

marijuana

Blunt, dope, ganja, grass, herb, joint, bud, Mary Jane, pot, reefer, green, trees, smoke, sinsemilla, skunk, weed

I/smoked, swallowed

hashish

Boom, gangster, hash, hash oil, hemp

I/smoked, swallowed

Heroin

Diacetylmorphine: smack, horse, brown sugar, dope, H, junk, skag, skunk, white horse, China white; cheese (with OTC cold medicine and antihistamine)

I/injected, smoked, snorted

Opium

Laudanum, paregoric: big O, black stuff, block, gum, hop

II, III, V/swallowed, smoked

Alcohol Alcohol (ethyl alcohol)

Cannabinoids Euphoria; relaxation; slowed reaction time; distorted sensory perception; impaired balance and coordination; increased heart rate and appetite; impaired learning, memory; anxiety; panic attacks; psychosis/cough, frequent respiratory infections; possible mental health decline; addiction

Stimulants

Euphoria; drowsiness; impaired coordination; dizziness; confusion; nausea; sedation; feeling of heaviness in the body; slowed or arrested breathing/constipation; endocarditis; hepatitis; HIV; addiction; fatal overdose

Chapter: Acute Effects/Health Risks

Opioids

7


Drugs of Abuse and Assessment Strategies

2011

Cocaine

Cocaine hydrochloride: blow, II/snorted, smoked, bump, C, candy, Charlie, injected coke, crack, flake, rock, snow, toot

Amphetamine

Biphetamine, Dexedrine: bennies, black beauties, crosses, hearts, LA turnaround, speed, truck drivers, uppers

Methamphetamine Desoxyn: meth, ice, crank, chalk, crystal, fire, glass, go fast, speed

II/swallowed, snorted, smoked, injected

Increased heart rate, blood pressure, body temperature, metabolism; feelings of exhilaration; increased energy, mental alertness; tremors; reduced appetite; irritability; anxiety; panic; paranoia; violent behavior; psychosis/weight loss, insomnia; cardiac or cardiovascular complications; stroke; seizures; addiction Also, for cocaine—nasal damage from snorting Also, for methamphetamine—severe dental problems

II/swallowed, snorted, smoked, injected

Club Drugs MDMA Ecstasy, Adam, clarity, Eve, (methylenedioxylover's speed, peace, uppers methamphetamine) Flunitrazepam***

GHB***

I/swallowed, snorted, injected

Rohypnol: forget-me pill, IV/swallowed, snorted Mexican Valium, R2, roach, Roche, roofies, roofinol, rope, rophies Gammahydroxybutyrate: G, Georgia home boy, grievous bodily harm, liquid ecstasy, soap, scoop, goop, liquid X

I/swallowed

Ketamine

Ketalar SV: cat Valium, K, Special K, vitamin K

III/injected, snorted, smoked

PCP and analogs

Phencyclidine: angel dust, boat, hog, love boat, peace pill

I, II/swallowed, smoked, injected

Salvia divinorum

Salvia, Shepherdess’s Herb, Maria Pastora, magic mint, Sally-D

Not scheduled/chewed, swallowed, smoked

MDMA—mild hallucinogenic effects; increased tactile sensitivity; empathic feelings; lowered inhibition; anxiety; chills; sweating; teeth clenching; muscle cramping/sleep disturbances; depression; impaired memory; hyperthermia; addiction Flunitrazepam—sedation; muscle relaxation; confusion; memory loss; dizziness; impaired coordination/addiction GHB—drowsiness; nausea; headache; disorientation; loss of coordination; memory loss/unconsciousness; seizures; coma

Dextromethorphan

Found in some cough and cold medications:

Feelings of being separate from one’s body and environment; impaired motor function/anxiety; tremors; numbness; memory loss; nausea Also, for ketamine—analgesia; impaired memory; delirium; respiratory depression and arrest; death Also, for PCP and analogs—analgesia; psychosis; aggression; violence; slurred speech; loss of coordination; hallucinations

Also, for DXM—euphoria; slurred speech; confusion; Not scheduled/swallowed dizziness; distorted visual perceptions

Chapter: Acute Effects/Health Risks

Dissociative Drugs

8


Drugs of Abuse and Assessment Strategies

(DXM)

2011

Robotripping, Robo, Triple C

Hallucinogens LSD

Lysergic acid diethylamide: I/swallowed, absorbed acid, blotter, cubes, microdot through mouth tissues yellow sunshine, blue heaven

Mescaline

Buttons, cactus, mesc, peyote I/swallowed, smoked

Psilocybin

Magic mushrooms, purple passion, shrooms, little smoke

I/swallowed

Altered states of perception and feeling; hallucinations; nausea Also, LSD and mescaline—increased body temperature, heart rate, blood pressure; loss of appetite; sweating; sleeplessness; numbness, dizziness, weakness, tremors; impulsive behavior; rapid shifts in emotion Also, for LSD—Flashbacks, Hallucinogen Persisting Perception Disorder Also for psilocybin—nervousness; paranoia; panic

Other Compounds Anabolic steroids

Anadrol, Oxandrin, Durabolin, III/injected, swallowed, Depoapplied to skin Testosterone, Equipoise: roids, juice, gym candy, pumpers

Inhalants

Solvents (paint thinners, gasoline, glues); gases (butane, propane, aerosol propellants, nitrous oxide); nitrites (isoamyl, isobutyl, cyclohexyl): laughing gas, poppers, snappers, whippets

Not scheduled/inhaled through nose or mouth

Steroids—no intoxication effects/hypertension; blood clotting and cholesterol changes; liver cysts; hostility and aggression; acne; in adolescents—premature stoppage of growth; in males—prostate cancer, reduced sperm production, shrunken testicles, breast enlargement; in females—menstrual irregularities, development of beard and other masculine characteristics Inhalants (varies by chemical)—stimulation; loss of inhibition; headache; nausea or vomiting; slurred speech; loss of motor coordination; wheezing/cramps; muscle weakness; depression; memory impairment; damage to cardiovascular and nervous systems; unconsciousness; sudden death

CNS Depressants Stimulants

For more information on prescription medications, please visit http://www.nida.nih.gov/DrugPages/PrescripDrugsChart.html

Opioid Pain Relievers * Schedule I and II drugs have a high potential for abuse. They require greater storage security and have a quota on manufacturing, among other restrictions. Schedule I drugs are available for research only and have no approved medical use; Schedule II drugs are available only by prescription (non-refillable) and require a form for ordering. Schedule III and IV drugs are available by prescription, may

Chapter: Acute Effects/Health Risks

Prescription Medications

9


Drugs of Abuse and Assessment Strategies

2011

have five refills in 6 months, and may be ordered orally. Some Schedule V drugs are available over the counter. ** Some of the health risks are directly related to the route of drug administration. For example, injection drug use can increase the risk of infection through needle contamination with staphylococci, HIV, hepatitis, and other organisms. *** Associated with sexual assaults.

History of Drug Abuse Drug abuse in one form or another has existed since history has been documented. People have used one type of drug or another for thousands of years. For example, wine was used at least from the time of the early Egyptians; narcotics from 4000 B.C.; and marijuana use has been dated to 2737 BC in China. It was not until the 19th century that the active substances in drugs were extracted. What followed was an onslaught of newly discovered drugs such as morphine, laudanum, and cocaine. These drugs were unregulated and prescribed freely by doctors for a wide variety of problems. They were also available through patent medicines which were sold by traveling salesmen, drugstores, and mail order catalogs. At the time of the American Civil War, the use of morphine was common. The wounded veterans would return home with their kits of morphine and hypodermic needles. It was estimated in the early 1900's there were 250,000 drug abusers in the United States alone.

During the 1930's, many states made it a requirement that anti-drug education be taught in schools. However, fears that knowledge about drugs would cause the students to experiment ceased drug prevention education in most places. After the repeal of Prohibition, the Drug Enforcement Administration started a campaign to portray cannabis as a powerful and addicting drug. The idea behind this campaign was to prevent people from using marijuana because it can lead to the abuse of harder drugs. Over time, the United State's general perception of the dangers of specific drugs has changed. Eventually, tobacco had a warning label on it informing the consumer about the danger or cancer and emphysema. A warning label was also placed on Alcohol regarding the dangers of fetal alcohol syndrome. Drug laws have tried to keep up with the ever changing opinions and real dangers of drug abuse. The Anti-Drug Abuse Acts of 1986 and 1988 increased funding for drug treatment and drug rehabilitation; the 1988 act created the Office of National Drug Control Policy. Its director, often referred to as the drug czar, is responsible for coordinating national drug control policy.

Chapter: History of Drug Abuse

The problems of drug abuse were not recognized at first but actually surfaced gradually. The first legal measures against drug dependence in the United States were in 1875. It was at this point that opium dens in San Francisco, California were outlawed. In 1906, the first national drug law was passed, the Pure Food and Drug Act. This law required accurate labeling of all patent medicines which contained opium and other drugs. Following the Pure Food and Drug Act was the Harrison Narcotic Act in 1914. This forbade the sale of opiates or cocaine except by licensed doctors and pharmacies. Eventually, heroin was banned in the United States and additional Supreme Court decisions made it illegal for doctors to prescribe any type of narcotic to addicted individuals. There were doctors who continued to prescribe "maintenance" doses to addicted individuals as part of a "treatment". They were arrested and put in jail. After that, all attempts at treatment for drug abusers were abandoned until the twentieth century. In 1919 the spirit of the temperance movement led to the prohibition of alcohol and was added to the Constitution as the Eighteenth Amendment; however it was repealed in 1933.

10


Drugs of Abuse and Assessment Strategies

2011

These days, drug abuse is defined as the chronic or habitual use of any chemical substance to alter states of body or mind for other than medically warranted purposes. The definition of substance misuse continues to change because the term is subjective and infused with the political and moral values of the society or culture one lives in. An example of this is the drug caffeine. It is physically addicting but is not considered an abused drug because it does not generally trigger antisocial behavior in users. Drug abuse is a problem which has an effect on people of all income levels, ages, and stations in life. Quite often the last person to see that there is a problem is the drug abuser them self. Every year, more and more people become drug addicts in their pursuit to get "high". In a 1992 study done by The Lewin Group for the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism, findings showed that $97.7 billion was spent on drug abuse alone in the United States. In another study done by The White House Office of National Drug Control Policy (ONDCP) findings showed that between 1988 and 1995, Americans spent $57.3 billion on illegal drugs. The breakdown of these findings is as follows: $38 billion on cocaine, $9.6 billion on heroin, $7 billion on marijuana, and $2.7 billion on other illegal drugs and on the misuse of legal drugs. If you are concerned about yourself or someone you love having a problem with substance miss-use consider these questions. Does the drug user take larger amounts of the drug over longer periods of time than intended? Do they have a persistent desire or one or more unsuccessful efforts to cut down or control their substance use? Is a great deal of time spent in activities necessary to get the substance, taking the substance, or recovering from its effects? Do they continue to use despite knowledge of having a persistent or recurrent social, psychological, or physical problem that is caused or exacerbated by use of the substance? The content of these questions are representative of a drug abuser. For those who have a problem with drugs, there is help. Drug abuse is not a way of life; it is just a means of getting by.

Causes of Drug Abuse

When it comes to the causes of drug abuse, it is not likely that anyone begins using a drug with the intention of becoming addicted. Experimentation and curiosity are the first factors that draw many to even try drugs. They want to feel that “high,” the sense of euphoria that comes with drug use. Additionally, drug abuse and addiction often results in painful withdrawal symptoms when drug use is stopped suddenly. This frequently provides drug users with another reason to continue their destructive drug behavior.

The medical causes of drug abuse are not fully understood. Researchers can only state with assurance that the repeated use of addictive drugs can bring about dramatic changes in both the structure and the function of the brain in destructive ways that can result in compulsive drug abuse. Another one of the causes of drug abuse is the effect of drugs on the user. By stimulating the internal reward system in the user’s brain, drugs and alcohol

Chapter: Causes of Drug Abuse

There are numerous causes of drug abuse. However, several key areas can be pinpointed. Drugs and alcohol kill the pain of ordinary life; they destroy the physical and emotional pain by changing an addict’s perception on life. Drugs and alcohol make the user become numb to the pain, unhappiness, or hopelessness that is a part of their lives. A person may abuse drugs such as alcohol, prescription drugs, inhalants, or other street drugs (cocaine, heroin, methamphetamines, etc.). Understanding one’s initial causes of drug abuse can help stop future users from becoming addicts.

11


Drugs of Abuse and Assessment Strategies

2011

make the addict crave the drug to again stimulate this reward center. These cravings lead the addict to stop focusing on those things that used to be important, and begin focusing on another dose of their drug or alcohol.

Common Causes of Drug Abuse: Advertising or media influence As a novelty As a relief from fatigue or boredom Childhood loss or trauma Curiosity Early initiation Easy access Emotional distress Family history, genetic predisposition Low self-esteem No interest in conventional goals Patterns of use in the addict's family or subculture Peer pressure Poor control Poor stress management Preexisting psychiatric or personality disorder, or a medical disorder Psychological distress Reinforcing effects of drugs Sensation seeking. (Feeling high) Social rebelliousness To escape reality Withdrawal effects and craving

Drug abuse can lead to drug dependence or addiction. Drug dependence may also follow the use of drugs for physical pain relief, though this is rare in people without a previous history of addiction. Another cause of drug abuse is peer pressure. However, at least half of those who go on to addiction have depression, attention-deficit disorder, post-traumatic stress disorder or another psychological problem. Children who grow up in an environment of illicit drug use may first see their parents using drugs. This may be another cause of drug abuse by putting them at a higher risk for developing an addiction later in life for both environmental and genetic reasons. Lastly, easy accessibility to drugs and lower prices are additional causes of drug abuse. Drugs can be found anywhere if a person simply asks. Street corners and alleyways are no longer the only place to find drugs. Schools, workplaces, and even the family next door might be new places to find drugs. With more drugs being produced, the price has also been driven down.

Chapter: Causes of Drug Abuse

                     

12


Drugs of Abuse and Assessment Strategies

2011

Signs of Drug Abuse There are no hard and fast rules when it comes to spotting the signs of drug abuse. The main thing to look for is changes in behavior, attitude, appearance, friends, or activities. People who are having problems with drug abuse are often trying to self-medicate or find escape from the issues that are really bothering them. In all instances of drug abuse, watch for a tendency on the part of the abuser to refrain and shun conversation and face-to-face meetings with others. You are watching for behavior that represents a somewhat dramatic change in character from previous experience. The person using the drugs will almost always try to explain away or justify the signs of drug abuse. Although every individual is different, the following represent some of the most common signs of drug abuse: Performance. This can either be at school or work - or in some other way. Are the person's grades suddenly dropping? Is the quality of work assignments becoming progressively worse? Does the person's performance in sports or music suffer? When someone suddenly becomes worse at something he or she is good at, this can be one of the signs of drug abuse. Additionally, someone abusing drugs may stop showing up on time - or at all. Personal care. This is a sign common to many drug abuse problems. When a person is abusing drugs, he or she may not take good care of him or herself. You may notice that personal hygiene, such as regular showers and changing one's clothing regularly, is no longer important. Someone who is involved in drug abuse may no longer care about fixing his or her hair, or performing other grooming tasks. Tendency toward recklessness. Someone abusing drugs often does not care about the natural consequences of his or her actions. He or she may do reckless things, such as steal to get money for more drugs - or even engage in other dangerous behaviors. Natural consequences of their choices are no longer important to abusing drugs.

Lack of money. An addict can spend money very quickly when drug abuse is involved. So, when a person is abusing drugs they will begin to run short of money and justify excuses to why their finances have diminished. Signs of this include having to borrow money from friends and family for food or gas. Coming up short for rent, bills, etc and also getting caught stealing money from friends and family.

Drug Abuse Treatment Drug Abuse is a learned behavior. Drug abuse treatment is the unlearning of this behavior so that living life clean and sober becomes natural and long lasting. Drug abuse treatment is a multi-step process; it means getting stable as well as staying stable in one’s life long after treatment. Individuals who are recovering from drug abuse first need to realize that they have a problem and are willing to work towards a solution.

Chapter: Signs of Drug Abuse

Withdrawal from friends, family and activities. Another sign of drug abuse is withdrawal from normal activities. New, more dangerous friends can indicate a drug abuse problem. Additionally, someone involved with drug abuse may also become more secretive, desiring to be left alone by family members. Drug abusers also may begin withdrawing from enjoyed activities, such as going out with friends or participating in clubs and organizations.

13


Drugs of Abuse and Assessment Strategies

2011

Drug abuse is a complex problem involving biological changes in the brain as well as a myriad of social, familial, and environmental factors. Therefore, drug abuse treatment is complex, and must address a variety of problems. Drug abuse treatment strategies should address the physical, psychological, emotional, social and behavioral aspects of the individual's drug abuse problem. There is more to drug abuse treatment than just ending drug use and abuse. Drug abuse treatment also helps to restore the individual to their pre-drug using days and guides them to become a productive and functioning part of their family, workplace, and community. Through drug abuse treatment, individuals begin to gain control of their thought processes, and slowly the obsession to use drugs or return to old ways of life will dissipate. While in drug abuse treatment, clients will examine harmful beliefs and destructive patterns of behavior as well as adopt new life skills, coping skills and constructive ways to interact with others. The length of time an individual needs to stay in drug abuse treatment varies and depends on the drug of abuse, length of abuse, degree of addiction, history of prior treatment, and history of relapse. However, research has clearly shown that the most effective drug abuse treatment programs are based on an adequate amount of time in the recovery program. Unfortunately, many individuals who enter into drug abuse treatment drop out before achieving all the benefits that the treatment program has to offer. Those who stay in drug abuse treatment longer than 3 months will have better outcomes than those who stay a shorter amount of time.

When choosing a drug abuse treatment program, the first thing to decide is whether the individual requires treatment as a resident or as an outpatient. Residential drug abuse treatment is more intense and strict in how the addiction is handled, but it will allow for the best possible care around the clock. Outpatient drug abuse treatment is typically only successful for a person who doesn’t use daily and still has a job, good family life, etc. In other words, drugs haven’t really ruined his life or relationships yet and he just needs some support before things get worse. An individual who is using drugs frequently and not able to control himself or who has experienced consequences as a result of his drug use really has no other option than a residential drug abuse treatment program. There is, and always has been, a huge debate over which drug abuse treatment programs are more successful. Treatments stem from vastly differing philosophies, and it is here that the conflicts are rooted. What is best for one individual may not be good for another, and only by working with a drug abuse treatment specialist will a patient be able to determine how best to tackle the addiction.

Principles of Drug Addiction Treatment More than three decades of scientific research show that treatment can help drug-addicted individuals stop drug use, avoid relapse and successfully recover their lives. Based on this research, 13 fundamental principles that characterize effective drug abuse treatment have been developed. These principles are detailed in NIDA's Principles of Drug Addiction Treatment: A Research-Based Guide. The guide also describes different types of

Chapter: Principles of Drug Addiction Treatment

It is common for many addicts to minimize their drug abuse problem and instinctively want to take the path of least resistance by choosing a minimal drug rehab program with the shortest amount of time involved. It is this way of thinking that most commonly leads to relapse. Keep in mind that gaining happiness and sobriety is a big job and it should last the rest of your life. The individuals who dedicate themselves to their recovery and allow themselves proper time and focus to achieve their sobriety are those who are the most successful in their recovery.

14


Drugs of Abuse and Assessment Strategies

2011

science-based treatments and provides answers to commonly asked questions. 1. Addiction is a complex but treatable disease that affects brain function and behavior. Drugs alter the brain’s structure and how it functions, resulting in changes that persist long after drug use has ceased. This may help explain why abusers are at risk for relapse even after long periods of abstinence. 2. No single treatment is appropriate for everyone. Matching treatment settings, interventions, and services to an individual’s particular problems and needs is critical to his or her ultimate success. 3. Treatment needs to be readily available. Because drug-addicted individuals may be uncertain about entering treatment, taking advantage of available services the moment people are ready for treatment is critical. Potential patients can be lost if treatment is not immediately available or readily accessible. 4. Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. To be effective, treatment must address the individual's drug abuse and any associated medical, psychological, social, vocational, and legal problems. 5. Remaining in treatment for an adequate period of time is critical. The appropriate duration for an individual depends on the type and degree of his or her problems and needs. Research indicates that most addicted individuals need at least 3 months in treatment to significantly reduce or stop their drug use and that the best outcomes occur with longer durations of treatment.

7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. For example methadone and buprenorphine are effective in helping individuals addicted to heroin or other opioids stabilize their lives and reduce their illicit drug use. Also, for persons addicted to nicotine, a nicotine replacement product (nicotine patches or gum) or an oral medication (buproprion or varenicline), can be an effective component of treatment when part of a comprehensive behavioral treatment program. 8. An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure it meets his or her 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 may require medication, medical services, family therapy, parenting instruction, vocational rehabilitation and/or social and legal services. For many patients, a continuing care approach provides the best results, with treatment intensity varying according to a person’s changing needs. 9. Many drug-addicted individuals also have other mental disorders. Because drug abuse and addiction—both of which are mental disorders—often co-occur with other mental illnesses, patients presenting with one condition should be assessed for the other(s). And when these problems co-occur, treatment should address

Chapter: Principles of Drug Addiction Treatment

6. Counseling—individual and/or group—and other behavioral therapies are the most commonly used forms of drug abuse treatment. Behavioral therapies vary in their focus and may involve addressing a patient’s motivations to change, building skills to resist drug use, replacing drug-using activities with constructive and rewarding activities, improving problem solving skills, and facilitating better interpersonal relationships.

15


Drugs of Abuse and Assessment Strategies

2011

both (or all), including the use of medications as appropriate. 10. Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. Although medically assisted detoxification can safely manage the acute physical symptoms of withdrawal, detoxification alone is rarely sufficient to help addicted individuals achieve long-term abstinence. Thus, patients should be encouraged to continue drug treatment following detoxification. 11. Treatment does not need to be voluntary to be effective. Sanctions or enticements from family, employment setting, and/or criminal justice system can significantly increase treatment entry, retention rates, and the ultimate success of drug treatment interventions. 12. Drug use during treatment must be monitored continuously, as lapses during treatment do occur. Knowing their drug use is being monitored can be a powerful incentive for patients and can help them withstand urges to use drugs. Monitoring also provides an early indication of a return to drug use, signaling a possible need to adjust an individual’s treatment plan to better meet his or her needs.

Figure 1: Harm Caused by Drugs

Chapter: Principles of Drug Addiction Treatment

13. Treatment programs should assess patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases, as well as provide targeted risk-reduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading infectious diseases. Targeted counseling specifically focused on reducing infectious disease risk can help patients further reduce or avoid substance-related and other high-risk behaviors. Treatment providers should encourage and support HIV screening and inform patients that highly active antiretroviral therapy (HAART) has proven effective in combating HIV, including among drugabusing populations. Retrieved from: http://www.drugabuse.gov/DrugPages/DrugsofAbuse.html

16


Drugs of Abuse and Assessment Strategies

2011

Types of drugs There are many different types of drugs. Different drugs have different effects. It's impossible to accurately predict the effects of any drug. The effects depend on the drug and the quantity taken, the mental and physical health of the user, and their mood and expectations at the time of use. Where the person is and who they're with at the time also plays a role. However, some drugs work in similar ways and can be divided into broad categories: stimulants, depressants, hallucinogens, and analgesics. Stimulants are drugs which act on the central nervous system and increase brain activity. (i.e. cocaine, speed, poppers, anabolic steroids, ecstasy, and tobacco). Depressants are drugs which act on the central nervous system and slow down brain activity. (i.e. alcohol, tranquilizers, gases, aerosols, and glue). Hallucinogen drugs act on the mind, distorting the way users see and hear things. (i.e. LSD, magic mushrooms, marijuana, and ketamine). Analgesics are drugs which have a painkilling effect and can also bring on feelings of warmth and contentment. (i.e. heroin, morphine, opium). Even though there are numerous types of drugs hard or soft, uppers or downers, addictive or non-addictive, most harmful or least harmful, legal or illegal, they all have one thing in common. They are drugs and can be dangerous if taken improperly or for some if taken at all.

Alcohol Abuse Alcohol Abuse is a major social, economic, and public health problem. Alcohol abuse is described as the consumption and preoccupation with alcoholic beverages to the extent that this behavior interferes with the alcoholic’s normal personal, family, social, or work life, etc.. These problems can range from mild to severe. Alcohol abuse is involved in more than half of all accidental deaths and almost half of all traffic deaths. A high percentage of suicides involve the use of alcohol along with other substances. The severity of an alcohol abuse problem depends on factors including the type of alcohol you drink, how much you drink, and how long you have been drinking. Alcohol abuse is sometimes referred to as alcoholism.

Alcohol abuse can be deadly. It kills friendships, marriages, families and communities. No one associated with the alcoholic goes unscathed. Alcohol abuse can develop very quickly or happen gradually over years. In the beginning, your drinking might not seem to be any different from the way other people drink. You may drink only with friends or at parties. It may stay like this, or you may begin to drink more. Your drinking might become a way for you to feel normal or to cope with life's problems. You might think that you can quit drinking at any time. Many people who have alcohol abuse problems quit for days, weeks, or even months before they start drinking again. But unless you can consistently

Chapter: Types of drugs

Every year, more money is spent promoting the use of alcohol than any other product. Perhaps through its elaborate and creative marketing, the most basic, yet important fact about alcohol is often overlooked alcohol is a drug the most commonly used and widely abused psychoactive drug in the world. Alcohol is consumed more frequently than all other illicit drugs combined and is the drug most likely associated with injury or death. In 2007, Americans consumed approximately 7.7 billion gallons of alcoholic beverages and approximately 14 million people in the United States suffer from alcohol abuse, that's 1 in every 13 adults according to the NIAAA.

17


Drugs of Abuse and Assessment Strategies

2011

keep your drinking under control and not fall back into unhealthy patterns, you have an alcohol abuse problem. When those suffering with alcohol abuse are asked why they continue to drink excessively, they will occasionally attribute their drinking to a particular mood such as depression or anxiety or to situational problems. Many times they simply describe an overpowering “need” to drink, variously described as a craving or compulsion. Just as often, however, the alcohol abuser is unable to give any plausible explanation for his or her excessive drinking. Drinking relieves guilt and anxiety; however, it then also produces anxiety and depression. The symptoms associated with depression and anxiety conditions, such as terminal insomnia, low mood, irritability, and anxiety attacks with chest pain, palpitations, and dyspnea often occur. Alcohol seems to relieve these symptoms, resulting in a vicious cycle of drinking followed by depression followed by drinking that ultimately leads to alcohol dependence accompanied by withdrawal syndrome. Sometimes the patient succeeds in stopping drinking for several days or weeks only to “fall off the wagon” again. Despair and hopelessness are common with alcohol abuse and for many it is difficult to imagine a life without alcohol. When alcohol abuse becomes a dominating force in someone's life, it's time to get help. Alcohol abuse treatment is designed to help individuals regain control of their life by helping them to eliminate their dependency on alcohol. A combination of educational life repair therapy and social programs can be very beneficial to individuals experiencing alcohol abuse problems. In addition, alcohol abuse treatment often incorporates alcohol detoxification followed by comprehensive alcohol abuse recovery therapies.

Legal Drugs Across America, there is a continual a rise in the misuse of legal drugs. People are taking others medications, buying them off the street, and purchasing them online. It has been estimated that 9 million people use prescription drugs for non-medical purposes. Internet sales of legal drugs is one of the key factors for this spike in prescription drug use. An example of this is the spam e-mail that many of us receive on a daily basis, offering any drug you "need" by having their online doctor provide you with a prescription on the spot. One online pharmacy sold 9.3 million doses of the generic versions of Valium and Vicodin in 18 months. These types of sites are leading to a national epidemic of abuse.

Recreational Drugs Recreational drugs can be either legal or illegal drugs. The term applies to the use of mind-altering substances for the purpose of altering one's mental state, typically without the supervision of a physician. The majority of human societies throughout history have practiced recreational drug use in various forms. Probably the best known example of a recreational drug is alcohol, which most cultures have manufactured in one form or another. As with any drugs, some recreational drugs are addictive, some are harmful to one's health, and some are illegal in most places.

Chapter: Types of drugs

Many Americans and misled into thinking that because it is a prescription drug it is not harmful. This is not the case however. "There's an assumption that these are legal, so they're OK — that they can use them and walk away without any consequences," says H. Westley Clark, director of SAMHSA's Center for Substance Abuse Treatment (CSAT). "They don't seem to realize that this misuse can lead to serious problems with addiction." Even though prescription drugs are legal, they are still drugs. Legal drugs now play a factor in a quarter of all overdose deaths reported in the United States.

18


Drugs of Abuse and Assessment Strategies

2011

The most popular recreational drugs worldwide are caffeine, alcohol (ethanol), nicotine, and cannabis (see also hashish and hash oil). Other substances commonly considered recreational drugs include: 2C-B, Meth, Benzodiazepines, Cocaine (and crack cocaine), DXM, Ecstasy, GHB, Ketamine, LSD, Mescaline (Peyote), Nitrous Oxide, Opiates (including heroin, opium, and various painkiller drugs), PCP, and Psilocybin (Magic Mushrooms).

Club Drugs Club drugs such as Ecstasy, GHB, LSD, and Ketamine are used at "raves" and dance clubs. These types of drugs are used to "enhance the club going experience". Unfortunately, many users are not aware how dangerous they can be. Taking these types of drugs can cause serious health problems and in some severe cases even cause death. When they are used in addition to alcohol they become even more toxic. Alcohol can increase the club drugs effects to dangerous levels, dehydrate the user even more than if they had only taken the the illegal drug, and combine to create dangerous concoctions in the users body. Club drugs often produce unwanted side effects that the user is not prepared for. These side effects include hallucinations, paranoia, amnesia, dehydration, and in extreme cases even death. In addition to these side effects, the user never truly knows how they will react to the drug they have taken until they have already taken it. Ecstasy for example, is often created with a variety of different substances. One experience with a type of ecstasy may go as planed but the second experience may be extremely different because the drug was created using different substances. Studies have shown that club drugs found at parities are often impure, making them even more dangerous. One never knows what they are going to get when it comes to these types of drugs.

Illicit Drugs

New estimates show, once again, that the most widely abused illicit drug worldwide is marijuana (around 160 million people). The break down of other illicit drugs that are being used is as follows: amphetamine-type stimulants such as meth (34 million people abusing amphetamines, notably Methamphetamine and amphetamine, and 8 million abusing ecstasy). The number of opiate and cocaine abusers are approximately the same (cocaine: more than 14 million people and opiates less than 15 million people, of whom close to 10 million are taking heroin). The total number of drug abusers is estimated at some 200 million people, equivalent to 3.4% of the global population or 4.7% of the population a

Prescription Drug Abuse Prescription drug abuse is not about bad drugs or even bad people. It involves a complex web of factors, including the power of drug abuse, drug addiction, and often the difficulty both patients and doctors

Chapter: Types of drugs

Illicit drugs are controlled substances that have a high potential for abuse. They currently have no accepted medical use in the United States. Controlled substances fall under seven headings: marijuana (marijuana, hashish); stimulants (amphetamines, cocaine); depressants (barbiturates, tranquilizers, hypnotics); hallucinogens (acid, PCP); opiates or narcotics (heroin, morphine, opium, codeine); inhalants (sprays, solvents, glue); and designer drugs (synthetic drugs similar in effect to stimulants, hallucinogens, and narcotics).

19


Drugs of Abuse and Assessment Strategies

2011

have discussing the topic. A recent survey by the National Institute on Drug Abuse at Columbia University indicated that approximately 50% of primary care physicians have difficulty speaking with their patients about substance abuse. There is also the delicate balance of curbing criminal activity related to prescription drug abuse while making sure that people with legitimate health needs can still access care, says Alan I. Leshner, Ph.D., director of NIDA. "We recognize the very real issue that millions of lives are improved because of prescription drugs--the same drugs that are sometimes abused," he says. Most patients take medicine responsibly, but approximately 9 million Americans used prescription drugs for non-medical purposes in 1999, according to the National Institute on Drug Abuse (NIDA). Nonmedical purposes include misusing prescription drugs for recreation and for psychic effects--to get high, to have fun, to get a lift, or to calm down. Prescription drug abuse is no different from alcoholism or an addiction to any other substance. However, no one is prescribed alcohol or cocaine for medical reasons. People who suffer from chronic pain are in a very difficult position. Painkillers do relieve pain. For people who suffer from constant and chronic pain, narcotics may be necessary to allow them to have any quality of life. The downside is becoming physically dependent and risking the possibility of addiction. The most common prescription drug abuse substances are opioids and benzodiazepines. Opioids are generally used to control pain. Benzodiazepines, or tranquilizers, are used to manage anxiety. These drugs are prescribed for short-term use such as acute pain and anxiety that is in reaction to a specific event. They may also be prescribed for chronic pain or generalized anxiety. Pharmacists can play a key role in preventing prescription drug abuse by providing clear information and advice about how to take a medication appropriately, about the effects the medication may have, and about any possible drug interactions. Pharmacists can help prevent prescription fraud or diversion by looking for false or altered prescription forms. Many pharmacies have developed "hotlines" to alert other pharmacies in the region when a fraud is detected. You may be concerned about your child, your spouse, your partner, your parent(s), your brother or sister, a friend, a work colleague, or even yourself. If you are looking for prescription drug abuse help for someone you care about here are some key points to keep in mind.

You cannot control the individual's actions. Only they can control their actions. They ultimately have to make the decision to get help for their prescription drug abuse problems. The very thought of not using may make some individuals frightened or scared. They may have abused one prescription drug or another for such a long period of time that it feels to them being intoxicated is natural. Or, they may fear withdrawal which sometimes can be quite painful.

Chapter: Types of drugs

You can offer your help and support. You can show that you care about them.

20


Drugs of Abuse and Assessment Strategies

2011

Only very powerful motivation can help an addict decide to end their abuse. This motivation comes about when the consequences of using become even more painful than not using. Years of research have shown us that addiction to both prescription drugs and illegal drugs are the same when it comes to treatment and recovery. However, no single type of treatment is appropriate for all individuals who have prescription drug abuse problems. Treatment must take into account the type of drug used and the needs of the individual. The two main categories of prescription drug abuse and addiction treatment are behavioral and pharmacological. Behavioral treatments teach people how to function without drugs, how to handle cravings, how to avoid drugs and situations that could lead to drug use, how to prevent relapse, and how to handle relapse should it occur. When delivered effectively, behavioral treatments - such as individual counseling, group or family counseling, contingency management, and cognitive-behavioral therapies - also can help patients improve their personal relationships and ability to function at work and in the community.

Marijuana Abuse Marijuana is the most commonly abused illicit drug in the United States. The latest treatment data indicate that in 2006 marijuana was responsible for about 16 percent (289,988) of all admissions to treatment facilities in the United States. Marijuana treatment admissions were primarily male (73.8 percent), White (51.5 percent), and young (36.1 percent were in the 15-19 age range). Those in treatment for primary marijuana abuse had begun use at an early age: 56.2 percent had abused it by age 14 and 92.5 percent had abused it by age 18. Marijuana abuse is characterized as the continual and habitual use of marijuana. Often the marijuana addict will continually make decisions to quit or cut down use but will quickly relapse due to overwhelming mental and emotional cravings for it. Many people that have developed marijuana abuse problems find that they must be high on marijuana to enjoy themselves and feel normal.

Marijuana use and abuse has been romanticized by writers and musicians, from Louis Armstrong to Bob Dylan, and it has been depicted as harmless or silly in movies like “Harold and Kumar,� however, marijuana is up to five times more potent now than it was in the 1970s, according to the National Institute on Drug Abuse. And this new more-potent marijuana and the growing support for legalization has led to an often angry debate over marijuana abuse. Many public health officials worry that this stronger marijuana has

Chapter: Types of drugs

Over time, marijuana abuse changes an individual in many ways. Changes can be seen socially, emotionally, physically, as well as psychologically. Individuals suffering with marijuana abuse tend to include marijuana as a part of their daily lives and gravitate to others who share their interest in the drug. Daily marijuana users also tend to compulsively seek out and use more marijuana, losing interest in activities or hobbies that once meant a lot to them. Marijuana abuse tends to lead to changes in appearance where he or she may begin to look unkempt or sloppy. Many marijuana abusers feel that every activity should revolve around smoking, obtaining, and getting stoned.

21


Drugs of Abuse and Assessment Strategies

2011

increased marijuana abuse and addiction rates and is potentially more dangerous to teenagers, whose brains are still developing. The truth is that more adults are now admitted to treatment centers for primary marijuana abuse and addiction than for primary addictions to heroin, cocaine and methamphetamine, according to the latest government data, a 2007 report by the Substance Abuse and Mental Health Services Administration. Marijuana abuse effects millions of people’s lives today, however, marijuana's reputation in society is still looked at as trivial and is considered by society as a "soft" drug. Also, because marijuana abuse withdrawal symptoms tend to be less severe than the symptoms of other drugs, this adds to marijuana's rise in social acceptance, however, many are unaware that the emotional and mental issues that come with marijuana abuse can last for more than 45 days. Unfortunately, the deceptive nature of marijuana abuse appears to be more of a diving board for which the unfortunate diver is unable to see the bottom of their marijuana abuse problems. Marijuana abuse and addiction is very deceptive in that most marijuana abusers do not feel that they are addicted at all. The typical attitude of those abusing marijuana is, "I can quit any time. I'm just doing it because it's fun and something to do when I'm board." So they smoke every day, even several times a day, and gravitate towards others who also smoke marijuana and compulsively seek out and use more marijuana and include marijuana as a part of their daily lives. Eventually the addict feels he "needs" marijuana and finds himself not wanting to quit for fear of withdrawal symptoms such as restlessness, loss of appetite, trouble sleeping, weight loss, and depression. Is this not addiction?

Methamphetamine Abuse

Meth abuse is particularly dangerous because of the intense cravings it induces in users, but also for the danger it can cause to bystanders. While a person is high on meth, he feels great, energized, but the initial rush is followed by high agitation, which in many people can lead to violent behavior. Sudden manic swings in mood are one sign of meth abuse. This fixation on getting more of the drug results in the addict stealing from family members, robbing friends, neglecting their job, abusing their spouse, and even wandering off for days or weeks at a time on a 'binge'. The result of this unexplainable behavior is the addict abandons their friends and family, leading to emotional pain for everyone. With chronic meth abuse, tolerance for this dangerous drug 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 bingeing 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. Chronic meth abuse can lead to

Chapter: Types of drugs

Methamphetamine abuse is a widespread problem in America. Fed by the manufacturer and smuggling of meth from Mexico, it began on the West Coast and is spreading inexorably eastward. Meth is a stimulant, so highly addictive that some users get hooked on the first use. Meth abuse is one of the hardest of all addictions to treat, and has a devastating and often permanent effect not only on the user’s body, but on relationships, careers, and emotions. Meth abuse requires a full body detox program plus life counseling and a careful after treatment program for the addict to even have a chance at rehabilitation and a normal life.

22


Drugs of Abuse and Assessment Strategies

2011

psychotic behavior, characterized by intense paranoia, visual and auditory hallucinations, and out-ofcontrol rages that can be coupled with extremely violent behavior. Meth abuse leads to many damaging effects, including addiction. Addiction is characterized by compulsive drug-seeking and drug use which is accompanied by functional and molecular changes in the brain. This drug can be smoked, snorted, injected, or taken orally, and its appearance varies depending on how it is used. Typically, it is a white, odorless, bitter-tasting powder that easily dissolves in water. Because much of the meth in the U.S. is homemade, its color and appearance can vary according to the skill of the chemist and the raw materials used. In addition to becoming addicted to meth, chronic meth abusers exhibit symptoms that can include violent behavior, anxiety, confusion, and insomnia. They also can display a number of psychotic features, including paranoia, auditory hallucinations, mood disturbances, and delusions (for example, the sensation of insects creeping on the skin, called "formication"). This extreme paranoia can result in homicidal as well as suicidal thoughts. The 2007 Monitoring the Future study, conducted by the National Institute on Drug Abuse, measured meth abuse and prevalence among 8th, 10th, and 12th graders, nationwide. The NIDA study recorded a decline in meth abuse over the past several years. Among 12th graders, the annual prevalence (the number of youth who tried meth within the last year) decreased to 1.6 percent-about half of what it was in 2002, and the lowest level reported by the study since 1992. Annual prevalence rates for meth abuse among 8th and 10th graders also declined this year and were 1.1 percent and 1.7 percent, respectively.

Heroin Abuse Heroin abuse is a serious problem in the United States. Recent studies suggest a shift from injecting heroin to snorting or smoking because of increased purity and the misconception that these forms of use will not lead to addiction. What is heroin? Heroin is a highly addictive drug that is processed from morphine, which comes from the seedpod of the opium Asian poppy plant. It is a depressant that inhibits the central nervous system. What does heroin look like? Heroin in its purest form is usually a white powder. Less pure forms have varied colors ranging from white to brown. "Black tar" heroin is dark brown or black and has a tar-like sticky feel to it.

What are the effects of heroin abuse? Users who inject heroin will feel a euphoric surge or 'rush' as it is often called. Their mouths may become dry. They may begin to nod in and out and their arms and legs will feel heavy and rubbery. They may experience a diminished mental capacity and dulled emotions. The effects of heroin abuse last three to four hours after the drug has been administered.

Chapter: Types of drugs

Heroin abuse, how do people ingest the drug and who is abusing it? Heroin can be injected in a user's veins, smoked or snorted. There is no 'cookie-cutter' heroin user. Individuals of all ages and lifestyles have used heroin. According to the DEA approximately 1.2% of the population reported heroin use at least once in their lifetime.

23


Drugs of Abuse and Assessment Strategies

2011

What are the hazards of heroin abuse? There are many health risks to using heroin. The short-term risks include fatal overdose and the high risk of infections such as HIV/AIDS. The long-term user has additional risks such as:       

Abscesses Cellulitis Collapsed veins Infection of the heart lining and valves Liver Disease Overdose Pulmonary complications, including various types of pneumonia

Is heroin addicting? Tolerance to heroin develops with regular use. This means it will take more heroin to produce the same level of intensity to the user. This results in physical addiction to the drug developing over time. What is heroin abuse withdrawal like? When the drug is discontinued, the user will experience physical withdrawal. The withdrawal can begin within a few hours since it was last administered. Heroin abuse withdrawal symptoms include:       

Cold flashes with goose bumps Diarrhea Insomnia Kicking movements Muscle and bone pain Restlessness Vomiting

Major heroin abuse withdrawal symptoms peak between 48 and 72 hours after the last dose and subside after about a week. Sudden withdrawal by heavily dependent users who are in poor health can be fatal.

Heroin Abuse: Drug Purity 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. In addition to the effects of the drug itself, street heroin may have additives that fail to dissolve and result in clogging the blood vessels that lead to the lungs, liver, kidneys or brain. This can cause infection or even death of small patches of cells in vital organs.

Chapter: Types of drugs

Heroin Abuse and Pregnancy: Heroin abuse during pregnancy usually has adverse consequences including low birth weight, an important risk factor for a child's later development.

24


Drugs of Abuse and Assessment Strategies

2011

Ecstasy Abuse Ecstasy abuse first gained popularity among adolescents and young adults in the nightclub scene or weekend long dance parties known as raves. However, the profile of the typical ecstasy user has been changing. Community-level data from NIDA's Community Epidemiology Work Group (CEWG), continued to report that use of ecstasy has spread among populations outside the nightclub scene. Ecstasy, which is really the drug MDMA (3,4-methylenedioxy-N-methylamphetamine also commonly known as X, E, XTC, Adam, etc.) is a semi-synthetic chemical compound. In its pure form, it is a white crystalline powder. It is usually seen in capsule form, in pressed pills, or as loose powder. The average cost of ecstasy ranges from $10-$30 (U.S.) a dose. Common routes of administration of ecstasy are swallowing or snorting, although it can be smoked or injected as well. Currently, ecstasy is on the U.S. Schedule I of controlled substances, and is illegal to manufacture, possess, or sell in the United States. Most other countries have similar laws. Ecstasy abuse can cause many problems for the user. Ecstasy has a physiological effect that is similar to amphetamines and cocaine. As such, studies have concluded that even mild to moderate ecstasy abuse may cause changes in the way the brain produces and distributes nero-transmitters. These are the chemicals, like serotonin and dopamine, known to play a role in regulating mood, memory, appetite, sleep, aggression, sexual activity and sensitivity to pain. This can lead to long-term depression and other mental illness. Studies have shown that the effects of ecstasy abuse on the user’s brain are serotonin related. Serotonin is a chemical in the brain that affects moods, so that after the initial high, the user may feel tired, depressed, or moody. Their body will eventually produce more serotonin, but it may take some time to get it back to normal levels. So, after a weekend of heavy ecstasy abuse, they may have trouble getting up and going to class or work.

Ecstasy is often taken orally. It is almost always swallowed in 100 to 125 mg pills. However, sometimes it is snorted or taken in a liquid form through injection, or shefed (insertion of pill into the anus) where it is absorbed. Sometimes ecstasy is taken deliberately with other controlled substances. A combination of ecstasy and LSD is called a "candy flip." The DAWN report indicates that ecstasy users who are admitted to hospital emergency rooms sometimes also test positive for marijuana, hallucinogens, or stimulants such as cocaine. The strength and contents of ecstasy tablets cannot be known accurately. Sometimes these pills are stamped with symbols (like clover leafs, horseshoes, or smiley faces) as underground brand names or identifying markers. However, these symbols do not mean that a pill is pure or safe. All ecstasy available on the street is produced in unregulated black market laboratories.

Chapter: Types of drugs

Extended use of ecstasy causes difficulty differentiating reality and fantasy and causes problems concentrating. Studies have found that ecstasy abuse destroys certain cells in the brain. While the cells may re-connect after discontinued use of the drug, they don't re-connect normally. Like most drugs, this one impairs memory and can cause paranoia, anxiety, and confusion. In a study in England, ecstasy users had memory impairment on average 2½ years after they stopped taking the drug!

25


Drugs of Abuse and Assessment Strategies

2011

The presence of paraphernalia linked with ecstasy use can also be a warning sign of ecstasy abuse. Items that seem harmless but may be associated with ecstasy use in adolescents include: pacifiers, lollipops, candy necklaces, glow sticks or glowing jewelry, mentholated rub and surgical type masks. Pacifiers and lollipops are frequently used to prevent ecstasy users from grinding their teeth, which is caused by involuntary jaw clenching. Candy necklaces are used to hide ecstasy pills. Glow sticks, mentholated rub and surgical mask are used to over stimulate senses.

Cocaine Abuse Cocaine abuse causes serious problems in the user’s life and typically leads to full blown cocaine addiction. Often the user will experiment with the drug once and find that the "high" they experience is like nothing they have ever felt before. Many cocaine users report that over time they fail to achieve as much pleasure as they did from their first cocaine exposure. However, they continue using cocaine in an attempt to recreate that initial “high.” At this point the person has a cocaine abuse problem that is very quickly becoming an addiction to the drug. They develop a tolerance to cocaine’s effects and in turn increase the amount they ingest. This drug is often thought to be less addictive because it lacks the physical withdrawal symptoms seen in alcohol or heroin addiction. Cocaine has powerful psychological addictive properties. As more than one user has reflected, "If it is not addictive, then why can't I stop?" Cocaine can be abused a number of different ways. Sniffing or snorting the powder is a popular method of using the drug because it is quick, convenient, and easier to keep secret. Smoking or injecting cocaine delivers a very powerful, short-lived high but requires more isolation. The pleasurable effects of snorting cocaine up the nose may last 15 to 30 minutes but will be less intense after each use unless the amount in increased. The effects of smoking or injecting cocaine last around 5 to 10 minutes and the intense high is followed by a strong desire to do more of the drug.

The physical warning signs of cocaine abuse can vary depending on the person. Quite often, the eyes are a good indicator of cocaine use. A cocaine user’s eyes will appear wide and often bloodshot with dilated pupils. Stimulants like cocaine increase heart rate and blood pressure so heart irregularities can be a warning sign. Cocaine users often have an elevated/speed up speech pattern so speech irregularities in the way they would normally speak is a warning sign. Cocaine is an appetite suppressant so people that use cocaine regularly often lose weight or are not hungry at meal time. Also, because cocaine is powerful stimulant, people who use it often have a difficult time falling asleep. These cocaine abuse warning signs are what to look for if you suspect someone you know might be using cocaine. Like any warning sign, they are no guarantee, merely indicators to raise serious concerns. The trend of drug abuse in the United States is presently multiple or polydrug abuse, and cocaine is no exception. Cocaine is often used with alcohol or sedatives such as Valium, Ativan, or heroin as an upper/downer combination. The other drug is also used to moderate the side effects of the primary drug being abused. A common polydrug abuse problem seen especially in adolescents is cocaine, alcohol, and marijuana. There are many negative consequences of cocaine abuse. Some of these include

Chapter: Types of drugs

After a short high, the pleasurable effects of the drug diminish and the cocaine user often takes more of the drug to recapture the desired effect. This in turn causes severe strain on their body. The damaging effects of cocaine abuse may include stroke, heart attack and unpredictable behavior in the user. Other physical side-effects depend on how the drug is abused and can include anything from nosebleeds to gangrene.

26


Drugs of Abuse and Assessment Strategies

2011

being arrested, isolating loved ones, deteriorating health, and having financial or job difficulties. Psychologically the cocaine user can feel depressed, have unexpected mood swings, and may have thoughts of suicide. In the end cocaine abuse, chemical dependency, and addictive behaviors spare no one and are a problem that is widespread throughout society. (drug-abuse.org, 2006)

Laboratory Testing Urine drug screens are frequently ordered on patients who exhibit symptoms of intoxication, experience trauma or have a history of drug ingestion. Most hospital laboratories use immunoassays to detect drugs because they are relatively simple to perform, have high sensitivity for drugs of abuse and provide rapid turnaround time. One example is the TriageÂŽ TOX Drug Screen, which is a fluorescence immunoassay for the qualitative detection of 10 distinct drug classes in urine, including acetaminophen/paracetamol, amphetamines, methamphetamines, barbiturates, benzodiazepines, cocaine, methadone, opiates, phencyclidine, tetrahydrocannibinol (THC) and tricyclic antidepressants (TCA).

Drug Class

Threshold

Acetaminophen

5 ug/mL

Amphetamines

1000 ng/mL

Methamphetamines

1000 ng/mL

Barbiturates

300 ng/mL

Benzodiazepines

300 ng/mL

Cocaine

300 ng/mL

Methadone

300 ng/mL

Opiates

300 ng/mL

Phencyclidine

25 ng/mL

THC

50 ng/mL

TCA

1000 ng/mL

Chapter: Laboratory Testing

Screening assays for drug of abuse are designed to detect urine drug levels above a predetermined cutoff concentration. The threshold concentration, above which each drug class will be detected by the Triageâ TOX Drug Screen, is summarized in the following table. The acetaminophen/paracetamol assay will yield positive results when acetaminophen/paracetamol is ingested at or above therapeutic doses.

27


Drugs of Abuse and Assessment Strategies

2011

The detection window for the most common drugs of abuse is summarized below.

Drug

Detection Time

Amphetamine

1 - 3 days occasional use 7 – 10 days chronic use

Methamphetamine

1 - 3 days occasional use 7 -1 0 days chronic use

Barbiturates

4 - 6 days

Benzodiazepines

2 – 7 days

Cocaine

2 – 3 days occasional use 4 days chronic use

Fentanyl

1 – 3 days

LSD

1 – 5 days

Marijuana

3 – 5 days occasional use

Methadone

2 – 3 days

Opiates

2 -3 days

PCP

7 – 14 days

Propoxyphene

1 – 7 days

Reference value is a negative result for all drugs tested. A positive result on a drug screen is not evidence that the person providing the specimen was under the influence of that drug at the time the specimen was submitted. A positive result only indicates previous use of the particular drug that was detected in the urine.

Chapter: Laboratory Testing

8 weeks chronic use

28


Drugs of Abuse and Assessment Strategies

2011

Confirmation of Positive Drug Screens The major problem with all rapid immunoassays is their less than perfect specificity for each drug class. Prescription and over the counter medications, as well as herbal supplements, may cause false positive results. Physicians need to be aware of the limitations of urine drug screens. If a falsely positive drug screen is suspected, a confirmatory drug screen should be ordered. As a reminder, many laboratories attach a comment to urine drug screen results such as, “This drug screen provides presumptive results for medical purposes only. False positive results may occur. Physicians should order confirmatory testing on this sample if the results are considered clinically significant”.

Sample Collection Freshly voided urine specimens should be collected in a clean, previously unused glass or plastic container. If the specimen will not be tested immediately, it should be refrigerated at 2 °C to 8 °C for a maximum of two days. Stat drug screens are available 24 hours a day. Turnaround time is approximately 30 minutes.

Drug Classes Amphetamines: Amphetamines are a class of phenethylamine compounds with varying degrees of sympathomimetic activity, which means that they mimic the actions of endogenous neurotransmitters and strongly stimulate the sympathetic nervous system. The amphetamine class of drugs includes: Amphetamine Methamphetamine 3,4-methylenedioxyamphetamine (MDA) Methylenedioxymethamphetamine (MDMA or Ectasy) Methylphenidate Pemoline Ephedrine

The therapeutic indications for amphetamines are obesity, narcolepsy and attention deficit hyperactivity disorder. Derivatives of amphetamines such as ephedrine, phentermine, and phenylpropanolamine are constituents of over the counter diet pills. The l-forms of amphetamine and methamphetamine cause vasoconstriction but lack potent sympathetic stimulating activity. For this reason, drugs such as pseudoephedrine, phenylpropanolamine, and phenylephrine are present in over the counter cold medications.

Chapter: Laboratory Testing

      

29


Drugs of Abuse and Assessment Strategies

2011

Because of their stimulant properties, methamphetamine and Ectasy have become some of the most frequently abused drugs. Their desirable properties include increased wakefulness, alertness and energy, decreased appetite and an overall sensed of euphoria. Undesirable side effects include headache, palpitations, dizziness, agitation, confusion, dysphoria, delirium, aggressiveness, and hallucinations. Most amphetamine immunoassays are designed to detect amphetamine and methamphetamine, while some are designed to detect MDMA and MDA. Drugs commonly considered to be illicit amphetamines include the D-isomers of amphetamine, methamphetamine, MDA, MDMA and methylphenidate. Many over the counter sympathomimetic amines may produce false positive screening results. Herbal supplements containing ephedra may produce a positive amphetamine reaction. Amphetamines are highly lipid soluble and well absorbed orally. Their circulating half is approximately 10 hours. Amphetamines can be detected in urine within 3 hours of any type of administration and remain detectable for 1 to 3 days after single use and 7 to 10 days after chronic use. Administering ammonium chloride to acidify the urine can accelerate amphetamine elimination.

Barbiturates: These drugs are powerful central nervous system depressants. Low doses induce relaxation, moderate doses induce sleep and high doses induce anesthesia. Tolerance of some of the barbiturates' desired effects develops rapidly. Physical dependence develops when a user's daily intake exceeds a threshold value; once a user is physically dependent, abrupt withdrawal can precipitate symptoms severe enough to cause death. Short acting barbiturates can be detected up to two days after use. Phenobarbital can be detected one to three weeks after use.

Erythroxylon coca that results in a state of increased alertness and euphoria. These effects are attributed by the blocking of dopamine reuptake by nerve synapses. Sympathomimetic effects include increased blood pressure, heart rate and body temperature. The route of administration has a marked impact on its addictive potential. The more rapid the rate of increase in drug levels in blood and brain, the greater the risk of addiction. Intravenous and smoked cocaine are much more addictive than intranasal snorting. Cocaine is rapidly metabolized in the blood and liver after inhalation and only small quantities of parent drug are excreted in urine. Benzoylecgonine and ecgonine methyl ester are the two main cocaine metabolites; neither is pharmacologically active. The half-life of cocaine ranges from 0.5 to 1.5 hours, ecgonine methyester from three to 4 hours and benzoylecgonine from 4 to 7 hours. Because of its longer half-life, most screening immunoassays have been designed to detect benzoylecgonine.

Chapter: Laboratory Testing

Cocaine: Is a potent, naturally occurring central nervous system stimulant derived from the plant

30


Drugs of Abuse and Assessment Strategies

2011

Opiates: are natural or synthetic analgesic and sedative drugs that have a morphine-like pharmacologic action and affect the cardiovascular and gastrointestinal systems. Opiates include morphine, codeine, hydrocodone, hydromorphone and oxycodone. Heroin is a synthetic opiate that is made from morphine. Both codeine and heroin are metabolized to morphine. Opiates have a high abuse potential because they produce euphoria, relaxation, and feelings of well-being. Long-term use can lead to tolerance and both physical and psychological dependence. Most immunoassays detect morphine with varying levels of cross reactivity to codeine, hydrocodone, and hydromorphone. Most of the opiates can be detected in urine for two to three days after single use and four to five days after chronic use. The majority of screening assays cannot reliably detect oxycodone, oxymorphone, and meperidine. Poppy seeds contain a number of substances including morphine and codeine. After the ingestion of large quantities of poppy seeds, a urine drug screen may be positive for opiates. Most urine drug screens have an opiate threshold of 300 ng/mL. The cut-off used for confirmation of both codeine and morphine is 2000 ng/mL. Poppy seed ingestion is usually associated with concentrations well below this cut-off. However, some ethnic communities that cook with poppy seed paste may have very high urine morphine concentrations. Morphine levels usually peak within 3 to 8 hours and remain positive for as long as 48 to 60 hours after ingestion of poppy seeds.

These drugs are widely prescribed as anxiolytics, sedative-hynotics, anticonvulsants and for treatment of obsessive compulsive disorder. They may cause cognitive impairment. Chronic benzodiazepine use increases the risk of developing dependence and abuse. Most screening immunoassays detect all benzodiazepine drugs that are metabolized in the body to oxazepam, temazepam, or nordiazepam. However, the large number of different chemical groups that may be attached to the benzodiazepine nucleus make it difficult for screening assays to detect all drugs in this class. Some drugs such as midazolam, chlordiazepoxide and flunitrazepam may not be detected by many manufacturers’ assays. Screening assays cannot distinguish between individual benzodiazepines. Benzodiazepines are undetectable in the urine after single use, but some can be detected for one to five weeks after chronic use. Over the counter remedies can produce false positive results in some benzodiazepine screening assays.

Phencyclidine: PCP is a dangerous drug of abuse that produces visual and auditory hallucinations, feelings of dissociation, intense euphoria, and distortions in perception of time, space and body image. It is taken orally, inhaled or injected. PCP can be detected one week after single use and two weeks after chronic use. Dextromethorphan and Doxylamine (Unisom) have been reported to cause false positive results with PCP screening immunoassays. Over the counter remedies can produce false positive results in some phencyclidine screening assays.

Chapter: Laboratory Testing

Benzodiazepines:

31


Drugs of Abuse and Assessment Strategies

2011

Cannabinoids: Marijuana is a mixture of dried leaves and the flowering tops of the plant Cannabis sativa and is the most widely used illicit drug. Delta-9-tetrahydrocannabinol (9-THC) is the principal psychoactive ingredient in marijuana. Street preparations of marijuana commonly contain 0-5% 9-THC. Hashish, the resinous coating from Cannabis sativa L. leaves and flowers, contains 5-15% 9-THC. The compound is quickly and effectively absorbed by inhalation or from the gastrointestinal tract and is almost completely metabolized. Fatty tissue absorbs 9-THC and then slowly releases it into the plasma. After exposure, 9-THC is rapidly incorporated and distributes to the adipose tissue, liver, lungs, and spleen. It is then released back into the blood slowly and eventually is metabolized and changed into THC-COOH, which is excreted in the urine. THC-COOH is the most important compound for clinical testing. Multiple factors can influence the duration of detectability of THC-COOH in the urine, including frequency of marijuana use, timing of specimen collection, body fat content, and degree of urine dilution. The window of detection for THC-COOH ranges from a few days in infrequent marijuana users to weeks or months in frequent users. False positive reactions for THC occur most commonly because several prescription medications including Clozaril, Propulsid, Protonix, Paxil, Tegretol and Zocor cross-react with the anti-THC monoclonal antibody used in some screening assays. K2 is an unregulated mixture of dried herbs that are sprayed with a synthetic cannabinoid-like substance, which is currently legally sold as incense. This product is also known as K2 Spice, Spice, K2 Summit, Genie and Zohai. The Missouri Regional Poison Center has recently reported several adverse reactions in patients between the ages of 14 and 27 years after smoking K2. Signs and symptoms include: Tachycardia Hypertension Anxiety Agitation Hallucinations Pallor Numbness and tingling Tremors and seizures

This constellation of signs and symptoms may suggest that K2 is contaminated with other unknown chemicals in addition to synthetic cannabinoid. K2 has also been used in combination with other legal and illegal substances. It is important to realize that K2 does not cross-react with tetrahydrocannibinol (THC) and is not detected by most drug screens performed in hospital laboratories. (ClinLab Navigator, 2011)

Chapter: Laboratory Testing

       

32


Drugs of Abuse and Assessment Strategies

2011

DIAGNOSTIC STUDIES Pre-Screening: Alcohol Use Disorder Identification Test (AUDIT) 1. How often do you have a drink containing alcohol? (Never, 0) (Monthly or less, 1) (Two to four times a month, 2) (Two to three times a week, 3) (Four or more times a week, 4) 2. How many drinks containing alcohol do you have on a typical day when you are drinking? (1 or 2 drinks, 0) (3 or 4 drinks, 1) (5 or 6 drinks, 2) (7 to 9 drinks, 3) (10 or more, 4) 3. How often do you have six or more drinks on one occasion? (Never, 0) (Monthly or less, 1) (Two to four times a month, 2) (Two to three times a week, 3) (Four or more times a week, 4) 4. How often during the last year have you found that you were not able to stop drinking once you had started? (Never, 0) (Monthly or less, 1) (Two to four times a month, 2) (Two to three times a week, 3) (Four or more times a week, 4) 5. How often during the last year have you failed to do what was normally expected from you because of drinking? (Never, 0) (Monthly or less, 1) (Two to four times a month, 2) (Two to three times a week, 3) (Four or more times a week, 4)

(Never, 0) (Monthly or less, 1) (Two to four times a month, 2) (Two to three times a week, 3) (Four or more times a week, 4) 7. How often during the last year have you had a feeling of guilt or remorse after drinking? (Never, 0) (Monthly or less, 1) (Two to four times a month, 2) (Two to three times a week, 3) (Four or more times a week, 4) 8. How often during the last year have you been unable to remember what happened the night before

Chapter: DIAGNOSTIC STUDIES

6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

33


Drugs of Abuse and Assessment Strategies

2011

because you had been drinking? (Never, 0) (Monthly or less, 1) (Two to four times a month, 2) (Two to three times a week, 3) (Four or more times a week, 4) 9. Have you or someone else been injured as a result of your drinking? (No, 0) (Yes, but not in the last year, 2) (Yes, during the last year, 4) 10. Has a relative or friend, or a doctor or other health worker been concerned about your drinking, or suggested you cut down? (No, 0) (Yes, but not in the last year, 2) (Yes, during the last year, 4) Scoring: The points awarded for each question range from 0 to 4. The total scores range from 0 to 40. The WHO has organized the scores into four "zones," each with a suggested clinical response. It is emphasized that clinical judgment is required and must be factored in, especially when the client’s score is not consistent with other evidence. Recommended Interventions Zone 1 Intervention: Alcohol education 0 - 7 points Zone 2 Zone 3 Zone 4

8 - 15 points 16 - 19 points 20 - 40 points

Intervention: Simple advice Intervention: Simple advice, plus brief counseling and continued monitoring Intervention: Referral for diagnostic evaluation and treatment

Sensitivity and Specificity % all alcoholics % all alcoholics with this score with lower score

Score 12 97 %

28 %

72 %

Score 8

90 %

61 %

39 %

Score 2

25 %

97 %

3%

(Kinney, 2010)

Chapter: DIAGNOSTIC STUDIES

% those with score who have alcohol abuse / dependence

34


Drugs of Abuse and Assessment Strategies

2011

DAST (Drug Abuse Screening Test) Instructions: Circle either yes or no to the right of the question to indicate your answer. 1. Have you used drugs other than those required for medical reasons? 2. Have you abused prescription drugs? 3. Do you abuse more than one drug at a time? 4. Can you get through the week without using drugs (other than those required for medical reasons)? 5. Are you always able to stop using drugs when you want to? 6. Do you abuse drugs on a continuous basis? 7. Do you try to limit your drug use to certain situations? 8. Have you had "blackouts" or "flashbacks" as a result of drug use? 9. Do you ever feel bad about your drug abuse? 10. Does your spouse (or parents) ever complain about your involvement with drugs? 11. Do your friends or relatives know or suspect you abuse drugs? 12. Has drug abuse ever created problems between you and your spouse? 13. Has any family member ever sought help for problems related to your drug use? 14. Have you ever lost friends because of your use of drugs? 15. Have you ever neglected your family or missed work because of your use of drugs? 16. Have you ever been in trouble at work because of drug abuse? 17. Have you ever lost a job because of drug abuse?

19. Have you ever been arrested because of unusual behavior while under the influence of drugs? 20. Have you ever been arrested for driving while under the influence of drugs? 21. Have you engaged in illegal activities to obtain drugs? 22. Have you ever been arrested for possession of illegal drugs? 23. Have you ever experienced withdrawal symptoms as a result of heavy drug intake?

Chapter: DIAGNOSTIC STUDIES

18. Have you gotten into fights when under the influence of drugs?

35


Drugs of Abuse and Assessment Strategies

2011

24. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, or bleeding)? 25. Have you ever gone to anyone for help for a drug problem? 26. Have you ever been in hospital for medical problems related to your drug use? 27. Have you ever been involved in a treatment program specifically related to drug use? 28. Have you been treated as an outpatient for problems related to drug abuse? (Kinney J. , 2010)

Fagerstrom Test Nicotine Dependence Instructions: Select the number of the answer that is most applicable, and write it on the line to the left. ——— 1. How soon after you awake do you smoke your first cigarette? 0. After 30 minutes

1. Within 30 minutes

——— 2. Do you find it difficult to refrain from smoking in places where it is forbidden, such as the library, theater, or doctors’ office? 0. No

1. Yes

——— 3. Which of all the cigarettes you smoke in a day is the most satisfying? 0. Any other than the first in the morning

1. The first one in the morning

——— 4. How many cigarettes a day do you smoke? 0. 1–15

1. 16–25

2. More than 26

——— 5. Do you smoke more during the morning than during the rest of the day? 1. Yes

——— 6. Do you smoke when you are so ill that you are in bed most of the day? 0. No

1. Yes

——— 7. Does the brand you smoke have low, medium, or high nicotine content? 0. Low 1. Medium

2. High

——— 8. How often do you inhale the smoke from your cigarette? 0. Never

1. Sometimes

2. Always

Chapter: DIAGNOSTIC STUDIES

0. No

36


Drugs of Abuse and Assessment Strategies

2011

MAST (Short Michigan Alcohol Screening Test) Response choices are: Yes or No.            

Do you feel you are a normal drinker? (By normal we mean you drink less than or as much as most other people.) Does your wife, husband, a parent, or other near relative ever worry or complain about your drinking? Do you ever feel guilty about your drinking? Do friends or relatives think you are a normal drinker? Are you able to stop drinking when you want to? Have you ever attended a meeting of Alcoholics Anonymous? Has drinking ever created problems between you and your wife, husband, a parent, or other near relative? Have you ever gotten into trouble at work because of drinking? Have you ever neglected your obligations, your family, or your work for two of more days in a row because you were drinking? Have you ever gone to anyone for help about your drinking? Have you ever been in a hospital because of drinking? Have you ever been arrested for drunken driving, driving while intoxicated, or driving under the influence of alcoholic beverages?

Addiction Severity Index (ASI) Assessment Tool: Produces a “problem severity profile” of the patient, including chemical, medical, psychological, legal, family/social and employment/support aspects, indicating areas of treatment needs.

DSM-IV Criteria for Substance Use Disorders Substance Abuse When any one of A and both B and C are "yes," a definite diagnosis of abuse is made.

1. Recurrent failure to meet important responsibilities due to use? 2. Recurrent use in situations when this is likely to be physically dangerous? 3. Recurrent legal problems arising from use 4. Continued to use despite recurrent problems aggravated by the substance use: B. These symptoms have occurred within a 12 month period

Chapter: DIAGNOSTIC STUDIES

A. Has the client experienced the following?

37


Drugs of Abuse and Assessment Strategies

2011

C. Client had never met the criteria for dependence

Substance Dependence When any three of A and B are "yes," a definite diagnosis of dependence is made. A. Has the client experienced the following? 1. Tolerance (needing more to become intoxicated or discovering less effect with same amount 2. *withdrawal (characteristic withdrawal associated with type of drug) 3. Using more or for longer periods than intended? 4. Desire to or unsuccessful efforts to cut down? 5. Considerable time spent in obtaining the substance or using, or recovering from its effects? 6. Important social, work, or recreational activities given up because of use? 7. Continued use despite knowledge of problems caused by or aggravated by use. B. Are three or more of the above positive? C. Have these positive items been present during the same 12 month period? Note: A clear cut withdrawal syndrome is not present with some classes of drugs: caffeine, phencyclidine, or hallucinogens.

Substance Use History and Physical Examination Name

Age

Date

Height _______ Weight ______ BAC (if known/applicable) _________________ I. Past Medical History Have you ever been told that you had: Gastritis _________________________________ Hepatitis _________________________

Abnormal liver tests _______________________ Diabetes ________________________

Chapter:

Pancreatitis ______________________________ Cirrhosis ________________________

38


Drugs of Abuse and Assessment Strategies

2011

High blood pressure _______________________ Delirium tremens’___________________ Gout ___________________________________ Anemia ___________________________ Do you use tranquilizers ___________________ Sedatives__________________________ Do you smoke ___________________History: Packs/day ______ Pack Years ______ Comments __________________________________________________________________________ II. Family History High blood pressure ________________________ Alcohol dependence/ drug dependence Diabetes _________________________________ Mother ___ / ___ Father ___ / ___ Liver Disease _____________________________ Siblings ___ / ___ Aunts/Uncles ___ / ___ Grandparents ___ / ___ Comments __________________________________________________________________________ III. Social History Occupation _______________________________ Marital Status _____________________ Lives with whom _____________________________________________________________________

IV. Review of Systems Yes No Explain Fatigue ___ ___ __________________________________ Anxiety ___ ___ __________________________________ Fever, Sweating ___ ___ __________________________________ HEENT Head Trauma ___ ___ __________________________________ Headaches ___ ___ __________________________________ Epistaxis ___ ___ __________________________________ Hoarseness ___ ___ __________________________________ Vision changes ___ ___ __________________________________

Chapter: Substance Use History and Physical Examination

Children? ___________________________________________________________________________

39


Drugs of Abuse and Assessment Strategies

2011

Cardiovascular Change in exercise tolerance ___ ___ __________________________________ Shortness of breath ___ ___ __________________________________ Chest/pain/discomfort ___ ___ __________________________________ Palpitations ___ ___ __________________________________ Dizziness ___ ___ __________________________________ Gastrointestinal Ingestion or nausea (especially A.M.) ___ ___ __________________________________ Heavy retching ___ ___ __________________________________ Vomiting (with blood?) ___ ___ __________________________________ Abdominal pain ___ ___ __________________________________ Jaundice ___ ___ __________________________________ Diarrhea ___ ___ __________________________________ Black “tarry� stools ___ ___ __________________________________

Trouble getting an erection ___ ___ __________________________________ Polyuria ___ ___ __________________________________ Amenorrhea ___ ___ __________________________________ Neuropsychiatric Tremors (especially A.M.) ___ ___ __________________________________ Blackouts ___ ___ __________________________________ Memory problems/changes ___ ___ __________________________________ Periods of confusion ___ ___ __________________________________ Hallucinations ___ ___ __________________________________ Staggering/balance problems ___ ___ __________________________________

Chapter: Substance Use History and Physical Examination

Genitourinary

40


Drugs of Abuse and Assessment Strategies

2011

Paresthesias ___ ___ __________________________________ Muscle weakness ___ ___ __________________________________ Depressed? Down mood ___ ___ __________________________________ Change in appetite ___ ___ __________________________________ Decreased energy level ___ ___ __________________________________ Decreased activity level ___ ___ __________________________________ Suicide attempts/ideation ___ ___ __________________________________ Sleep (hrs.) _______ EMA ______ MCA _______ TFA _____ Changes _____________________ V. Substance Use History Alcohol Do you use alcohol? ___________________________________________________________________ How often (days per week) do you drink? __________________________________________________ What do you prefer? _____________________ How much do you drink per day?_________________

How many until you feel drunk? _________________ Is this more than it has taken in the past?_______________ Has there been any change in your pattern over the past 6 months or 1 year? ___________ What age did you begin using alcohol? _______________________________________ Have you ever drunk (in one day): Case of beer?_____ Fifth of liquor _____ Gallon of wine? ______ Have you ever used non-beverage alcohol? __________________________________________ Longest period without alcohol? __________________________________________________ Why did you stop?________________________________________ Did you experience any discomfort? (hallucinations, tremors, fever) __________________

Chapter: Substance Use History and Physical Examination

How many drinks until you feel happy? ______

41


Drugs of Abuse and Assessment Strategies

2011

Drugs What drugs other than alcohol have you used?__________________________ How much ________________________________________________________________ ________________________________________________________________________________ __________________________________________________________________ ___________________ When did you last use these drugs? _______________________________________________________ When using, how much do you spend on drugs in a week? ____________________________________ Consequences of use Has drinking or drug use ever caused you to miss or be late for work?____________________________ Has drinking or drug use ever affected your relationships or home life?___________________________ How do you feel about your drinking or drug use? ___________________________________________ Has your physician ever told you to cut down or quit? ________________________________________ Have you ever attended an AA meeting?_____ Why?________________________________________ CAGE Screening Test

A ______ Have you ever felt Annoyed when other criticize your drinking? G ______ Have you ever felt Guilty about your drinking? E ______ Have you ever had a drink as an Eye opener to get going in the morning or to stop tremors? When was your last drink? ___________ How much? _________ What? ______________ When was your last drug use? _________ What? _____________ How much? _________ VI. Physical Examination General Appearance (dress, cleanliness, etc.) Blood pressure ____________________ Respiratory rate___ / minute Pulse_____________ Regular ______ Irregular ___ Explain ____________________________ Behavior Yes No Explain

Chapter: Substance Use History and Physical Examination

C ______ Have you every felt the need to Cut down on your drinking?

42


Drugs of Abuse and Assessment Strategies

2011

Anxious ___ ___ __________________________________ Irritable ___ ___ __________________________________ Uncooperative ___ ___ __________________________________ Hyperactive ___ ___ __________________________________ Alcohol on breathe ___ ___ __________________________________ Dermatology Vascular dilation ___ ___ __________________________________ Clubbing/edema ___ ___ __________________________________ Deputyrens contractures ___ ___ __________________________________ Rhinophyma ___ ___ __________________________________ Palmer erythema ___ ___ __________________________________ Cigarette burns ___ ___ __________________________________ Spider nevi ___ ___ __________________________________ IV drug needle marks ___ ___ __________________________________

HEENT Evidence of head trauma _______________________________________________________________ Extraocular movements intact______________ Explain ___________________________________ Pupil Size ___________ PERRIA _________ Sclera Clear _____________ Icteric ___________ Nasal septum: Intact __________________ Periodontal Disease Yes ______ No ______ Swollen Parotids Yes ______ No ______ Chest Gynecomastia __________ Lungs Clear to A&P _______ Dullness ______ Rales________ Rhonchi ______ Wheezes _____

Chapter: Substance Use History and Physical Examination

Other burns/scars not attributable to surgery? Where _________________________________________

43


Drugs of Abuse and Assessment Strategies

2011

Heart — PMI: size and location Rhythm Regular ___________ Irregular __________ Explain ___________________________ Sounds S1_____ S2 ______ Others? (S3, S4, Rubs, Gallops) ___________________________ Murmur (describe if possible) ___________________________________________________________ Abdominal Examination Bowel sounds (+ / - ) _________________________________________________________________ Ascites __________ Tenderness________ Masses ________________________________________ Liver (size @MCL) _________ Palpable? ______ Splenomegaly ___________________________ Neuropsychiatric Cranial nerves intact? ____________________ Cerebellar: Tremor ________ Tandem Walk ________ F to N ________ Romberg + / - ? ______ Extremities Sensory (upper + lower) intact ________ Symmetrical ______________________

Symmetrical ______________________ Cognition Object Retention 3 @ ______ minute World _________________________________________________________________________ Serial Sevens _____ _____ _____ _____ _____ _____ _____ Assessment of Alcohol Use/Drug Use _____________________________________________________ ____________________________________________________________________________________ Withdrawal Risk _____________________________________________________________________ Interviewer’s Name __________________________________ Date __________________________ From: Nordsey D; Smith N. Protocol for Medical Assessment, Project Cork Weekend Program. Hanover NH, 1989. (Kinney, 2010)

Chapter: Substance Use History and Physical Examination

Motor (upper + lower) intact _________

44


Drugs of Abuse and Assessment Strategies

2011

Nursing Diagnosis with Interventions “Nurses care for chemically impaired clients in a variety of settings and situations. Some interventions call for medical interventions and skilled nursing care, whereas others call for effective use of communication and counseling skills.” (Varicolis, 2006, p. 320)

Overdoses and Withdrawal Syndromes Overdoses and withdrawal syndromes are medical situations. “Mortality rates range between 5% and 10% even with treatment.” (Varicolis, 2006, p. 321) Therefore the most appropriate nursing diagnosis for persons experiencing withdrawal or are past an overdose is RISK FOR INJURY. “Many nursing diagnoses apply to the majority of clients with substance abuse problems. For example, individuals who have been abusing drugs for a long period of time most likely have poor general health. These clients may have nutritional deficits, be susceptible to infections, or be at risk for AIDS or hepatitis.” (Varicolis, 2006, p. 321) INEFFECTIVE HEALTH MAINTAINANCE

Recovery INEFFECTIVE DENIAL is another diagnosis useful with addiction clients as the person has a tendency to minimize the scope of the problem. The nurse can also use the diagnoses of INEFFECTIVE COPING, RISK FOR OTHER-DIRECTED or SELF-DIRECTED VIOLENCE.

Suicide A sound assessment provides the framework for determining the level of protection the client warrants, and assessing for suicide is paramount to good nursing assessment in Mental Health Areas. RISK FOR SUICIDE and HOPELESSNESS are other diagnosis.

Nursing Priorities for In-Hospital Care 2. Strengthen individual coping skills. 3. Facilitate learning of new ways to reduce anxiety. 4. Promote family involvement in rehabilitation program. 5. Facilitate family growth/development. 6. Provide information about condition, prognosis, and treatment needs.

Discharge Goals 1. Responsibility for own life and behavior assumed. 2. Plan to maintain substance-free life formulated. 3. Family relationships/enabling issues being addressed.

Chapter: Nursing Diagnosis with Interventions

1. Provide support for decision to stop substance use.

45


Drugs of Abuse and Assessment Strategies

2011

4. Treatment program successfully begun. 5. Condition, prognosis, and therapeutic regimen understood. 6. Safety, (self and others), is planned for and copy of plan is with the patient at discharge. 7. Follow-up appointments are arranged.

Author’s Note: I have taken care of drug abuse and addiction clients for many years. It is my express pleasure to teach each and every one of you what it means to provide addiction nursing services. Many times these patients are the ones who most have given up on, including themselves. You are often the life-raft of these lost souls. You provide safety, stability, and courage to many who have lost all hope. Addiction nursing is challenging and rewarding for the nurse, who when she sees her former patient doing “well” on the “outside”, can rejoice with them in Recovery. And who also sees her “repeat offenders” coming back time, after time, after time, can always provide the level of support that these patients need with a kind smile and polite demeanor. I challenge you today, to put yourself in your clients shoes…and imagine if you lost everything you ever had. How would you feel, and who would you want to take care of you? If your answer was “me”(meaning YOU), then you’re on the right track. In Service to Humanity,

Fran Hodgkins, Addiction nurse, Holistic Nurse, Board-Certified Psych Nurse, Geri Nurse, ER Nurse, Chemo nurse, pulmonary nurse, cardiac and telemetry nurse, but most of all….Human-Nurse. Catch me at: www.vanursescare.com

Twitter @ caritasnursing

Wordpress: CaritasNurse

Chapter: Discharge Goals

Your Coach,

46


Drugs of Abuse and Assessment Strategies

2011

References American Psychiatric Nurses Association. (2011). You know your a psychiatric nurse if.... Retrieved August 24, 2011, from American Psychiatric Nurses Association: http://www.apna.org/i4a/pages/index.cfm?pageID=4311 ClinLab Navigator. (2011). Test Interpertation. Retrieved August 24, 2011, from ClinLab Navigator: http://www.clinlabnavigator.com/Test-Interpretations/drug-of-abuse-screenurine.html?letter=D Drug-Abuse.org. (2006). Drug-Abuse.org. Retrieved August 24, 2011, from Drug-Abuse.org: http://www.drug-abuse.org/ Kinney. (2010). AUDIT. Retrieved August 24, 2011, from Project Cork: http://www.projectcork.org/clinical_tools/html/AUDIT.html Kinney, J. (2010). DAST (Drug Abuse Screening Test). Retrieved August 24, 2011, from Project Cork: http://www.projectcork.org/clinical_tools/html/DAST.html UCLA. (n.d.). Michigan Alcoholic Screening Test. Retrieved August 24, 2011, from http://chipts.cch.ucla.edu/assessment/IB/List_Scales/MAST%20SCREENER.htm

Chapter: References

Varicolis, E. (2006). Manual of Psychiatric Nursing Care Plans. New York: Elsevier.

47


Introduction to Drugs of Abuse with Assessment Strategies