IntKesehatanMasyarakatJ2016;8(4):455484ISSN:19474989NovaIlmuPublishers,Inc.

aspekkesehatanmasyarakatdaripenggunaannarkoba
danpenyalahgunaandimasaremaja
DonaldEGreydanus1,*,MD,DrHC(Athena),WilliamJReed2,MD,danElizabethKHawver,MSW3
1JurusanPediatricandAdolescentMedicine,WesternMichiganUniversityHomerStrykerMDSchoolof
Medicine,Kalamazoo,Michigan,USA2DepartmentofPediatrics,RumahSakitDriscollAnak,TexasA&M
UniversityCollegeofMedicine,CorpusChristi,Texas,USA3ElizabethUpjohnKomunitasHealingCenter,
Kalamazoo,Michigan,USA

*Correspondence:ProfesorDonaldEGreydanus,MD,DrHC(Athena),PendiriKetuaDepartemenPediatricandAdolescent
Medicine,WesternMichiganUniversityHomerStrykerMDSchoolofkedokteran,OaklanddriveKampus,1000Oakland
drive,Kalamazoo,MI490081284,AmerikaSerikat.Email:donald.greydanus@med.wmich.edu~~V

Abstrak

penggunaan zatdan penyalahgunaan tetap menjadi masalah kesehatan masyarakat yang utama remaja di seluruh dunia,
termasukAmerikaSerikat.Doronganolehmedia,temansebaya,danbanyakorangdewasabersamadenganaksesmudahke
obatdarisemuajenisterusmemikatjutaanyangtakterhitungjumlahnyapemudadalampenggunaandanpenyalahgunaan
banyakobat.HasildariPusat2013PengendalianPenyakitdanPencegahanPemudaSurveillancePerilakuRisikomencatat
bahwaadapenyalahgunaansignifikanobattermasukobatobatanterlarang,tetapijugaresepobattermasukobatperangsang,
narkotikasintetis,dan"rekreasi"batuksirup.Ulasaninimenganggapberbagaiobat,termasuktembakau,alkohol,ganja,
kokain,heroin,halusinogen,inhalansia,danobatobatandesainer.

Katakunci:Remaja,kesehatan,penyalahgunaanzat,kesehatanmasyarakat,perilaku

Pendahuluan

Amerika Serikat SAMHSA (Penyalahgunaan Zat dan Kesehatan Mental Layanan Administrasi)
mengarahkansurveisetiaptahundaripendudukAS(nonmiliter,nondilembagakan)yang12tahun
danlebihtua(1).PublikasidisebutNSDUH(SurveiNasionalPenggunaanObatdanKesehatan)dan
laporan2013yangmencatatbahwa24,6jutaorangAmerikausia12tahundanobatobatanterlarang
yang lebih tua digunakan dalam bahwa mereka telah menggunakan obat terlarang selama bulan
sebelum survei (1) . Perbedaan ras di penggunaan narkoba sedang diidentifikasi oleh berbagai
penelitian(2,3).

Adalah penting bahwa dokter yang merawat remaja terlibat langsung dalam mengajar pasien
merekabagaimanamencegahpenggunaandanpenyalahgunaanobatobatan(Tabel1);dokterjuga
dapat tetap aktif dalam pengelolaan gangguan penyalahgunaan zat, jika berkembang pada pasien
mereka(11/4).Paparanremaja

Donald456EGreydanus,WilliamJReed,danElizabethKHawveruntukobatobatanterlarangdapat
menyebabkanseumurhidupefekmedisdanpsikiatris(7).Dampakdariobatobatanterlarang,ketika
diambilselamakehamilan,dapatmenghancurkanjanindananak(12).Kecanduannarkobamelibatkan
disfungsisirkuitmesocorticolimbicdanbisamenjadimasalahseumurhidup,terutamadariganja,
kokain,nikotin,alkohol,danekstasi(13).Sejumlahfaktoryangterlibatdalamkecanduanobat,
termasukperanserotonin,ghrelin,danfaktorfaktorlainyangberadadibawahstudi(14,15).
Kematiandaripenggunaanobatobatanterlarangterus,sepertiyangterlihatdenganpenggunaan
heroin,amfetamin,inhalansia,danlainlain(16).

Skrininguntuk penyalahgunaan zat (17) sangat pentingkarena perubahan neuropsikiatri yang

disebabkanoleh beberapa obat (yaitu, Ekstasi) mungkin tidak dapat diubahdanada laporan dari
psikosis akut setelah ganja dan phencyclidine (PCP). Satu juga harus mempertimbangkan
kemungkinankondisicomorbid(lihatTabel2)disetiapdewasaremajaataumudadenganriwayat
penyalahgunaan zat melanjutkan atau mengulangi; kondisi ini termasuk ADHD, terutama bila
dikaitkandenganatausekunderuntukgangguanbelajarmanapengobatanpelindung.Faktorrisiko
penyalahgunaan narkoba ditinjau pada Tabel 3, sedangkan Tabel 4 menganggap indikator non
spesifikpenyalahgunaannarkobadanTabel5menguraikanfaktorpelindunguntukpenyalahgunaan
narkoba. Tes skrining dapat membantu, seperti pertanyaan CRAFFT untuk penggunaan alkohol.
Peranresepobatketergantunganharusdiperhatikanjugaolehdokter(18).

Sumbanganutamayangdokterperawatanprimerdapatmemberikanadalahuntukmembangun
rumahmedisuntuksemuapemudatermasukdenganpenggunaanzat(19).Keberhasilanmanajemen
sebagian didasarkan pada genetika bawahan kecanduan bagi seseorang, terutama dengan opioid,
alkohol, dan ketergantungan kokain (20). Bicara langsung dengan remaja tentang penggunaan
narkobaadalahpentingdalamprosespenyaringan,meskipunperkiraanremajaseringkalilebihrendah
daripadapenggunaanaktual.Klinisidapatbekerjadenganmasyarakatdalammendukungprogram
pencegahanpenyalahgunaannarkobaberbasismasyarakat.Modelpengobatanyangtersediamulai
dari singkat kepada manajemen intensif (21). Perhatian untuk meningkatkan disfungsi tidur pada
merekadenganketergantunganzatdandepresimerupakantujuanpentingdalammanajemensecara
keseluruhanorangtersebut(22).

Tabel1.Obatpenyalahgunaan

TembakauMarijuanaAlkoholKokainHeroinAmphetamineMetamfetaminMDMA[Ekstasi]
flunitrazepam[Rohypnol]Gammahidroksibutirat[GHB]Ketamine[Ketalar]LSD{lysergicacid
diethylamide}PCP{phencyclidine}tryptaminesBarbituratobatDesignerOlahragaDopingdan
PeningkatanKinerjaobat

Tabel2.gangguanComorbidgangguanpenyalahgunaanzat

ADHDoposisipemberontakDisorderPerilakuDisordergangguanKepribadian(antisosial,borderline,

narsis)moodgangguanKecemasangangguanberkembangPsikosisPosttraumaticstressDisorder
gangguanmakan

Remajaumumnyakemajuandaripenggunaanobatawaluntuklebihseriuspenggunaannarkoba
perilakudalampolayangdikenali(lihatTabel6).Padaawalnya,adarasaingintahutentangnarkoba,
meskipuntidakadapenggunaannarkobamungkinterjadi.Kebutuhanuntukditerimaolehbeberapa
kelompoksebayabersamadenganhargadirirendahdapatmenyebabkaneksperimendenganbeberapa
obatsering"gateway"obattembakau,alkoholdan/atauganja.Dibeberapatitikeuforiabeberapa
obatmemberikandirasakanolehremaja,biasanyadipestapestaakhirpekanataubiladikombinasikan
 denganzatlain.Dalambeberapapemuda,adamengembangkankeadaanaktifmencarieuforia
penggunaannarkobadenganpelebaranjenisobatyangdigunakan(yaitu,kokain,ekstasi,heroin,
oranglain),

Zatmenggunakan457

menggunakankepemilikanobatpribadi,membelidan/ataumencuriobatsecarateratur,danmenjadi
lebih tergantung pada satu atau lebih obatobatan. Sering ada penurunan nilai, pakaian ganti,
switchingpeergroup,danpenolakanyangkuatdarimenggunakan/menyalahgunakanobatobatan.
Mencarikeadaangembiramenjadibagianpusatdarikehidupanindividuyangmenjadidiluarkendali

sebagaimenuobatmencobapeningkatanlingkup.Mungkinjugaadabuktidepresi,memburuknya
perubahansuasanahati,bertindakkeluarperilaku,bunuhdiri,kekerasan,malaise,dankelesuan.Pada
tahapini,pelakuberupayanegaraeuforiamerasa"normal."Perkembanganinidaribereksperimen
dengan obatobatan untuk penyalahgunaan dan kelelahan dapat dilihat selama beberapa bulan ke
tahun.

Tabel3.Faktorrisikopenyalahgunaanzatpadaremaja*

GenetikaAlkoholismeantara1ataugelar2kerabat

sendirijeniskelaminLakilaki/Individu/PenyalahgunaanPribadi

onsetdinipenggunaannarkobaAwalseksualkegiatan/homoseksualitasgangguanAttentiondefisitBelajarperilaku
antisosialagresiftemperamenDepresiMiskincitradirigangguanParentalpenolakankurangnyapengendaliandirirendah
diriEuphoric/suasanahatiefekobatmodifikasitubuhmengubah(pemotongan)keluargadisfungsionaldinamikakeluarga

permisifOtoriterismeParentalkonflik,perceraian,perpisahanyangburukpengawasan,kurangnyapengawasanperan
orangtuamiskinpemodelanKomunitas/Lingkunganketersediaan/MasyarakatMudahobatdanalkohol

PenerimaandaripenggunaannarkobaperilakukualitasumumyangburukdarikehidupandiMedialingkungan
mempengaruhikegiatanPidanadilingkunganbudayadansanksiagamareligiusitasLowKerjaPeningkatanpenggunaan
obatobatandanalkoholpadakelompoketnistertentuSebayakelompokZatPengaruhmenggunakantemansebaya

pemberontakanRitusperalihandaripubertasperilakuCuriosityDesireRisikomengambilmilikKemerdekaanpenggunaan
tembakauAwalsekolah/AkademikMiskinkinerjasekolahlingkungansekolahMiskinPembolosan*Modifieddenganizin:
PatelDRdanGreydanusDE:penggunaanzat:perhatiananak.IndiaJ.Pediatrics66:557567,

1999.

Donald458

EGreydanus,WilliamJReed,danElizabethKHawverTabelindikator4.Nonspesifikpenyalahgunaanzat*

indikatorfisikindikatorAkademikPerilakudanindikatorpsikologis

beratbadanUnexplainedmataHipertensiRedhidungiritasi

KerusakanmemorijangkapendekMiskinpenghakimanJatuhnilai
RiskmengambilmoodperilakuayunanDepresi,penarikanreaksipanikFrequent"pilek"atau"alergi"batuk
kronisSuaraserakHemoptysisnyeridadaDesahSeringcederadijelaskanNeedletrektatapankosongketanda
ruangScratchTatoberlebihanjerawattestisatrofiMalaise

SeringabsenPembolosanKonflikdenganguruSkorsingPengusiran

akutpsikosisParanoiaBerbohongMencuriPergaulanKonflikdenganotoritasdananggotakeluargaperilaku
pelarianpolaDiubahtidurDiubahnafsumakankebersihanyangburukKehilanganminatdalamkegiatan
ekstrakurikulerObatmenggunakanrekanrekanPreferensiuntukgaun,musik,film,mengidentifikasidengan
obatmenggunakanbudayaobatperlengkapan*Digunakandenganizin:PatelDRdanGreydanusDE:
penggunaanzat:perhatiananak.IndiaJPediatrics66:557567,1999.

Tabel5.Faktorpelindungdaripenyalahgunaanzatpadaremaja*

lingkunganNurturingrumahKomunikasiyangbaikdalamkeluargaorangtuayangmendukung,keluarga
yangutuh,pengawasanorangdewasayangtepatPositifhargadiriKetegasanSocialkompetensi
Akademiksuksessekolahyangbaikbaikkesehatanumumkecerdasantinggipositifmodelperanorang
dewasakelompoksebayadenganatributpribadipositifketerlibatanAgamarasapribadimoralitas

*Digunakandenganizin:PatelDRdanGreydanusDE:Penggunaanzat:aperhatiananak.IndiaJPediatrics66:557567,

1999.

Substansimenggunakan459

Tabel6.tahapMacDonaldpenyalahgunaanzat*

Tahap1.Belajar

moodswing

2.Mencariayunansuasanahati3.Keasyikan

denganmoodswing

4.MenggunakanobatuntukmerasanormalsuasanahatiPerubahan

Euphorianormal

EuphorianormalBeberapanyeri

EuphorianormalnyeriDefinite

EuphorianormalPerasaansakitDitandaiTerasabaik;Beberapa

konsekuensi

Semangat;bersalahawal

tertinggiEuphoric;keraguan,termasukrasamaluberatdanrasabersalah;depresi,pikiranbunuhdiri
bersalahkronis;malu,penyesalan,depresi

NarkobaRokok

GanjaAlkohol

Semuaplusinhalansiadiatas,hashish,depresi,methamphetamine,obatresep

Semuatercantumditambahpsilocybin,PCP,LSD,kokain

Apapuntersedia

SumberPeersMembeliJualApacarayangmungkinPerilakukecil

perubahanterdeteksi;moderatsetelahthefaktaberbaring

Menjatuhkankegiatanekstrakurikulerdanhobi;temancampuran(lurusdanpenggunanarkoba);berpakaian
berubah;kinerjasekolahtidakmenentudanbolos;terdugasuasanahatidansikapayunan;manipulatifperilaku

"Cool"penampilan;temanlurusturun;perkelahiankeluarga(lisanataufisik);mencuri(insidenpolisi);
berbohongpatologis;kegagalansekolah;pembolosan,pengusiran,pekerjaanyanghilang

kerusakanfisik(beratbadan,batukkronis);kemerosotanmentalyangberat(kehilanganmemoridankilas
balik);paranoia,kemarahanvulkanik;putussekolah;seringoverdosisFrekuensiKemajuanuntuk

penggunaanakhirpekan

penggunaanWeekendmajukeempatsampailimakaliperminggu;beberapasendirianmenggunakan

Harian;seringmenggunakansendirianSemuaharisetiaphari

PCP=phencyclidine;LSD=lysersicdiethylamideasam.*Digunakandenganizin:PatelDRdanGreydanusDE:
Penggunaanzat:perhatiananak.IndiaJPediatrics66:557567,1999.

DSM5

TheAmericanPsychiatricAssociationmenerbitkanedisike5dari"Diagnostikdanmanualstatistik
gangguan mental" (DSM5) pada tahun 2013 (23). Beberapa perubahan terlihat pada edisi ini 5
berbeda dengan edisi ke4 (24) (lihat kata pengantar). DSM5 tersedia perubahan dalam kriteria
diagnostikgangguansubstansiterkait(SRD).Dalamedisisebelumnya(DSMIVTR,2000),SRDS
diklasifikasikansebagaigangguanpenggunaanzat(SUD)dangangguansubstansidiinduksi(SID).
SUDjugadiidentifikasisebagai"penyalahgunaan"dan"ketergantungan"gangguanmenurutzatzat
tertentu (misalnya, penyalahgunaan opioid dan ketergantungan, penyalahgunaan alkohol dan
ketergantungan,dansebagainya).SIDtermasukklasifikasisepertiintoksikasi,penarikan,delirium,
kecemasandanlainlainsebagaidiinduksiolehzatzattertentu(misalnya,opioid,alkohol,oranglain)
(25).Diagnosa"penyalahgunaan"dan"ketergantungan"kategoridiperlukankriteriakhususmereka
sendiri.Penyalahgunaandapat
didiagnosisdenganhanyamemenuhisalahsatudarikriteriatersebutsementaraketergantungan
dibutuhkansetidaknyatigakriteriatersebut.

DalamistilahDSM5SUDdanSIDtetaptetapidiSUDperbedaandiagnostiksebelumnyaantara
penyalahgunaan dan ketergantungan telah dihapus dan satu kategori dikembangkan disebut
"penggunaanzatgangguan"yangberkisardariringansampaiberat.Sebuahgangguanyangringan
defiendsebagaimemenuhi23darikriteriaSUDdibandingkan45untukmoderatdan6ataulebih
untukgangguanberat(AmericanPsychiatricAssociation,DSM5,2013).

Dalam DSM5 adapeningkatan ambangdiagnostikdi bahwa setidaknya 2 kriteria (versus 1)

wajibuntukSUD."Keinginan"ditambahkansebagaikriteriabarudanmengacupadakeinginanyang
kuatataudoronganuntukobat.Juga,kriteria,"masalahdenganpenegakhukum"telahdihapussejak
undangundangbervariasidarisatunegarakenegaradandariwaktukewaktu.

Berbagai obat illict ditelaah dalam bab ini dengan prevalensi terutama didasarkan pada US
CentersforDiseaseandPrevention(CDC)2013

Donald460EGreydanus,WilliamJReed,danElizabethKHawverYouthRiskBehavioral
Surveillance(YRBS)(2).Pembacadidoronguntukmeninjaudokumenini.Sejumlahisuobatlain
yangdipertimbangkandalamlaporaninitermasukmengambilsteroidtanparesepdokter,mengambil
obatreseptanparesepdokter,danpernahmenyuntikkanobatobatanterlarang.Surveiini
mengungkapkanbahwa3,2%darisiswaSMAAStelahmengambilpilsteroidatausuntikantanpa
resepdokter;inimeningkatdari2,7%padatahun1991menjadi3,2%padatahun2013(2).

Laporanitujugamencatatbahwa17,8%siswatelahmengambilobatreseptanparesepdokter
satukaliataulebihselamahidupmereka;obatinitermasukOxycontin,Percocet,Vicodin,kodein,
Adderall,Ritalin,atauXanax.Prevalensiadalah20,7%padatahun2011.Juga,1,7%darisiswatelah
menggunakanjarumuntukmenyuntikkanobatilegalkedalamtubuhmerekasatuataubeberapakali
selamahidupmereka;Prevalensiiniadalah2,3%padatahun2011(2).Surveitersebutjugamencatat
bahwa22,1%siswatelahditawarkan,dijual,ataudiberikanobatilegalolehseseorangdiproperti
sekolahselama12bulansebelumsurvei;Prevalensiiniadalah24,0%padatahun1993.

Energiminum

Efeknegatifdariminumanenergiseringmengandungsejumlahbesarkafeinmenjadimasalahyang
meningkatpadaremajadandewasamuda;efeksampingkardiovaskulardanneurologisyangterutama
terlihat(26).DSM5berisiempatkafeinterkaitgangguan:intoksikasikafein,kafein,gangguankafein
diinduksilainnya,dantidakditentukanterkaitkafeingangguan(23).

Obatdesainer

ahlikimiaKlandestindanlaboratoriumdiamdiamsedangmengembangkanberbagaimacamobat
desaineratau"hukumtertinggi"yanganalogobatobatansepertiopioid,cannabinoids,phencyclidine,
amfetamin, danlainlain(2732). Perkembangan mereka dapat ditelusuri ke tahun 1960an tetapi
produksimerekatelahmeningkatsejaktahun2008.Merekadigunakanuntukmeniruefekobatini
seperticannabinoidssintetisyangmeniruefekpsikoaktifganjadantelahdisebut
obatrempahrempahatauobatK2.Cathinoneadalahterjadiamfetaminanalogalamiyangditemukan
dalam daun tanaman Catha edulis dan katinona sintetis (seperti mephedrone atau valerone 3,4
methylenedioxypyro[MDPV])adalahturunandariaminaphenylalkylyangsebagaiefekamfetamin
seperti.Beberapaturunanpiperazine.Psychostimulantsdesainertelahdikembangkanuntukmeniru
efek dari amfetamin, kokain, atau ekstasi. Methoxydine dan methoxetamine adalah obat desainer
denganefekphencyclidine.

Mereka dapat dijual di internet atau di tempat lain sebagai "garam mandi" atau "makanan
tanaman"danditandaisebagai"tidakuntukkonsumsimanusia"untukmenghindarituntutanhukum.
Banyak efek samping dapat mengakibatkan tergantung pada produk yang tepat, dosis yang, apa
kotoran mengandung dan faktor lainnya. Penggunaannya dapat menyebabkan efek negatif yang
kardiovaskular, saraf, ginjal, psikotik dan lainlain termasuk kematian. Manajemen reaksi yang
merugikanbisasulitdanrumitolehkurangnyapengetahuanpasiendandokterapayangdiambil.
Reaksi negatif kekatinona sintetis ( "garam mandi") misalnya, fokus pada melenguhagitasi dan
psikosisyangterlihatbersamadenganpendukungperfusiginjal;benzodiazepindanantipsikotikyang
digunakan(33).Orangmencaripengalamaneuforia,termasukremajadandewasamuda,harusdididik
tentangobatdesaineriniyangsemakinmenjaditersediahukumlokaldiluar.

Tembakau

tembakautetapbanyakdigunakandandisalahgunakanobatyangmenikmatitingkattinggipenerimaan
olehmasyarakat,termasukpemerintahyangmemungkinkanuntuktumbuhuntukkeuntungan.Dalam
1999surveinasionalyangdilakukanolehCentersforDiseaseControl,satudisetiapdelapansiswa
sekolah menengah dilaporkan menggunakan beberapa bentuk tembakau (rokok, cerutu, bidi, atau
rokok kretek) dalam satu bulan terakhir. Bidi (atau Beedies) berwarna coklat, linting tangan,
tembakaurasasementaraRokokkretek(rokokkretek)mengandungcampurantembakaudancengkeh;
keduanyadiimpordariIndonesia.Rokokelektronik(Erokok)sekarangtersediadipasaryangjuga
dapat menimbulkan ancaman bagi remaja, meskipun penelitian lebih lanjut diperlukan (34, 35).
Perannikotin

Zatmenggunakan461

sebagaiobatgatewaytelahditunjukkanolehpenelitian(36,37).DSM5daftarsejumlahgangguan
yang berhubungan dengan tembakau: penggunaan gangguan tembakau (ringan, sedang, berat),
penarikan tembakau, gangguan tembakau yang disebabkan lainnya, dan tidak ditentukan terkait
tembakaugangguan(23).

2013RisikoPemudaBehavioralSurveillance(YRBS)melaporkanbahwa41,1%darisiswaSMA
pernah mencoba merokok dengan prevalensi 42,5% pada lakilaki dan 39,6% pada wanita (2).
PrevalensilebihtinggidiantarasiswaputihdanHispanikdarisiswakulithitam.Prevalensirokok
pernahmerokokdari70,1%di199141,1%padatahun2013.Surveiinijugamengungkapkanbahwa
9,3%telahmerokokseluruhrokokuntukpertamakalinyasebelumusia13tahundaniniturundari
23,8%padatahun1991menjadi9,3%pada2013.juga,15,7%siswatelahmerokokpadasetidaknya
satuhariselama30harisebelumsurveidaninitelahturundari27,5%padatahun1991menjadi
15,7%padatahun2013.Halinijugamencatatbahwa5,6%darisiswatelahmerokokrokok20atau
harilebihselama30harisebelumsurveidaniniturundari12,7%padatahun1991menjadi5,6%pada
tahun2013.diantara15,7%yangsaatinimerokok,8,6%telahmerokoklebihdari10batangperhari
padahariharimerekamerokokselama30harisebelumsurvei;initurundari18,0%padatahun1991
menjadi8,6%padatahun2013(Kann,2013).

Diantara15,7%yangsaatinimerokokrokok,48,0%telahmencobauntukberhentimerokok
selama12bulansebelumsurvei;prevalensiinimenurundari57,4%di200148,0%padatahun2013.
Juga,8,8%darisiswayangpernahmerokoksedikitnyasatubatangrokoksetiaphariselama30hari
daniniturundari20,0%padatahun2001menjadi8,8%padatahun2013.Survei2013melaporkan
bahwa4.0%darisiswatelahmerokokdisemua30hariselama30harisebelumsurvei;prevalensiini
menurundari9,8%padatahun1991menjadi4,0%padatahun2013.rokokJuga,3,8%telahmerokok
dipropertisekolahpadasetidaknyasatuhariselama30harisebelumsurvei;prevalensiinimenurun
dari13,2%padatahun1993menjadi3,8%tahun2013.

pada2013laporanmengungkapkanbahwa8,8%darisiswatelahmenggunakantembakautanpa
asap pada setidaknya 1 hari selama 30 hari sebelum survei; ini turun dari 11,4% di tahun 1995
menjadi8,8%padatahun2013.Halinijugamencatatbahwa12,6%siswatelahmerokokcerutu,
cerutukecil,ataucerutukecilpadasetidaknyasatuhariselama30harisebelum

survei;ini menurun dari 22,0% pada tahun 1997 menjadi 12,6% pada tahun 2013. Hal ini juga
mencatatbahwa22,4%siswatelahmelaporkanpenggunaansaatinirokok,penggunaantembakau
tanpaasapsaatini,ataupenggunaancerutusaatini;prevalensiinimenurundari43,4%padatahun
1997menjadi22,4%padatahun2013(2).

Umum

Asapcerutulebihbasadaripadarokok,larutlebihmudahdalamairliur,danmencapaidosisyang
diinginkandarinikotintanpaperlumenghirupasapkeparuparu.Cerutumampumemberikantingkat
tingginikotinpadatingkatyangcukupcepatuntukmenghasilkanketergantunganyangjelas,bahkan
jikaasaptidakterhirup.Risikokankerparuparuuntukpecintacerutu(terkenaluntukperokok),jauh
lebih tinggi dari sekali berpikir. Tingkat ini meningkat lebih untuk perokok cerutu jika mereka
perokoksebelumnya.Sebuahkelassenyawakarsinogenikyangdikenalsebagaitembakautertentu,N
nitrosamin(TSNA)hadirdalamasapcerutuditingkatsignifikanlebihtinggidaripadadalamasap
rokok. Pemeriksaan pada "per gram dari asap rokok" dasar mengungkapkan bahwa tar, karbon
monoksida,danamoniadiproduksidenganjumlahyanglebihbesardengancerutu.Ketikadosisyang
samaditerapkan,taryangdihasilkanolehcerutumemberikansebuahaktivitastumormemproduksi
lebih besar pada tikus karena konsentrasi yang lebih tinggi dari hidrokarbon aromatik polisiklik
karsinogenik.

Nikotin,merupakankomponenpentingdalamtembakau,sangatadiktifdansejumlahgenyang
terlibat seperti nicotinic cluster gen reseptor pada kromosom 15q25 (38). Penelitian saat ini
menunjukkanbahwaremajamengalamigejalaketergantungannikotinjauhsebelummerekamenjadi
perokoksetiaphari.Awaldanterusintervensi,termasukpenggunaanklinisdariinstrumenseperti
HONC (kecanduan checklist nikotin), diperlukan karena inisiasi merokok selama masa remaja
berhubungan dengan mabukberorientasi penggunaan alkohol dan peningkatan risiko untuk
penyalahgunaanzatmasadepan.Prediktorpalingkuatdarimengemudidalamkeadaanmabukdalam
penelitianiniadalahmerokokbiasapadausia14.
 Nikotindiserapmelaluiberbagaisitus:paruparu,mukosabukal,kulit,dansaluranpencernaan.
Sekitar 10 mg nikotin ditemukan dalam satu batang rokok; ketika merokok, 1,03,0 mg nikotin
diserapolehpengguna.Nikotindengancepatdiambiloleh

Donald462EGreydanus,WilliamJReed,danElizabethKHawvernicotinicreseptorasetilkolinotak
yangditemukandalambanyaknonkolinergikdaerahpresynapticdanpostsynaptic.Pecandu
tembakaumemilikipaparankronisbanyakbahankimiaberbahaya,termasuknikotin,tar,karbon
monoksida,oksidaarsenous,poloniumradioaktif,benzopyrene,oranglain.Thepelakurokok
kecanduanmenjadidewasadenganrisikoyangsignifikanuntukbanyakkomplikasiterkenalkanker
iniobatparu,emfisema,kankerlaring,kankerlainnya,penyakitjantung,danbanyakpenyakit
lainnya.Kankerparuparupadaperokokperempuandewasasekaranglebihumumdarikanker
payudara.

Sebuahkondisiumummencatatpadaperokokdanmembalikkanperokokadalahkeratosisdari
langitlangit posterior mukosa ke rugae tersebut. Ini awalnya digambarkan pada tahun 1926 dan
disebabkanolehuappanasterkonsentrasiasapdanbahankimiamenghasilkannikotinatau"patch
perokok."Reversemerokoktelahdikaitkandengandisplastikdanperubahanganasdariwaktuke
waktu.Penelitianterbarujugamencatatefeknegatifyangterjadidarimerokokselamakehamilan,
termasukberatbadanlahirrendahdanattentiondeficithyperactivitydisorder.PewarnaanNikotin
gigi,kakigagakdarioklusimikroarterioldekatmata,baumulut,batuk,dandyspneajugayangdiakui
danstigmataluasmerokok.Merokokpasifjugadikenaluntukmenjadiberbahayauntukmerekayang
terpapardenganmerokokoranglain.Kankermulutmerupakankonsekuensiseriusdarimenggunakan
tembakaukunyah.

Halinipentingbagidoktermerawatremajauntukbergabungdenganperjuanganuntukmembatasi
penggunaan

tembakauolehremaja.Misalnya,iklanuntukpemudaharusdicegah,danupayauntukmengurangi
penerimaan tembakau oleh masyarakat diperkuat. Pencegahan dan pengurangan penggunaan
tembakauremajadanpenyalahgunaanharusdidorongpadatingkatnasionaldandiseluruhnegara
bagian.Padatingkatlokal,programberbagaidianjurkanyangmenargetkankeluarga,masyarakat,dan
sekolah.

Manajemenfarmakologis

Tabel7ulasansaatinipilihanmanajemenfarmakologisuntukpecandutembakauyangtermotivasi
untuk berhenti menggunakan produk tembakau (39). Dokter harus mengambil setiap kesempatan
untuk mengingatkan tembakau kecanduan remaja bahwa kebiasaan mereka sangat berbahaya dan
bantuantersediaketikamerekasiapuntukberhenti.Masalahpsikososialdalamkehidupanperokok
remaja dan isyarat yang mendasari untuk merokok harus ditinjau dengan remaja. Situasi khusus
mungkintimbul,sepertiremajahamilyangjugamerokok.Berbagaipenggantinikotin(NT)produk
yangdihasilkan,sepertidiulasdalamTabel7dan8;tingkatberhentimerokokadalahduakalilipat
denganmenggunakanprodukiniuntukperokoktermotivasi(yaitu,30%),berbedadenganmereka
yangberusahaberhentimerokoktanpaagenfarmakologis(yaitu,15%).PilihanprodukNTadalah
pasiendriven; remaja seharusnya tidak merokok saat produk NT, meskipun tidak ada gejala sisa
negatifyangjelastelahdilaporkandalamkasustersebut.
Tabel7.produkfarmakologisyangtersediadiAmerikaSerikatuntukmengobatikecanduantembakau*

nikotinObat

PermenkaretNikotin

NicoretteOTCNicoretteDSOTC

Nikotinpatchyang

NicodermCQ(SmithKlineBeecham)OTCNicotrolpatch(McNeil)OTCNikotininhalerHabitrol
(Novartis)

Nasalsemprot

Prostep(Lederle)NicotrolInhaler(McNeil)NicotrolNasalSpray(McNeil)NonNikotinObatBupropion

ZybanSR(GlaxoWellcome)tabletberkelanjutanrelease*Dicetakulangdenganizindari:PatelDRdanGreydanusDE:
intervensiOfficeuntukremajaperokok.Negara

Art:AdolescentMedicine11(3):111,2000.

Substansimenggunakan463

Tabel8.NikotinrejimenPatch*

MerekDurasiDosis

NicodermCQdanHabitrol

4minggu

kemudian2minggukemudian2minggu

21mg/24jam14mg/24jam7mg/24jam

Prostep

4minggu

kemudian4minggu

22mg/24jam11mg/24jam

Nicotrol8minggu15mg/24jam*Dicetakulangdenganizindari:PatelDRdanGreydanusDE:intervensiOfficeuntuk
perokokremaja.Negara

Art:AdolescentMedicine11(3):111,2000.

Tabel9.Rekomendasiuntukpenggunaanpermenkaretnikotin
Chewsepotongsetiapjamselama6minggu.Kemudian,mengunyahsepotongsetiap2jamselama3minggu.
Akhirnya,mengunyahsepotongsetiap4jamselama3minggu.Batasmaksimumadalah30buahperhariuntuk
karet2mgdan20lembarperhariuntukgusi4mg.Mengunyahpetunjuk:

Chewperlahanlahansampairasapedasmuncul(seringkalisetelah15mengunyah)Kemudianmenempelkan
permenkaretantarapipidanmukosabukalsampairasapedastelahmenghilang(seringsatu

menit)MulaimengunyahlagidanulangisiklusdiatasDapatkanmenyingkirkanpermenkaretketika
rasapedashilang(sering30menit).

PBpatchdiresepkanselamaduabulan(berubahsetiappagi),menggunakanpatchkekuatantinggi
selama satu bulan, dan kemudian dosis rendah selama satu bulan (lihat Tabel 8). Patch tidak
ditempatkandiatassitusdenganrambut.Sampaisetengahakanmengembangkandermatitislokal,
biasanyaditingkatkandenganaplikasihidrokortisonlokal.Patchhanyaditerapkansaatterjagajika
patchdiinduksi mimpi hidup sekunder atau insomnia berkembang. PB gum (nikotin polacrilex)
memilikirasapahitbahwabanyakremajatidaksuka;beberaparemajamerasamalusaatmemilih
permenkaretnikotin.Jikapecandutembakaumerokoklebihdari25batangsehari,reseppermenkaret
4mg;akhirnyamenurunkanpasienkegusi2mg.Sejakcairanasammengurangipenyerapannikotin,
mereka tidak boleh digunakan selama 15 menit sebelum digunakan gusi dan saat mengunyah.
InstruksiuntukmemberikanpasienyangmengunyahpermenkaretinidiberikandalamTabel9.Efek
sampingdaripermenkaretini,meskipunsementara,termasukdispepsia,mulutnyeri,rahangsakitdan
cegukan.

Inhalernikotindirancanguntukmenirugerakantangankemulutperokok;4mg

nikotindikirimdaricartridgeyangberisisekitar10mgkeseluruhan(lihatTabel7).Kadarnikotin
rendah diproduksi dan pengguna menghirup 616 kartrid setiap hari. Penyerapan nikotin yang
memadaidicapaidengan80penarikanlebihdari20menit;penyerapanmelaluimukosamulut.Halini
diresepkan untuk 3 bulan dan kemudian perlahanlahan meruncing off lebih dari 3 bulan. Efek
sampingyangseringmeningkatkandariwaktukewaktutermasukbatuk,dispepsia,iritasipadamulut
dantenggorokan,daniritasihidung.

Semprotanhidungnikotindiberikansebagaisalahsatuuntukduadosis(1sampai2mgnikotin)
perjamselama3bulan;adapeningkatanpesatdalamkadarserumnikotin(lihatTabel7).Halini
diresepkansebagaiminimal8dosisperhari,tidaklebihdari40perhariataulebihdari5penarikan
perjam.Bronkospasmedapatterjadidansemprothidungtidakdigunakanuntukpecandunikotin
denganasma.Efeksampinglainnyatermasukbatuk,rhinitis,iritasihidung,bersin,danmataair.
Penggunaanrokokelektronikuntukpenghentianataupenguranganmerokokpadaorangdewasatetap
dibawahpenelitianaktif(40).

Donald464EGreydanus,WilliamJReed,danterapiElizabethKHawverNonnikotin

Penggunaanbupropion(lihatTabel7)dipecandunikotinyangtermotivasiuntukberhentimerokok
adalahmembantudalamhingga40%darikasus;Keberhasilanrelatifdikaitkandengankemampuan
obat untukmenurunkankeinginannikotin klasik sambil meningkatkanmasalah nikotinpenarikan
beratbadandandepresi.Ituditemukanduakalilebihefektifsebagaiplasebo.Halinidiresepkan
sebagaiZybandalambentuklepaslambatyangdisediakansebagai150mgsehariselamatigahari;
jikaditoleransi,itumeningkatmenjadi150mgduakalisehari.Dosisyangtidakbolehmelebihi300
mgperhari.Selainitu,dosiskeduatidakbolehdiberikankurangdari8jamsetelahyangpertama
untukmengurangikejadiankejang.MeskipunterapipenggantianNTtidakresmidimulaisaatremaja
masih merokok, dapat diterima untuk memulai perokok remaja di bupropion sementara masih
menggunakan nikotin; tanggal menghentikan tembakau masih harus dinegosiasikan sambil
memberikanbupropiontersebut.Bupropionmerupakankontraindikasipadaremajayangmemiliki
kejangterbukadanorangorangdenganfaktorfaktoryangmeningkatkanrisikountukkejang;yang
terakhirtermasukmerekayangmemilikiriwayatepilepsi,gangguanmakan,tumorsistemsarafpusat,
dansetiapobatyangdapatmenurunkanambangkejang.Bupropionmerupakankontraindikasipada
orangorangpadainhibitorMAO.Bupropionefeksampingtermasukinsomnia,reaksikulit,tremor,
sakitkepala,danmulutkering.

Clonidinedannortriptylinemungkinbergunauntukbeberaparemajaakhirdanperokokdewasa
untukmembantumerekaberhentimenggunakantembakau.Berbagaiobattelahdipelajarinamuntidak
terbuktimembantumeningkatkankeinginanuntuknikotin;theseincludebuspirone,mecamylamine,
naltrexone, doxepin, and oral dextrose. Another smoking cessation product is varenicline tartrate
(Chantix),analpha4beta2nicotinicacetylcholinereceptorpartialagonistthatbindstocentral
nervoussystemreceptorswithagreateraffinitythannicotine.ItisFDAapprovedforadultswith
nicotineaddictionandmaybemoreeffectivethanbupropion.Abstinenceratesare22%versus16%
forbupropionand8%forplacebo.Intheshortterm,44%ofstudypatientsquitsmokingv.30%using
Zyban.Startingdoseis0.5mgperdayforthreedays,twiceadayfor47days,then1mgtwicedaily.
Chantixdecreasesthepleasureofnicotineuseandlessensthewithdrawalcraving.Themajorside
effectisnausea,

butweightgainisnotaproblem.Therearereportsofsuicidality,agitation,hostility,andagitation(7).
Theuseofcytisine,apartialagonistthatbindsthenicotinicacetylcholinereceptor,isunderstudy
(41).Theuseofanicotinevaccineisalsounderactiveresearch(42,43).

Marijuana

Marijuana(cannabis)remainsapopulareuphoricandhallucinogenicdrugformillionsofyouthand
adults;ithasmanynames,includingpot,hash,weed,.doobs,BCBud,Ganja,grass,
smoke,andothers.ItisthemostwidelyusedillicitdrugintheUnitedStates,accountingforupto
85%oftheillicitdrugtrade.The2013YRBSreportedthat40.7%ofhighschoolstudentshadused
potoneormoretimesduringtheirlife(2).PreviousCDCsurveysnotedthatthecategoryofever
usedmarijuanahadincreasedfrom19911997(31.3%to47.1%);itdidthendecreasefrom1997to
2013(47.1%to40.7%)(2).Thesurveynotedthat8.6%ofstudentshadtriedpotforthefirsttime
beforeage13yearsand23.4%ofstudentshadusedpotoneormoretimesduringthe30dayspriorto
thesurvey.Theprevalenceofhavingeverusedpotwashigheramongmalesversusfemalesand
higheramongblackandHispanicyouthversuswhiteyouth.Inthe2013NationalSurveyonDrugUse
andHealthmarijuanawasthemostcommonlyillicitconsumeddrugwith19.8millionusers12years
ofageandolderoverthepastmonthofthesurvey(1).From2006to2013thenumberofpersons
usingdailycannabisalmostdoubledinthissurvey.

ThiscontroversialdrugisderivedfromCannabissativaorCindica(hempplant)andtheactive
euphoricchemicalisdelta9tetrahydrocannabinolorTHC.Itispresentinthedriedleaves,stems,
seeds,flowers(sensimilla)andoil.Thismajorlipophilicdrugworksonthecannibinoidreceptors
(ECS) in the mesocortical and limbic systems. The marijuana of the 1960s and 1970s' hippie
generation containedonly 2% THC, while the Hawaiiansensimilla product was about 3% THC.
Today'sstreetpotcanvaryfrom3to7%+THCcontent,whilecultivatedsensimillacancontain7to
13%+.ApopularbrandofpotisBCBud,aproductimportedbythetonfromCanadaat$30008,000
dollarsperpound;itisgrowninBritish

Substanceuse465

Columbia and may contain up to 24% active ingredients. Many growers, commercial exporter
consortiums(Canada),asignificantfractionofthepublicandtheirelectedofficials,aswellasactive
potusersareactivelyadvocatingforthelegalizationofmarijuana.

Cannabis contains over 60 phytocannabinoids including cannabinol (or CBNmetabolite of

THC),cannabidiol(orCBDisomerofTHC),cannabigerol(orCBGalpha2adrenergicreceptor
agonist),tetrahydrocannabivarin(orTHCV;THVTCHhomolog),andcannabichromene(orCBC)
(8,11). Many other chemicals are found in this complex plant, including terpenoids, and
endocannabinoids (such as 2AG [2 arachidonoyl glycerol] and anandamide [arachidonoyl
ethanolamide]).Theroleofpotsmokingasagatewaydrugiswellknownandmanysmokersalsouse
tobacco,alcohol,andotherdrugs.

Commercial preparations of synthetic cannabinoids include nabilone (schedule II drug),

dronabinol (synthetic THC in sesame oil; schedule III drug), and nabiximols (phytocannabinoid
marketedinCanada).DronabinolcapsuleswereapprovedonMay31,1985bytheUSFoodandDrug
Administration(FDA)fornauseaandemesismanagementduetocancerchemotherapy;theUSFDA
alsoapproveddronabinolonDecember22,1992forpersonswithAIDSwhohaveanorexiaassociated
withweightloss.OralnabilonewasapprovedbytheUSFDAonDecember26,1985fornauseaand
vomitingduetocancerchemotherapy.Thoughtheseandothercannabisproductsaresuggestedfor
various other medical disorders, they are not approved by the FDA. Smoking marijuana is not
approvedby the FDA nor leading medical organizations because there is no research to support
smoking pot and because of the many potential adverse side effects from cannabis smoking
(Greydanus,2014,2015).InCanadatheoromucosalspray,nabiximols,isindicatedformanagement
ofcancerpaininadditiontoneuropathicpainandspasticityseeninpersonswithmultiplesclerosis.

Thoughusuallysmoked,marijuanacanalsobeeateninsuchhomemadeconcoctionsascookies,
brownies,andspaghetti.Thetypicalcannabiscigarette(joint)usuallycontainsapproximately20mg
ofTHCobtainedfromaboutagramofleavesandbuds;however,muchvariationcanbenoted.The

bluntisanotherpopularwaytosmokepotandconsistsofacigarettewithmarijuanaaddedtoa
hollowed cigarette. Pot is often combined with other drugs, such as phencyclidine, though
glutethimideandmethaqualonewerealsopopularinthepastasadditives.PCP(phencyclidine)is
frequentlydissolvedinanorganicsolvent,suchasformaldehyde,inwhichajointorhandrolled
cigaretteisfirstdipped,dried,andthensmoked.Thispreparationisvariouslyreferredtoaswet'
water,orSherms;thelattertermreferstothewellknowntobacconistNatSherman.Thisisa
goodreasonfordoingaurinedrugtestwithinformedconsentandassentofausingteenager.
 Marijuanauseresultsinapotentsensationofeuphoria(buzz)thatisnotedwithinminutesofits
use,andwhichcanlastforhours.BothTHCanditsmetabolitesarehighlylipidsolubleandarestored
infattytissue.Serumhalflifeis19hours.Marijuanacanbefoundonurinedrugscreenandstoolfor
aslongasonemonthfollowingregularuse,andtendaysafterasingleuse.Thebehavioraleffectsare
mediatedbycannibinoidreceptorsandresultsinthereleaseofdopamineinthenucleusaccumbens.
TheeffectsofTHCalsoincluderelaxation,timeandperceptualdistortions,andheightenedsensory
experiencessuchaslisteningtomusic,watchingtelevision,oreating(gettingthemunchies).Some
drugs (alcohol or diazepam) may potentiate the sedative effects of marijuana, while other drugs
(cocaineoramphetamines)worsenthestimulatoryeffectsofmarijuana.

Alargenumberofpotentialadverseeffectsareseenwithsmokingcannabis,includingcardio
vascular,pulmonary,gastrointestinal(cannabishyperemesissyndrome),dental,andcentralnervous
system effects (8,11). Cardiovascular adverse effects cam include arteritis, cardiomyopathy,
myocardial infarction, sudden cardiac death, transient ischemic accident (TIA), cardiovascular
accident(CVA),andcardiacarrhythmias.Pulmonarysideeffectscanincludechroniccough,allergic
hypersensitivity, bronchitis, bullous emphysema (COPD: chronic obstructive pulmonary disease),
pneumothorax/pneumomediastinum,pulmonarydyplasia,pulmonarytuberculosis,otherrespiratory
infections,andevendustdisease(talcosis)inhempworkers.

Donald466

EGreydanus,WilliamJReed,andElizabethKHawverPotentialadversedentaleffectscan
includedentalcaries,dentaldysplasia,gingivalenlargement,gingivitis,leukoedema,nicotinic
stomatitis,oralinfections,periodontaldisease,poordentalhealth,uvulitis,andxerostomia.Potential
adverseeffectsontheoffspringoffemalessmokingcannabiswhilepregnantincludelowbirthweight,
pretermlabor,smallforgestationalage,treatmentinaneonatalintensivecareunit,andvarious
childhoodeffectssuchasinattentionproblems,problemsolvingproblems,aggression,executive
functiondysfunction,problemswithmemoryandprocessinginformation,anddepressivesymptoms.

Cannabispoisoningcanarisefromconsumingoralcannabisproductsandthisisincreasingbeing
seeninyoungchildrenwhoseparentsarepotsmokers.Cannabissmoking(includingSpicedrugs)
increasesrisksforMVAs(doubleormore)andthiscanbeworsenedwhencombinedwithotherdrugs
(ie,alcohol,others).Ifonehassmokedcannabis,8ormorehoursshouldpassbeforedrivingamotor
vehicle.Potsmokingalsoincreaseroadrage.

Thecentralnervoussystemofyoungadolescentsisverysensitivetocannabisandadverseeffects
may include decline in IQ, decreased coordination, distorted visuospatial perception, impaired
executivefunction,impairednovellearning,impulsivity,inattention,memoryloss,neuropsychiatric
disorders(ie,psychosis),andcannabisdependence.TheDSM5haslistedanumberofcannabis
relateddisordersincludingcannabisusedisorder(mild,moderatesevere),cannabisintoxication(with
or without perceptual disturbances), cannabis withdrawal, other cannabisinduced disorders, and
unspecifiedcannabisrelateddisorders(23).

Management of cannabis use disorder is very difficult and there is no pharmaceutical agent
approvedforitsmanagement.Researchcontinuestofindmedicationsthatmaybeofhelptothose
withcannabisusedisordersandtheseincludealpha2adrenergicagonists,antipsychotics(atypical),
benzodiazepines,cannabidiol,dronabinol,gabapentin,lithium,lofexidine,nabilone,nabiximols,N
acetylcysteine (NAC), Narachidonoylethanolamine (anandamide), nefazodone, 2arachidonoyl
glycerol(2AG),andothers(11).

Therapyistypicallyprescribedanditsefficacymaybelowbecauseoflackofmotivationforthe

personwithcannabisdependencetostoptheirdrugofchoice.Approximately25%ofthe19.8million
cannabisusersintheUnitedStatesmeettheDSM5criteriaforcannabisusedisorders.Manyfailto
seektreatmentandthistendstobeduetofailuretorecognizetheseverityoftheirdisorderandthis
denialmayreflecttheirownbraindysfunction.Ofthe7.6millionpersonsaged12orolderwhoneed
treatmentforanillicitdruguseproblemin2013,only1.5million(19.5%)receivedmanagementina
specialtyprogram(11).Ofthe6.1millionpersonswhoneededbutdidnotreceivemanagement,only
395,000(6.4%)reportedtheywereawareofaneedfortreatment.

Alcohol

Alcoholcontinuestobeamongthemostusedandabusedlicitsubstances(#1choiceof29%youth)
thatenjoysawiderangeofsocietalacceptance(44).Alcoholistheleadingcauseofsubstanceuse
morbidityandmortalitycontributingto8,000deathseachyear.SurveyshaverevealedthatUShigh
schoolseniorshavealifetimeprevalenceofover80%,withover50%notingalcoholuseduringthe
previoussurveymonth,and4%admittingtodailyuseTheaverageagethatalcoholisfirstmisusedis
age12.TheprevalenceofalcoholuseishigheramongwhiteandHispanicyouththanamongblack
youth.Itisimportanttoaskyouthiftheydrinkandifso,whattheirdrinkingpatternis;repeateduse
of alcohol or other substances is not part of normal adolescent defiant behavior. The CRAFFT
screeningtestforadolescentsubstanceabuseisaneasytouseinstrumentforscreeningdruguse(17,
45).

Abouthalfofadolescentswhoarevictimsofamotorvehicleaccidentorsuicideweredrinking
beforetheirdeath.Themostcommonpatternofalcoholicconsumptionisbingedrinking,asdefined
by5drinksinarowinmales,andfourinfemales.Blackingoutspellsarefrequentlyaresultofbinge
drinkingbehavior.Bingedrinkingisdirectlyrelatedtodrunkdriving,increasedsexualactivity(and
teenpregnancy),smoking,datingviolence,attemptedsuicide,andothersubstanceabuse.

The 2013 Youth Risk Behavioral Surveillance (YRBS) revealed that 66.2% of high school
studentshadhadatleastonedrinkofalcoholonatleastone

Substanceuse467

dayduringtheirlife(2).This2013surveyalsorevealedthat18.6%ofstudentswhohaddrunkalcohol
(apartfromafewsips)forthefirsttimebeforeage13yearsofage,34.9%ofstudentshadatleastone
drinkofalcoholonatleast1dayduringthe30daysbeforethesurvey,andamongthe34.9%of
students who currently drank alcohol41.8% had usually obtained the alcohol they drank from
someonewhogaveittothemduringthe30daysbeforethesurvey.Theprevalenceofhavingever
drunkalcoholwashigherinfemalesversusmalesandhigherinHispanicyouththanwhiteorblack
youth.
 Thesurveynotedthat20.8%ofstudentshadhadfiveormoredrinksofalcoholinarowonat
least1daysduringthe30dayspriortothesurvey.Also,6.1%ofstudentsnotedthelargestnumberof
drinkstheyhadinarowduringthe30daysbeforethesurveywas10ormore.Inthe2013YRBS
21.9%ofhighschoolstudentsrodeinacareatleastoncewithsomeonewhohadbeenconsuming
alcohol(2).Ofthe64.3%ofhighschoolstudentswhodroveacarorothervehicleduringthe30days
beforethesurvey,10.0%haddrivenafterdrinkingalcoholduringthe30dayspriortothesurvey.

Alcoholeffects

Alcoholisacentralnervoussystemdepressantthatalsoinduceseuphoriaintheuser;toleranceand
psychologicaldependencemaydevelop,inadditiontophysiologicdependenceinalcoholics.Alcohol
drinksvaryintheiramountofthisdrug,rangingfrom3%to6%inbeer,12%inwine,and50%in
variousliquors.Legalintoxicationisusually0.08to0.10g/dl,thoughjudgmentmaybeimpairedata
bloodalcoholconcentration(BAC)of0.01g/dlorlower.Centraleffectsoccurat2030ng/dl.Acute
intoxicationmayleadtorespiratorydepression,coma,anddeath.Adolescentsshouldbecarefully
educatedabout thedangersofalcohol consumption, includingthe deadlymixtureof drivingand
drinkingthatkillsinnocentaswellasalcoholconsumingvictims.

Alcoholdependenceisaseriouspsychiatricdisorderinadults,andyouthmaybeinvolvedinthis
disorderaswell.Thegeneticsofalcoholdependencehasbeenstudiedfordecadesanditsmolecular
biologicbasisisbeingrevealed(46,47).Theabuseof

alcohol depletes a number of socalled comfort hormones (opioid peptides, serotonin, gamma
aminobutryic acid, dopamine) in addition to inducing stress hormone release (ie, corticotropin
releasingfactor).Manyadolescentsdonotstopatthesocialdrinkingorexperimentalstageandrapid
progressioncandevelopthroughthelaterstagesofdrugabuse.Youthwhoabusealcoholtendto
comefromfamilieswhereproblemdrinkingoccursaswellasfamilieswhereproblemdrinkingis
absent.TheDSM5listsanumberofalcoholrelateddisorders:alcoholusedisorder(mild,moderate,
severe),alcoholintoxication,alcoholwithdrawal,otheralcoholinduceddisorders,andunspecified
alcoholrelateddisorders(23).

Medicalcomplicationsofproblemdrinkingincludeintoxication,pancreatitis,gastritis,worsening
ofcomorbidmedicaldisorders(ie,diabetesmellitus,epilepsy),andtoxicpsychosis.Thealcohol
withdrawalsyndromepresentswithsuchsymptomsastremors,seizures,hallucinations,andeven
overtdeliriumtremens.Youthwhoabusealcoholmaydevelopanemia,macrocytosis,andelevationin
alkalinephosphatase,bilirubin,uricacid,glutamicoxaloacetic,gammaglutamyltranspeptidase,or
pyruvic transaminases. The diagnosis of alcohol abuse disorder is made mainly by a history of
excessivealcoholuse,andnotonthebasisofapositiveserumordrugscreeningtest.Thefetal
alcoholsyndromeandtheeffectofalcoholonneuronalmigrationandpruning(apoptosis)inthe
unborn fetus exposed to intrauterine alcohol are well recognized consequences of alcohol
consumptionduringpregnancy.Themortalityrisktothefetusis5%,whiletheaccidentalriskofharm
tofamilymembersofalcoholusersisincreasedconsiderably.

Managementofalcoholabuse
Acute alcohol ingestion is treated with gastric emptying, intravenous fluids, glucose, respiratory
support,andsometimes,dialysis.Thepossibilityofadditionaldruguseissuggestedbyrespiratory
depressiongreaterthanthatsuggestedbytheavailableBAC;headinjurymayalsohaveoccurredin
this situation. Medications used in the management of alcohol withdrawal syndrome include
clorazepate,

Donald468EGreydanus,WilliamJReed,andElizabethKHawverlorazepam,chlordiazepoxide,
diazepam,andvariousantipsychotics.Medicationsapprovedforthemanagementofadultswith
alcoholdependenceincludeacamprosate,calciumcarbimide,naltrexone,tiapride,anddisulfiram.
Variousmedicationshavebeenused,buthavenotbeenapprovedforuseinadultswithalcohol
dependence;theseincludebuspirone,carbamazepine,nalmefene,selectiveserotoninreuptake
inhibitors,andtricyclicantidepressants(7).MothersAgainstDrunkDrivers(MADD)andselfhelp
groups(AlcoholAnonymous[AA]andAlateen)areimportantprogramsfoundinmanycommunities
thathelpwiththewidespreadprogramofalcoholuseandabuseinadolescentsandadults.Attention
tothesleepdisruptionseeninthoseabusingalcohol(andotherdrugs)isimportantinanoverall
managementstrategy(48).

Amphetamines

Amphetamines(Dexedrine,Benzedrine,Desoxyn,chalk,meth,speed,Mollies,blackbeauties)are
classiccentralnervoussystemstimulantswhichleadtoavarietyofcomplications,aslistedinTable
10.

Table10.Amphetamineadversereactions

AnorexiaAnxietyExhaustionHyperactivityHyperhidrosisHypertensionInsomniaMydriasis
PersonalitychangesPsychoticexperiencesTachycardiaToleranceWeightlossWithdrawalsyndrome

The DSM5 lists a number of stimulantrelated disorders with regard to amphetaminetype

substance:stimulantusedisorderamphetaminetypesubstance(mild,moderate,severe),stimulant
intoxicationamphetaminetypesubstance,stimulantwithdrawal

amphetaminetype substance, other stimulantinduced disorders amphetaminetype substance, and

unspecifiedstimulantrelateddisorderamphetaminetypesubstance(23).

Table11.Managementofamphetamineoverdose

Activatedcharcoal/magnesiumcitratefororalintoxication

Coolingblanketforhyperthermia

Medicalcontrolofhypertensionandarrhythmias

Haloperidolordroperidolforagitationordelusions

Lorazepam(Ativan)ordiazepam(Valium)forseizures
Urineacidificationwithascorbicacid

Amphetaminescanbetakentodevelopeuphoria,lessenfatigue,improveattention,loseweight,
and/orallowcontinuedsportsperformance.In2003,highschoolseniorsreportedalifetimeuseof
14.4%,9.9%overthepastyear,and5.0%overthepast30daysofthesurvey.Inthe2008MTF,
Johnsonreportedadeclineinstimulantusewithaprevalenceof4.5%in8thgradersand6.8%in12th
graders(49).Theuseofamphetamineshassignificantlydecreasedbutisnextinfrequencyofabuseto
marijuana. Amphetamine can be abused in various formsoral, subcutaneous, or intravenous.
Amphetaminelookalikeshavebecomemoreavailablethroughmailordersitesorfromgarage
productionusingsimplecompoundssuchaphenylpropanolamine,pseudoephedrine,andephedrine
includingtheherbalmahuang.

While the mechanism of action is not entirely known, amphetamines may act by inhibiting
catecholamine reuptake or facilitating the release of norepinephrine in the presynaptic cleft.
Alternatively,theymayactasmonoxidaseinhibitors.Theyareabsorbedthroughthegastrointestinal
tractwithin30minutesandwithin5minuteswhenusedsubcutaneously.Aninitialrushisfollowed
by a prolonged euphoria, alertness, confidence, and excitation. Flushing, sweating, temperature
elevation,tachycardia,significantriseinbloodpressure,andmydriasisoccur.Toleranceisrapidand
confusion, irritability, headache, insomnia, seizures, and weight loss may follow. Cerebral
hemorrhageandcardiac

Substanceuse469

arrhythmiashavebeenreported.Adruginducedpsychosisiswellknowninlongtimeusers,buthas
occurredfollowingasingleuse.Acuteoverdosecanbelifethreateninganddiagnosisandprompt
treatmentisnecessary(seeTable11).

AninfectedneedlemayleadtoHIV/AIDS,endocarditis,hepatitis,andotherinfections(50).An
abstinenceorwithdrawalsyndromeisdescribedinamphetamineabusers,withthedevelopmentof
severe apathy, depression, and hypersomnia. Amphetamine abusers develop tolerance and an
overdosecanleadtohyperthermia,hypertension,cardiacarrhythmias,seizures,anddeath.Table11
outlinesbasicmedicalsupportforanamphetamineoverdose;avoidtheuseofphenothiazines,since
rapiddecreaseinbloodpressureandincreasedseizuresactivitymayresult.

Cliniciansusingstimulantmedicationstomanageadolescentswithattentiondeficithyperactivity
disorder (ADHD) should appreciate the potential for abuse of short acting Adderall (mixed
amphetaminesalts)andRitalin(methylphenidate)(51).Ritalinisalsocalledthesmartdrugand
vitaminRbyabusers,whocrushthemethylphenidatetabletsandsnortthischemicaltoobtainan
intenseeuphoria;largedosescanleadtoseizureactivity,stroke,andpsychosis.Publishedguidelines
should be followed carefully when providing stimulant medications to adolescents. This should
includetheuseofthelongactingpreparations,suchasConcerta,whichhaveformulationsthat
reducetheriskfordispersionandthequickbuzz.Anotherstimulantadditionwithdiminishedabuse
potentialislisdexamfetamine(Vyvanse)aprodrugformulationThelongactingpreparationsused
forthetreatmentofADHDdonotproducetachyphylaxis,norhavetheyleadtoaddiction.

Methamphetamine
Thisillicitdrug(meth,ice,crystal,fire,glass,chalk,crank)isanNmethylhomologofamphetamine
andhasbecomethestimulantfavoredbymostadolescents,duetoitspotentstimulanteffectonthe
centralnervoussystem(52).Itisahighlyaddictivedrugpreparedbyillicitdruglaboratoriesusing
relativelyinexpensivechemicalsandsoldonthestreetsandusingdrugnetworks.Thetermiceor

crystalcomesfromitsproductionasclear,chunkycrystalsthatlooklikeice;itcanalsobebought
asanodorless,bittertasting,whitepowderthateasilydissolvesinliquids.

Thelifetimeuseinthe2007YRBSrangedfrom3.7to5.3%whilethe2013YRBSnotedthat
3.2% of students had used this drug one or more times in their lifetime revealing a decreased
prevalenceof9.1%in1999to3.2%in2013(2).Methamphetamineisnowresponsibleforone
quarterofillicitstimulantuse.

Thisdrugcanbetakenasapilloritspowdercanbesnorted,leadingtoahighoreuphoria;
when inhaled via smoking or taken intravenously, methamphetamine hydrochloride induces an
immediate,potenteuphoriathatisdescribedasaflashorrushlastingafewminutes.Itisthis
intensefeelingthatabusersseekleadingtorapidaddictionwithincreaseddosageandfrequencyof
use.Thisisnotthecasewiththelongactingmixedamphetaminesaltspreparation(AdderallXR)
thatisusedtomanagepatientswithADHD.

Usersofthisdrugnotethatthereisincreasedwakefulness,lessneedforsleep,andincreased
physicalactivity;sometimesextremeanorexiamaydevelopalongwithweightloss.Thetemperature,
respirations,pulse,andbloodpressureareincreased;theremaybeexcitedspeech.Methamphetamine
releaseshighlevelsofdopamineandthuscanaffectbodymovementsandmoodintheseaddicts.
Centralnervoussystemcellsthatcontaindopamineandserotoninaredamaged,eventuallyleadingto
low levels of dopamine, thought dysfunction, and a depressed mood (blue Tuesdays). Motor
impairmentoraParkinsonianlikemovementdisordercandevelop.Adversereactionsaremanyand
somearelistedinTable12.Aswithotherillicitdrugsthataretakenintravenously,thisdrugcanlead
to various infectious diseases, including sexually transmitted diseases, such as hepatitis B and
HIV/AIDS.Urinedrugtestingremainspositive48hoursandmayreflectlookalikedesignerdrugsor
prescriptionpsychostimulants.

The treatment of acute toxicity includes the support of cardiac and respiratory function.
Orogastriclavageandactivatedcharcoalmaybeindicatediforalingestionofothersubstancesis
suspected. Droperidal or haloperidol are more effective thanthe benzodiazepines inblockingthe
behavioraleffectsof

Donald470EGreydanus,WilliamJReed,andElizabethKHawveramphetaminesandproducefairly
rapidsedation.However,benzodiazepinesareindicatedforseizuremanagementandthorazineis
contraindicatedBloodpressureisbestmanagedwithlabeteloloresmolol.Managementofthissevere
drugaddictionisdifficultandcurrentresearchisseekingamedicationtoblocktheeuphoriceffectsof
methamphetaminetoallowtheaddicttogetoffthedrug,ifthereismotivation.Thisantibodytype
medicationresearchispartofotheraddictionresearchstudiesseekingtoneutralizetheeuphoric
effectsofdrugs,suchascocaine,heroin,andothers.Managementofmethamphetaminepsychosisis
difficultbutimportantasistreatmentofdepressionoranxietyrelatedtotheuseofthisdruginorder
toreducerisksformethamphetaminerelapse(53).
Table12.Adverseeffectsofmethamphetamine

IrritabilityAnxietyConfusionMemorylossInsomniaTremorsConvulsionsComaHypertension
CardiacdamageRhabdomyolysisParanoiaandpsychoticbehaviorIncreasedaggressivenesswithviolent
behaviorCardiovascularcollapseanddeath

Cocaine

ThiscentralnervoussystemstimulantisanalkaloidmadefromleavesoftheSouthAmericanplant,
Erythroxyloncoca.Thereareanumberofwaystotakethisdrug:intranasal,intravenous,inhalation,
smoking,chewed(cocaleaves),orswallowed.Previously,thisdrugwasproducedasacrystalline
powderthatiswatersolubleanddevelopedfromanalkaloidalpasteoftheplant'sleaves.Freebase
andcrack(rock)arepopularcocaineproductsusedforsmoking.Freebasecocaineisvaporized
ina

waterpiper (bong) or evenasodacanwithahole init.Crack is the streetnamefor cocaine

bicarbonatepelletsthatarepeasizedandproducedusingammoniaorsodiumbicarbonate(baking
soda);heatingthisconcoctiontoremoveitshydrochloridecomponentproducesacracklingsound.
Crackmaybecrushed,tobaccoadded,andthenthiscigaretteissmoked;otherchemicalsoften
addedincludemannitol,quinine,ormarijuana.Overhalfofthecocaineusedonthestreetsisnow
crackcocainebecausecocainepowderisdecomposedwhenignitedtosmoke.Crackcocainehas
becomerelativelyinexpensiveandverypopularwithadolescents.

The2013YRBSnotedthat5.5%ofstudentshadusedanyformofcocaineoneormoretimes
duringtheirlife(2).TheCDCsurveysnotedthattheprevalenceofeverusedcocaineincreasedfrom
1991to1999(5.9%to9.5%)anddecreasedfrom1999to2013(9.5%to5.5%)(2).Theprevalenceof
everused cocaine was higher among male youth versus female youth. Approximately 23% of
Americansreporttheyhaveexperiencewithcocainebeforeage30.TheDSM5listsanumberof
stimulantrelateddisorderswithregardtococaine:stimulantusedisordercocaine(mild,moderate,
severe), stimulant intoxication cocaine, stimulant withdrawalcocaine, other stimulantinduced
disorderscocaine,andunspecifiedstimulantrelateddisordercocaine(23).

Cocaine is a topical anesthetic, a peripheral sympathomimetic, and a central nervous system

stimulant.Thedruginterfereswithneuronalcatecholaminereuptakeanddopaminereabsorption.The
popularityofcocaineisbasedonitsreadyavailabilityandthepotenteuphoricfeelingitproduces;this
highlasts5to10minutesifcocaineissmoked,incontrastto10to30minutesiftakenintravenously.
Becausethehighisshortlived,theusualpatternofuseisescalatedanddependenceispromoted.
Urineandbloodtestingremainspositivefor4872hoursfollowingitsuse.Oncetheeuphoriaisgone,
irritability and fatigue set in. Users of this powerful drug develop severe psychological and
physiologicaladdictionalongwithtolerance.Seriousphysiologicalcomplicationsareinfrequentand
thedeathrateisloweveninheavylongtermusers;but,whentheyoccur,theycanbedisastrous.A
partiallistoftheserioussideeffectsofcocaineislistedinTable13.

Substanceuse471

Table13.Adverseeffectsofcocaine
AnxietyIrritabilityandrestlessnessConfusionPeripheralbloodvesselconstrictionPupillarydilation
Hyperpyexia,tachycardia,andhypertensionCardiaccomplicationsAnginapectorisMyocardialinfarction
VentriculararrhythmiaSuddendeathSeizuresNasalseptuminfectionandperforationFrontallobe
infarctionIntravenousneedlecomplications(including

hepatitisB,HIV/AIDS,endocarditis)IncreasedprematuredeliveryAbruption(bleedingbetween
placentaand

uterinewall)Adverseneurodevelopmentalsequelaein

infantsVascularspasminducedlimbreduction

anomaliesandstrokes

As with other drugs, addicts look to mix various drugs together to intensify the pleasant or
euphoric feeling of their drug of choice. When alcohol is mixed with cocaine, cocaethylene is
producedintheliver;thischemicalheightensthecocaineeuphoria(ie,morepotentandlastslonger),
bluntssomeofthestimulantadversecocaineeffects,andincreasestheriskofsuddencardiacdeath25
fold. Theterm, speedballing, refers to the mixture of cocaine and heroin (or morphine) andthis
combinationalsoincreasestheriskforsuddendeath.

Themethodofusingcocaineleadstovariouscomplications,asnasalperforation/infectionwith
snorting and the infectious sequelae from intravenous use. The high abuse rate of cocaine is
associatedwithincreasedriskofsexuallytransmitteddiseasesamongadolescentsandyoungadults;
thisincludesHIV/AIDS,lymphogranulomavenereum,andchancroid.Smokingcrackmayleadtothe
developmentofaveryaggressiveparanoia.Suddendeathoccursandisaconstantrisk,whetheritis
thefirsttimeortheuserisveryexperiencedwiththisdrug;suchdeathisprobablyduetoaterminal

ventriculararrhythmia.Useofcocaineduringpregnancycanleadtoavarietyofadverseeffectsonthe
fetusincludingpretermlabor,placentainfarction,placentalabruption,preeclampsia,impairedfetal
growth,andneurodevelopmentaldefects(54).

Managementofcocaineaddiction

Whileacuteintoxicationisusuallynotsevere,itmaybecomplicatedbytheuseofopioids,alcohol,
marijuana, and other drugs. Emergency management includes the maintenance of an airway and
naloxoneifopiateuseissuspected.Treatmentofarrhythmiasmayrequirelidocaine,phenytoin,or
cardioversion.Lorazepamordiazepamcanbeusedforsevereagitationorseizures.Nitroprussideor
labetalolcanbeusedforhypertension.Acoolingblanketandintravenousfluidsmaybeusedfor
hyperthermia.Phenothiazinesarecontraindicated.

Cocaineaddictionisadifficultcentralnervoussystemdisordertomanage.Iftachycardiaand
hypertensiondevelopwhileoncocaine,shortactingbetablockersandshortactingdirectvasodilators
(as esmolol) may be helpful; clinicians should avoid longacting vasodilators, since cocaine
intoxicationistypicallyashort,selflimitedphenomenonanduseoftheseotherdrugs(asmorphine,
propranolol, thorazine) may lead to severe hypotension. Though naloxone is helpful for opioid
addiction,itdoesnothelpwithcocaineaddiction.
 CocaineaddictswithADHDmayobservethatmethylphenidatecalmsthemdownalongwith
improvingtheirconcentrationabilities;areductionincocaineusehasbeenobservedinsomecocaine
addictswhohaveADHDandusemethylphenidate.

Currentaddictionresearchseekstofindawaytostopthepotenteuphoriceffectsofcocaineand
enablethemotivatedabusertostopthisdrug.Dependenceoncocaineinvolvesvariouspathways(ie,
noradrenergicanddopaminergic)intheprimitivemidbrainrewardcenter.MultipleCNSsitesare
involvedwiththeaddictionandthusanydrugusedtohelptheaddictmustworkovermanyCNS
areas. Table 14 lists proposed drug mechanisms that are being researched to potentially manage
cocaineaddictionbyblockingthisdrug'smanyeffects,includingtheuseofvaccinetechnology(55).

Donald472

EGreydanus,WilliamJReed,andElizabethKHawverTable14.Potentialmechanismtomanage
cocaine

addiction

BindtococainemoleculesandpreventmovementintotheCNSviathebloodbrainbarrierChangecocaine
moleculesintoharmless

(inactive)particlesRemovethecocainemoleculeasavaccine

usinganantibodytyperesponseCatalyticantibodieschangingcocaineinto

inactivefragments

Forexample,researchislookingatdrugscalledperipheralblockers,suchasDopamineD3
ReceptorAgonists(D3agonists),topreventcocaineinducedCNSstimulationbyneutralizingthis
drugintheblood;suchdrugsmayhelpwithaddictionaswellaswithoverdoseandcocaineinduced
seizures. Oxytocin may be helpful via effects on the glutamate receptor systems (56). N
acetylcysteineisalsounderactiveresearchforthemanagementofcocainedependence.

If the addict uses other drugs, treatment of dependence on those other drugs may help. For
example,naltrexoneordisulfirammayhelpwithalcoholabuseandbeofbenefittotheaddictwho
usesbothcocaineandalcohol.

Opioids

Anumberofopiatenarcoticsareabusedbyadolescentsandadults,asreviewedinTable15.The
DSM5listsanumberofopioidrelateddisorders:opioidusedisorder(mild,moderate,severe),opioid
intoxication, opioid withdrawal, other opioidinduced disorders, and unspecified opioidrelated
disorders(23).

Prescribed narcotics have been popular for many years, and are available in many ways, as
stealingthemfromhomemedicinesupplies,obtainedfromemergencyroomorofficecliniciansby
faking(exaggerating)injuriesorillnesses(ie,migraineheadaches,dysmenorrhea),orsimplybuying
theopiateofchoiceonthestreet.Mostareobtainedfreefromfriendsorboughtfromschoolmates.
The2008MTFreportsuseby10%of12thgraderswithVicodin

beingthechoiceof9.7%(49).Oxycontinusewasreportedby2.1and4.7%of8thand12thgraders
respectively.Sevenofthetop11abusedprescriptionmedicationsareopiates.

Table15.Narcoticopiates

CodeineFentanylHeroinMeperidineMethadoneMorphineOxycodonePentazocine
PropoxypheneOthers

Cliniciansmayforgetornotbeawareoftheaddictivepotentialofsuchclassicanalgesicsas
Darvocet,Dilaudid,Percocet,Stadol,Vicodin,orUltram.Newsmediahavecoveredthe
recentincreasedpopularityofOxycodone(OxyContin),anarcoticthatisabusedbysomeinplace
ofheroin;avarietyofwaysofabusearenoted,includingchewinganoxycodonetablet,crushingthe
pillandeithersnortingthecontentsorintravenoususeafterboilingthepowder.Itsacceptanceby
addictsisreflectedinthemanystreetnamesithasacquired,includingOXY,OC,oxycotto,and
killers.Fentanylisaprescribednarcoticthatistentimesmorepotentthanheroinandtherearea
numberofreportedoverdosesfromthisdrug.

Heroin

Inexpensive and potent heroin (diacetyl morphine hydrochloride) is available and comes from
Mexico,Columbia,Afghanistan,andPakistan.Heroin(junk,smack,Mexicanbrown,Chinawhite)
canbeabusedinasnuffform,intravenously,orsubcutaneously(skinpopping).ChinaWhiteis2000
timesmorepotentthanmorphineandresponsibleforsome28documentedfatalities.Speedballing,as
notedabove,referstothecombinationofheroinormorphinewithcocaineinanefforttoblockthe
sedativeeffectofheroin.Useofbothheroinandmorphineiscalled

Substanceuse473

NewJackswing.CheesewhichblendsblacktarheroinandTylenolPMhasbeenassociated
with12deathsintheUnitedStates.

Themeanageofheroinusedroppedfrom27yearsofagein1988to19yearsofagein1995.
Therewasadoublingofhighschoolseniorswhousedthisdrugfrom1990to1996atatimewhenthe
priceofheroinwasdroppingalongwitha40%increaseindrugpurity.Thepurityofavailableheroin
hasincreasedfrom5%inthe1990stoover80%presently.The1999YRBSnotedthat2.4%ofhigh
schoolstudentshadtriedheroinonatleastoneoccasion;thiswasbrokendownto3.5%malesand
1.3%females.The2003MonitortheFuture(MTF)Studyrecordedthat1.5%ofhighschoolseniors
hadalifetimeuseofheroin,0.8%overthepastyearand0.4%overthepastsurveymonth(49).The
lifetimeheroinusefortheseseniorswas1.5%inthe2007YRBS,and<1%inthe2008MTFStudy.
The2013YRBSreportedthat2.2%ofstudentshadusedheroinoneormoretimesduringtheirlife
andthisdecreasedfrom2.9%in2011to2.2%in2013(2).
 Unfortunately,thisuseincreasesastheseseniorsleaveschoolandalsoincreasesinthosewho
dropoutofschoolbeforegraduationoftheirpeerswhostayinschool.Thetypicalsituationisan
adolescentwhobeginstosnortthisdrug,thendevelopsanintensecravingfortheresultanteuphoria,
and progresses to smoking or intravenous use (mainlining). An all consuming addiction with
tolerancedevelops,asnotedbythesaying:onceistoomuch,1000timesnotenough;alsoclassic,is
the development of physical addiction, psychological dependence, and a narcotic withdrawal
syndrome.Thismayfollowinitiationofabusebyaslittleasseveralweeks.Approximately30%of
adolescentswhosmokeheroinbecomemainliningadults.Thosewhosmokeorsnortthisdrugoften
mistakenlyfeeltheyarebypassingthedangerouseffectsofheroinbysmoking.However,thisisnot
true,andtheyoungertheaddictionstarts,thegreateristheriskforpostcessationrelapse.

OpiateoverdosepresentswiththetriadofrespiratoryandCNSdepressionassociatedwithmiotic
constrictionofthepupils.Mydriasisisseenwithwithdrawalwhichpresentswithflulikesymptoms,
lacrimation,irritability,abdominalcrampsanddiarrhea.Cardiopulmonaryfailurewithbradycardia,
hypotension,andpulmonaryedemacan

occur.Arapidresponsetotheopiateantagonistnaloxoneisdiagnosticofopiateoverdose.Supportof
both respiratory and circulatory systems with airway maintenance is imperative. Correction of
hypotensionisnecessarywhilemonitoringforhypoglycemia,pulmonaryedema,andarrhythmias.
Thinlayerchromatographyimmunoassaywilldetectopiatemetabolitesfor23days.

Table16listssomeofthemedicalcomplicationsofheroinabuse,includinganoverdosethatleads
to death from respiratory depression and pulmonary edema. For example, an increase in heroin
overdosedeathsin28stateswasreportedbytheCDCfortheperiod2010to2012(57).Clinicians
shouldobservefortheuseoftattoostoobscurepuncturewoundsorneedletractmarksmadebythe
heroin intravenous abuse; such mainlining and tattooing phenomena increase the infectious
complications of needle use. A newborn withdrawal syndrome is described in newborns whose
mothers abuse narcotics; heroin withdrawal in utero can lead to meconium aspiration, bile
pneumonitis,andsevererespiratorydistress.

Table16.Medicalcomplicationsofheroinabuse

AmenorrheaEndocarditis(fromStaphylococcusaureus)FalsepositiveVDRLFatnecrosisHIV/AIDS
Hepatitis(BandC)LipodystrophyOsteomyelitisPepticulcerdiseasePulmonaryedemaandpneumonia
RespiratoryarrestSkininfectionsTetanusOthers

Managementofopioidaddiction

Addictionresearchofthelastpartofthe20thcenturyledtotheconclusionthatopioiddependenceis
aneurobiologicalcentralnervoussystemdisorderthatinvolvesbrainreceptors.Thissciencelooksat
rewardcircuitscontrollingsuchprocessesashunger,thirst,

Donald474EGreydanus,WilliamJReed,andElizabethKHawverreproduction,andevendrug
addiction.DruginducedalterationsinCNSopiatereceptorsleadtodrugdependenceandtolerance
phenomena.Opiateaddictioninducessignificantsocialdysfunctionwithcomplexbiologicaland
psychologicalcomponentsthatarenotcorrectedbyincarceration.Unfortunately,themajorityofsuch
addictsarenotintreatmentdesignedtomanagetheirbraindisorder.Thesepatientsoftenneedacute
detoxificationmeasuresfollowedbyresidentialand/oroutpatientmanagementofsufficientnatureto
blunttheiroftenoverwhelmingneedtofindthenarcoticeuphoria.Communityprogramsasthe12
Stepgroups(ie,NarcoticsAnonymous)canbeveryhelpfultotheseindividualstostayoffthedrug
(s).

Theopioidaddictmaybenefitfromthejudicioususeofvariousmedicationsthatareavailableas
partoftheoverallmanagementprogram(seeTable17)(7).Naltrexone(ReVia,Depade)isan
opiateantagonistthatcanhelpmanywithopiateaddiction,includingaddictswithadditionalalcohol
dependence.Methadonemayblockclassicnarcoticeffectswithoutgivingtheusertheclassicopiate
euphoria; it can also remove withdrawal symptomatology and help with ongoing desires for
additionaldrugs.Clinicianshaveusedthisdrugasasubstituteagonistforopiatedependencesincethe
1960s.Pharmacokineticsallowonceadaydosingandthepatientofficiallymustbeatleast18years
ofageorolder.Dailydosesmayrangefrom40mgto400mgandsuccessfulpatients,whileon
methadone,arethenabletomaintainamorenormallife,incontrasttotheaddict'schaoticlifeofonly
seekingmoneyforanotherhigh.

In search of longeracting alternatives to methadone, addiction specialists have turned to

levomethadyl acetate and buprenorphine, both of which are medications that are effective with
narcotic addicts Clinicians can also use the sublingual combination of buprenorphine/naloxone
(Suboxone)thatprovidesbenefitatleastequaltothatofmethadoneandseemsmoreefficacious
thandetoxification/counseling.Thenaloxonepartofthisdualtreatmentisusedtostopdiversionof
the buprenorphine to intravenous administration. There have been some reports of ventricular
tachycardiawithprolongedQTintervals(Torsadedepointes)aftertakingLAAMandmoreresearch
isneededtoseeifthisdrugissafeenoughtobeused.

Table17.Medicationsavailableforopioidaddiction

Naltrexone

Methadonehydrochloride

LAAM(levoalphaacetylmethadolor

levomethadylacetate)

Buprenorphine

Antidepressantdrugs(asselectiveserotonin

reuptakeinhibitors)

Antistressmedications(asbuspirone)

Hallucinogenicdrugs
Both the hallucinogens and dissociative drugs may alter a youth's state of mind and mood.
HallucinogensincludePsilocybin,Psilocyn(Shrooms,mushrooms),LSD,andmescaline(peyote);
these drugs can cause auditory, visual, and tactile hallucinations. Dissociative drugs, such as
KetamineorPCP,alterapersons'stateofmindandmood,causingafeelingofdetachmentor
dissociatereaction,butdonotcausehallucinations.The2013YRBSnotedthat7.1%ofsurveyed
studentsreporthavingusedahallucinogenicdrugoneormoretimesduringtheirlifetime(2).From
2001to2013theprevalencedroppedfrom13.3%in2001to7.1%in2013.

TheDSM5listsanumberofhallucinogenrelateddisorders:phencyclidineusedisorder(mild,
moderate, severe), other hallucinogen use disorder (mild, moderate, severe), phencyclidine
intoxication, other hallucinogen intoxication, hallucinogen persisting perception disorder, other
phencyclidineinduceddisorders,otherhallucinogeninduceddisorders,unspecifiedphencyclidine
relateddisorder,andunspecifiedhallucinogenrelateddisorder(23).

PCP(phencyclidine)andLSD(lysergicaciddiethylamide)aretakenaspillstoinduceapotent
realitydistortionwithsynesthesiasoralterationsofsensoryperception(involvingsightandsound)
and emotions (involving euphoria and intense fears), in addition to time and place. Tolerance is
describedintheseindividualsasarecasesofpsychosisandthewellknownflashbackthatcanbe
inducedby

Substanceuse475

antihistaminesormarijuana.Overdosingcaninducerespiratorydepressionwithcomaanddeath.A
recentadditiontothetripsceneisSalviadivanorum(VirginMary'sHerb,Mary'sleaf).Thisisa
hallucinogenicethnobiologicalplantgrowninthesouthwestUSwhichmaybesmoked,squeezedinto
water,orsteepedintoatea.Itisabsorbedthroughthemucusmembranesandproducesaeuphoric
experiencewithGod.Itcannotbedetectedbycurrenturinarydrugscreens.

Phencyclidine(PCP)

Thisdrughasmanystreetnames,includingpeace,pill,sternly,peacepill,angeldust,hog,andsheets.
PCP is an arylcyclohexalamine that can be made in illicit laboratories; it causes adrenergic
potentiationbyinhibitionofneuronalcatecholamines.PCPcanbetakenastablets,liquid,orina
powderform,sometimessprinkledonmarijuanaorcigarettes(joints)toaugmentpot'spotency.Itisa
dissociativeanestheticwithhallucinogenic,stimulant,anddepressiveproperties.Sinceitislipophilic
ithasa72hourhalflife.PCPistheactiveingredientandcanbedetectedforuptoeightdaysafter
ingestion.Clinicalexpressionmayincludefrankpsychosis,mania,delirium,andlatemanifestations
ofdepression.Agitationassociatedwithverticalandhorizontalnystagmus,mioticbutreactivepupils,
elevatedbloodpressure,gaitataxia,anddelusionsshouldsuggestPCPintoxication.

Diagnosiscanbeconfirmedwithgaschromatography/massspectrometryusingbloodlevelswith
or without urine testing. Excretion is pH dependent (increased in acid pH) High doses of
dextromethorphan,especiallywhenmixedwithbenzodiazepines,havebeenassociatedwithasimilar
toxicitytophencyclidine.
 Management of a PCPinduced trip (bad reaction) involves keeping the patient in a dark,
paddedroomwiththeprovisionofdiazepam(1020mgorally,or10mgintramuscularlyeveryfour
hours).Lorazepam(12mg)maybeusedIM/IVforseizures.Haloperidolmaybereservedforsevere
agitation.DeathmaybecausedbyPCPbecauseofthedevelopmentofhypothermia,seizures,trauma,
severehypertensionorhypotension,and/orpsychotic

delirium/coma.However,mostdeathsarecausedbyaccidentalinjuryoccurringduringintoxication.
PsychosismaybehelpedwithD3agonistsandresearchseekschemicalstoactasantibodiesto
neutralizePCPmolecules.

Lysergicaciddiethylamine(LSD)

LSDisthemostpowerfulhallucinogenandhasearnedmanystreetnames,includingacid,L,sugar,
dots,cubes,bigD,andblotters.LSDisfoundinmorninggloryseedsandryefungus(Ergot).Itis
easytoproducebyamateurchemistsandeasytohidesinceitisodorless,tasteless,andcolorless;
because of this, it has become popular at marathon dances (raves) where it can be given to
unsuspectingvictims.Adoseaslowas20mcg(placedonsmallobjectsasasugarcube,paperblotter,
orpostagestamps)canleadtoitsclassiceuphoricorhallucinogeneffectsbyincreasingserotonin;
sympatheticactivityispotentiatedwithresultanttachycardia,fever,conjunctivalinjection,mydriasis,
lacrimation,flushing,drymouth,blurredvision,tremors,incoordination,andelevatedbloodpressure.
Onsetofsymptomsfollowinganoraldoseis3045minutes.Thehalflifeis3hours,butroutineurine
drugscreensdonotdetectLSD.Mostyouthwithabadtriporunpleasantflashbackrespondtoa
reassuranceandcalminteractionwiththeclinician;ifnecessary,haloperidolhasbeengivenformajor
reactions,includingprolongedseizureactivity.

Tryptamines

TryptaminesincludeanumberofnaturallyoccurringScheduleIhallucinogenicsubstancesobtained
frommagicmushroomsindigenoustoSouthAmerica,Mexico,andtheUnitedStates.Theycanbe
syntheticallyproducedandincludePsilocybin(0phosphoryl4hydroxyN,Ndimethyltryptamine)
and Psilocyn (4hydroxyn, ndimethyltryptamine). These chemicals produce muscle relaxation,
mydriasis,vividauditoryandvisualdistortions,aswellasemotionalliability.Thesedrugeffectsare
notwellpredictableandvarybythespecificmushroomsusedaswellasthemannerinwhichtheyare
dried,brewed,and

Donald476EGreydanus,WilliamJReed,andElizabethKHawverconsumed.Usersoftryptamines
oftenexperienceamultitudeofeffectsthatincludehallucinations,euphoria,dilatedpupils,empathy,
emotionaldistress,feelingsoflove,andvisualauditorydisturbancesordistortions.Some
experiencegastrointestinaleffects,asnausea,emesis,anddiarrhea.

Dimethyltryptamine(DMT)occursnaturallyinavarietyofwildplantsandseeds.Itisusually
smoked,sniffed,orinjected.DMTisinactivatedorallyandrapidlymetabolized.Thedrugexperience
iscalledabusinessman'stripbecauseitseffectsareforonlyonehour.Diethyltryptamine(DET)is
ananalogueofDMTandproducesthesamepharmacologiceffects,butislesspotentthanDMT.
Alphaethyltryptamine(AET)isanothertryptamineclasshallucinogenaddedtothelistofScheduleI
hallucinogensin1994.

N,NDiisopropyl5methoxytryptamine (referred as FoxyMethoxy) is an orally active

tryptaminerecentlyencounteredintheUnitedStates.Alphamethyltryptamine(AMT),knownas
spirals,wasdesignatedaScheduleIdrugin2003.Tryptamines,likeFoxyandAMT,arevery
dosedependent,whichmeansthatthedoublingofamoderatedosecouldresultineffectssimilarto
LSD.Thedurationofeffectsfrom20mgofAMTusuallylastbetween12and24hours,whilethe
effectsfrom6to10mgofFoxyreportedlylastfrom3to6hours.5methoxyalphamethyltryptamine
(5MeOAMT)isalsoatryptamine.Othercommonnamesfor5MeOAMTarealphaO,alpha
andODMS.

Bufotenine(bufagin,bufotenin,5hydroxyNNdimethyltryptamine)isaScheduleIsubstance
foundincertainmushrooms,seeds,andmostnotably,theskinglandsofthegreenandredCaneToad
(Bufomarinus).Inthe1960s70s,thetoadsmilksinnorthernFloridawereobtainedbydaringto
lick(suckthetoad)whichleadtoaccidentalhandlingofthetoads.Historically,thesetoadswere
killedandtheirskinboiledtoproduceabittertastingbroth.InAustralia,themilkisdriedintoa
powderandsmoked.InSouthAmerica,thissubstanceisusedassnuff.Amild,thoughfrightening
tripoccursasthis3indoleamineworksonserotonergicsitesintheamygdaleandventrallateral
geniculate. The toad can continuously replace the supply and, in general, most bufotenine
preparationsfromnaturalsourcescanbeextremelytoxic.

MDMA(ecstasy)

Phenethylaminesareafamilyofover100chemicalsthatarehallucinogenic.MDMA(3,4methylene
dioxymethamphetamine)isaphenethylaminethatresemblesbothastimulant(methamphetamine)and
ahallucinogen(mescaline).TheUSFoodandDrugAdministrationclassifiedMDMAasaScheduleI
drug in 1985. MDEA (3,4methylenedioxyNethyl amphetamine) or Eve isa close congener of
MDMA. There is also a designer version of the banned decongestant and diet drug,
phenylpropanolamine;itisreferredtoasU4iaandissimilarinactiontoMDMAwithbothstimulant
andhallucinogeniceffects.

MDMAwasdevelopedin1912byGermanscientistsandsynthesizedasanappetitesuppressant;
itwasutilizedinthe1970sand1980sinanattempttoimprovepsychotherapy.Concernoverthisdrug
developedasitsseveresideeffectsbecameevident.

The2013YRBSreportedthat6.6%ofstudentshadusedecstasy(MDMA)oneormoretimes
duringtheirlifetimeandthisdroppedfrom11.1%in2001to6.6%in2013(2).

MDMAproducesanintenseeuphoriaandenergizingeffectinusersandthusispopularatdance
orclubhalls(calledraves,trances,ordancepartiesthatlastallnight);itisalsopopularwithcollege
students.Itisadesignerdrugthatabusersfeelissafeat12mg/kgandproducesprolongedeffects;
becauseofthis,itsavailabilityanduseismorecommonthancocaineatteenageraves.Itseffectis
normally3to6hours,thoughitmaybeseveraldays.Itspurestformisasawhitecrystallinepowder
andifredorbrownMDMAisfound,thissuggestsimpuritiesarepresent.MDMAhasmanystreet
names,suchasecstasy,XTC,X,hugdrug,lover'sspeed,diamonds,clarity,dex,essence,roll,bean,
M,E,andAdam.

MDMA has mescaline like effects, probably due to interaction with and destruction of
serotoninergicneuronsinthecentralnervoussystemthatareinvolvedwiththoughtandmemory.This
mayresultfromtheformationofquinoneswhichcancombinewithglutathioneandotherthiols.
MDMAproducesananxiousstateofwellbeing,changesinperception,moderatederealizationand
depersonalization without producing psychomotor agitation. MDMA abuse may leadtocognitive
dysfunction,memoryimpairment,

Substanceuse477

andbehavioralproblems.Iftakenduringpregnancy,theriskforcongenitalanomaliesisincreased.
UserstakeMDMAtoenhancesensualawarenessandaugmentedpsychicoremotionalenergy.A
numberofsideeffectsarenoted,aslistedinTable18.

Table18.SideeffectsofMDMA

HypertensionandincreasedpulseDehydrationandpossibleheatstrokeFatigueSleepdysfunction
MusclespasmsSweatingOrgandysfunction:renal,liver,CNS,muscularIntracerebralhemorrhage
IrreversibleCNSdamagewithmemorylossin

chronicabuseConfusionandparanoiaPsychosisDepressionAnxiety,includingpanicattacks

MDMA can hide thirst and eventual death that may be due to dehydration (which is not
uncommonandhenceitsassociationwithwaterbottlesatraves),hyperthermia,hyponatremia,or
cerebral edema. High doses can lead to muscle breakdown, breakdown of muscles, malignant
hyperthermia,renalfailure,andcardiovascularfailureattheraves.MDMAandsomeoftheother
designerdrugshavebeenassociatedwithintracerebralhemorrhageinadolescentsandyoungadults
whohaveundiagnosedvascularmalformations.Also,anxiety(includingparanoiaandpanicattacks)
may last for weeks after drug cessation. MDMA is a popular daterape drug(see below). Acute
managementrequiresdiagnosis,rehydration,cardiovascularsupport,andtheuseofbenzodiazapines
forsympathomimeticeffects.

MDMAusersmaymixthisdrugwithalcohol,marijuana,LSD,dextromethorphan,andother
drugs.Preparationswithcamphor,menthol,andephedrineareappliedtothenasalmucosaorchestto
enhancethedesiredMDMAeffects.MDMAcanalsobetakeninincreasingdosesinastacked
schedulesimilarto

that used with anabolic steroids. The drug user may also take chemicals that are ecstasylike in
appearance, such as ketamine (special K), alpha methyl fentanyl (synthetic heroin, china
white)andephedrinetablets(herbalecstasy,Chineseephedra,MaHuang);largeamountsof
thesechemicalsmayleadtohypertension,cardiacarrhythmias,myocardialinfarction,cerebrovascular
accidents,anddeath.TheephedrinefoundinHerbalecstasyproductsasfoundinhealthfoodstores
hasonlyrecentlybeenbanned.
Daterapedrugs

Novelandmorecreativeusesforpreviouslylegitimatepharmaceuticalsandnutriceuticalscontinue
to emerge on the street, including familiar drugs as marijuana (ie, increased THC content),
phencyclidine (PCP), crack cocaine (or opium) with Viagra, variations on MDMA described
previously,shortactingbenzodiazepines(benzos),andthosecompoundsreadilymadeusingrecipes
availableontheinternetandconcoctedbyamateurchemists.

Table19.Clubdrugs

Methylenedioxymethamphetamine(Ecstasy,

MDMA)Rohypnol(Flunitrazepam;Roofies,TheDate

RapeDrug,Roches,Rope)Gammahydroxybutyrate(GHB,Liquid

Ecstasy)Gammabutryllactone(GBL,Bluenitro,

Renewtrient)Butanediol(BD,soap,Revitalizeplus)Methamphetamine(meth,ice,crystal,fire,

glass,chalk,crank)LSD(acid,L,sugar,dots,cubes,bigD,

andblotters)Ketamine(Ketalar;SpecialK,CatValiums)

Avarietyofchemicalshavebeenusedtolowerexternalandinternalinhibitionsand/orconsciousness,
helping to facilitatesexual assault. These socalled date rape drugs are named for their strong
sedative

Donald478EGreydanus,WilliamJReed,andElizabethKHawverandhypnoticeffectsthatare
enhancedwithalcohol.Theycontinuetobepopularatallnightdancepartiesorraves,andthus,
havealsobeencalledClubDrugsorPartyDrugs.Somearesoldinnutritionstoresorviamagazine
adsassleepaids,musclebuilders,andevenaspartydrugs.Avarietyofdrugshavebeenused,as
partiallylistedinTable19;thislistincludesMDMAmethylenedioxymethamphetamine(Ecstasy)
previouslydiscussed.

Flunitrazepam(Rohypnol)

Thisisapotentbenzodiazepinewithsedative,anxiolytic,andanticonvulsanteffects.Itbelongstothe
same group as Halcion, Ambien, Xanax (Z Bars), Klonopin, Sonata, Versed, and Valium.
Flunitrazepam is acentral nervous system depressant produced commerciallyinSwitzerlandthat
reducesinhibitionandresultsinmemoryloss(blackouts)withshorttermanterogradeamnesiafor
activitythattakesplacewhileundertheinfluenceofthedrug.

Itcanalsoleadtosuchadverseeffectsasurinaryretention,drowsiness,confusion,dizziness,
gastrointestinal dysfunction, visual disturbances, hypotension and others. It is available by
prescriptioninEurope(nottheUnitedStates)andusedasasedativeformanagementofinsomniaand
alsoasapresurgeryanesthetic.
 Flunitrazepam is a tasteless, odorless, and colorless chemical that can be taken as a pill or
dissolvedinabeverage;anecdotalreportsofsnortingarenotedaswell.Onemilligramcanbesecretly
placedinaliquidtosedateavictimfor8to12hourswithunfortunateamnesiaforthesexualassault
thatmayfollowtheingestion.Thevictimisseenvoluntarilyleavingwiththerapist,recallslittleif
anythingoftheevents,andisunabletotestifyinanylaterprosecution.Ithasbecomeapopularand
classicdaterapedrugusedbygangmembersandevenhighschoolorcollegestudentsoperatingat
local parties. Its many street names include forgetme pills, Rope, Roche, Mexican valium, and
roofies.Itisalsoanaddictivedrugusedvoluntarilybyyouthasanalternativeoradjunctivedrugto
marijuanaorLSD,aswellastheselftreatmentofanxiety.Itseffectsareenhancedwithalcohol.If
usedonaregularbasis,increasinglyhigherdosesareneededforthedesired

euphoriceffect.Itsusehasincreased50%overthepastseveralyears.InSouthTexas,alongthe
UnitedStatesMexicoborder,itisfrequentlyreplacedbythemorereadilyavailableKlonopinor
Xanax,bothofwhichareassociatedwithblackingoutspellsandwithdrawalseizures,especially
whenabusedwithalcoholandmarijuana.

Gammahydroxybutyrate(GHB)

ThisisaCNSdepressantthatinduceseuphoriaandloweredinhibition.Ithasmanystreetnames,
including:LiquidX,LiquidE,LiquidXTC,LiquidEcstasy,NaturalSleep500,OrganicQuaalude,G
Caps, Gamma Hydrate, Georgia Home Boy, Growth Hormone Booster, Cherry Meth, Sodium
oxybutyrate,SomatomaxPM,GrievousBodilyHarm,GRiffick,OxySleep,Scoop,Fantasy,Easy
Lay,Soap,SaltyWater,VitaG,GammaOH,Somsanit,GHB;LiquidEcstasy;G;Georgiahomeboy,
caps,organicqualude,andgoop.

LikeRohypnol,GHBanditsanalogsareusedasdaterapedrugs.Ithasasoapyorsaltytaste,
andhencethenamesaltisuseduntilitismixedwithanyliquid,includingwater.Becauseitis
colorless,tasteless,andodorless,itiseasilyandquietlyslippedintoanunattendedpartydrinkto
inducesedationandamnesia.Effectsdevelopin1020minutes,peakin1to2hours,andlastfor4
hours.GHBisrapidlyclearedfromthebodyandisundetectedinsubsequentrapeinvestigations.The
clinicianprovidingcareinanemergencysituationmustrequestthatthelaboratoryspecificallylook
forGHB.Adolescentfemalesneedtobewarnedaboutthedangerofleavingdrinksunattended.

ItisusedbybodybuildersandathletesbecauseofbeliefsthatGHBwillaugmentendogenous
humangrowthhormone(HGH)releasewhilesleeping.GHBisavailableinsingledosesthataugment
ormimiceffectsofalcohol;increasinglyhigherdosesareneededfordesiredeffects.Theriskof
seizuresanddeathcausedbyGHBinducedrespiratorydepressionisraisedwhenmixingGHBwith
otherdrugs,suchasalcohol,heroin,LSD,andpsilocybin.TheCNSdepressionoccursbecauseof
increasingCNSdopamineandGABA(gammaaminobutyricacid);theendogenousopioidsystemis
alsoactivated.It

Substanceuse479

becameaScheduleIsubstanceinMarchof2000andinJuly,2002,GHBwasapprovedbyanFDA
advisorycommitteeforstudyinthetreatmentofcataplexy.MostoftheGHBusedintheUnited
StatesisillegallymanufacturedintheUS.LawenforcementineveryregionoftheUnitedStates
reportsthatGHBhassurpassedRohypnolasthemostcommonsubstanceusedindrugfacilitated
sexualassaults.

Gammabutyrolactone(GBL)

BecausetheDEAiscrackingdownonGHBuse,someareusingGHBprecursors,suchasGBLas
wellasBD(14butanediol),anindustrialsolvent;botharepromotedtoenhancesexualabilityand
pleasure.StreetnamesforGHLaremany,includingRenewtrient,Revivarant,ReivivarantG,Blue
Nitro, Blue Nitro Vitality, GH Revitalizer, Gamma G, Remforce, and Soap; it is found in paint
thinnersandfloorstripperproducts.BDleadstobradypneaandcaninduceemesis,aspiration,and
coma.GBLandBDarebotheasilychangedtoGHBinvivo,andinvitrobyaddingwater.Some
producersaresubstitutingBDforGHB,eventhoughtheFDAhasidentifiedBDasapotentiallylife
threateningdrug.Itissoldasadietarysupplementinanumberofsleepaidandmuscleenhancing
products;namesincludeSomatoPro,NR63,ThunderNectar,Enliven,GHRE,WeightBeltCleaner,
RevitalizePlus,andSerenity.TheFDAaskedthatproductswithGBLberecalledinJanuary,1999;
somestates,suchasCalifornia,havetoldmanufacturesthatitisillegaltoselltheseproductsor
marketthemasasupplementornutritionalsubstance.GBLrelatedproductshavebeenassociated
with reports of at least 55 adverse health effects, including one death. In 19 of these cases, the
consumersbecameunconsciousorcomatose,severalrequiringintubationforassistedbreathing.

Ketamine

Thisdrughasbeenapprovedsince1970intheroleofaninjectableairwaypreservingveterinary
anesthetic;itistakenorallytoinducedissociativestates,

described as dreamlike and hallucinatory. Street names include K, Cat Valium, Special K, and
VitaminK.Itcanbeobtainedasawhitepowderthatcanbeaddedtotobaccoormarijuanaorthe
powdercanbesnorted;intramuscularabuseisalsodescribed.Theeffectsofketaminelastonehalfto
twohoursproducinganoutofbodydistortionoftimeandspace.Ketamineinlowdosescanleadto
dysfunctionoflearningability,memory,andattentionspan;inhighdoses,itcanleadtomyalgia,
paranoia, elevated blood pressure, delirium, motor function impairment, amnesia, long term
flashbacks,andrespiratorydepressioninduceddeath.Thereisnourinemetabolite.

Inhalants

Inhalantdrugs(seeTable20)arecentralnervoussystemdepressantstypicallyabusedbyyoung(ages
68,peaksat14),oftenmale,andhomelessadolescentstoinducetemporaryeuphoriaandexcitement
(58,59).Theseinhaledchemicalvaporsareviewedaseasilyavailableandasinexpensivesubstitutes
or precursors to other drugs, such as alcohol or marijuana. Delivery is by sniffing, huffing, or
bagging.

In1995thelifetimeusewas21.6%for8thgradersversus19.7%in1999and17.3%in2004(60).
Approximately5%ofadolescentgirls(age1217)usedinhalantsthatincludednitrousoxidevials
(19.3%),gluesniffing(34.9%),correctionfluid(23.4%),hairspray(23%),andinhalationofpaintsor
sprays(616%)(49).The2013YRBSreportedthat8.9%ofstudentshadsniffedglue,breathedthe
contentsofaerosolspraycans,orinhaledanypaintsorspraystogethighoneormoretimesduring
theirlife(2).Theprevalencedroppedfrom20.3%in1995to8.9%in2013.

The main ingredient in airplane glue and some rubber cements is toluene. Another popular
inhalantisgasoline,notedespeciallyinruralareasoftheUnitedStatesandwithNativeAmerican
adolescents.Amylnitrite,butylnitrite,andothervolatilenitratesarefoundinroomdeodorizersand
areusedbyolderadolescentstoinduceaphrodisiaceffects.

Donald480

EGreydanus,WilliamJReed,andElizabethKHawverTable20.Typesofinhalantdrugs*

SolventsGasesNitrites(Aliphaticnitrites)

Industrialorhouseholdsolventsorsolventcontainingproducts

PaintthinnersorsolventsDegreasers(drycleaningfluids)GasolineGluesArtorofficesupplysolvents

CorrectionfluidsFelttipmakerfluidElectroniccontactcleaners

Gasesusedinhouseholdorcommercialproducts

ButanelightersPropanetanksWhippingcreamaerosolsordispensers(whippets)RefrigerantgasesHousehold
aerosolpropellantandassociatedsolvents

FoundinspraypaintsFoundinhairordeodorantspraysFoundinfabricprotectorspraysMedicalanesthetic
gases

EtherChloroformHalothaneNitrousoxide

Cyclohexylnitrite(availabletogeneralpublic)Amylnitrite(availableonlywithprescription)Butylnitrite
(Illegalsubstance)

*GreydanusDE,PatelDR:Substanceabuseinadolescents:Acomplexconundrumfortheclinician.PediatricClinNo
Amer59(5):

11791223,2003.(withpermission).

Table21.Effectsofinhalants*

Hearingloss

Toluene(paintsprays,glues,dewaxers)Trichloroethylene(cleaningfluids,correctionfluids)Peripheral
neuropathiesorLimbspasms

Hexane(glues,gasoline)Nitrousoxide(whippingcream,gascylinders)CNSorBrainDamage:tolueneBone
MarrowDamage:benzene(gasoline)LiverandKidneyDamage
 ToluenecontainingsubstancesChlorinatedhydrocarbonsCorrectionfluidsDrycleaningfluidsBloodOxygen
Depletion/Methemoglobinemia

Organicnitrites(poppers,amyl,boldandrush)Methylenechloride

VarnishremoversPaintthinnersLossofthesenseofsmell(nitrites)Thermalburninjurywithnebulized
alcohol/Robitussin(RoboFires)DeathKaposi'ssarcoma*adaptedfromGreydanusDE,PatelDR:Substance
abuseinadolescents:Acomplexconundrumfortheclinician.PediatricClin

NorthAmer59(5):11791223,2003.(withpermission).

Substanceuse481

Inhalantuseisusuallyexperimentalandmayoccurasagroupactivity.Inhalationoccursafter
these substances are placed in a plastic bag (bagging), wrap, or inhaled from a soaked rag
(huffing) to induce the intoxicating (psychoactive) effects. Absorption is rapid and the altered
mentalstatelastsfor515minutes.Afteramildstimulatoryeffect,aninhibitionreductionoccurs,
followedbyunconsciousness.Deathmayoccurfromcardiacarrhythmias.Tolerancedevelopsafter
longtermuse,thoughwithdrawalisrare;dependencemaydevelop(61).

Table21listsvariouscomplicationsknowntooccurwithvariousinhalants.TheDSM5listsa
number of inhalantrelated disorders: inhalant use disorder (mild, moderate, severe), inhalant
intoxication,otherinhalantinduceddisorders,andunspecifiedinhalantrelateddisorders(23).

Most abusers of inhalants discontinue these drugs by stopping substance abuse ingeneral or
movingontootherdrugs.Managementofthosewhobecomechronicinhalantabusersisdifficult,
oftenbeinghinderedbytheirmany,variedbehavioralandsocialproblems.Researchonmanagement
is focusing on inhalant effects on dopaminergic, glutamatergic and GABAergic systems (61).
Unfortunately death from volatile substance misuse may occur as seen, for example, with
difluoroethanecanoccur.

Barbiturates

TheseareCNSdepressantsthatareclassifiedassedativehypnoticdrugs.TheyactontheCNSby
enhancingtheneuroinhibitoryactionofgammaaminobutyricacid(GABA)andproducingrelief
from anxiety and sedation. They are classified as ultrashort acting (thiopental), short acting
(pentobarbital[yellowjackets],secobarbital[reds]),andlongacting(phenobarbital).Theshortacting
barbiturates have a higher potential for abuse and are more lipid soluble than the long acting
formulations.

Theycanbecomeaddictingin1to2monthsandaredeadlyinhighdosesorwhencombinedwith
opioidsoralcohol.Abuseofthesedrugsleadstophysicaladdiction,abstinence,anddiscontinuation
syndrome,similartothatnotedwithalcoholabuse.TheDSM5listsanumberofsedative,hypnotic,
or

anxiolyticrelateddisorders:sedative,hypnotic,oranxiolyticusedisorder(mild,moderate,severe);
sedative, hypnotic, or anxiolytic intoxication; sedative, hypnotic, or anxiolytic withdrawal; other
sedative,hypnotic,oranxiolyticinduceddisorders;andunspecifiedsedative,hypnotic,oranxiolytic
relateddisorders(23).

Barbituratesaredetoxifiedintheliverand/orexcretedunchangedintheurine.Symptomsofacute
use and overdose are similar to those of alcohol and include euphoria, slurred speech, lethargy,
miosis, and ataxia. Overdosing leads to low blood pressure, bullous dermatological lesions,
respiratorydepression,coma,anddeath.Itisnotcommonlyabusedatcurrenttimesandinvolvesless
than 3% of high school students. This reduced abuse probably reflects infrequent clinician
prescriptionofthesedrugs,reducedavailabilityonthestreets,andtheavailabilityofmanyotherillicit
drugs. Barbiturates should usually not be prescribed to adolescents and then, only with extreme
caution.

Conclusion

Substanceabusecontinuestobeawidespreadandveryseriousphenomenonforouradolescentsand
youngadultsintheUnitedStatesandaroundtheglobe.Manyfactorsdrawouryouthintothese
deadlydrugs,leadingtomanyacuteandchronicsequelae,rangingfromaddictiontodeath.Youth
mustbeclearlyandcarefullytaughtthatdruguseandabusecomeswithconsiderablecomplications
fortheircurrentandfuturelife.Theyalsomustbetaughtthatthereisnoscientificevidencethat
smokingcannabisissafenorismedicallybeneficial.Theymustalsobecomeawareofthedangersof
thedesignerdrugsthatarebeingproducedingreateramounts.

Cliniciansmustjoinwithothermembersofsocietytoeducateourpatientstothemanydeadlyand
dangerousdrugsofabusethatareavailableandworkwithsociety(includinggovernments)toreduce
theavailabilityofdrugs(6278).Thehumaninstinctforpleasureatanycostmustbetemperedwith
educationanddirectionfromclinicians.Managementofthoseaddictedtodrugsisacomplex,often
discouragingprocess.Psychosocialandbehavioraltherapiesareimportantthatinvolveavarietyof
healthspecialists.

Donald482EGreydanus,WilliamJReed,andElizabethKHawverGroup,family,andindividual
therapyallhaveaplaceinmanagementandmanyneedintensivetreatmentindrugabuseprograms.

References

[1]NSDUHSAMHSA,2013.URL:http://www.samhsa

.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf[2]KannL,KinchenS,
ShanklinSL,FlintKH,HawkinsJ,HarrisWA,etal.YRBS:YouthRiskBehavioralSurveillanceUnitedStates,2013.
MMWR2014;63(4):1169.[3]LuiCK,ChungPJ,FordCL,GrellaDE,MuliaN.Drinkingbehaviorsandlifecourse
socioeconomicstatusduringthetransitionfromadolescencetoadulthoodamongwhitesandblacks.JStudAlcoholDrugs
2015;76(1):6879.[4]GreydanusDE,PatelDR.Substanceabuseinadolescents:Acomplexconundrumfortheclinician.
PediatrClinNorthAm2003;59(5):11791223.[5]GreydanusDE,PatelDR.Substanceabuseinadolescents:current
concepts.DiseaseaMonth2005;51(7):392431.[6]GreydanusDE,CallesJRJL,PatelDR.Pediatricandadolescent
psychopharmacology:Apracticalmanualforpediatricians.Cambridge:CambridgeUniversityPress,2008:24177.[7]
GreydanusDE,KaplanG,PatelDR,MerrickJ.Substanceabuseinadolescentsandyoungadults:Amanualforpediatricand
primarycareclinicians.Berlin:DeGruyter,2013.[8]GreydanusDE,HawverEK,GreydanusMM,MerrickJ.Marijuana:
currentconcepts.FrontPublicHealth2013;1(42):117.[9]GreydanusDE,KaplanG,PatelDR,MerrickJ.Specialissue:
Theburdenofsubstanceabuse.IntPublicHealthJ2014;6(3):21590.[10]GreydanusDE,KaplanG,PatelDR,MerrickJ.
Editorial:Substanceabuse.IntPublicHealthJ2014;6(3):21524.[11]GreydanusDE,KaplanG,BaxterLESr.,PatelDR,
FeuchtCL.Cannabis:Theneverending,nefariousnepentheofthe21stcentury:Whatshouldtheclinicianknow?DisaMon
2015;61(4):11376.[12]ViteriOA,SotoEE,BahadoSinghRO,ChristensenCW,ChauhanSP,SibaiBM.Fetalanomalies
andlongtermeffectsassociatedwithsubstanceabuseinpregnancy:aliteraturereview.AmJPerinatol2014Dec8[Epub
aheadofprint].[13]NaimFeilJ,ZangenA.Addiction.HandbClinNeurol

2013;116:61330.[14]MillerCP,HombergJR.Theroleofserotoninindrug

useandaddiction.BehavBrainRes2015;277:14692.

[15]PanagopoulosVN,RalevskiE.Theroleofghrelininaddiction:areview.Psychopharmacology2014;231(14):272540.
[16]LeeD,DelcherC,MaldonadoMolinaMM,BazydloLA,ThogmartinJR,GoldbergerBA.Trendsinlicitandillicit
drugrelateddeathsinFloridafrom2001to2012.ForensicSciInt2014;245:17886.[17]HarrisSK,LouisJacquesJ,Knight
JR.Screeningandbriefinterventionforalcoholandotherabuse.AdolescMedStateArtRev2014;25(1):12656.[18]Imtiaz
S,ShieldKD,FisherB,RehmJ.HarmsofprescriptionopioiduseintheUnitedStates.SubstAbuseTreatPrevPolicy2014
Oct27;9:43.doi:10.1186/1747597X943.[19]LevyS,WilliamsJF.Adolescentsubstanceuse:theroleofthemedical
home.AdolescMedStateArtRev2014;25(1):114.[20]NielsenDA,NielsenEM,DasariT,SpellicyCJ.Pharmacogenetics
ofaddictiontherapy.MethodsMolBiol2014;1175:589624.[21]WintersKC,TannerSmithEE,BresaniE,MeyersK.
Currentadvancesinthetreatmentofadolescentdruguse.AdolescHealthMedTher2014;5:199210.[22]UrrilaAS,Paunio
T,Palom?kiE,MarttunenM.Sleepinadolescentdepression:physiologicalperspectives.ActaPhysiol(Oxf)2015Jan5.
doi:10.1111/apha.12449.[23]AmericanPsychiatricAssociation.Diagnosticandstatisticalmanualofmentaldisorders
(DSM5)Washington,DC:AmericanPsychiatricAssociation,2013.[24]AmericanPsychiatricAssociation.Diagnosticand
statisticalmanualofmentaldisorders,FourthEdition,TextRevision(DSMIVTR).WashingtonDC:AmericanPsychiatric
Publications,2000.[25]AmericanPsychiatricAssociation.Substancerelatedandaddictivedisorders.URL:
http://www.psychiatry.org/file%20library/practice/dsm/dsm5/dsm5substanceusedisorder.pdf.[26]AliF,RehmanH,
BabayanZ,StapletonD,JoshiD.Energydrinksandtheiradversehealtheffects:asystematicreviewofthecurrentevidence.
PostgradMed2015;6:115.[27]MusselmanME,HamptonJP.Notforhumanconsumption:areviewofemerging
designerdrugs.Pharmacotherapy2014;34(7):74557.[28]BaumannMH,SolisEJr,WattersonLR,MarusichJA,
FantegrossiWE,WileyJL.Bathsalts,spice,andrelateddesignerdrugs:thesciencebehindtheheadlines.JNeurosci
2014;34(46):151508.[29]UrbanDJ,RothBL.DREADDs(Designerreceptorsexclusivelyactivatedbydesignerdrugs):
Chemogenetictoolswiththerapeuticutility.AnnuRevPharmacolToxicol2015;55:399417.

Substanceuse483

[30]SmithCD,RobertS.'Designerdrugs':updateonthemanagementofnovelpsychoactivesubstancemisuseintheacute
caresetting.ClinMed2014;14(4):40915.[31]CastanetoMS,GorelickDA,DesrosiersNA,HartmanRL,PirardS,Huestis
MA.Syntheticcannabinoids:epidemiology,pharmacodynamics,andclinicalimplications.DrugAlcoholDepend
2014;144:1241.[32]NelsonME,BryantSM,AksSE.Emergingdrugsof

abuse.EmergMedClinNorthAm2014;32(1):128.[33]BanksML,WorstTJ,RusyniakDE,SpragueJE.Synthetic
cathinones(bathsalts).JEmergMed2014;46(5):63242.[34]HajekP,EtterJF,BenowitzN,EissenbergT,McRobbieH.
Electroniccigarettes:reviewofuse,content,safety,effectsonsmokersandpotentialforharmandbenefit.Addiction
2014;109(11):180110.[35]KnorstMM,BenedettoIG,HoffmeisterMC,GazzanaMB.Theelectroniccigarette;thenew
cigaretteofthe21stcentury?JBrasPneumol2014;40(5):56472.[36]RosenbergJM.Amolecularbasisfronicotineasa
gatewaydrug.NEnglJMed2014;371(21):2038.doi:10.1056/NEJMc1411785#SA1.[37]KandelD,KandelE.Thegateway
hypothesisofsubstanceabuse:developmental,biologicalandsocietalperspectives.ActaPaediatr2014Nov6.doi:
10.1111/apa.12851.[38]LoukolaA,HillforsJ,KorhonenT,KaprioJ.Genetics

andsmoking.CurrAddictRep2014;1(1):7582.[39]CollinsGB,JerryJM,BalesR.Quittingsmoking:stilla
challenge,butnewtoolsshowpromise.CleveClinJMed2015;82(1):3948.[40]McRobbieH,BullenC,HartmannBoyce
J,HajekP.Electroniccigarettesforsmokingcessationandreduction.CochraneDatabaseSystRev2014;12:CD010216.
[41]WalkerN,HoweC,GloverM,McRobbieH,BarnesJ,NosaV,etal.Cytisineversusnicotineforsmokingcessation.N
EnglJMed2014;371(25):235362.[42]JainR,MajumderP,GuptaT.Pharmacologicalinterventionofnicotine
dependence.BiomedResInt2013;2013:278392.doi:10.1155/2013/278392.[43]WoltersA,deWertG,vanSchayckOC,
HorstmanK.Vaccinationagainstsmoking:anannotatedagendafordebate.Areviewofscientificjournals,20012013.
Addiction2014;109(8):126873.[44]GutierrezA,SherL.Alcoholanddruguseamongadolescents:aneducational
overview.IntJAdolescMedHealth2014Nov20.pii:/j/ijamh.aheadofprint/ijamh20155013/iljamh20155013.xml.
doi:10.1515/ijamh20155013.[45]KnightJ,SherritL,ShrierL:ValidityoftheCRAFFTsubstanceabusescreeningtest
amongadolescentclinicpatients.ArchPediatrAdolescMed2002;156:607.[46]SamochowiecJ,SamochowiecA,PulsI,
BienkowskiP,SchottBH.Geneticsofalcoholdependence:areviewofclinicalstudies.Neuropsychobiology2014;70(2):77
94.

[47]FerragutiG,PascaleE,LucarelliM.Alcoholaddiction:amolecularbiologyperspective.CurrMedChem2014Dec28
[Epubaheadofprint].[48]ThakkarMM,SharmaR,SahotaP.Alcoholdisruptssleephomeostasis.Alcohol2014Nov11.
pii:S07418329(14)201157.doi:10.1016/j.alcohol.2014.07.019.[49]JohnstonL,O'MalleyPM,BachmanJG,
SckhlenbergJE.NationalSurveyResultsonDrugUsefromtheMonitoringtheFutureStudy,2003,2006,2007,2008.Ann
Arbor:InstituteforSocialResearch,UniversityofMichigan,2009.[50]TungMK,LightM,GiriRLaneS,AppelbeA,
HarveyC,AthanE.Evolvingepidemiologyofinjectingdruguseassociatedinfectiveendocarditis:aregionalcentre
experience.DrugAlcoholRev2014Dec29.doi:10.1111/dar.12228.[51]ClemowDB,WalkerDJ.Thepotentialformisuse
andabuseofmedicationsinADHD:areview.PostgradMed2014;126(5):6481.[52]RawsonRA.Currentresearchonthe
epidemiology,medicalandpsychiatriceffects,andtreatmentofmethamphetamineuse.JFoodDrugAnal2013;21(4):S77
S81.[53]GlasnerEdwardsS,MooneyLJ.Methamphetaminepsychosis:epidemiologyandmanagement.CNSDrugs
2014;28(12):111526.[54]CressmanAM,NatekarA,KimE,KorenG,BozzoP.Cocaineabuseduringpregnancy.JObstet
GynaecolCan2014;36(7):62831.[55]AlvingCR,MatyasGR,TorresO,JalahR,BeckZ.Adjuvantsforvaccinestodrugs
ofabuseandaddiction.Vaccine2014;32(42):53829.[56]ZhouL,SunW,YoungAB,LeeK,McGintyJF,SeeRE.
Oxytocinreducescocaineseekingandreverseschroniccocaineinducedchangesinglutamatereceptorfunction.IntJ
Neuropsychopharmacol2014Oct31.pii:pyu009.doi:10.1093/ijnp/pyu009.[57]RuddRA,PaulozziLJ,BauerMJ,
BurlesonRW,CarlsonRE,DaoD,etal.Increaseinheroinoverdosedeaths,28states,20102012.MMWR
2014;63(39):84954.[58]TormoehlenLM,TekulveKJ,Na?agasKA.Hydrocarbontoxicity:areview.ClinToxicol(Phila)
2014;52(5):47989.[59]NakawakiB,CranoW.Patternsofsubstanceuse,delinquency,andriskfactorsamongadolescent
inhalantusers.SubstUseMisuse2015;50(1):11422.[60]GrunbaumJA,Kann,LKinchenS,RossJ,HawkinsJ,LowryR,
etal.Youthriskbehaviorsurveillence,UnitedStates2003.MMWRSurveillSumm2004;53(2):196.[61]DuncanJR,
LawrenceAJ.Conventionalconceptsandnewperspectivesforunderstandingtheaddictivepropertiesofinhalants.J
PharmacolSci2013;122(4):23743.[62]ComerciGB,SchwebelR:Substanceabuse:Adolesc

Med2000;11(1):79101.

Donald484EGreydanus,WilliamJReed,andElizabethKHawver[63]FriedmanRA:The
changingfaceofteenagedrug

abusethetrendtowardprescriptiondrugs.NEnglJMed2006;354:144850.[64]MarascoCC,GoodwinCR,WinderDG,
SchrammSapytaNL,McLeanJA,WikswoJP.Systemslevelviewofcocaineaddiction:theinterconnectionoftheimmune
andnervoussystems.ExpBiolMed(Maywood)2014;239(11):143342.[65]OssianderEM.Volatilesubstancemisuse
deathsinWashingtonState,20032012.AmJDrugAlcoholAbuse2015;41(1):304.[66]PatelDR,GreydanusDE:Office
interventionsfor

adolescentsmokers.AdolescMed2000;11(3):111.[67]NationalInstituteonDrugAbuse.URL:www.nida.gov/

NIDAHome.html.[68]NationalClearinghouseonAlcoholandDrug

Information.URL:www.health.org.[69]NationalInstituteonAlcoholAbuseandAlcoholism.

URL:www.niaaa.nih.gov.[70]Monitoringthefuture.URL:http://www.Monitoring

TheFuture.org.[71]FioreMC,JaenCR,BakerTB,BaileyWC,BenowitzNL,CurrySJ,etal.Treatingtobaccouse
anddependence:2008update.Washington,DC:USDepartmentHealthHumanServices,2008.

[72]LancasterT,SteadLF.Individualbehavioralcounselingforsmokingcessation.CochraneDatabaseSystRev
2005;2:CD001292.[73]LancasterT,SteadLF.Selfhelpinterventionsforsmokingcessation.CochraneDatabaseSystRev
2002;3:CD001118.[74]LondonED,KohnoM,MoralesAM,BallardME.Chronicmethamphetamineabuseand
corticostriataldefectsrevealedbyneuroimaging.BrainRes2014Nov4.pii:S00068993(14)014668.doi:
10.1016/j.brainres.2014.10.044.[75]O'ConnorPG:TreatingopioiddependenceNewdataandnewopportunities.N.Engl
JMed2000;343(18):1935.[76]PoikolainenK:Ecstasyandtheantecedentsofillicit

druguse.BMJ2006;332:8034.[77]WorldHealthOrganization.Theworldhealthreport1999:Combatingthe
tobaccoepidemic.Geneva:WHO,2000.[78]GreydanusDE,KaplanG,PatelDR,MerrickJ,eds.Specialissue:
Managementofsubstanceabuse.IntJChildAdolescHealth2014;7(4):257380.

Submitted:June07,2015.Revised:June26,2015.Accepted:July01,2015.

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