At Home Drug Withdrawal

Sobriety Success

The dependence on sobriety is defined as the state of sobriety. When a person is sober, they can live on a daily basis without their thoughts and behaviors being controlled by substance dependence. They do not feel obliged to use it because they manage to live without it. They see and appreciate so much the benefits of living without substance that they do not feel they have to use drugs or alcohol. Therefore, they refrain from using it to continue enjoying this new, healthier lifestyle. The success product of sobriety is a step-by-step manual for everyone. The product has been said to be beneficial for many people around the world. The reason why the product is gaining so much popularity among individuals. They see and appreciate so much the benefits of life without substance that they do not feel they have to use drugs or alcohol. Therefore, they refrain from using it to continue enjoying this new, healthier lifestyle. This strategy encourages you to maintain the long-term vision of recovery. Recognize that this is not a one-off thing, something you try for a few weeks to several months, then return to your previous life. You will be in recovery if you decide it's the life you want to live for the rest of your life. As such, there is no immediate timeline to which you must adhere, nor should you strive to achieve goals that you are clearly not ready to face. Read more here...

Sobriety Success Summary


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The writer presents a well detailed summery of the major headings. As a professional in this field, I must say that the points shared in this ebook are precise.

As a whole, this book contains everything you need to know about this subject. I would recommend it as a guide for beginners as well as experts and everyone in between.

Comparing cocaine exhibits

The process is different for cocaine comparisons. For one thing, the cocaine need not be removed from the sample. Four different ccGC examinations can be conducted which evaluate and compare the by-products and impurities down to trace levels by 1. Flame ionization gas chromatography (GC-FID) to evaluate cocaine hydrolysis products, manufacturing impurities, and naturally occurring alkaloids 5 These four gas chromatographic methods provide an in-depth evalutation of trace level components and allow the precise comparison of two different cocaine exhibits. The number of components evaluated range in the hundreds. This data provides the analyst with an abundance of analytical points to form a conclusion regarding commonality of source. and GC-ECD analyses that follow will result in organic profiles of the many compounds from the cocaine and heroin samples being analyzed. A further MS analysis may serve to identify the chemical composition of many of the components of each exhibit. Many...

Coca Cocaine Erythroxylum coca Erythroxlyaceae

The coca plant is a bush or shrub that grows to a typical height of about 3 feet (1 m), and the chewing of its leaves is a traditional practice in a wide area extending from Central America throughout the Andes and into the Amazon region. There are fourteen different alkaloids (alkaline, nitrogen-containing organic substances, usually with toxic potential) contained in the leaves of the coca plant with the most famous of course being cocaine (although nicotine is also present in smaller quantities). The amount of the cocaine alkaloid so obtained is of course far lower than in chemically pure extracts from the plant. By introducing the coca leaf orally, the cocaine is absorbed slowly and without harming the digestive system. It is a stimulant used to suppress hunger, to increase physical endurance and, in the Andes, to help cope with high altitudes. According to archaic indigenous beliefs coca chewing is harmless, and this conclusion has also been reached by distinguished...

Pharmacological Treatment of Chronic Cocaine Addiction

Clinical researchers have tried to identify drugs to reduce cocaine craving and prevent relapse. Numerous drugs looked promising in initial open-label trials but did not prove efficacious in subsequent placebo-controlled studies. These pharmacological treatments have included dopaminergic agonists (e.g., monamine oxidase inhibitors, amantadine, mazindol, methylphenidate, pemoline, bromocriptine, L-dopa, and pergolide), neurotransmitter precursors (L-tyrosine, L-tryptophan, and multivitamins with B complex), carbamazepine, and antide-pressants, including desipramine and fluoxetine. In a meta-analysis examining 45 clinical trials examining mostly antidepressants, carbamazepine, and dopa-mine agonists, no significant impact of drug treatment was found, regardless of the type of drug or dose used (Lima, Soares, Reisser, & Farrell, 2002). Clinical trials with bupropion, olanzapine, naltrexone, buprenorphine, and other drugs are ongoing. As our understanding of the neurobiological basis of...

Medical Complications Direct Results of Cocaine

Medical consequences of acute and chronic cocaine abuse may be categorized as those caused directly by cocaine, those due to adulterants, and those related to route of administration. The most common direct medical consequences of cocaine use include cardiovascular and CNS difficulties. Cocaine use may account for up to 25 of cases of acute myocardial infarction among patients 18-45 years of age (Weber, Hollander, Murphy, Braunwald, & Gibson, 2003). Upon acute administration, cocaine increases blood pressure and heart rate, primarily through an action on the sympathetic nervous system. Through its pharmacological effect at alpha- and beta-adrenergic receptors, cocaine may increase oxygen demand of the myocardium by increasing blood pressure and heart rate. Cocaine also suppresses the baroreflex response and vagal tone, further contributing to its effects on heart rate. At the same time that cocaine is increasing the workload on the heart, it induces coronary artery vasoconstriction...

Drug Dependence Versus Physical Dependence

A patient who seeks to continue using a medicine because it is helpful is no more demonstrating drug-seeking behavior than is a patient who finds eyeglasses helpful in the treatment of myopia demonstrating glasses-seeking behavior if deprived of a corrective lens. Drug abuse and drug dependence are characterized by use despite problems caused by that use (loss of control) and by denial (and dishonesty) neither of which is seen in appropriate medical treatment (DuPont & Gold, 1995).

Medical Alcohol Drug Abuse or Dependence Detoxification or Other Symptom Treatment with CC

Psychoactive substances are drugs or chemicals that have an effect on the central nervous system (CNS). The National Institute of Drug Abuse defines drug abuse or drug dependence as a condition in which the use of a legal or illegal drug causes physical, mental, emotional, or social harm. Drug usage impairs one's ability to function in daily activities of living and in work environments. Relationships with family and friends become impaired and dysfunctional. Most of the abused drugs fall into two main categories, CNS depressants and CNS stimulants. CNS depressants include narcotics, sedatives, barbiturates, tranquilizers, and inhalants. The desired effect by the user is a sense of increased self-esteem, euphoria, relaxation, and relief from pain and anxiety. CNS stimulants include amphetamines, hallucinogens, and cocaine. The desired effect by the user is a sense of well-being, alertness, excitation, overconfidence, and increased initiative.

Interpretive Toxicology Drug Abuse and Drug Deaths

The three curses of mankind alcohol, morphine and cocaine In medical examiner's offices, the results of toxicologic testing are correlated with the medical history of the deceased, the autopsy findings, and the circumstances leading up to or surrounding the death, so as to determine whether a drug was a cause of death, a contributing factor, or played no role. In many instances, drug levels alone cannot be interpreted. All physicians and toxicologists have had cases where an individual was found to have a fatal level of drug in the blood but was functioning with this level the drug had nothing to do with the death. This is seen typically in drug abusers who acquire a tolerance to drug levels that would kill an ordinary person, but are normal functioning levels to them. This same situation is seen by clinical physicians the patient admitted to the emergency room conscious and coherent, with drug levels that would be associated with unconsciousness or death in most individuals.

National Institute on Drug Abuse NIDA

NIDA, established in 1974, is the leading federal agency for research on the incidence and prevalence of drug abuse, its causes and consequences, and improved methods of prevention and treatment of drug abuse, with the intention of increasing knowledge and solving problems associated with drug abuse and improving understanding of the effects of drugs. NIDA supports research on effective prevention and treatment of drug abuse and on the role of drug abuse as a factor in the spread of AIDS. Research findings are usually presented in NIDA research monographs, available from the U.S. Department of Health and Human Services.

Methamphetamine and Amphetamine

Methamphetamine is a potent CNS stimulant that is readily produced illicitly.14,18 In the brain, it acts by both increasing release of dopamine and blocking its re-absorption, causing hyperstimulation of receptor neurons. Methamphetamine is also a cardiovascular stimulant. It blocks re-uptake of norepinephrine and causes an increase in catecholamine release. The euphoric effect is similar to cocaine but may last as long as ten times that of cocaine. Methamphetamine is metabolized to amphetamine, its major active metabolite. Amphetamine itself is rarely encountered. In overdoses, meth-amphetamine causes restlessness, confusion, hallucinations, coma, convulsions, and cardiac arrhythmias. With chronic abuse, just like cocaine, it can produce a chemical paranoid psychosis. Methamphetamine may be sold as cocaine. It is usually taken orally or intravenously though it may be snorted or smoked. Methamphetamine may be transformed into amphetamine hydrochloride ( ice ) which is smoked like...

Cocaine and Other Stimulants

Cocaine is an alkaloid extracted from the leaf of the Erythroxylon coca bush. The hydrochloride salt is water soluble and can be administered orally, intravenously, or intranasally. The intravenous route of administration has an onset of action of 10-60 seconds, with a peak effect achieved in minutes and duration of effect that lasts up to 1 hour. Administration of the drug by the intranasal route has an onset of action of up to 5 minutes, with a peak effect achieved in approximately 20 minutes. The total duration of action by the intranasal route is 1 hour. The free-base form, known as crack cocaine, can be heated and smoked. This form has the quickest onset of action of 3-5 seconds, reaching its peak effect in 1 minute. (Lange and Hillis, 2001) The quick and intense effects of crack cocaine may potentially make it the most addictive form of the drug. The effects of cocaine are mediated by blocking the synaptic reuptake of norepinephrine and dopa-mine, resulting in an excess of these...

Pathology Drug Abuse

Karch's pathology of drug abuse Steven B. Karch. 3rd ed. p. cm. 1. Drugs of abuse Pathophysiology. 2. Drugs of abuse Toxicology. I. Title. DNLM 1. Substance-Related Disorders physiopathology. 2. Anabolic Steroids adverse effects. 3. Cocaine adverse effects. 4. Designer Drugs adverse effects. 5. Narcotics adverse effects. 6. Substance-Related Disorders history. WM 270 K18p 2001 RM316 .K37 2001

Drug Abuse Dependence

A common comorbidity associated with alcohol use disorders is co-occurring drug use disorders. In 2001, the National Household Survey on Drug Abuse found that among teenagers who binge drink, two-thirds were also abusing drugs. In contrast, one in 20 teenagers who did not drink abused drugs. Drawing upon the ECA and NCS data, it has been determined that one in five individuals with an alcohol use disorder will also have a drug use disorder. A breakdown of the NCS data indicates that those with either alcohol abuse or alcohol dependence in 40 of cases have either drug abuse or drug dependence. The more serious the drug use disorder, the more likely it is that alcohol abuse-dependence will be found. For example, the ECA data indicate that if no drug problem exists, the rate of alcohol abuse-dependence is 11 (compared to 13 for the total population). When tetrahydrocannabinol abuse-dependence is present, the prevalence of alcohol abuse-dependence rises to 36 . The rates of alcohol...


According to the NHSDA (Substance Abuse and Mental Health Services Administration, 2001b), approximately 4 of the population (8.8 million people) have tried methamphetamine in their lifetime. Emergency department (ED) mentions of methamphetamine in 2001 (15,000 mentions) were not significantly different from mentions in 1994, 1999, or 2000. However, there was an increase and subsequent decline of ED mentions in 1997 (Substance Abuse and Mental Health Services Administration, 2001a). The highest rates of use are seen in patients 26-29 years of age, followed by patients ages 18-25 39 of methamphetamine admissions were patients 20-29 years old. In addition, TEDS data reveal that 80 of ED mentions were white (Substance Abuse and Mental Health Services Administration, 2002). Rates of use are highest in Hawaii, San Francisco, San Diego, Phoenix, Seattle, Denver, Los Angeles, and, Minneapolis (Substance Abuse and Mental Health Services Adimnistration, 2001b). D-Methamphetamine hydrochloride...


Metabolites in humans benzoylecgonine and ecgonine methyl ester are major metabolites. Norcocaine is a minor metabolite. Cocaine's plasma half-life is very short that of benzoylecgonine is much longer. Benzoylecgonine can be detected for days after use. Urine concentrations of benzoylecgonine can be extremely high (100,000s of ng mL). Preferred routes of administration smoking, snorting and injection. Oral route reported to be ineffective but Therapeutic uses Ear-Nose-Throat (ENT) surgical procedures and Tetracaine-Cocaine-Adrenalin (TAC) solution for open wound instillation and topical anesthesia for suture repair of lacerations.

Preface to the first edition

Physicians deal with the consequences of drug abuse on a daily basis, but information about the basic pathology of abused drugs is hard to come by. Hundreds of papers have been published describing the effects of drug abuse on brain neurochemistry, but practitioners are hard pressed to find out how cocaine affects blood vessels or how heroin affects the lungs. I hope this book supplies the information they need. While far from encyclopedic, I think the book does provide answers to most of the questions physicians ask when they are confronted with cases of drug-related death or disability.

Preface to the second edition

Nearly 900 new references have been added since the first edition. The large increase in number is explained partly by the addition of new subjects, such as solvent abuse. Most of the increase is simply due to increased interest in drug abuse, which is reflected by an increase in the number of papers being published. This increase became apparent late in 1991, and already seems to have peaked. This edition contains 233 new references from 1993, 224 from 1994, and 110 from the first 6 months of 1995. There have been some major advances since the first edition was published, but most of these have been in the fields of molecular biology and neurochemistry. The characterization of receptor changes in agitated delirium and the cloning of opiate receptors come quickly to mind. By comparison, advances in the field of pathology have been pitifully few. Fewer than 2 of the new references added to this edition have anything to do with anatomy or pathology. Whether this dismal finding reflects...

Preface to the third edition

Six years have elapsed since publication of the second edition of The Pathology of Drug Abuse (now titled Karch's Pathology of Drug Abuse). Important advances in the molecular biology of addiction have occurred since then. Some of these advances are directly relevant to the clinical disciplines of pathology and toxicology. Recent discoveries about heritable channelopathies and their role in the causation of sudden cardiac death are particularly exciting. Nonetheless, the pathology of drug abuse remains essentially an orphan science. When the first edition of this book was published in 1992, the Drug Abuse Warning Network (DAWN) survey reported 3465 cocaine-related deaths, and there were 1044 Medline citations for cocaine. The number of cocaine-related deaths had increased to nearly 5000 in 1999, but the number of published studies on cocaine was unchanged. Similarly depressing figures could be quoted about heroin and heroin-related research. Government sponsorship for pathology and...

Professor Arlt And His Recent Work In Glaucoma

Cocaine Filtering

Sir The usual Ophthalmological Congress in Heidelberg has just closed its session, and a few cursory notes at this early date may interest some readers. At this meeting elaborate papers are not read, but condensed statements are presented of the subjects introduced. The notable feature of this Society is that only new things or new phases of old topics are presented. This is not from any expressed rule, but is from the tacit understanding which controls men who are so diligently investigating the unknown in science as are these eager workers. These men have no patience with mere reiterations. Perhaps the most notable thing which was presented was the exhibition to the Congress upon one of the patients of the Heidelberg Eye Clinic, of the extraordinary anaesthetic power which a two per cent, solution of muriate of cocaine has upon the cornea and conjunctiva when it is dropped into the eye. Two drops of the solution were dropped into the eye of the patient at the first experiment, and...

Addictionsubstance abuse

Statistics compiled by the National Institute on Drug Abuse (NIDA) indicate that the prevalence of substance abuse and the cost of this disorder are considerable. In 1994, an estimated 9.4 of the US population was involved in substance abuse. Since most of the drugs of abuse are illegal, prevalence estimates often come from either treatment program data or an assessment of the incarcerated population. In 2003, 1.7 million people were admitted to publicly funded treatment programs. A survey of 14 major metropolitan areas between 2000 and 2002 found that 27-49 of male arrestees tested positive for cocaine. Substance abuse is also surprisingly common in school-aged children, with 2004 estimates of 8.4 of 8th-graders reporting illicit drug use during the last 30 days, a number that rises to 23 in the 12th grade population. The cost to society is estimated to be in excess of 320 billion annually with significant amounts going directly to healthcare costs and law enforcement. Additionally,...

The Dopamine DA Hypothesis

Until recently, the modal hypothesis on the pathophysiology of schizophrenia was that excessive dopaminergic transmission in the forebrain is a key causative factor. This DA hyperfunction hypothesis was primarily based on the observation that all clinically effective antipsychotic drugs have potent antagonist or inverse agonist activity at DA D2 receptors, and that the therapeutic efficacy of these compounds was highly correlated with their affinity for striatal D2 receptors. In addition, the psychotomimetic properties of indirect DA agonists like amphetamine and cocaine, and observed alterations in striatal DA release in schizophrenic patients, further supported the involvement of DA in the pathophysiology of schizophrenia.

Psychiatric Disorders 601411 Schizophrenia

Cocaine related disorders Cocaine induced disorders Dopamine (DA) and glutamate have been implicated in the molecular pathophysiology of schizophrenia. Thus stimulants that activate brain dopaminergic systems, e.g., cocaine or amphetamine, induce a paranoid psychosis similar to that seen with the positive symptom core of the disease suggesting that overactive DA transmission is a key facet of the disease. Similarly, based on the ability of the psychotomimetics phencyclidine and ketamine to block glutamate receptors (N-methyl-D-aspartate (NMDA)-subtype) the glutamate hypothesis suggests a hypoactivity of excitatory glutamatergic systems.7

The Dangers of Alcohol and Other Drugs

According to scientific research, the incidence of heart disease in men who consume a moderate amount of alcohol (two drinks a day or less) is lower than in men who do not drink. But there is not much difference between moderate drinking and heavy drinking. A typical drink is 5 ounces of wine, 1V 2 ounces of 80-proof distilled spirits, 12 ounces of wine cooler, or 12 ounces of beer (see page 24). Although moderate drinking may reduce your risk of heart disease, doctors do not recommend drinking alcohol because it carries many health risks, including cancer of the liver, mouth, throat, and esophagus. Excessive alcohol consumption also increases your chances of having an accident, makes you more prone to violence, and makes you more apt to engage in risky behaviors such as illicit drug use or unsafe sex (see page 111). Nutritional deficiencies and even malnutrition also can result from overconsumption of alcohol. Alcohol is not the only drug that is easy to abuse. Men use a number of...

Transition To Addiction

As we have seen, the pleasure derived from various drugs' activation of the brain's natural reward system promotes continued drug use during the initial stages of opioid addiction. Subsequently, repeated exposure to these drugs induces the brain mechanism of dependence, which leads to daily drug use to avert the unpleasant symptoms of drug withdrawal for many substances, although for some drugs, withdrawal symptoms are minimal and may contribute minimally to dependence features and relapse after discontinuation. Further prolonged use of drugs that produce dependence lead to more long-lasting changes in the brain that may underlie the compulsive drug-seeking behavior and related adverse consequences that are the hallmarks of addiction. Recent research has generated several models to explain how habitual drug use produces changes in the brain that may lead to drug addiction. In reality, the process of addiction probably involves components from each of these models, as well as other...

The Important Role Of Stress

That drug abuse patients are more vulnerable to stress than the general population is a clinical truism. Numerous preclinical studies have documented that physical stressors (e.g., foot shock or restraint stress) and psychological stressors can cause animals to reinstate drug use (e.g., Shaham, Erb, & Stewart, 2000). Furthermore, stressors can trigger drug craving in addicted humans (Sinha, Catapano, & O'Malley, 1999). One potential explanation for these observations is that abused drugs, including opiates and stimulants, raise levels of cortisol, a hormone that plays a primary role in stress responses cortisol, in turn, raises the level of activity in the mesolimbic reward system (Kreek & Koob, 1998). By these mechanisms, stress may contribute to the abuser's desire to take drugs in the first place, as well as to his or her subsequent compulsion to keep taking them.

Pharmacological Interventions And Treatment Implications

In summary, the various biological models of drug addiction are complementary and broadly applicable to chemical addictions. We next illustrate how long-term pharmacotherapies for opioid dependence, such as methadone, nal-trexone, and buprenorphine, can counteract or reverse the abnormalities underlying dependence and addiction. These agents are particularly informative, because they are an agonist, antagonist, and partial agonist, respectively. We do not review short-term treatments for relieving withdrawal symptoms and increasing abstinence but refer readers elsewhere for detailed neurobiologi-cal explanations for various abstinence initiation approaches (see Kosten & O'Connor, 2003).

Neuronal Nicotinic Receptor Agonists

The incidence of smoking is high in patients with schizophrenia, a rate at least three times higher than the general population. In fact, nicotine appears to produce a modest transient improvement in cognitive and sensory deficits in these patients. It has been suggested that smoking in schizophrenia represents an attempt to self-medicate.39 However, these views must be interpreted with caution. Overall, schizophrenic patients have a high degree of comorbid abuse of a variety of substances including nicotine, alcohol, cannabis, cocaine, and amphetamine. Importantly, the rate of substance abuse is higher than in the general population for all of these substances in spite of the fact that such abuse is associated with poorer outcomes, exacerbation of positive symptoms, increased hospitalization, and increased frequency of homelessness. This increased propensity to abuse a variety of substances regardless of consequences suggests that there may be a disregulation of reward systems in...

Controlled Substance Analogue Enforcement Act Of 1986

In recent years, the phenomenon of controlled substance analogues and homologues has presented a most serious challenge to the control of drug trafficking and successful prosecution of clandestine laboratory operators. These homologues and analogues are synthesized drugs that are chemically and pharmacologically similar to substances that are listed in the Controlled Substances Act, but which themselves are not specifically controlled by name. (The term designer drug is sometimes used to describe these substances.) The concept of synthesizing controlled substances analogues in an attempt to circumvent existing drug law was first noticed in the late 1960s. At about this time there were seizures of clandestine laboratories engaged in the production of analogues of controlled phenethylamines. In the 1970s variants of methaqualone and phencyclidine were being seized in clandestine laboratories. By the 1980s, Congress decided that the time had come to deal with this problem with a federal...

Dopamine transporter polymorphisms

DAT terminates dopaminergic neurotransmission by reuptake of dopamine (DA) in presynaptic neurons and plays a key role in DA recycling. DAT can also provide reverse transport of DA under certain circumstances. Psychostimulants such as cocaine and amphetamines and drugs used for attention deficit hyperactivity disorder (ADHD) such as methylphenidate exert their actions via DAT Altered DAT function or density has been implicated in various types of psychopathology, including depression, BPAD, suicide, anxiety, aggression, and schizophrenia. Altered transport properties associated with some of the coding variants of DAT suggest that individuals with these DAT variants could display an altered DA system.17'20 Multiple human dopamine transporter (hDAT, SLC6A3) coding variants have been described, though to date they have been incompletely characterized. The antidepressant, bupropion (6) dose-dependently increases vesicular DA uptake an effect also associated with VMAT-2 protein...

Preparation for Quitting

The physician should then provide the patient with some basic didactic information about quitting smoking. (1) Smoking represents an addiction to nicotine. Therefore smoking cessation must be undertaken as seriously as one would approach any other drug addiction. Willpower alone is insufficient. The patient must make quitting smoking his her top priority. (2) The goal should be total tobacco abstinence after the quit date. (3) The patient can expect to experience unpleasant nicotine withdrawal symptoms (e.g. mood disturbance, insomnia, irritability,

Multiplicity and ligand selectivity

CESs are largely microsomal in origin, with molecular weights of 55-60 kDa. At least four families (CES1-CES4, EC exist, based on sequence similarity, and in humans, the liver (CES1A1, hCE1) and intestinal forms (CES2, hCE2) appear to play the most important roles in detoxication bioactivation of xenobiotics.95 hCE1 metabolizes heroin and cocaine and is relatively selective for several of the angiotensin-converting enzyme inhibitors, such as delapril and imidapril, whereas hCE2 is more selective for irinotecan and oxybutynin. Therefore, hCE1 often appears to be associated with the removal of small (methyl, ethyl) groups, whereas hCE2 seems to prefer larger moieties, although this is far from a strict rule.92

Psychiatric Disturbance

Substance abuse can occur conjointly with virtually any Axis I or Axis II psychiatric disorder. This has important treatment implications, the most obvious of which is that for some individuals, alcohol or drug consumption may constitute an attempt at self-medication. Hence, treatment of the primary disorder may in some circumstances be sufficient to ameliorate the substance use disorder. Alternatively, prolonged drug abuse may precipitate a psychiatric disturbance, either directly by inducing neurochemical changes or indirectly through stress or maladjustment concomitant to a substance abusing lifestyle. A major task is therefore to delineate the type and severity of psychiatric morbidity that may be present and to determine whether it preceded or developed after the substance use disorder.

Rates Of Psychiatric Disorders Among People Living With Hiv Infection

The landmark HIV Cost and Services Utilization Study (HCSUS) found that a large, nationally representative probability sample of adults receiving medical care for HIV in the United States in early 1996 (N 2,864 2,017 men, 847 women) reported major depression (36 ), anxiety disorder (16 ), and drug dependence (12 ) (Bing et al., 2001 Galvan et al., 2002), as well as heavy drinking at a rate (8 ) almost twice that found in the general population and high rates of drug use (50 ). The HCSUS study remains the most comprehensive view we have of the prevalence of psychiatric disorders among people living with HIV AIDS, though the study was not designed as a diagnostic assessment of psychiatric disorders among people with HIV AIDS and so rates of psychosis, bipolar disorder, alcohol abuse or dependence, and substance abuse, among others, were not obtained. Disorders of alcohol and other drug (AOD) abuse are differentiated from dependence in the Diagnostic and Statistical Manual of Mental...

Head Computerized Tomographic CT Scan

Head Septic Emboli

Intracranial hemorrhage Suspect intraparen-chymal cerebrovascular accident or subarach-noid hemorrhage amphetamines, cocaine, ephedrine and pseudoephedrine, phenylpro-panolamine, phencyclidine (PCP) or subdural head trauma (alcohol, sedative-hypnotics, seizures). Lucencies Suspect basal ganglia necrosis carbon monoxide, cyanide, hydrogen sulfide (H2S), methanol suspect vasospasm cocaine, ergots septic emboli intravenous drug users (IVDUs). Figure 3.12 Subarachnoid hemorrhage intravenous cocaine abuse. Cranial computerized axial tomogram (CT) at the level of the pons that demonstrates acute blood hyperdensities in the suprachiasmatic cistern extending into the left Sylvian fissure, consistent with acute subarachnoid hemorrhage following intravenous cocaine overdose. (Courtesy of Carlos R. Gimenez, M.D., Professor of Radiology, LSU School of Medicine, New Orleans, LA.)

Unique Identify Factors

There are unique factors associated with controlled substance examinations which involve packaging. Heroin and cocaine are usually imported into the U.S. clandestinely packaged. Sometimes this packaging takes the form of legitimate household or commercial products which have been hollowed out or have natural crevices into which drugs can be stored for shipment. These kinds of packages will usually be transported via commercial carriers to distributors who will reclaim the drugs and repackage them for street distribution. Sometimes drugs are shipped via human beings who store packages in body cavities, or swallow small packages in order to clear customs checks at points of entry. In these cases, it is not unusual for the packaging to break while in the body of the person transporting the drug. This usually results in severe injury or death. Another common way of transporting controlled substances is to package the controlled substance in brick-size, 1 kg, packages for shipment to the...

How Psychiatrists Can Contribute To Containment Of The Most Challenging Public Health Problem The World Has Faced On A

The range of mental health issues encountered by HIV AIDS care providers is broad (e.g., abuse of alcohol, cocaine, crystal methamphetamine personality disorders agitation psychosis) and population-specific (e.g., adolescents, Latinas, people who are homeless or incarcerated). Because service delivery systems (medical care, mental health care, substance abuse treatment) are structured to work separately (historically due to different funding streams), efforts to navigate multiple systems often fail. Integrated HIV mental health care remains rare (Satriano et al., 2007), and comprehensive listings of regional HIV mental health service agencies do not exist. Patients may not themselves recognize the role that mental health problems are playing in their health (Messeri et al., 2002). As a result, HIV AIDS medical service providers may be unable to integrate adequately HIV AIDS, mental health, and substance abuse treatment services, even through existing referral networks, let alone to...

Hypertensive Emergency

Pheochromocytoma, cocaine overdose, or other hyperadrenergic states C. Causes of secondary hypertension include renovascular hypertension, pheochromocytoma, cocaine use, withdrawal from alpha-2 stimulants, clonidine, beta-blockers or alcohol, and noncompliance with antihypertensive medications.

Current Classification Systems

Defective or Inappropriate Incentive Systems. Maladaptive behavior may be due in large part to the fact that certain potentially harmful or culturally prohibited stimuli have very strong positive reinforcing functions for the individual. Sexual deviations, such as fetishism and transvestism, are examples of these maladaptive patterns. Various types of drug abuse and their reinforcing pharmacological aspects are other examples. These response patterns are learned through reinforcement and modeling. Aversive Behavioral Repertoires. In this category, an individual engages in behavior that generates aversive consequences to others. Individuals in this category include children who are very aggressive, annoying, or attention seeking children who show clinging dependence and adolescents or adults who engage in antisocial activities or other forms of socially disruptive behavior. Aversive behavioral patterns are learned patterns of response to stress, frustration, and other forms of...

Alcohol and Other Drugs

Drug Dependence A person who uses a drug for other than a recommended or prescribed purpose is said to be abusing that drug. Drug dependence (or addiction) is an uncontrollable craving for a particular substance, which can, in some cases, take over a person's life. A person who is psychologically dependent on a drug experiences emotional distress when the drug is withdrawn. Physical dependence means that the body has adapted to the presence of the drug, causing symptoms of withdrawal when deprived of it. Examples are cocaine and amphetamines. Some people are more susceptible than others to drug dependence for reasons that may include both genetic and environmental factors. Heavy use of any addictive drug may encourage the use of other drugs adolescents who use alcohol, tobacco, or marijuana are more likely than their peers who don't use these drugs to use cocaine or heroin eventually. In general, the younger people are when they start and the more types of drugs they use, the greater...

Sympathetic Denervation Unilateral Miosis

Horner syndrome is produced by a lesion at any site along the sympathetic pathway to the eye and is characterized by unilateral miosis (with sluggish dilatation) and ptosis anhidrosis (absence of sweating) and enophthalmos are part of the syndrome but are of no practical diagnostic value. The affected pupil will fail to dilate in response to the instillation of 5 cocaine eyedrops. Preganglionic lesions (i.e., those proximal to the superior cervical ganglion) can be distinguished from postganglionic lesions by the instillation of 5 pholedrine eyedrops (at least three days after the cocaine test) the miotic pupil dilates more than the normal pupil if the lesion is preganglionic, symmetrically if it is postganglionic. Central Horner syndrome (first preganglionic neuron) may be due to lesions of hypothalamus, brain stem, or cervicothoracic spinal cord the second preganglionic neuron may be affected by lesions of the brachial plexus, apical thorax, mediastinum, or neck the postganglionic...

Testing Programs for Athletes

Despite the long history of drug abuse in sports and in the workplace, laboratory testing to detect drug use is a modern phenomenon. Only since 1967 has the International Olympic Committee Medical Commission banned certain drugs and tested for their use. Full-scale drug testing for doping by athletes began in the 1972 Munich Games. Since 1967, the number of banned substances has grown every year, and the sophistication of laboratory analysis and testing protocols has advanced.

Epidemiology of Reproductive Toxicology

Antimicrobials, antiemetics, theophylline, caffeine, ethanol, and nicotine. From 15 to 25 of pregnant women report licit drug use (ethanol nicotine), or illicit drug use (marijuana cocaine heroin), or have positive urine drug screens during pregnancy. Analgesics, vitamins, iron, antibiotics, theoph-ylline, and psychotropic medications account for 50 to 80 of all reported toxic ingestions by pregnant women.

Testing Programs in Occupational Settings

The five substances routinely tested for include marijuana, cocaine, amphetamines, opiates, and PCP. Other drugs, such as alcohol, may be added to the panel if suspected by the employer from objective evidence (i.e., slurred speech, alcohol on the breath). Keeping with the Rule of Fives, there are five situations in which drug testing is conducted (1) preemployment, (2) random, (3) postaccident, (4) probable cause, and (5) return to work follow-up. The employer may request testing for additional substances in the case of postaccident, reasonable suspicion, and return-to-work situations. In order to undergo this additional testing, the employee must be notified via an official Employee Drug Policy document. Recognizing the high prevalence of alcohol abuse, ethanol testing was mandated in a 1994 amendment. There are separate regulations for alcohol testing, including not requiring MRO participation.

Sympathomimetic Toxidrome

Features Fight or flight hypertension, tachycardia, sweating, fever, excitation-psychomotor agitation, tremor, seizures, dilated pupils. Causes Amphetamines diet drugs, cocaine, theophylline, caffeine, methylphenidate, mono-amine oxidase inhibitors over-the-counter cold medications, especially those containing phenylpropanolamine (PPA), ephedrine, and pseudoephedrine. Mechanisms Increased release of catechol-amines (amphetamines), blockade of cat-echolamine re-uptake (cocaine), inhibition of catecholamine metabolism (monoamine oxidase inhibitors), indirect adrenergic receptor stimulation (ephedrine). Antidote Beta-blockers.

Unsafe Driving Habits

Never drive under the influence of alcohol. It slows your reaction times, distorts your vision, and impairs your judgment. And never use other psychoactive drugs (those that alter your mind or behavior, such as marijuana or methamphetamine) while driving. Be sure to read the labels on all prescription and over-the-counter medications for warnings about how they could affect your ability to drive.

Current and Targeted Medications

A current list of medications approved for the treatment of drug addiction is shown in Table 4. A brief description of these medications for treatment of specific drugs of abuse is described below. In all cases, new medications are under clinical and preclinical investigation. Examples of potential medications currently under clinical investigation are listed in Table 5 with their chemical structures being shown in Figure 8. As the mechanisms of actions of these agents are widely varied, no attempt to describe structure-activity relationships (SARs) within these classes of molecules has been made. However, the interested reader is referred to relevant review articles throughout the text that describe in more detail the drug design and synthesis of these agents.

Behavioral Environmental Modification

Although medication development for the treatment of drug addiction has been highlighted in this chapter, a brief discussion of the importance and role of behavioral therapy must be included for completeness. Indeed, drug addiction results from human behavior gone awry, and in most cases addicts who seek recovery from their addiction are more successful if they also engage in some form of behavioral environmental modification. The literature is vast on the topic of conditioned behavior and no attempt to further describe it will be made herein. However, as mentioned in the Introduction of this chapter, environmental factors and associations play a large role in relapse, and clinical intervention in the form of therapy and behavioral modification are proving successful.66 Recent investigations have shown that concepts of rewarding and aversive mechanisms can be applied to therapy, which, if available, can further be paired with pharmacotherapy.67 In contingency management,...

Unmet Medical Needs

Cocaine methamphetamine substantial burden of medical illness compared to age- and gender-matched US population controls.70 Drug-related complications occur not only in public sector patients, but also in a community sample of patients enrolled in a health maintenance organization.71 Some of the widely accepted medical complications are summarized in Table 7. Drug abuse is a leading contributor to the spread of AIDS, HIV, and hepatitis C, and drug abuse treatment can reduce the spread of these illnesses.8 Not unexpectedly, intravenous drug use causes various surgical complications.72 The medical and psychiatric needs of patients with substance dependence are far from met. There are a variety of reasons for this, as described in detail in the 1999 report of the US Surgeon General.73 Unfortunately, the various infrastructure and financial factors that affect the delivery of mental health and drug abuse treatments adversely impact the ability to develop new medications for substance...

New Research Areas

Intensive investigation toward novel clinical candidates for treatment of drug addiction has ensued and many candidates with a diversity of mechanisms of action have been identified and are in various stages of preclinical and clinical development. A list of these potential medications is given in Table 6 with their chemical structures shown in Figure 8. These compounds have been identified based on their current clinical use and or their mechanism of action which has been deemed pertinent to drug addiction, as discussed in Section 6.07.2. Their efficacy in treating drug addiction remains to be established but in all cases, a proof of concept in animal models has been provided.8'51'54'75'76

Preclinical Targets for Stimulant Addiction

Since there are no FDA-approved medications for the treatment of cocaine and amphetamine addiction, intensive efforts have been directed toward discovering medication candidates. In this regard, over the past decade, a focus on elucidating mechanisms underlying the reinforcing effects and addictive liability of cocaine, as well as those underlying relapse, has prompted the identification of receptor transporter candidates for drug discovery. Although many targets have been proposed, the following receptors transporters and examples of promising drug candidates that have high affinity and selectivity for these targets have been widely studied and currently hold the most potential for medication development. The monoamine neurotransmitter transporters are the principle sites of action of the psychostimulants cocaine and methamphetamine. These psychostimulants bind to the monoamine transporters and inhibit the reuptake of their respective neurotransmitters. Methamphetamine is further...

Identifying and Quantitating Controlled Substances

Cocaine can exist as either the hydrochloride (HCl) salt or as the base. Pursuant to federal law, there are sentencing guidelines based on the identification of cocaine as either the base or as the salt form (usually HCl). Cocaine can be adulterated with benzocaine, procaine, lidocaine, or any combination of these non-controlled drugs, and further diluted with manni-tol, lactose, or other processing sugars. A variety of instrumental techniques can be used to distinguish cocaine HCl from cocaine base. FTIR spectrophotometry is commonly available and used in many laboratories. The IR spectra of cocaine HCl and cocaine base are quite different and easily distinguished. The IR spectrum of a cocaine HCl sample mixed with an adulterant presents a problem. The same sample analyzed by GC FTIR presents the chemist with a total response chromatogram showing all peaks in a mixture. The resulting IR spectrum and mass spectrum are identifiable. However, in this technique, cocaine HCl and cocaine...

Clinical Trial Issues

For PD, two different clinical study designs (drug wash-out and randomized delayed starts) have been used in attempts to distinguish this difference for NCEs.69 The first uses a drug wash-out period at the end of the treatment course. Patients are followed for different time periods following drug withdrawal to determine if a benefit persists in the absence of continued drug use. While this is a logical design, there are inherent problems. One issue is that the pharmacodynamic effects of treatment may outlast the duration of the physical presence of the drug. Another is that patients with more severe symptoms cannot tolerate discontinuation of a symptomatic treatment thus patients with less severe symptoms may be preferentially retained in a study. The second design is a randomized delayed-start trial in which patients are randomized to treatment groups following receipt of placebo for various durations. This study design also has challenges (1) treatment earlier in the course of...

Clinical Findings CT Radiographic and MRI

Crack cocaine inhalation intracranial and interventricular hemorrhage. Intravenous crack cocaine abuse septic cerebral emboli with multiple brain abscesses. Crack cocaine inhalation radiolucencies throughout the left lung interstitium. Intravenous crack cocaine abuse dissecting thoracic aneurysm. Intravenous cocaine abuse fatal mesenteric infarction with small bowel perforation. Figure 9.10 Dissecting Thoracic Aneurysm. Contrast-enhanced, T1-weighted, sagittal-oblique, computerized axial tomogram (CT) of the chest that demonstrates an intimal flap dividing the descending thoracic aorta into true and false lumens consistent with dissecting thoracic aneurysm Type B in an intravenous cocaine abuser. (Courtesy of Carlos R. Gimenez, M.D., Professor of Radiology, LSU School of Medicine, New Orleans, LA.)

Guidelines for Client Selection

ACT can be used with a variety of clients and clinical presentations, with no specific limitations to its use. However, it is most useful when applied with clients who are assessed to be emotionally avoidant and or cognitively fused, have chronic conditions, or who have multiple treatment failures. ACT has been demonstrated to be effective when used in the treatment of PTSD (Follette et al., 1993 Walser, Loew, Westrup, Gregg, & Rogers, 2003a Walser, Westrup, Rogers, Gregg, & Loew, 2003b Batten & Hayes, 2005), anxiety and stress (Bond & Bunce, 2000 Twohig & Woods, 2004 Zettle, 2003), substance abuse dependence (Gifford etal., 2004 Hayes etal., 2002), coping with positive psychotic symptoms (Bach & Hayes, 2002), chronic pain (Dahl, Wilson, & Nilsson, 2004 McCracken, Vowles, & Eccleston, 2004), stigma and prejudice in drug abuse counselors (Hayes et al., 2004a), depression (Folke & Parling, 2004 Zettle & Hayes, 1986 Zettle & Raines, 1989), self-management of diabetes (Gregg, 2004), and a...

Cardiovascular Toxicity

Confirm cocaine packs by abdominal x-ray. Institute ECG monitoring. Activated charcoal (AC) and cathartic, then multi-dose activated charcoal (MDAC) to reduce absorption and enhance elimination. Whole-bowel irrigation (WBI) with polyethylene glycol electrolyte solution (PEG-ELS) to reduce gastrointestinal mucosal contact time, speed transit, and increase elimination. Surgical removal for symptomatic patients with packet rupture or intestinal obstruction. Follow-up imaging with abdominal x-rays consider barium enema. Figure 9.12 Management Cocaine v. Heroin Body Packers. A flow chart outlining the clinical practice management strategies for body packers of cocaine or heroin. Figure 9.12 Management Cocaine v. Heroin Body Packers. A flow chart outlining the clinical practice management strategies for body packers of cocaine or heroin.

Research Issues and Problems

Although many of the points stressed in this section may appear obvious, they have been overlooked and continue to be disregarded by investigators in psychopathology. For example, a recent study of borderline personality disorder, with several positive features, also exhibited some of the deficiencies previously discussed (Nurnberg, Hurt, Feldman, & Suh, 1988). Patients for this study were selected from consecutive admissions to a twenty-three bed adult inpatient unit of a university teaching hospital. The criteria used specified an age range of 16 to 45, ''no evidence or history of organic mental disorder, neurologic disorder, substantial concurrent medical illness, mental retardation, or alcohol or drug addiction as a primary diagnosis no DSM-III-R diagnosis of schizophrenia, major affective disorder, paranoid disorder, or schizoaffective disorder and an independent clinical diagnosis of borderline personality disorder by the treatment team'' (p. 1280). All patients also were rated...

General Appearance Manner and Attitude

And neatness of attire, responsiveness, cooperation, and ability to maintain eye contact. Observation for psychomotor retardation (slowing) or agitation can be helpful. The psychiatrist can listen carefully for rate, quality, tone, audibility, modulation, and form of speech, including evidence ofprosody, aphasias, or dysphasias. Additionally, observation of skin for icterus, pallor, cyanosis, edema, rashes, or other lesions can be helpful. The psychiatrist should also evaluate whether the patient appears healthy or ill, robust or cachectic, with signs of wasting and protein energy undernutri-tion. Obvious signs ofspecific medical illness or organ impairment include seizures, involuntary movements, tremors, paresis, paralysis, facial droop or asymmetry, exophthalmos, neck fullness, spider angiomata, asci-tes, anascarca, dyspnea, clubbing, and pedal edema. The psychiatrist can look for signs of delirium such as fluctuating levels of consciousness, mood, and behavior and falling asleep...

Analyzing Drugs In The Forensic Science Laboratory

The color test is usually the first chemical examination examiners conduct after a package suspected of containing controlled substances is opened and weighed. Small amounts of the unknown material are placed in depressions in a porcelain spot plate or a disposable plastic or glass spot plate. Chemical reagents are then added to the depressions and the results noted color changes, the way in which the color changes take place (flashing or bleeding), the rate at which the color changes take place, and the intensity of the final colors. The most common color reagents are the Marquis reagent for opium alkaloids, amphetamines, and phenethylamines such as MDA or MDMA cobalt thyocyanate reagent for cocaine and phencyclidine (PCP) Dille-Koppanyi reagent for barbiturates Duquenois reagent for marijuana and Ehrlich's reagent for LSD. A more complete listing of these tests is available in the literature.1 Many of these tests are multi-step and multi-component.

Clinical evaluation

The majority of patients with COPD will have either a history of cigarette smoking or exposure to second-hand cigarette smoke. Occasionally, patients will develop COPD from occupational exposure. A minority of patients develop emphysema as a result of alpha-1-protease inhibitor deficiency or intravenous drug abuse.

Strategies to improve cell productivity

A clear example of success in obtaining high productivity is that of tropane alkaloids (Verpoorte et al., 1999). These are a well-recognized group of structurally related natural products and have long been known to have anticholinergic, antiemetic, parasympatholytic, anaesthetic, and many other actions. This class of alkaloid includes such important medicinal alkaloids as cocaine, scopolamine and atropine. The genera Atropa, Datura, Duboisia, Hyoscyamus and Scopolia, which belong to the Solanaceae, are especially rich sources of tropane alkaloids.

Initial Evaluation Of The Patient With Substance Use Disorders

Team and be used to develop the safest possible treatment plan. The clinician should ask about specific illicit substances such as heroin, cocaine, marijuana, and the club drugs (see below). For taking a history of alcohol use, some clinicians have suggested the use of the CAGE questionnaire (Ewing, 1984) 1. Can you cut down on your drinking 2. Are you annoyed when asked to stop 3. Do you feel guilty about your drinking 4. Do you need an eye-opener when you wake up in the morning One should also ask about sedative or stimulant use, whether prescribed or nonprescribed, and any dietary supplements or herbs the patient may be taking. A substance abuse review of systems, focusing on renal, cardiac, gastrointestinal, and, for HIV patients especially, neurological symptoms, is essential. Other points of inquiry are the date the substance was first used patterns, amount, and frequency of use and routes of administration and reactions to the use. The time of last use is important to know to...

In Search of a Mechanisms of Action

At least in narcoleptic dogs, via a mechanism independent of the hypocretin receptor.36 Additionally, in DAT knockout mice, modafinil-like methamphetamine and the selective DAT blocker, GBR 12909, lacked wake-promoting effects.36 Increases in dopamine release in the rat nucleus accumbens were observed following modafinil administration but this was secondary to a reduction in GABAergic transmission that led to a reduction of GABAA receptor signaling in dopamine terminals.37 Modafinil dose-dependently reduced g-amino-butyric acid (GABA) outflow from the cortex of awake guinea-pig,38 and from the striatum, pallidum, and substantia nigra,39 and, more importantly, from the medial preoptic area and posterior hypothalamus of the awake rat.40 The latter are hypothalamic fields where functional inhibition of GABA release by modafinil may be relevant for its vigilance-promoting effects. Modafinil also increased glutamate release in the ventrolateral and ventromedial thalamic areas,...

In Search and Discovery of Potential New Therapeutic Indications

Despite its stimulant activity, modafinil did not produce reinforcing or rewarding effects and did not modify the effects of cocaine in rats.97 Evaluation for cocaine-like discriminative stimulus effects in rats and for reinforcing effects in rhesus monkeys maintained on intravenous cocaine self-administration demonstrated that the reinforcing and discriminative stimulus effects of modafinil required very high doses.98 The low abuse potential was confirmed via an extensive data set in healthy human volunteers23,99 and in volunteers with a recent history of cocaine abuse where cocaine and methylphenidate, but not modafinil, produced cocaine-like discriminative stimulus, subject-rated, and cardiovascular effects.100 Based on the low potential of addiction and dependence, a preliminary study provided evidence that modafinil improved clinical outcome when combined with psychosocial treatment for cocaine dependence.101 An anecdotal story in a woman outpatient with social phobia and...

Treatment And Management Of Substance Use Disorders

Methadone detoxification is the preferred method of managing opioid withdrawal. Schedules using bu-prenorphine and or clonidine for opioid detoxification are also available (NIH Consensus Development Conference, 1998). Detoxification from cocaine and stimulants is not done pharmacologically. Network therapy is an office-based treatment of SUD advocated by Galanter and colleagues (Galanter and Brook, 2001) that employs both psychodynamic and cognitive-behavioral approaches. The treatment includes a therapeutic network of non-abusing family members, significant others, and peers who actively participate with the therapist to provide cohesiveness and support, undermine denial, and promote compliance with treatment. Studies have demonstrated significantly less illicit substance use among patients receiving this treatment for cocaine and opiate abuse. (Galanter et al., 1997, 2004)

Cerebral Cortex And Swimming

Mesolimbic Mesocortical Pathway

Dopamine (DA) is the major cate-cholamine neurotransmitter of the mammalian CNS, comprising at least 50 of the total CNS catecholamine content. There are four major dopaminergic pathways in the brain. The mesolimbic pathway originates in the ventral tegmental region of the midbrain, near the substantial nigra, and projects to several higher centers of the limbic system, including the amygdala, the frontal and cingulate cortex, the nucleus acumbens, the olfactory tubercle, and the septum. These areas mediate mood changes and cognitive function, and are believed to be the sites where drugs such as cocaine and amphetamines produce their stimulant effects. Other CNS drugs such as antidepressants, which block MAO, and antischizophrenia neu-roleptic drugs, which block DA receptors, may act in these regions. The nigrostriatal pathway projects from the substantia nigra to the corpus striatum, and specifically to the putamen and caudate nuclei, which are implicated in the control of fine motor...

Epidemology Considerations

Dressler and Roberts, for example, analyzed 168 drug-related deaths and reported that the incidence of cardiac abnormalities in drug abusers was nearly 100 9 However, toxicologic findings were not known for the individual patients, and all of the cases had been referred to a tertiary center for diagnosis. The availability of comprehensive toxicologic screening has been something of a mixed blessing because polypharmacy is now more often detected. In San Francsico, more than half of the drug related deaths are due to drugs taken in combination, often stimulants and narcotics. Attempts at correlating specific drugs with certain types of lesions are futile when more than one drug is present. Even when just one drug is detected, the possibility of past multi-drug use is not ruled out. Nonetheless, certain generalizations are possible. The hearts of stimulant abusers, whether of cocaine or methamphetamine, often manifest changes consistent with the known effects of prolonged catecholamine...

Myocardial Hypertrophy

Stimulant abusers are prone to modest degrees of myocardial hypertrophy, and there is some evidence that opiate abusers may also share this tendency. Increased left ventricular mass is an independent risk factor for sudden cardiac death.11,12 As ventricular mass increases, coronary artery reserve declines,13 and myocardial contractility becomes impaired.14 Increased mass makes ventricular arrhythmias, and sudden death, more likely,15 even in the absence of relative myocardial ischemia provoked by the decline in coronary artery reserve.16 This combination of effects may well explain many cases of cocaine-related sudden death. The mechanism by which stimulant abuse causes myocyte hypertrophy is not known. In general, stimuli associated with myocardial hypertrophy activate G-proteins, and either adenyl cyclase or phospholipase C. When one of the latter is activated, genes needed to make the proteins necessary for cell growth are also activated.17 After myocardial infarction, there is...

What Is Not Part Of The Treatment

Thus far, only a few studies of clients with PTSD and substance abuse have used exploration of past trauma as a key intervention. In one study (Brady et al., 2001) results indicated that the 39 of their sample who was able to complete at least 10 of the 16 sessions showed positive outcomes in PTSD symptoms and cocaine use (as well as other symptoms), which were maintained at the 6-month follow-up. However, most clients were noncompleters and the researchers excluded clients with suicidal ideation, and thus likely selected a less impaired sample. In a study that combined Seeking Safety plus Exposure Therapy-Revised (Najavits et al., in press-a), positive outcomes were found in various domains, including psychiatric and substance abuse symptoms. However, a large number of modifications to standard exposure therapy was created, the treatment was conducted individually, and various safety parameters were put in place to maximize clients' ability to safely tolerate the work. For a...

Psychosocial Treatments

Although this chapter has presented only pharmacotherapies for opioid addiction, it is crucial that psychosocial interventions be used to help these patients change their lifestyles. It is generally accepted that escape from drug seeking and the accompanying antisocial impulses requires a change in deeply rooted behavioral patterns. Individual and group psychotherapy may be useful in approaching this goal. Contingency management may be very helpful (Robles, Stitzer, Strain, Bigelow, & Silverman, 2002). The various 12-step programs such as Narcotics Anonymous are also useful adjuncts to treatment and facilitate significant degrees of change. For those persons who continue to relapse in less restrictive treatment settings, a therapeutic community may be the appropriate next step (O'Brien & Biase, 1981) these nonhospital, community-based, 24-hour, live-in programs are geared to subject the addict to continuous treatment pressure for as long as 1 or 2 years. Personal freedom is severely...

Myocardial Disease in Opiate Abusers

While no general pattern of myocardial diseases is associated with opiate abuse, an assortment of drug abuse-related disorders may occasionally be encountered. Myocardial fibrosis is not uncommon, but its presence probably is just a consequence of concomitant stimulant abuse. Perivascular fibrosis, when it occurs, usually signals previous bouts of healed endocarditis. Larger zones of fibrosis are the results of ischemia and healed infarction. But unlike cocaine users, who appear to be prone to accelerated coronary artery disease,28,67 there is no evidence that coronary artery disease is any more common among heroin abusers than it is in the general population. Intravenous drug abusers are prone to pulmonary hypertension as a consequence of granuloma formation in the pulmonary bed,68 and the occasional talc granuloma may even be seen in the myocardium.69

Primary Nursing Diagnosis

If the patient has developed endocarditis as a result of IV drug abuse, an addiction consultation is essential, with a possible referral to an appropriate treatment program. Surgical replacement of the infected valve is needed in those patients who have an infecting microorganism that does not respond to available antibiotic therapy and for patients who have developed infectious endocarditis in a prosthetic heart valve. (See Coronary Artery Disease, p. 248, for a full discussion of the collaborative and independent management of a patient following open heart surgery.)

Myocardial Disease Associated with HIV Infection

In some areas of the U.S. more than one half of all intravenous drug abusers carry the HIV virus. Given that endocarditis is the only cardiac disorder unequivocally associated with intravenous opiate abuse, it is highly probable that any myocardial lesion encountered in the heart of an intravenous heroin abuser is there as a result of either concomitant stimulant abuse, HIV infection, or an opportunistic infection related to HIV infection. In most cases, cardiac manifestations of HIV infection are clinically silent and not discovered during life.70-71 Pericardial effusion is the cardiac lesion most commonly seen in AIDS patients. One third of the patients dying of AIDS have effusions, with or without pericarditis,71,72 and the probability is that the effusion will not have been symptomatic during life. Ventricular hypertrophy is even more common than pleural and pericardial effusions,71 with evidence of ventricular thickening in nearly half the HIV victims autopsied. Right ventricular...

Inflammation nasal vestibulitis

Vestibulitis Nasal

A deviation of the septum has predisposed to a chronic vestibulitis. Digital irritation, or the use of cocaine, which may also lead to a septal perforation, may underlie this problem. Fig. 3.50 Vestibulitis. Painful crusting of the nasal vestibule and anterior nares may be a simple eczematous type of skin lesion which settles with a topical antibiotic and steroid ointment. There should, however, be an awareness that this vestibulitis is a granuloma, or part of the manifestation of systemic disease such as polyarteritis nodosa or systemic lupus erythematosus. A further possibility is an irritative vestibulitis from cocaine snuff, or columellar carcinoma, as in this case Fig. 3.50 Vestibulitis. Painful crusting of the nasal vestibule and anterior nares may be a simple eczematous type of skin lesion which settles with a topical antibiotic and steroid ointment. There should, however, be an awareness that this vestibulitis is a granuloma, or part of the manifestation of systemic disease...

Major Depressive Disorder

Similarly, interpersonal therapy (IPT) has demonstrated efficacy in treating major depressive illness in HIV disease (Markowitz et al., 1992, 1995), and IPT may offer advantages to patients who have been recently diagnosed with HIV AIDS or have recently progressed in their disease severity. IPT is notable for its brevity and can successfully focus on the common problems encountered in HIV disease, including grief, changes of life after disease diagnosis, role identity during times of illness progression, interpersonal disputes related to family strife surrounding diagnosis, issues of homosexuality or drug abuse, and support of existing coping strategies.

Incidence and Clinical Profile

Although intravenous drug abuse is a recognized risk factor for infectious endocarditis, this complication is not a frequent complication among intravenous drug users. The incidence of Uncommon Pathogens in Endocarditis of Intravenous Drug Abusers11 infective endocarditis in intravenous drug abusers is estimated at 1.5-2.0 cases per 1000 intravenous drug abusers admitted to the hospital.1 Intravenous drug abusers with infective endocarditis are more likely to be young men (ave. age 29 years, M F 3 1) compared with non-addicts with endocarditis (ave. age 50, M F 2 1).2 The frequency of underlying heart disease in intravenous drug abusers with endocarditis is 26 compared with 60 of non-addicts with endocarditis. In a cohort of 85 intravenous drug abusers, echocardiography failed to detect any valvular vegetation consistent with endocarditis.3 Eight intravenous drug abusers had thickened or redundant leaflets (with or without prolapse) of the mitral, aortic, or tricuspid valve. Focally...

Secondary Sleep Disorders

Secondary Sleep Disorders

Depression (of various types) can impair sleep, though paradoxically sleep deprivation can ameliorate depression. Depressed persons typically complain of early morning awakening, nocturnal restlessness, and difficulty in starting the day. Sleep disturbances are also common in patients suffering from psychosis, mania, anxiety disorders, alcoholism, and drug abuse.

Vascular effects of substance abuse

Statistics provided by the Drug Abuse Warning Network (DAWN) over the past two decades have documented an increasing prevalence in substance abuse as manifested by emergency room and Medical Examiner data (i.e., drug mentions). For example, the Office of the Chief Medical Examiner (OCME) has reported a marked increase in the number of drug abuse deaths in Maryland from 1986 to 1993, with drug deaths increasing sharply from 119 cases in 1986 to 356 in 1993, a 199 increase over seven years.1 Narcotic drugs, specifically heroin, have played a major role in the rising number of drug abuse deaths.1 Not surprisingly, cardiovascular complications have accompanied this increase. However, characterizing the effects of drugs of abuse on the vasculature is difficult because not all abused drugs result in anatomic changes. Direct human studies are scarcely available, and the studies that exist are performed under limited, controlled conditions which do not replicate the usage picture or...

Differential Diagnosis of Sympathetic Toxidromes

Poisoning Pulmonary Edema

Figure 9.4 Noncardiogenic Pulmonary Edema Crack Cocaine Injection. Frontal chest radiograph that demonstrates normal size and configuration of the cardio-mediastinal silhouette and bilateral diffuse pulmonary edema following the intravenous injection of crack cocaine. Noncardiogenic pulmonary edema may also follow opioid overdoses with the same radiographic patterns. (Courtesy of Carlos R. Gimenez, M.D., Professor of Radiology, LSU School of Medicine, New Orleans, LA.) Figure 9.4 Noncardiogenic Pulmonary Edema Crack Cocaine Injection. Frontal chest radiograph that demonstrates normal size and configuration of the cardio-mediastinal silhouette and bilateral diffuse pulmonary edema following the intravenous injection of crack cocaine. Noncardiogenic pulmonary edema may also follow opioid overdoses with the same radiographic patterns. (Courtesy of Carlos R. Gimenez, M.D., Professor of Radiology, LSU School of Medicine, New Orleans, LA.) Toxins Cocaine, phenycyclidine (PCP), amphetamines,...

Woman with Guilt and Shame about Not Disclosing Childhood Sexual Abuse

Mary, who was in her mid-30s, had a longstanding history of drug abuse and had been in two relationships with boyfriends who were abusive. She had had almost 2 years of sobriety when she volunteered to receive cognitive trauma therapy (CTT). To correct hindsight-biased thinking, it is critical to identify negative outcomes that were unforeseeable. Recalling unforeseeable outcomes as foreseeable reflects hindsight-biased thinking, and if outcomes were not foreseeable, they were not preventable. Mary's therapist established that many important outcomes were not foreseeable when Mary chose to keep the molestation a secret after it first happened. Mary did not know that her uncle was going to molest her again, that the abuse was going to continue for 5 years, and that it was going to result in her dropping out of school and engaging in years of drug addiction. In addition, she did not know that, when she was molested on subsequent occasions, it was going to make her appear more implicated...

Multiple Lumbar Spine Surgery Failed Back Syndromes

Patients with profound emotional disturbances and instability (e.g., alcoholism, drug abuse, depression) and those involved with compensation and litigation should undergo a thorough psychiatric evaluation. Even if they are found to have a genuine neurosurgical problem, the psychosocial problem should be dealt with first, as additional low back surgery would otherwise fail again. After exclusion of the psychosocial group of patients, a smaller group of patients with back and or leg pain due to mechanical instability or scar tissue remains only those patients with mechanical instability will benefit from additional surgery.

Stephen L Dilts Jr Stephen L Dilts

The history of opioid use goes back thousands of years in human history. The Ebers Papyri from approximately 7000 B.C. refer to the use of opium in children suffering from colic (Deneau & Mule, 1981). In the Victorian era, the use of laudanum was socially acceptable. In the present day, opioids use is stringently regulated, especially in the United States however, demand by addicts results in the existence of a black market characterized by crime, disease, poverty, and loss of personal and social productivity. The sexually promiscuous intravenous heroin user is at high risk to contract and effectively spread the deadly acquired immune deficiency syndrome (AIDS) virus, as well as venereal and other infectious diseases, such as hepatitis C. High overall death rates are associated with opioid abuse, approximately 10-15 per 1,000 in the United States (Jaffe, 1989). The Drug Abuse Warning Network (Substance Abuse and Mental Health Services Administration, 1995) indicates an alarming...

Commonly abused drugs 2421 Excited Delirium

Excited delirium is a drug-induced delirium or psychosis accompanied by agitation and hyperthermia, and often ending with respiratory arrest and sudden death. Cocaine is the drug most often implicated in this syndrome,13 but amphetamines have also been implicated in some cases. The syndrome is not due to any contaminants that may accompany the cocaine sample. The pathogenesis of cocaine-induced excited delirium is unknown. One hypothesis is that cocaine initially elevates brain dopamine levels causing the delirium. This cocaine-induced Table Comparison Between Neuroleptic Malignant Syndrome and Cocaine-Induced Agitated Delirium Cocaine delirium brain dopamine elevation has been demonstrated in animals.14 The syndrome is thought to be similar to the neuroleptic malignant syndrome (NMS) in Parkinson disease patients withdrawn from levodopa, a dopaminergic drug. Patients experience hyperthermia, autonomic instability, and delirium (see Table NMS is characterized by...

Neurotransmitters And Behavioral Pharmacology

Cocaine is both a stimulant of the central nervous system (CNS) and a local anesthetic, with large abuse liability due to its reinforcing properties. It is widely believed that the cocaine reward system is the mesocorticolimbic pathway, which originates in the ventral tegmental area (VTA) and projects to numerous areas of the forebrain, including the frontal cortex, hippocampus, amygdala, and the striatum (including the nucleus accumbens and the caudate putamen) (Koob, 1992). Recent work examining neurochemical turnover rates suggests that discrete subpopulations of dopamine, serotonin, glutamate, and gamma-aminobutyric acid (GABA)-releasing neurons are responsible for cocaine reward. Data suggest that dopamine in the nucleus accumbens, VTA, septum, lateral hypothalamus, and brainstem glutamate in the nucleus accumbens and VTA and serotonin in the medial hypothalamus are implicated in cocaine reward. In addition, surprising findings in the cerebral cortex have included noradrenergic...

Coronary Artery Spasm

Anterior Descending Coronary Artery

Death is believed to be due to transitory coronary artery spasm. The phenomenon of coronary artery spasm without anatomical narrowing of the coronary arteries in association with angina has been demonstrated angiographically and has actually been witnessed during operative procedures.11-13 Myocardial infarction secondary to coronary artery spasm induced by use of cocaine is a well recognized phenomena.

Miscellaneous complications

The most frequently encountered renal abnormality among drug abusers seen today is myoglobinuric nephrosis secondary to cocaine-induced rhabdomyolysis. These are frequently seen in victims of drug-induced excited delirium accompanied by hyperpyrexia and intense muscular activity.1 Survival for several days reveals, at autopsy, massive necrosis of skeletal muscle which is easily identified because of its distinctive yellow (instead of dark brown) coloration.2 These deaths are invariably marked by pronounced elevations in serum creatine kinase, profound hypotension, and disseminated intravascular coagulation. Abuse of stimulant drugs has also been associated with renal artery thrombosis and infarction, and renal vasculitis.1 Maternal cocaine abuse has been associated with a plethora of fetal anomalies, most notably urogenital abnormalities such as hydronephrosis and atresia of the distal ureters.1 Liver damage from drug abuse is often related to direct drug toxicity, allergic or...

Gender Ethnicracial And Life Span Considerations

MI is the single largest cause of death among American men and women, including white, African American, and Hispanic Latino populations. The risk of MI increases with age, and it occurs most commonly in people older than 45 years of age. MIs also occur in young adults, such as individuals who use cocaine, those who are insulin-dependent diabetics, and those who have hypercholesterolemia and a positive family history for early coronary disease.

Severe Mental Illness And Hiv Risk

Although abstinence from mood- or cognitive-altering substances is often considered the ideal, agonist-based therapies may provide a particularly effective form of treatment for opiate users. Metha-done maintenance therapy is highly useful in the management of opiate addiction among the chronically mentally ill. Adherence to a methadone program has been shown to decrease HIV risk behavior (Wong et al., 2003) it removes individuals from high-risk behaviors and environments while reducing motivation to seek IVDU in the community. It also keeps the individual actively participating in a treatment community. Individuals on methadone maintenance therapy demonstrate better adherence to highly active antiretroviral therapy (HAART), which decreases the overall cost of health care (Sambamoorthi et al., 2000). Methadone can be used by providers to give positive reinforcement for desired behaviors, such as rewarding a patient with take-home methadone after several months of negative toxicology...

Drug Induced Vasculitis Including Illicit Drugs

Cocaine Vasculopathy

Some drugs, such as chemotherapeutic agents (e.g. sulfonamide, thiouracil) and illicit drugs (e.g. cocaine), can cause vasculitis 26 . Stroke can occur soon after administration of illicit drugs by an intravenous, oral or nasal route. Cocaine, heroin, amphetamine and other sympathomimetic drugs are most commonly implicated. The diagnosis of vasculitis depends on the pathological findings, not on the an-giographic findings, which are usually non-specific Cocaine use has emerged as an important cause of cerebrovascular events in young adults 27 . Vas-culitic changes can be present on angiography, but the significance of these changes has been debated. However, elevated sedimentation rate and biopsy changes of vasculitis have been documented. MR angiography may reveal irregularity of the intracerebral vessels and DW imaging is useful for the detection of acute ischemic changes (Fig. 7.10). Cocaine-induced vasculopathy in a 41-year-old man with dysarthria. a T2-weighted image shows...

Obstetric And Developmental Effects

In the United States, more than 100,000 babies are exposed prenatally to cocaine each year (Office of the Inspector General, 1990). Increasing evidence indicates that prenatal cocaine exposure is associated with negative perinatal outcomes, including premature delivery, low birthweight, microcephaly, newborn behavioral abnormalities, and possible long-term cognitive and developmental difficulties (Singer et al., 2002). However, the impact of cocaine on the developing fetus is difficult to ascertain, because no confined, homogeneous, syndromic pattern of malformations has been identified, and because the mechanisms by which cocaine impacts on the unborn child are complex maternal cocaine use may have both indirect and direct effects on a developing fetus (Vidaeff & Mastrobattista, 2003). Indirect effects of maternal cocaine use include negative health consequences for mothers, which then impact their pregnancies. Women using cocaine are more likely to suffer arrhythmias, cardiac...

Comprehensive Hiv Services Lead To Improved Outcomes For Patients And Providers

Alterman AI, Erdlen FR, and LaPorte DJ (1982). Effects of illicit drug use in an inpatient psychiatric population. Addict Behav 7 231-242. Bleuler, E (1911). Dementia praecox oder Gruppe der Schizophrenien', In G. Aschaffenburg (ed.), Handbuch der Psychiatrie. Spezieller Teil. 4. Abteilung, 1. H lfte. Leipzig und Wien Franz Deuticke. Carey MP, Carey KB, Weinhardt LS, and Gordon CM (1997). Behavioral risk for HIV infection among adults with a severe and persistent mental illness patterns and psychological antecedents. Community Ment Health J 33(2) 133-142. Caton CLM, Gralnick A, Bender S, and Robert S (1989). Young chronic patients and substance abuse. Hosp Community Psychiatry 40 1037-1040. Chander G, Himelhoch S, and Moore RD (2006). Substance abuse and psychiatric disorders in AIDS patients epidemiology and impact on antiretroviral Dixon L, Hass G, Weiden PJ, Sweeny J, and Frances AJ (1991). Drug abuse in schizophrenic patients clinical correlates and reasons for use. Am J...

Identifying Adulterants and Diluents

Most street exhibits of heroin and cocaine contain adulterants and diluents. Samples taken from large scale, brick size, kilogram seizures will be relatively pure. Except for some by-products from the opium poppy and the coca leave, there will be little in the way of foreign materials. Adulterants are encountered, in increasing proportions, as the heroin and cocaine progress down the distribution chain from the main supplier to the dealers to the users. Adulterants commonly encountered in heroin include quinine, procaine, acetaminophen, caffeine, diphenhydramine, aspirin, phenobarbital, and lidocaine. Adulterants commonly encountered in cocaine include procaine, benzocaine, and lidocaine. Diluents found in heroin include different kinds of starches. It is not uncommon to find in heroin substances such as calcium carbonate which had been added during the morphine extraction processes. Diluents found in both cocaine and heroin include lactose, mannitol, sucrose, and dextrose. The...

Figure 46 Chemical structures of selected smallmolecule monoamine neurotransmitters

The dopamine transporter (DAT) - a Na+ and CP-dependent neuronal transmembrane protein - was first cloned in the early 1990s, and is involved in locomotor control, including functions lost in Parkinson's disease. DAT is also involved in reward systems, and thus in addiction to drugs such as amphetamine and cocaine, and in ADHD and Tourette's syndrome, among other illnesses.367-371 Indeed, the actions of many small molecule neurotransmitters containing a basic amine are modulated through transporter sites, including those of adrenaline and noradrenaline (epinephrine or norepinephrine), dopamine, histamine, and serotonin (Figure 46). That is, transporters serve to modulate synaptic neurotransmitter levels through reuptake into nerve terminals, and once inside they are taken up into vesicles via different transporters (Figure 47). These effects lend themselves to being studied via in vivo imaging techniques, as outlined later.

Experimental Models of Addiction

Animal Models Drug Abuse

In order to identify potential medications for the treatment of drug addiction, animal models have been created that allow the elucidation of the underlying mechanisms of drug-induced behaviors. By its definition, addiction is a unique and complicated human behavior and a single animal model simply cannot predict medication efficacy in humans. Thus most investigators use an arsenal of in vitro and in vivo tests to study neurochemical mechanisms underlying the pharmacological actions and abuse liability of various drugs of abuse, as well as for discovering potential medications. In vitro binding and functional assays are generally used to determine mechanisms of action of test compounds (new compound entities, NCEs) and then those with the desired in vitro profile are further investigated in animal models. Biochemical assessment using in vivo microdialysis is often employed to further delineate NCE effects on neurotransmitter levels in various brain regions. Ultimately, behavioral...

Future Considerations

Thomas E Prisinzano was born in New York City, and studied at the University of Delaware, where he obtained a BS in 1995, and Virginia Commonwealth University, where he completed his PhD in 2000 under the direction of Professor RA Glennon. He was then awarded an Intramural Research Training Award Fellowship to study in the laboratory of Dr Kenner C Rice at the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). While at NIDDK, he worked on drugs of abuse and treatment agents. Subsequently, he took up his present position as an Assistant Professor in Division of Medicinal and Natural Products Chemistry at the University of Iowa in May 2003. His scientific interests include the development of novel analgesics, in particular, the development of novel compounds to study the neurochemical mechanisms of drug dependence and tolerance.

Personality Disorder In Hiv Atrisk And Hivpositive Individuals

Personality disorder is a risk factor for HIV infection (Brooner et al., 1993). Prevalence rates of personality disorders among HIV-positive (19 -36 ) and HIV at-risk (15 -20 ) individuals (Perkins et al., 1993 Jacobsbergetal., 1995 Johnson etal., 1995) arehighand significantly exceed rates found in the general population (10 ) (Weissman, 1993). Antisocial (ASPD) and borderline (BPD) personality disorders are the most common (Golding and Perkins, 1996). Individuals with personality disorder, particularly ASPD, have high rates of substance abuse and are more likely to inject drugs and share needles compared to those without an Axis II diagnosis (Kleinman et al., 1994 Hudgins et al., 1995 Dinwiddie et al., 1996). Approximately, half of drug abusers meet criteria for a diagnosis of ASPD (Hudgins et al. 1995 Dinwiddie et al., 1996). Individuals with ASPD are also more likely to have higher numbers of lifetime sexual partners, engage in unprotected anal sex, and contract STDs, compared to...

Myocardial Disease in Stimulant Abusers

Biopsy findings in a group of cocaine users with recent onset of chest pain and congestive failure showed changes very similar to those described above, with microfocal interstitial Figure Contraction band necrosis in a 32-year-old cocaine abuser with arrhythmic sudden death. The dark cross banded lesions are a marker for intracytasolic calicum overload secondary to catecholamine excess. Cells with these lesions may or may not be viable. If severe, the cells are replaced by fibrous tissue with abnormal conduction properties. Figure Contraction band necrosis in a 32-year-old cocaine abuser with arrhythmic sudden death. The dark cross banded lesions are a marker for intracytasolic calicum overload secondary to catecholamine excess. Cells with these lesions may or may not be viable. If severe, the cells are replaced by fibrous tissue with abnormal conduction properties. Figure Patchy myocardial fibrosis in a 28-year-old cocaine abuser who died in a motor...

Case Example Illustrating Common Obstacles

Sam was a 34-year-old unemployed European American male with a college education. He had a long history of alcohol and drug abuse, starting with his first drink at the age of 8. In addition, Sam had an extensive history of being physically and sexually assaulted. At the time he sought treatment, he had already been abstinent from alcohol and drugs for 6 months, due to a previous traumatic incident. Thus, at his initial assessment, Sam met criteria for PTSD, major depressive disorder, and polysubstance dependence in early full remission. The index event that brought him into treatment this time was a more recent assault, which included a sexual assault. The CPT treatment then began, and during the first session, the therapist explained the symptoms of PTSD, gave a rationale for treatment, described the course of the therapy, and explained the first homework assignment, which was to write an Impact Statement about the meaning of the index assault.

Medical Use And Abuse

Workplace drug testing is usually limited to identification of marijuana, cocaine, morphine-codeine, amphetamine-methamphetamine, and phencycli-dine (PCP). However, benzodiazepines and barbiturates may be added to the test panel. Laboratory positive test results for patients with legitimate prescriptions for benzodiazepines and barbiturates are reported to employers by medical review officers (MROs) as negative, as are other laboratory results that reflect appropriate medical treatment with other controlled substances (MacDonald, DuPont, & Ferguson, 2003).

As Sources Of Distress

Similarly, respiratory events and illnesses such as opportunistic infections, tuberculosis, malignancies, adult respiratory distress syndrome, and pulmonary fibrosis (Rosen et al., 1997) remain common in HIVseropositive populations, especially among those with CD4 counts

Descriptive Approaches

Most broadly, the literature frequently describes polydrug use or poly-substance use. This nondiagnostic designation generally describes the use of multiple substances rather than framing the use and its effects in clinical terms, which is the intent of diagnosis. As such, polydrug use describes, at minimum, the use of multiple substances, whether licit or illicit. In the treatment research literature, polydrug use is often used to describe the lifetime number of drugs regularly used to a threshold SUD, in addition to the index substance (Ball, Carroll, Babor, & Rounsaville, 1995 Feingold, Ball, Kranzler, & Rounsaville, 1996). However, in other than addiction or mental health treatment settings, the expressions polysubstance use or polysubstance abuse are frequently meant to describe the use by subjects of as few as two substances, such as cocaine and alcohol, alcohol and cannabis, or opiates and cocaine (Ross, Kohler, Grimley, & Bellis, 2003). In a more differentiated...

Population Based Studies

When considered in community samples, the presence of an SUD diagnosis elevates lifetime risks of additional SUD diagnoses (Regier et al., 1990). This is true with most classes of abused drugs. For example, the risk for a nonalcohol SUD is elevated among both males and females with alcohol dependence. In the National Comorbidity Survey (NCS), more than 40 of individuals with a DSM-III-R alcohol dependence had, excluding nicotine dependence, co-occurring drug abuse or dependence (Kessler et al., 1997). Between 13 and 18 of those with alcohol abuse will also have a co-occurring lifetime drug use disorder (NCS Kessler et al., 1997). Lifetime drug use disorder was also present in 21.5 of subjects (odds ratio OR 7.1) with an alcohol use disorder identified in the Epidemiologic Catchment Area survey (ECA Regier et al., 1990). In addition, among individuals with a nonalcohol substance use disorder in the ECA study, 47.3 also had a lifetime alcohol use disorder. Excluding nicotine dependence,...

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