Drug Abuse Treatment

Drug Addiction

Drug Addiction

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Withdrawal from Harmful Drugs at Home

How to safely detox at home especially from drugs like methadone, benzodiazepines, alcohol, suboxone, oxycontin, cocaine, crack, heroin, crystal meth, pain killers. How to prepare your body before withdrawal and dramatically lower withdrawal symptoms. The dangers of withdrawing from methadone, benzodiazepines, alcohol, crack, cocaine and opiates, and how to avoid them. What to expect when going through withdrawal. (mentioned throughout the video) How to make withdrawal easier and safer. The best way to overcome sleeplessness when withdrawing. How to alleviate depression when withdrawing. What factors could cause you to have more severe withdrawal symptoms and what step to take to address them before attempting withdrawal. Whether you can die from methadone withdrawal. The difference between withdraw, detox and rehab. What to look for when comparing detox centers.

Withdrawal from Harmful Drugs at Home Overview


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Connections Between Interval Timing Neuropharmacology And Drug Abuse

Drugs that increase the effective level of dopamine in the brain, such as cocaine and methamphetamine, are among the most commonly abused drugs today (Stahl, 2000). The connection between interval timing and drug abuse comes from the fact that dopaminergic drugs cause predictable distortions in timing and time perception. The dopamine agonist, methamphetamine, causes a leftward shift in psychophysical timing functions that is proportional in size to the duration of the interval being timed (e.g., Meck, 1983, 1996). This result is compatible with the hypothesis that increasing the effective level of dopamine in the brain causes an increase in the speed of the pacemaker or oscillatory processes used for timing if the pacemaker is caused to run faster than when a time interval was first learned, then participants will think that feedback is due earlier than it actually is, and consequently timing functions will be horizontally shifted to the left. Genetic modifications of the dopamine...

Behavioral Pharmacology Of Drug Abuse

Chiatry, epidemiology, etc.) that are pursued in the hope of greater understanding of the phenomena of abuse of drugs. The present discussion will attempt to relate behavioral pharmacological matters to phenomena of drug abuse in society. It seems self-evident that in the abuse of drugs, such as intravenous injection of heroin or sniffing of cocaine base, the drug represents the reinforcer that maintains the behavior of obtaining the drug. Nevertheless, it was not until it was arranged in the laboratory for an injection of certain drugs to occur occasionally on a response, according to an appropriate schedule, that it was established scientifically that some drugs could function as reinforcers. Responding can be maintained much as with similar presentation of food, fluid, etc. These drugs include most of those that are abused on the streets notably heroin, cocaine, and amphetamines but not most of the drugs that are not abused. So-called self-administration has proved to be a useful...

The psychostimulants cocaine and the amphetamines

Psychotropics Chemical Diagram

Cocaine is a major alkaloidal component from the Andean bush Erythroxylon coca. Leaves of this plant are chewed by Andean Indians to decrease the feeling of hunger and fatigue there is little evidence that dependence is caused by this means of administration. A major health problem arises, however, when cocaine is used in industrialized countries. Thus in the US over 20 million people are estimated to use the drug, by nasal administration (snorting), injection of the salts, or smoking the free alkaloid (crack). The main difference between cocaine and the amphetamine-like drugs lies in its shorter duration of action, the half-life for cocaine being about 50 minutes while that of amphetamine is 10 hours. Because of its widespread abuse, particularly in the US, detailed studies have recently been undertaken on the pattern of abuse of cocaine. Some 20 of those experimenting with the drug go on to become regular users (i.e. psychologically dependent). Once dependent, the individual may...

Cocaine Associated Myocardial Ischemia

Management of patients with cocaine associated myocardial ischemia focuses on reversal of coronary vasoconstriction, hypertension, tachycardia, and predisposition to thrombus formation.31 Central nervous system protection and decreased sympathetic outflow should be accomplished with the administration of benzodiazepines. Multiple animal experiments and widespread anecdotal experience in humans support the use of diazepam as the initial agent for the management of cocaine intoxicated patients. Diazepam alone will often calm the agitated patient and return abnormal vital signs to the normal range. Reduction in hypertension and or tachycardia will decrease the myocardial oxygen demand. Aspirin and or heparin should be used as they would be in patients with myocardial ischemia unrelated to cocaine, despite the lack of any clinical or experimental data. The success with platelet inhibitors and anticoagulants in traditional myocardial infarction patients and the propensity of cocaine to...

Drug Withdrawal and Seizure Relapse

Of the patients on AED treatment, 70-80 will eventually become seizure free.1 Because of the possibility of long-term side effects of drugs, it is good practice to consider drug withdrawal after a substantial remission period. There are risks of relapse, however, in doing so and several studies have addressed this issue.13-17 The probability of relapse has varied between 11 and 41 . Most studies in children have reported figures at the lower end of the spectrum while studies in adults tend towards the higher end. A number of risk factors for seizure recurrence after discontinuation of treatment have been identified.14,15 These include a long history of

Cocaine Ingestion

Cocaine ingestion is an increasingly widespread problem. Carriers will ingest multiple small packets of cocaine in attempts to conceal the drug. A favored packet is the condom, which may hold up to 5 g cocaine. Rupture of even one such packet may be fatal. Webb recommends surgery as the safest method of recovery to avoid the likelihood of packet rupture during endoscopic retrieval. If the packet appears to be passing intact through the intestinal tract, the clinician may choose to observe the patient and wait for the packet to be delivered spontaneously through the rectum.

Drug dependence

Three factors are generally involved in drug dependence tolerance, physical dependence and psychological dependence. Regarding drugs of abuse, tissue tolerance commonly occurs to the opioids, ethanol, and the sedatives of the benzodiazepine type. Tolerance does not develop to all drugs of abuse, however. Thus cocaine and the amphetamines maintain their stimulant and euphoriant effects for a prolonged period of administration without any need to increase the dose appreciably. This term is used to describe the phenomenon in which abnormal behavioural and autonomic symptoms occur when the drug is abruptly withdrawn or its effects are terminated by the administration of a specific antagonist. Most drugs of abuse (e.g. the opioids, sedatives, alcohol) produce some physical dependence, although withdrawal symptoms are relatively mild following the abrupt withdrawal of cannabis, the stimulants, and cocaine. The nature of the withdrawal symptoms depends upon the neurotrans-mitter systems...

Coca and Cocaine

Coca contains fourteen drugs, cocaine being the most important. The other drugs are present in smaller amounts and seem to modify the stimulating effect of the cocaine. In addition, coca leaves contain many vitamins and minerals that are probably important in the diets of Indians who use them. There are several varieties of coca some taste like green tea, some like wintergreen. Coca users put dried leaves in the mouth and work them into a large wad. They suck on this wad for thirty minutes or so, swallowing the juices, after which they spit out the residue. To get an effect from coca, a tiny amount of some alkali, such as lime (the powdered mineral) or ashes, must be added to the wad of leaves. In the late 1800s coca became very popular in Europe and America in the form of tonics and wines. Coca-Cola began as one of these early preparations. At the same time, scientists isolated cocaine from the leaves and made it available to doctors in the form of a pure white powder. As the first...

Paul R Stasiewicz and Kellie E Smith

The origin of the term special population can be attributed to several U.S. government agencies involved in health and human services in the mid-1970s. The term is reserved for groups whose need for substance abuse treatment programs has been under-served. The purpose was to identify subgroups in order to help with planning and evaluating the national treatment system for alcohol and drug problems. The goal was to provide funding for specialty programs, or to ensure that mainstream programs were structured to provide appropriate treatment services. Special population groups are most often defined in terms of age, race eth Ethnic and racial diversity is increasing in the United States, and according to the 1991-1993 National Household Survey on Drug Abuse members of various ethnic minorities report higher rates of substance use and related problems than do Whites. Although a need for treatment services exists, special populations often encounter barriers to obtaining treatment for...

Future Directions

The best estimates available at this writing suggest that in 1998 the combined cost to the U.S. economy of alcohol and drug abuse totals more than 325 billion. This includes the costs of substance abuse treatment and prevention, as well as lost job productivity, unemployment, crime, and social welfare costs. This represents an increase of nearly 50 from the total in 1992 (Harwood, 2000 Office of National Drug Control Policy, 2001). Given this trend, it is clear that SUD treatment will become even more important, making it imperative to identify critical factors in treatment and in patients. complement other treatments (Longabaugh & Morgenstern, 1999). Van Horn and Frank (1998) suggest that, at least in the area of cocaine addiction treatment, there should be greater efforts to bridge the gap between clinicians and researchers both to evaluate existing programs and to disseminate new approaches. Carroll (1999) concluded that cognitive behavioral therapies are well-defined approaches...

Neural Basis Of Interval Timing

Studied in order to determine mechanisms of compensation and regulation (see Hills, this volume). Isolating the neural substrate of these properties is a major challenge for neurobiology (Gibbon et al., 1997). On the basis of the accumulation of evidence from drug and lesion studies, a potential mapping between the information-processing elements of SET and structures in the brain has been proposed (see MacDonald and Meck, this volume Malapani and Rakitin, this volume Matell and Meck, 2000 Matell et al., this volume Meck, 1996 Meck and Benson, 2002). Specifically, the output from dopaminergic neurons in the substantia nigra pars compacta is proposed to play a central role in initiating and maintaining the temporal integration process involving cortico-striatal circuits. This hypothesis is supported by the observation that methamphetamine, a stimulant drug that acts by facilitating the synaptic release of dopamine, speeds up the clock, whereas haloperidol, which acts by blocking...

Empiric Antimicrobial Therapy

Empiric therapy should be effective against gram-positive organisms (Streptococcus spp. and Staphylococcus spp.) and gram-negative bacteria. The route of administration should be intravenous in the maximum doses allowed. In neonates, a regimen of ampicillin plus cefotaxime is recommended. For infants one to three months of age, the combination of ampicillin with cefotaxime or ceftriaxone is recommended. In nonimmunocompromised children three months or older, cefotaxime or ceftriaxone is the drug of choice. In adults (non-neutropenic) without an obvious source of infection, a third-generation cephalosporin or an antipseudomonal b-lactamase-susceptible penicillin is recommended. Some experts advise the addition of an aminoglycoside (tobramycin, gentamicin, or amikacin) to this regimen. Alternatively, imipenem or meropenem alone is acceptable. In neutropenic children and adults, ceftazidime, imipenem, or meropenem alone is acceptable. Alternatively, the combination of an antipseudomonal...

Addiction and dependence

While addiction has been called a victimless crime, nothing could be further from the truth. Research consistently demonstrates that acts of violence against self and others, accidents, decreased productivity, health problems, and a number of other social ills have links to alcohol and drug abuse and addiction. Every day we read about, hear about, or know someone who is a victim of a crime caused by those who use or seek drugs. For some, it is tempting to ignore the ravages of addiction by rationalizing their lack of substance use. However, much like recent findings on secondhand smoke, researchers are identifying other deleterious secondhand effects of substance abuse and dependence. These events include dealing with noise from intoxicated partiers, assault from intoxicated persons, and encountering intoxicated drivers (Wechsler, Lee, Nelson et al.). trauma centers testing positive for alcohol has declined by about one-third. However, during this same period, the number of patients...

Is Addiction a Real Disease

And sex pleasurable, reinforcing, and thus likely to reoccur. It has become evident that virtually all drugs of abuse target this same area of the brain and result in neurotransmitter brain reward. The problem is that the neurotransmitter changes caused by these drugs far exceed those produced by the natural reinforcers. Animals will press a lever for a drug injection or a puff of cocaine. Once they learn that pressing the lever gives them cocaine, they press and press and press, frequently at the expense of eating, drinking, and ultimately their lives. Unfortunately, the same is true in humans where it is not uncommon to see addicts lose family, careers, and even their lives because of their addiction. To understand this process in more detail let us examine the drug cocaine. Drugs like cocaine trick the limbic system by triggering the reward response through the release of neurotransmitters. Neurotransmitters are chemical messengers between nerve cells that are intricately involved...

Local Anesthetic Agents

LAs are all synthetic drugs derived from cocaine. The chemical structure includes a hydrophillic and hydrophobic region and a linkage (amide or ester) region. LAs are weak bases supplied as a salt (usually HCl), with an acidic pH to increase stability, solubility, and shelf life. The most commonly used pharmacologic agents for local infiltrative as well as regional anesthesia are the amide agents, lidocaine and bupivacaine. Lidocaine has a shorter duration of action compared to bupivicaine but has a lower toxicity profile. Tetracaine, an ester LA, is frequently used in topical anesthetic preparations. Esters are metabolized via hydrolysis by cholinesterase enzymes in plasma. Amide LAs are metabolized by hepatic microsomal enzymes. The metabolism rates of amide LAs (prilocaine > lidocaine > bupivacaine) are slower overall than those of ester LAs, creating the potential for sustained plasma levels and cumulative effects of amide LAs. Maximum doses, volumes, and duration of action of...

Management Of Patients With Drugseeking Behavior

There are few controlled studies on drug-seeking behavior. Although it is known that approximately 10 percent of patients seeking treatment for drug addiction identify a prescription drug as the principal drug of abuse,20 there is no statistical documentation of the problem in the ED. The spectrum of drug-seeking patients includes those who have chronic pain and have been advised to avoid taking narcotics, the drug addict who is trying to supplement his or her habit, and the hustler who is obtaining prescription drugs to sell on the street. Patients may move from chronic pain patient to addict to hustler as their social and financial support deteriorates.

Clinical Features

Because of the spectrum of drug-seeking patients, the history given may be factual or fraudulent. Drug seekers may be demanding, intimidating, or flattering. In one ED study, the most common complaints of patients who were drug seeking were (in decreasing order) back pain, headache, extremity pain, and dental pain. 23 Patients may complain of panic disorder or drug withdrawal symptoms and request benzodiazepines. Additional fraudulent techniques are listed in Iab e,3.4-4 In some cases, observations of vital signs and physical examination findings will help the physician identify factitious illness, but even experienced clinicians are frequently misled.23

Factors Such As Charge That Affect Drug Absorption Distribution And Excretion

Charged drugs or other molecules do not readily pass through lipid membranes. However, this often leads to the mistaken conclusion that drugs that are strong acids or bases, i.e., mostly ionized at physiological pH, will not be absorbed from the gut or pass the blood-brain barrier. If a drug is a strong base and has a p a of 9.4, the ratio of ionized to un-ionized will be 100 1 at pH 7.4, but that still means that approximately 1 of the drug is un-ionized and free to go through a lipid membrane. And there is always about 1 that is un-ionized because the equilibrium is virtually instantaneous therefore, the effect of the drug being a strong base or acid is that it decreases the effective concentration available to diffuse across the membrane. This slows the rate of diffusion but not the ultimate amount absorbed given adequate time for absorption. With absorption from the gut, the surface area is quite large and transit time in the small intestine, where most absorption occurs, is...

Age and Gender as Risk Factors

Age and level of social development are highly significantly correlated. Men fall ill with schizophrenia 3 to 4 years earlier and, in our population of origin, married 2.5 years later than women. Their level of social development at illness onset, in the social role of marriage in particular, was therefore considerably lower than that of women. In addition, young men with schizophrenia showed a significant excess of socially adverse behaviour at first admission, e.g. self-neglect, lack of interest in finding a job, deficits in hygiene, aggressive behaviour and an elevated lifetime prevalence of alcohol and drug abuse until first admission. Female patients in contrast showed a significant excess of ''social conformity'', which presumably reflects a different type of adaptive behaviour. The socially adverse behaviour of young males has been confirmed in many population studies by elevated rates of conduct disorders, aggressiveness, antisocial personality, and alcohol and drug abuse...

Can Substance Misuse Trigger a Premature Onset of the Prepsychotic Prodromal Stage

In the ABC Schizophrenia Study, the lifetime prevalence of alcohol abuse until age at first admission was 24 for the first-episode sample and 12 for matched controls from the same population 119,136,137 , and that of drug abuse 14 for patients and 7 for controls. Studies on the topic almost invariably show a preponderance of men in substance abuse. We found a cumulative prevalence (until first admission) of any type of substance abuse of 39 for men and 22 for women. Cannabis was the most frequently abused substance (88 ), followed by alcohol (58 ). In this study, 35 of the patients with drug abuse and 18 of those with alcohol abuse started with the abuse behaviour in the same month as the onset of schizophrenia occurred. In this small group, precipitation of illness onset by substance abuse cannot be excluded, especially since these patients were significantly younger (8 years) at illness onset than non-abusing patients. In contrast, we could not support in our study the...

Time required for study conduct

The washout period between treatment periods in a crossover design is critical to ensure that there are no carryover effects from one period to another. This study design is inappropriate for drugs with long half-lives, for drugs with late toxicity, and if sensitization or tolerance develops. This study design is generally not used for FIH studies due to the general lack of information needed to rule out late toxicity, sensitization, tolerance, or to select an appropriate washout period. Sensitization is a phenomenon whereby the effects of a drug are augmented. Although it might sound counterintuitive, the same drug can evoke both tolerance and sensitization. Behavioral sensitization is a well-documented effect of repeated exposure to drugs such as amphetamine and cocaine (Pierce and Kalivas, 1997). Unlike transient drug effects, such as tolerance and withdrawal, behavioral sensitization can last as long as a year after the last drug administration in rats. The persistence of these...

What are the types of observational studies

Other case reports have led to a faster regulatory response and drug withdrawal, e.g, the association between Guillain-Barre syndrome and the antidepressant zimeldine (Zelmid) and the connection between serious ventricular arrhythmias and the antihistamine terfenadine (Seldane). Although the clinical value of case reports is usually limited, they can sometimes give important warning signals for serious, unexpected or rare adverse events.

In a public health context

Psychoactive drugs are substances that alter the mental state of humans after ingestion. There are a wide variety of those substances, both naturally occurring and synthesized, including tobacco, alcoholic beverages, coffee, tea, chocolate, and some spices, as well as substances that are legally available only through medical channels, such as benzodiazepides, cannabinols, opiates, and cocaine. Such substances often have other use values along with their psychoactive properties. Users may like the taste or the image of themselves that the use of those substances conveys. Substance use may be a medium of sociability (Partanen) or part of a religious ritual. Some substances have other useful properties alcohol, for example, is a source of calories and is used as a solvent in many tinctures.

Elicit a Medical History

The patient reports no past medical history. He has not seen a doctor since he was a child and has had no hospitalizations and no history of past surgeries. He reports smoking a half of a pack of cigarettes per day, moderate alcohol use, and occasional drug use, including marijuana and cocaine. He takes no medications except for an over-the-counter multivitamin daily and ibuprofen for the occasional headache and muscle pain. He has no known drug allergies. At the same time that you have been learning the medical history, a nurse has been putting in two large bore IVs and starting intravenous fluids for resuscitation. What next

Elicit a More Thorough History of the Current Complaint

The patient has told you already that his pain started off in the midepigastrium and then moved diffusely all over his abdomen. But how about other symptoms and the timing of events When asked, he reports that the pain initially started after dinner. He states that he had been out with his friends. When asked directly, he reports some drug use and drinking, consisting of a couple of beers, some mixed cocktails, marijuana, and a small amount of crack cocaine. Later in the evening, he noticed that he had some slight, sharp abdominal pain that he attributed to reflux from the dinner. The pain seemed to go away. He stayed out for about an hour more and then went home where he again noticed the abdominal pain. He slept poorly throughout the night and then in the morning, noticing that his pain was much worse, presented to the ED.

Hanging During Incarceration

Imprisoned suicide victims had made a prior suicide attempt, about two-thirds had made at least one attempt during their imprisonment, and about two-thirds had a history of alcohol and substance abuse (88). Other studies have shown a similar high incidence of drug abuse and suicide attempts (76,83). Lack of access to alcohol and drugs may reduce the ability of the inmate to deal with the stresses of prison life (88). The majority (60 ) of prisoners in a British study killed themselves within the first 3 mo of incarceration (89). Studies have shown that many hanging suicides tended to happen between midnight and 8 00 am, when supervision was reduced (80-82,87). Some suicides occur during the day with the expectation by the victim that imminent resuscitation by staff is possible (89). An inmate may stage a hanging to stimulate apparent unconsciousness. Consequent hospitalization can provide a means of escape (78). The majority of victims are male

The nature of tobacco smoking

Tobacco smoking is a complex behavior to which psychologic, social, and pharmacologic factors contribute.14 Its acquisition is almost invariably in adolescence, as the result of desire for experimental rebellious behavior, which is perceived as adult and encouraged by peer group pressure. However, pharmacologic addiction usually then becomes a factor determining persistence of the behavior, making it difficult to stop because of the addictive effects of nicotine and the discomforts associated with withdrawal. Although the balance between psychologic factors and pharmacologic addiction varies from smoker to smoker, there is now increasing awareness of the importance of nicotine addiction in maintaining smoking behavior, and the powerful nature of this addiction has been compared with addiction to heroin or cocaine.15

Change in Attitudes Beliefs and Practices Regarding Gender

Increases in population, out-migration, communication, and transportation throughout the 20th century have drawn rural people into more relationships with the rest of the world. The Bolivian and Peruvian Aymara were as affected as their compatriots by the political and economic turmoil of the late 20th century. Terrorism in Peru, the growing, trading, and processing of coca and cocaine in the Bolivian lowlands and its trade through Peru, dizzying rates of inflation, and many changes in governments have affected many aspects of Aymara life including gender roles.

Choice And Definition Of Problems To Be Studied

Prostitutes in general (CDC, 1987 Cohen et al Rosser, 1994) and African-American women as prostitutes in particular. Several studies have also revealed that practitioners recognize and report at higher rates crack-cocaine abuse in African-American women and alcohol abuse in American Indian women, compared to white women seeking prenatal care. An American Civil Liberties Union study revealed that in forty-seven out of fifty-three cases brought against women for drug use during pregnancy in which the race of the woman was identifiable, 80 percent were brought against women of color (Pattrow, p. 2).

Relationships Between Disease States and Neurotransmitter Transporters

Contribute to the etiology of multiple neurobiological diseases. Indeed, many studies have suggested for years, largely on the basis of pharmacology, that the monoamine transporters NET, DAT, and SERT play an important role in regulating mood, learning, and motor activity, while GABA transporters have been implicated in neuronal excitability dysfunction such as epilepsy. Indeed, a decade of innovative pharmacology resulted in the development of compounds that, by targeting neurotransmitter transporters, alleviate the symptoms of neurological diseases such as drug abuse and attention deficit hyperactivity disorder. New hopes for the cure of these conditions are coming from studying the gene organization and polymorphisms of these membrane proteins. It has been shown that variations in the human neurotransmitter transporter sequences, known as polymorphisms, may alter transporter expression level, activity, or regulation that ultimately may influence the levels of extracellular...

Special Considerations

THE LEGALITIES OF TREATING ADOLESCENTS WITHOUT PARENTAL CONSENT Consent is not required to evaluate and initiate treatment in an emergency. State consent statutes and case law vary, so emergency physicians should know and follow their state law and hospital policy with respect to consent. There should be a mechanism in place to obtain consent from the courts when necessary. The American College of Emergency Physicians policy on consent is summarized in Figure., 98 3. All states allow minors to consent to diagnosis and treatment of STDs and drug abuse without parental consent. Many states have similar statutes allowing minors independent direct access to prenatal care, termination of pregnancy, and medical care for crime-related injuries. Special considerations are included in some state legislation for emancipated and mature minors. Common sense and appropriate documentation should prevail above all with respect to issues of consent. An a priori awareness of the statutes and policies...

Step 3 Strong opioids

A range of alternative strong opioids to morphine (methadone (Physeptone), pethidine, levorphanol (Dromoran) papaveretum (Omnopon)) are available but have no advantage over morphine. Diamorphine (heroin) is a semisynthetic derivative of morphine which, as its solubility in fat is greater, crosses the blood-brain barrier more readily than morphine. When given parenterally it is 2.5 times more potent than morphine, but when given by mouth it is equipotent. As it is a pro-drug for release of morphine, and does not itself bind to opioid receptors, its only advantage over morphine is that its greater solubility in water allows smaller volumes to be used when parenteral medication is required. Such traditional remedies as the Brompton cocktail (morphine or diamorphine, cocaine and alcohol), Schlessinger's solution (morphine, ethyl-morphine and hyoscine) and nepenthe (alcoholic tincture of opium) are no better than oral morphine sulphate in controlled-release form.

Timothy J OFarrell and William Fals Stewart

Keywords alcoholism, drug abuse, couples therapy, behavioral contracts, communication skills training Although alcoholism and drug abuse have been historically viewed as individual problems best treated on an individual basis, there has been a growing recognition over the last three decades that couple and family relationship factors often play a crucial role in the maintenance of substance misuse. The relationship between substance abuse and couple relationship problems is not unidirectional, with one consistently causing the other, but rather each can serve as a precursor to the other, creating a vicious cycle from which couples that include a partner who abuses drugs or alcohol often have difficulty escaping. * Preparation of this article was supported by grants to the first author from the National Institute on Alcohol Abuse and Alcoholism (K02AA0234) and to the second author from the National Institute on Drug Abuse (R01DA14402)), and by the Department of Veterans Affairs. A...

Serotonin and drugs of abuse

Regarding other types of drugs of abuse, the 5-HT3 antagonist MDL 72222 has been shown to block place preference conditioning induced in rodents by morphine or nicotine without affecting the preference for amphetamine. It is possible that these effects of 5-HT3 antagonists are associated with the reduction in dopamine release as it is well established that the rewarding effects of many drugs of abuse are due to increased dopaminergic activity in limbic regions. On the strength of the experimental findings, it has been proposed that 5-HT3 antagonists might be useful in treating drug abuse in man. Only appropriate placebo-controlled studies of 5-HT3 antagonists will clarify the therapeutic value of such agents in different types of drug abuse.

Social Cost Outcomes and Benefitto Cost Ratio

Three BCT studies (two in alcoholism and one in drug abuse) have examined social costs for substance abuse-related health care, criminal justice system use for substance-related crimes, and income from illegal sources and public assistance. The average social costs per case decreased substantially in the 1-2 years after as compared to the year before BCT, with cost savings averaging 5000- 6500 per case. Reduced social costs after BCT saved more than 5 times the cost of delivering BCT, producing a benefit-to-cost ratio greater than 5 1. Thus, for every dollar spent in delivering BCT, 5.00 in social costs is saved. In addition, BCT was more cost-effective when compared with individual treatment for drug abuse and when compared with interactional couples therapy for alcoholism.

Intracranial Arterial Disease and Stroke

Intracranial arterial disease may lead to ischemic and hemorrhagic strokes. Aneurysms and arteriovenous malformations (AVMs), intracranial atherosclerosis, and vasculitis are some of the major diseases of intracranial arteries producing stroke. Approximately 80 of nontraumatic subarachnoid hemorrhage is due to ruptured intracranial aneurysm. Arteriovenous malformations carry a 40-50 lifetime risk of rupture with subsequent fatal or disabling hemorrhagic stroke. Central nervous system vasculitis may occur with or without coexisting systemic vasculitis. Fibromuscular dysplasia rarely affects intracranial arteries. Cerebral amyloid angiopathy may lead to both ischemic and hemorrhagic stroke. Migraine may cause sufficient constriction of intracranial arteries to produce ischemia and infarction. Vasospasm (constriction of vessels due to contraction of vascular smooth muscle) is common following subarachnoid hemorrhage. Toxic substances such as cocaine and other stimulants may lead to...

Urine Alarm Plus Medications

Doleys, which was referred to earlier, several medications including dex-amphetamine sulfate (Dexadrine), methamphetamine hydrochloride (Methadrine), and imipramine (Tofranil) were used in the treatment of nocturnal enuresis. When dexamphetamine, methamphetamine, or imipramine was combined with the standard urine alarm protocol the duration of treatment was shorter although sometimes by a very small number of nights. However, the relapse rate was higher. In an analysis of the data, Gordon Young and Keith Turner indicated that the shorter duration of treatment was probably not clinically significant and amounted to perhaps one or two trials. This fact, combined with the indication of the possibility of misuse of the drugs by children in the absence of proper safeguards, resulted in the conclusion that there was little distinct advantage to adding these preparations to the urine alarm procedure.

Second and Third Trimester Pregnancy

Ultrasound evaluations of second- and third-trimester pregnancies are often done in order to evaluate fetal well-being when maternal problems arise. Maternal vaginal bleeding, preeclampsia, diabetes, drug abuse, and trauma may all compromise the fetus. Ultrasound can be used to quickly evaluate several important structures that may have a bearing on the final outcome of the pregnancy. Although emergency physicians are not relied upon to perform routine ultrasound examinations during late pregnancy, many of the structures and abnormalities seen in late pregnancy are easily recognizable, even to those with little ultrasound training.

Personality Differences by Gender

Many psychological problems are gender specific. While boys and men tend to suffer from aggression-related problems, women are more apt to experience depression. Substance abuse and alcoholism are also gender specific. While men form the majority of heavy drinkers and alcoholics, women form the majority of psychiatric drug abusers. While male alcoholics attract public attention because they usually behave noisily and aggressively,

The role of dairy products in preventing dental caries

An individual's dietary and social patterns are major contributors to one's oral health. The quality of life can be greatly impacted as a result of poor oral health leaving a negative impact on self-esteem, eating ability, and social functioning (Moynihan, 2005). Several oral diseases can be linked back to poor nutrition, and as teeth deteriorate the conditions are exacerbated. Studies (Johansson et al., 1994, Norlen et al., 1993) have shown edentulous individuals are more apt to have inadequate dietary intake (high carbohydrate, high fat, low nutrient density foods) than dentate individuals. Sugars, specifically sucrose, are recognized as being a major contributor to dental caries' etiology. Other social factors such as alcohol and tobacco use, drug abuse, poor hygiene, and poor nutrition are also cited as being major contributory factors to oral diseases.

Differentiating The Models

First, Meck and Church (1983) trained rats in the duration bisection procedure to make one response to a 2-sec two-cycle stimulus and another distinct response to an 8-sec eight-cycle stimulus. Rats were then tested with duration held constant at 4 sec and number varied, or number held constant at 4 and duration varied. In both cases, the rats' behavior was modulated by the stimulus dimension that varied, showing that the rats had encoded both number and time when the two were confounded. Second, when the probability of making a long or many response was plotted against stimulus duration or number, the point of subjective equality (PSE) was equivalent for time and number and the functions were virtually identical. The PSE is the value at which the animals were equally likely to categorize the stimulus as long or short, or many or few. Third, when the rats were administered methamphetamine, they showed the same leftward shift in the psychophysical curve that relates the probability of...

Laboratory Assessment

Routine laboratory studies are not needed in a child with a clear episode of vasovagal syncope. However, patients with an atypical presentation or worrisome associated symptoms should have a serum chemistry panel, hematocrit, thyroid function tests, chest radiograph, and ECG in the emergency department. Hyperthyroidism predisposes patients to supraventricular tachycardias (SVTs), so thyroid function tests must be obtained with any child where an SVT is considered. In adolescents, a serum alcohol level and urine drug screen should be considered due to the possibility of illicit drug use (most commonly cocaine and amphetamines).

Nonsystemic Pharmacologic Agents

Nonsystemic topical, local and regional techniques are of great value in the management of painful conditions or procedures fvor the pediatric ED patient and may minimize the need for use of narcotics and sedatives. The amide and ester local anesthetic medications (lidocaine, bupivacaine, prilocaine, and procaine) and refrigerant agents are the most commonly used nonsystemic agents. Techniques range from topical applications such as tetracaine, adrenaline, and cocaine (TAC) lidocaine, epinephrine, and tetracaine (LET) eutectic mixture of local anesthetic (EMLA) and ethyl chloride, local infiltration of LA, peripheral nerve block, hematoma block, and IV Bier's block. The general discussion of these agents as well as specific comments regarding their use in children is found in Chap 32.

Emerging valve disease

Cardiac disease is not a common complication of AIDS, but the incidence of AIDS related heart involvement will increase as this infection becomes more prevalent and patients live longer.10 11 Valve involvement is less common than myocardial or pericardial disease in AIDS patients, unless a predisposing factor such as intravenous drug abuse exists.12 In these cases, endocarditis is caused by Staphylococcus aureus or Streptococcus pneumoniae, but can also be caused by fungi or HACEK (Haemophilus species, Actinobacillus actinomycetencomitans, Car-diobacterium hominis, Eikenella corrodens, and Kingella species). It has been reported that the degree of immunosupression caused by the HIV infection increases the severity of valve disease and the resulting mortality.13

Attention Deficit Hyperactivity Disorder

Many animal studies using a variety of different paradigms to study the role of dopamine in the rewarding properties of the psychostimulant drugs have suggested that dopamine is critically involved in this process in experimental animals. In the case of cocaine, studies carried out in human subjects have also supported the idea that enhanced dopamine transmission is responsible for the euphoric effects of this drug in humans. Dopamine appears to be a critical mediator of reward in the brain. Dopamine also appears to play a role in craving, which often leads to relapse in abstinent human substance abusers. Brain imaging studies have identified the amygdala and the dopamine-rich nucleus accumbens as putative neuroanatomical substrates for cue-induced craving. Nucleus accumbens dopamine levels increased withdrawn from cocaine when they were exposed to cues that were previously associated with cocaine intake. Studies in humans examining the level of the dopamine metabolite HVA have...

TABLE 1383 Case Definition of Streptococcal Toxic Shock Syndrome

STSS associated with GAS invasive infections, in contrast to previous reports of GAS bacteremia, most commonly affects individuals between the ages of 20 and 50 without predisposing illnesses.10 There is regional variability in populations at risk for developing STSS and necrotizing fasciitis from GAS infections. Extremes of age, diabetes, alcoholism, drug abuse, and immunodeficiency appear to be risk factors for GAS invasive infections. 1 ,12

Dairy consumption energy intake and body weight

The major site of action of the adiposity hormones in the brain is a discrete hypothalamic region called the arcuate nucleus (ARC) (Schwartz et al., 2000 Cummings, 2006). Functional receptors for these hormones are expressed in the ARC. Despite the differences in leptin's and insulin's signalling pathways, both hormones elicit an increase in the expression of anorexigenic (appetite-suppressing) neuropeptides and a decrease in that of orexigenic (appetite-stimulating) neuropeptides (Schwartz et al., 2000). On the other hand, the actions of ghrelin in the ARC are opposite to those of leptin and insulin (Cummings, 2006). The major anorexigenic neuropeptides are the pro-opiomelanocortin a-melanocyte stimulating hormone (POMC a-MSH) and the cocaine-amphetamine related transcript (CART), whereas the major orexigenic neuropeptides are Neuropeptide Y (NPY) and Agouti related protein (AgRP) (Schwartz et al., 2000). Neurons expressing these neuropeptides project to neighbouring hypothalamic...

Dietary Factors That Lower Blood Pressure

Additional trials have documented that modest weight loss can prevent hypertension by approximately 20 among overweight, prehypertensive individuals and can facilitate medication step-down and drug withdrawal. Lifestyle intervention trials have uniformly achieved short-term weight loss, primary through a reduction in total caloric intake. In some instances, substantial weight loss has also been sustained over 3 or more years.

Use of Behavioral Responses

The drug study used behavioral measures more directly in analyzing the fMRI data. The study involved the challenging task of measuring fMRI changes during the administration of a psychoactive drug, cocaine. Subjects were regular cocaine users who had declined treatment but who had volunteered for a study. During the course of an imaging session they were given either a placebo or an injection of cocaine. (There were two imaging runs, so each subject received the cocaine on one run and the placebo on the other.) During the runs subjects regularly reported on their subjective state of ''high,'' low, ''rush,'' and ''craving'' terms that were known to be associated with cocaine experiences. Note that there are unique technical challenges in this study. In addition to being a psychoactive drug, cocaine is also a cardiovascular stimulant. Therefore, before considering the possible effects of cocaine in its psychoactive and addicting role, it was necessary to demonstrate that such effects...

Clinical Applications

Many other areas of obvious potential clinical importance (in psychopharmacology, neurology, stroke treatment and recovery, drug addiction, and psychiatric disorders) are still largely in the stages of initial research. Although many studies have been performed, there are no specific clinical interventions that are driven by fMRI. A brief summary of some of the ideas in this area is presented in the following sections.

Suggested Reading

L., Weisskoff, R. M., Kennedy, D. N., Makris, N., Berke, J. D., Goodman, J. M., Kantor, H. L., Gastfriend, D. R., Riorden, J. P., Mathew, R. T., Rosen, B. R., and Hyman, S. E. (1997). Acute effects of cocaine on human brain activity and emotion. Neuron 19(9), 591-611. Gollub, R. L., Breiter, H. C., Kantor, H., Kennedy, D., Gastfriend, D., Mathew, R. T., Makris, N., Guimaraes, A., Riorden, J., Campbell, T., Foley, M., Hyman, S. E., Rosen, B., and Weisskoff, R. (1998). Cocaine decreases cortical cerebral blood flow but does not obscure regional activation in functional magnetic resonance imaging in human subjects. J. Cereb. Blood Flow Meta. 18, 724-734.

Summary Episodic and Tonic Factors in the Regulation of Appetite

Mct1 Pathway

Figure 3 The integration of peripherally generated episodic and tonic signals critical to the expression of appetite. Signals generated by both meal consumption and fat deposition are integrated into a complex hypothalamic system of neuropeptides, which in turn either stimulate or inhibit subsequent food intake. Abbreviations 5-HT, serotonin aMSH, alpha melanocortin stimulating hormone AgRP, agouti-related peptide A-IV, apoliproprotein-IV ARC, arcuate nucleus CART, cocaine and amphetamine-regulated transcript CCK, cholecystokinin CRF, corticotropin releasing factor GAL, galanin GLP-1, glucagon-like peptide-1 GRP, gastric releasing peptide LH, lateral hypothalamus MC, melanocortin NPY, neuropeptide Y OX, orexin PVN, paraventricular hypothalamus POMC, pre-pro-opiomelanocortin PYY, peptide YY. Figure 3 The integration of peripherally generated episodic and tonic signals critical to the expression of appetite. Signals generated by both meal consumption and fat deposition are integrated...

Cultural Overview

Manufacturing grew rapidly in the 1950s and 1960s, but has struggled since then. The most valuable export over the past five decades has been bauxite ore and its refined derivative alumina, the basis for aluminum. Jamaica became a major supplier of marijuana to North America in the 1970s, as well as a trans-shipment point for cocaine from South America in the 1980s. Tourism, which began with banana boats over 100 years ago, reached 1.2 million visitors in 1998.

Benzodiazepine Abuse And Dependence

Genuine physiologic addiction to benzodiazepines may occur, particularly with prolonged and high doses. 37 However, the abuse potential of benzodiazepines appears to be low in comparison with that of agents such as alcohol, cocaine, opiates, and barbiturates. 89 Benzodiazepine abuse usually occurs in individuals with a history of abuse of other psychoactive drugs. Primary drug abuse with benzodiazepines is not common.

Central Nervous System

An array of neurologic syndromes are described in association with cocaine abuse, most commonly seizures, intracranial infarctions, and hemorrhages. Pathology results from the hyperadrenergic tone, inducing severe transient hypertension, hemorrhage, or focal vasospasm and sometimes, exacerbation of underlying abnormalities of cerebral blood vessels. In their studies using a dog model, Catravas and Waters demonstrated that lethal doses of intravenous cocaine initially induced seizures, lactic acidosis, hyperthermia, and death.9 Progression of toxicity could be prevented by sedation and cooling. These authors also demonstrated that diazepam was an optimal sedative because it prevented hyperthermia and seizures in the cocaine-poisoned dog and thereby improved survival. Although coronary vasospasm has been well documented in humans exposed to cocaine, a recent study using magnetic resonance angiography also demonstrated cerebral vasoconstriction following cocaine administration. Other CNS...

Anthropological Theory and Urban Poverty Ways of Representing the Urban Poor

In the 1980s, urban anthropology gradually oriented itself less toward micro-level analyses, and away from Lewis's psychologically grounded theory of poverty, and more toward research exploring political, economic, and historical structures of urban living (Low, 1999 Sanjak, 1990). Examples include Hannerz's (1969) ethnography of an African American ghetto in Washington, DC, illustrating intra-group variation and offering an alternative view to the relatively monolithic culture of poverty (Good & Eames, 1996). Similarly, Susser's detailed ethnographic account shows how working class families in a Brooklyn neighborhood actively respond to the limited economic possibilities available to them (Susser, 1982). At the same time, reflecting a broader trend in anthropology overall, medical anthropologists writing about health and the urban poor began to offer alternatives to primarily relativistic, ahistorical, and apolitical traditions (Morsy, 1990). Schensul and Borerro (1982), for...

Chapter References

Rich JA, Singer DE Cocaine related symptoms in patients presenting to an urban emergency department. Ann Emerg Med 20 616, 1991. 2. Marzuk PM, Tardiff K, Leon AC, et al Fatal injuries after cocaine use as a leading cause of death among young adults in New York City. N Engl J Med 332 1753, 1995. 3. Hoffman RS, Henry GC, Howland MA, et al Association between life-threatening cocaine toxicity and plasma cholinesterase activity. Ann Emerg Med 21 247, 1992. 5. Lange RA, Cigarroa RG, Yancy CW, et al Cocaine-induced coronary artery vasoconstriction. N Engl J Med 321 1557, 1989. 6. Lange RA, Cigarroa RG, Flores ED, et al Potentiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade. Ann Intern Med 112 897, 1990. 7. Hollander JE, Hoffman RS Cocaine induced myocardial infarction An analysis and review of the literature. J Emerg Med 10 169, 1992. 8. Hollander JE, Hoffman RS, Gennis P, et al Prospective multicenter evaluation of cocaine associated chest pain. Acad Emerg...

Associated Factors And Correlates Of Hiv Neurocognitive Complications

In terms of risk factors, contrary to expectation, there is no clear-cut association between injection drug use and heightened risk of neurocognitive complications. Although the rates of neuropsychological impairment tend to be higher among injection drug users generally, there does not seem to be an interaction between drug abuse and HIV status. An exception to this rule may be dependence on central stimulant drugs, especially methamphetamine. Preliminary observations suggest that history of methamphetamine dependence may enhance the likelihood of HIV-associated neurocognitive impairment perhaps because of some commonalities in mechanisms of neural injury that involve excitotoxicity.

Differential Diagnosis

Cyanide poisoning always should be considered in the poisoned patient with metabolic acidosis. The differential diagnosis of acidosis in the setting of inhalational exposure includes other cellular toxins such as hydrogen sulfide and carbon monoxide and simple asphyxiants. Hydrogen sulfide is a product of organic decomposition encountered in septic tanks and sewers, petroleum production, and a number of other occupational settings. The characteristic odor of rotten eggs is frequently detectable. Carbon monoxide poisoning is readily confirmed by measurement of a carboxyhemoglobin level. The differential diagnosis of (increased anion-gap type metabolic) acidosis in patients with suspected ingestions includes methanol, ethylene glycol, metformin, salicylates, and iron. The slower time course of deterioration and the variable depth of mental status depression frequently help to distinguish the effects of these agents from those of cyanide. Severe isoniazid and cocaine poisoning are also...

TABLE 1153 Differential Diagnosis of Congestive Heart Failure Based on Age of Presentation

MYOCARDITIS AND CARDIOMYOPATHIES Myocarditis affects children of all ages and is the leading cause of end-stage cardiomyopathy requiring transplantation. Viral etiologies include enteroviruses (coxsackie, echovirus, and poliovirus), as well as mumps, influenza virus, and Varicella zoster. An emerging cause is HIV-associated myocarditis and chronic Epstein-Barr myocarditis. Many bacterial species have been associated with myopericarditis, but not myocarditis alone. Noninfectious causes include lupus erythematosus, toxins such as tricyclic antidepressants, and cocaine. Myocarditis is often preceded by a viral respiratory illness and needs to be differentiated from pneumonia. As with the latter diagnosis, presenting signs and symptoms are often respiratory distress, fever, tachypnea, and tachycardia. Clues that suggest myocarditis include generalized malaise, fever, and myalgias in age-appropriate children. 17,18

Dopamine And The Internal Clock

FIGURE 12.1 Dopamine and clock speed. (A) An information-processing model of interval timing. (Adapted from Gibbon, J. et al., Annals of the New York Academy of Sciences Timing and Time Perception, New York Academy of Sciences, New York, 1984, pp. 52-77.) (B) The scalar property as implemented in the information-processing model the peak time response function is twice as wide when subjects time a 40-sec interval as when they time a 20-sec interval. (C) Theoretical increase in speed of accumulation of temporal units by indirect dopamine agonist methamphetamine and theoretical decrease in speed of accumulation of temporal units by dopamine antagonist haloperidol. Effects on the peak time of responding are predicted to be proportional to criterion interval. (D) Effect of systemic administration of MAP and HAL on the peak time of responding. (Adapted from Meck, W.H., Cognit. Brain Res., 3, 227-242, 1996.) MAP produces a proportional leftward shift of the response function, and HAL...

Extrapyramidal Disorders

Dystonic reactions are involuntary muscle contractions that may affect the muscles of the neck (torticollis), jaw (trismus), trunk (opisthotonos), tongue, or those surrounding the eye (oculogyric crisis). Laryngospasm, although rare, may also occur, and threaten the airway. Dystonia may involve an isolated muscle group or, more frequently, a combination of the above. Affected patients commonly exhibit evidence of adrenergic hyperactivity, including diaphoresis, tachycardia, tachypnea, and hypertension, and are often in obvious pain and quite anxious. 5 A history of therapeutic (including long-acting depot preparations of some antipsychotics such as fluphenazine and haloperidol) and illicit drug use is key dystonic reactions have been reported with a variety of agents, including tricyclics, street Valium (haloperidol), and cocaine.5 Acute treatment includes administration of diphenhydramine (Benadryl), 25 to 50 mg intramuscularly or intravenously the latter route provides the most...

Diagnostic Assessment

Medical conditions which may present with manic symptoms include infectious diseases (encephalitis, influenza, syphilis, AIDS), endocrine disorders (hyperthyroidism), tumours, and neurological conditions (temporal lobe epilepsy, multiple sclerosis, Wilson's disease, closed or open head injury). Manic symptoms may be induced by medications (steroids, isoniazid, sympathomimetics) and alcohol or drug abuse.

Mechanisms Underlying Modality Effects In Time Perception

Pacemaker Switch Accumulator System

A large body of work in rats, and other animals, much of it interpreted within the framework of scalar timing theory, has addressed both the neural and neurochemical substrates of the pacemaker-accumulator component of the internal clock (for a detailed review of the pharmacological basis of the internal clock, see Meck, 1996). For example, Maricq and Church (1983) reported that the dopaminergic agonist methamphetamine increased the rate of the internal clock, whereas the dopaminergic antagonist haloperidol decreased the rate of the internal clock when rats timed intervals in the seconds range. The importance of the dopaminergic system for timing has also been extended to human participants (Malapani et al., 1998 Malapani and Rakitin, this volume Raamsayer, 1997a, 1997b). Although there is strong experimental evidence that both the rate of the internal clock and the latency with which timing processes are initiated are affected by pharmacological manipulations, the question of whether...

Table 142 Etiology of epistaxis

Local irritants Cocaine, nasal sprays, cigarette smoke, toxic gases Inflammatory Rhinitis, sinusitis, granulomatous disease Mass lesions Nasal sinus tumors, carotid artery aneurysm Medications Anti-platelet agents, NSAID's, warfarin, heparin Systemic disease Liver renal failure, DIC, thrombocytopenia

Integrating BCT with Recovery Related Medication

BCT has been used to increase compliance with a recovery-related medication. Among male opioid patients taking naltrexone, BCT patients, compared with their individually treated counterparts, had better naltrexone compliance, greater abstinence, and fewer substance-related problems. Among HIV-positive drug abusers in an outpatient drug abuse treatment program, BCT produced better compliance with HIV medications than did treatment as usual. BCT also has improved compliance with pharmacotherapy

Other Scene Findings and Background Information in Suicide

Similar factors motivate single victims of suicide and perpetrators of murder-suicide (28). These include relationship problems, financial economic stresses, poor health or incurable disease, ethanol and drug abuse, legal difficulties including pending incarceration, mental illness, low self-esteem, and a past history of physical and sexual abuse (18,21,24,37,110). Perpetrators of murder-suicide, depending on the situation, are driven by jealousy, retaliation, altruism (to save the family from the evils of the

Enzymes Associated With Fatty Acid Ethyl Ester Synthesis

In studies on the FAEE synthase enzyme, it was demonstrated by Tsujita and Okuda that carboxylesterase is capable of catalyzing the FAEE synthesis reaction (Tsujita, 1992 Tsujita, 1994b). They demonstrated that purified carboxylesterase was able to promote the synthesis of FAEEs in a number of organs. In support of the findings of Tsujita et al., who showed that carboxylesterase can promote the synthesis of FAEE, we reported that purified FAEE synthase also has cocaethylene (an esterification product of ethanol and cocaine) synthetic capacity (Heith, 1995). Cocaethylene synthase, like FAEE synthase, has been shown to have carboxylesterase activity (Dean, 1991), linking FAEE synthesis again to carboxylesterase.

Efficacy Of Problemsolving Therapy

If effective problem-solving skills serve as an important buffering factor regarding the stress process, training individuals in such skills should lead to a decrease in emotional distress and improvement in psychological functioning. In fact, PST has been shown to be effective regarding a wide range of clinical populations, psychological problems, and the distress associated with chronic medical disorders. These include unipolar depression, geriatric depression, distressed primary care patients, social phobia, agoraphobia, obesity, coronary heart disease, adult cancer patients, schizophrenia, mentally retarded adults with concomitant psychiatric problems, HIV risk behaviors, drug abuse, suicide, childhood aggression, and conduct disorder (see Nezu, D'Zurilla, Zwick, & Nezu, in press, for a review of this literature).

Lessons from Other Prevention Efforts

Although the number of successful large-scale obesity prevention programs is limited, there is a wealth of information from past public health programs that can be used to address other chronic diseases and risk factors. The International Obesity Task Force identified 10 key principles on which efforts to prevent obesity at a population level should be based. These are presented in Box 2 and are drawn from experiences addressing cardiovascular disease, smoking, alcohol and drug problems, dental disease, road accidents, and other public health issues.

Values Inherent in Health Economics Output versus Input

An alternative does not view health care as a final output, but as one input among many others that contribute to a final outcome termed good health. In this view improvements in health can be the result not only of treatment services, but also prevention programs such as health education, lifestyle change, pollution reduction, and even research and improved training of providers. There is no doubt that the good health that has resulted in the tremendous increase in longevity in the last hundred years is not only the consequence of improved medical care, but also the result of such factors as a safe food and water supply and inoculations. At the present time most poor health and disability results from lifestyles reflecting stress, poor eating habits, lack of exercise, alcohol and drug abuse, tobacco use, and automobile accidents.

Self Wounding and Self Mutilation

Self-inflicted cutting can be part of either psychotic or nonpsychotic destructive behavior and is enhanced by alcohol or drug abuse (Fig. 29 refs. 56, 93, and 95-101). Self-cutting also occurs as a religious ritual or as a means for personal gain (e.g., malingering, insurance fraud 56,64,93,95,96 ). Self-wounding of the skin of the extremities (e.g., wrist slashing) is common (56,99,101). Self-wounding injuries are usually relatively minor. Superficial skin wounds in less pain-sensitive areas are observed, and

Psychopharmacology of Drugs of Abuse

Mankind has always shown a surprising ingenuity for finding drugs which have a pleasurable effect. Alcohol in its various forms is perhaps the oldest drug to be used for its effects on the brain, closely followed by various naturally occurring hallucinogens for example fungi have long been known to be an important component of religious ritual in many societies. Other drugs, some of which have had therapeutic uses, include the opioid analgesics such as morphine and codeine, cannabis, cocaine (until recently in a relatively crude form extracted from the leaf of the Andean coca plant) and the milder stimulants, caffeine and nicotine. The use of extracts of opium, coca leaves and khat, a plant growing in some Middle Eastern countries that contains several stimulant components, has had social importance in some non-industrialized societies, where such substances are commonly used as social alternatives to alcohol and also have a role in counteracting hunger and fatigue. Most societies in...

Explanatory Behavioral Models

Finally, if this type of coping style exists, any additional factors that may decrease behavioral self-control, such as alcohol or drug abuse, may be important contributing factors (Nezu, Nezu, & Dudek, 1998). As such, theories that focus on impulse control may also partially explain the problem.

Sedative drugs of abuse

Recent epidemiological evidence shows that very moderate alcohol consumption, amounting to under three units per day for men and two units for women (one unit being equivalent to about 0.25 litres of beer, one glass of wine or spirits), may protect against myocardial infarction. However, regular consumption of alcohol above 21 units per week for men and 14 units for women predisposes to brain, liver, heart and gastrointestinal tract malfunction. Additional health problems arise as a consequence of the multiple drug abuse which many alcoholics exhibit, particularly of tobacco, minor tranquillizers, sedatives and caffeine.

Applications And Exclusions

Ing, and the evidence supporting the efficacy of electrical aversive procedures in alcoholism was weak. Law-son and Boudin in their 1985 review also concluded that the use of electrical aversion in the treatment of alcoholism was associated with a high degree of attrition and was relatively ineffective. They considered that there was a growing consensus that its use for this condition could no longer be justified. In their 1996 review of 339 alcoholism treatment outcome studies reported between 1980 and 1992, Floyd, Monahan, Finney, and Morley found electrical aversion therapy to be used in only one study. However, in their 1997 study, Smith, Frawley, and Polissar found that patients treated with electrical or chemical aversion had a significantly superior outcome to matched inpatients from a treatment registry. Landabaso and colleagues in 1999 concluded from a 2-year follow-up of 30 patients treated for alo-cholism that combining electrical aversion with nal-trexone was effective...

Excessive Alcohol Consumption during Pregnancy

FAS is only seen in infants born to women who are excessive drinkers, but it is not an inevitable result of heavy drinking in pregnancy, and even children born to mothers who are active alcoholics may not show it. This differing susceptibility of fetuses to the syndrome is thought to reflect the interplay of genetic factors, social deprivation, nutritional deficiencies, and tobacco and other drug abuse, along with alcohol consumption.

Binge Drinking and Social Alcohol Consumption during Pregnancy

The question of whether moderate or occasional alcohol consumption is safe during pregnancy has been widely debated. Currently, there is little evidence that modest drinking (< 10 units per week) has any harmful effects. Although there is general agreement that women should not drink alcohol excessively during pregnancy, a consensus opinion of a safe limit to drink has not been established at any stage of pregnancy, and advice differs between countries. Many studies are confounded by factors such as cigarette smoking, social class, drug abuse, very high levels of caffeine intake, and different crosscountry categorization of 'light,' 'moderate,' and 'heavy' drinking. A review of the evidence by the Royal College of Obstetricians and Gynaecologists in the United Kingdom concluded that alcohol consumption of more than 3 drinks per week during the first trimester increases the risk of spontaneous abortion, and consumption of more than 15 units per week can have a small negative effect...

Right Sided Infective Endocarditis

Isolated tricuspid valve (TV) endocarditis is rare, except in the setting of intravenous drug abuse. Valve surgery is infrequent in isolated TV endocarditis, because of less pronounced impact on hemodynamics compared to the involvement of aortic or mitral valve. Involvement of the TV, however, does often accompany left-sided IE. In any case, surgical procedures on the TV mostly involve repair, and not replacement, owing to the anatomic and hemodynamic characteristics

Self Inflicted Venipunctures

Recent venipunctures in drug abusers. (A) Antecubital fossa. (B) Dorsum of foot. (C) Neck. (Courtesy of Dr. E. Tweedie, London Health Sciences Centre, London, Ontario, Canada.) Fig. 41. Recent venipunctures in drug abusers. (A) Antecubital fossa. (B) Dorsum of foot. (C) Neck. (Courtesy of Dr. E. Tweedie, London Health Sciences Centre, London, Ontario, Canada.) Fig. 42. Venipunctures in a drug user can be caused by resuscitation. Intravenous line inserted. A witness indicated where the deceased had injected cocaine (arrow). Fig. 42. Venipunctures in a drug user can be caused by resuscitation. Intravenous line inserted. A witness indicated where the deceased had injected cocaine (arrow). Fig. 43. Track marks (cutaneous scars on forearm) indicative of past intravenous drug abuse. Recent venipunctures (arrow). Fig. 43. Track marks (cutaneous scars on forearm) indicative of past intravenous drug abuse. Recent venipunctures (arrow).

Cardiovascular System

Most local anaesthetic agents (except cocaine) relax vascular smooth muscle causing vasodilatation. In addition, centrally administered drugs cause asodilatation by sympathetic blockade. Direct cardiovascular toxicity occurs due to the membrane stabilizing activity of the drugs on myocardial muscle, by blocking voltage-gated fast sodium channels. This reduces the maximum rate of rise of the cardiac action potential and reduces the duration of the action potential. Conduction of the action potential through the myocardium is slowed. Cardiac toxicity may result in any of the following effects

The abuse potential of designer drugs

Structures of some ''designer drugs'' of abuse. Compare the structure of alpha-methyl fentanyl with that of fentanyl, MMP+ with that of pethidine, and ecstasy with that of methamphetamine. Figure 15.5. Structures of some ''designer drugs'' of abuse. Compare the structure of alpha-methyl fentanyl with that of fentanyl, MMP+ with that of pethidine, and ecstasy with that of methamphetamine.

Phencyclidine and related compounds

Phencyclidine has been favoured as an illicit drug of abuse for some 20 years, but such a use appears to have declined recently owing to the availability of relatively inexpensive cocaine. The drug has the street names of PCP, ''angel dust' and ''crystal''. The structures of phencyclidine and ketamine are shown in Figure 15.7.

The Secrets in My Genes Genetic Discrimination and Privacy

The definition of disability in the act is broad, and has been interpreted just as widely. In a recent case, Marsden v HREOC and Coffs Harbour & District Ex-Servicemen and Women's Memorial Club 2000 FCA LEXIS 992 the federal court of Australia found that this definition of disability extended to drug dependence. In Marsden, the complainant alleged that the club had discriminated against him by refusing to serve him alcohol. Mr. Marsden used prescribed methadone to manage his heroin addiction. His use of methadone meant that he sometimes was unsteady on his feet, slurred his words, was uncoordinated, and appeared intoxicated. The club made Mr. Marsden's membership dependent on his not consuming alcohol because they were concerned, without medical evidence, that alcohol should not be consumed on a methadone program. The federal court found that addiction was a form of disability, and that it continued to be a disability even if it were satisfactorily treated and no symptoms were...

Use of psychotropic drugs in specific childhood disorders

This is a heterogeneous disorder of inattention, hyperactivity and impulsivity that starts in childhood and may persist into adulthood. Children with the disorder can be identified by their inattention which leads to daydreaming, distractability and difficulty in sustaining an effort to complete a task. Their impulsivity makes them accident prone and disruptive while their hyperactivity, combined with excessive talking, is poorly tolerated particularly in schools. As teenagers, the hyperactivity and impulsivity tend to diminish but other symptoms persist. The adolescent with ADHD often has low self-esteem, poor relationships with peers and often becomes subject to drug abuse. To what extent ADHD persists into adulthood is open to debate, but some longitudinal, family and genetic studies would favour this view. ADHD is often co-morbid with conduct, depressive, bipolar and anxiety disorders. Evidence of fronto-limbic dysfunction with poor inhibitory control of the cortex over the limbic...

Historical development of antidepressants

The use of cocaine, extracted in a crude form from the leaves of the Andean coca plant, has been used for centuries in South America to alleviate fatigue and elevate the mood. It was only relatively recently, however, that the same pharmacological effect was discovered when the amphetamines were introduced into Western medicine as anorexiants with stimulant properties. Opiates, generally as a galenical mixture, were also widely used for centuries for their mood-elevating effects throughout the world. It is not without interest that while such drugs would never now be used as antidepressants, there is evidence that most antidepressants do modulate the pain threshold, possibly via the enkephalins and endorphins. This may help to explain the use of antidepressants in the treatment of atypical pain syndromes and as an adjunct to the treatment of terminal cancer pain. Finally, alcohol in its various forms has been used to alleviate anguish and sorrow since antiquity. Whilst the opiates,...

Attitudes toward Other Drugs

The image of alcohol did not wax and wane in isolation from the public's perception of drugs such as morphine, heroin, and cocaine, although the peaks of their favorable and unfavorable public images did not coincide precisely with those of alcohol. The use of cocaine rose rapidly after its introduction into the United States in the mid-1880s. Not until the Harrison Act of 1914 did the federal government prohibit the sale of cocaine without a prescription. A similar restriction on alcohol, National Prohibition, was enacted five years later, and by the mid-1920s the federal government had moved to eliminate heroin completely as a legally obtainable substance (Musto, 2002b).

Danish Research Project In Clinical Setting

The patient group participating in the Danish part of the study suffers from chronic schizophrenia and regular drug abuse, and participants display significantly higher levels of psychopathology and poorer social skills than other patient groups. Patients with dual diagnoses also often experience a multitude of comorbid difficulties including anxiety, depression, and disturbances in personality.

Programming of the Adipoinsular Axis and Altered Adipogenesis

A range of genetic components of obesity have been identified.7072 and research on alterations in biochemical pathways caused by single gene mutations in animal models has contributed significandy towards knowledge of physiological mechanisms of obesity.73 It is well established that leptin acts at the level of the hypothalamus to regulate appetite and energy homeostasis. The long-form, or signalling form, of the leptin receptor (OB-Rb) is expressed in high levels in several cell groups of the hypothalamus and in various tissues throughout the body.48'75'76 Under normal physiological conditions, increased leptin signalling in the medial hypothalamus is associated with reduced neuropeptide Y (NPY) and agouti-related (AgRP) protein production77 but increased cocaine- and amphetamine- regulated transcript (CART) and pro-opiomelanocortin (POMC) production.7 These leptin-induced changes in neuropeptides lead to decreased food intake and increased energy expenditure.

TABLE 2711 Causes of Rhabdomyolysis

Consider hereditary causes in patients with a history of recurrent rhabdomyolysis and exercise intolerance. Patients in coma are at risk for development of rhabdomyolysis due to immobility from unrelieved pressure upon gravity-dependent body parts. In one study, the most common positions leading to rhabdomyolysis were the lateral decubitus, lithotomy, sitting, knee-chest, and prone positions. 4 Alcohol consumption can result in rhabdomyolysis secondary to coma-induced muscle compression and a direct toxic effect. Nutritional compromise and hypophosphatemia, both common in alcoholics, increase the risk of rhabdomyolysis. Alcohol is considered to be a causative or contributory factor in approximately 20 percent of all cases of rhabdomyolysis. 5 Drugs of abuse that have commonly been implicated in acute rhabomyolysis include cocaine, amphetamines, LSD, heroin, and phencyclidine (PCP). Common medications associated with the development of rhabdomyolysis include diuretics, narcotics,...

Miscellaneous Applications

As mentioned in an earlier section, it was a report of the successful use of a treatment protocol involving NF with a group of alcoholic clients that stimulated revival of interest in NF during the late 1980s. There continue to be reports of the successful use of that protocol and others involving NF with alcohol and drug addiction. However, to the author's knowledge, there have been no published reports of controlled research on this topic. As with NF treatment of dissociative disorders, most of the treatment protocols have included other procedures, and the relative contribution of NF to treatment success is unknown.

The Social Force of Diagnosis

Historical perspective can increase our awareness that medical practitioners and researchers have tended to discover what already was assumed. More recent political uses of disease concepts (e.g., in psychiatry) have been closely connected with repressive goals and political agendas of certain governments. Social employment of disease definitions is often meant to be benevolent, however, such as advocating a view of alcoholism and drug addiction as diseases so as to recruit the forces of medicine to aid in their control. Moreover, such conditions may be termed diseases in order to relieve alcoholics and drug addicts of the social opprobria that attend what is often viewed as immoral behavior.

Family Interaction Environment and Psychopathology

Distinguish families with a BN daughter from families of healthy controls and families with restricting AN daughters 59 . Kendler et al. 11 reported low levels of paternal care as well as parental substance abuse and parental depression associated with definite and probable cases of BN. In another analysis, Kendler et al. 53 reported that familial-environmental influences substantially influenced the liability to BN. Fairburn et al. 51 recorded low parental contact, more negative comments from family members about appearance, eating habits and weight, and parental arguments in comparison to psychiatric controls. Rates of parental alcoholism, depression and drug abuse were also increased. A significant problem with Fairburn et al.'s risk factor studies in eating disorders 24,51 is that all information concerning the families, including the psychiatric diagnoses, was obtained from the patients and not derived from independent interviews of family members.

Changes in food preferences after infancy

By becoming unfashionable and no longer considered appropriate for human consumption a perfectly good food can disappear. This was the fate of the parsnip in France which was once widely eaten but is now largely unknown nevertheless it remains very popular in other European countries. The generally accepted explanation is that although well known in the fourteenth century (Pichon 1847) parsnips, known as escheroys or panais, were used less and less while carrots grew in popularity, finally the parsnip was cultivated only as a fodder crop for animals and gradually it was perceived as being suitable only for this. As other crops replaced it in this respect, especially the higher yielding varieties of beet, the parsnip finally disappeared. The perception of a food as being mainly something eaten by the poor can also lead to its demise in 1920 there were more than 200 shops preparing and selling tripe in Manchester and now there are essentially none (Mason 2002). In contrast to these...

TABLE 2802 Behavioral Characteristics that Suqqest Various Clusters of Personality Disorders

The sociopathic behavior begins before the age of 15, but the diagnosis may not be made until after the age of 18. Sociopathy is much more frequent in males, in lower socioeconomic classes, and in relatives of alcoholics and sociopaths. Alcohol and drug abuse, imprisonment, multiple divorces, traumatic injury, accidental and violent deaths, and poor medical compliance are common complications.

Applications in Biology and Medicine

Winograd and co-workers have pioneered the adoption of fast-freezing and in situ freeze-fracture methodology in SSIMS analysis of frozen hydrated specimens using a variety of liposome and cellular systems (9,37-39). Using characteristic phospholipid fragments, they observed fusion and mixing events between DPPC and cholesterol-containing liposomes using imaging TOF-SIMS (9). The same freeze-fracture methodology was applied to successfully image components of the outer membrane and organelles of frozen hydrated red blood cells (9,38) and to image the distribution of cocaine doped into the single-celled organism Paramecium (39) TOF-SIMS imaging has been combined with bright-field and fluorescence microscopy to image frozen hydrated, freeze-fractured rat pheochromocytoma (PC12) cells (40,41). This integrated approach aids identification of the fracture plane and subsequent interpretation of the TOF-SIMS data. Recently, the group used TOF-SIMS and PCA to demonstrate the heterogeneous...

Issues And Directions For Future Research

It is hoped that the future of CBT research will also include the development of more finely tuned measurement scales of treatment fidelity, for specific disorders or CBT techniques. With the exceptions of treatment for psychosis and for cocaine use, there has been a lack of research targeting the issues of treatment integrity in the context of specific disorders. What is needed is the development of integrity measures that evaluate the delivery of CBT techniques in the context of specific disorders. Further research is also needed to evaluate issues of competency in the administration of specific CBT techniques that target cognitive content and processes.

Changing Role of Emergency Department Physicians

In light of the enormous impact of alcohol and other drug abuse on society and individuals, it is no longer sufficient to treat only the emergency condition and the medical complications of substance abuse without providing proper screening, brief counseling, and referral to further treatment when appropriate. Connecticut State Law 472 mandates universal screening in the health care setting and requires documentation of training in intervention for all personnel working in health care institutions and clinical settings licensed by that state. Research is currently under way at a number of EDs to discover best practices. A growing number of emergency physicians and nurses are engaged in helping patients with alcohol and drug problems to change negative behaviors. In some EDs, social workers, addiction specialists, volunteers from Alcoholics Anonymous or Narcotics Anonymous, or health promotion advocates (peer educators) are part of a team approach to providing identification,...

Early Identification and Screening in the Emergency Department

CRITERIA It is important for emergency physicians to distinguish between at-risk alcohol and drug abuse and dependent use. Any illicit drug use poses potential risk to the user, such as a criminal arrest, cocaine chest pain, seizures, heroin overdose, asthma exacerbation as a result of smoking drugs, and intentional or unintentional injury under the influence of drugs. Similar questions can be asked for use of illegal substances. Questions about drugs should elicit the type of substance used, the frequency, the quantity (hits for crack and bags for heroin), the route, and whether drugs are used in combination with each other or with alcohol. It is also important to include an inquiry about nonmedical use of prescription drugs, since this is a common source of problems among women. If concerns about drugs and alcohol arise based on these data, it is recommended that brief intervention and referral be delayed to attend to acute medical issues before negotiating behavior change with the...

The Measurement Of Treatment Fidelity

The principal alternative measure of adherence in CBT is the Cognitive Therapy Adherence and Competence Scale (CTACS Liese, Barber, & Beck, 1995), which was developed in the context of a randomized clinical trial for cocaine users. The CTACS uses Likert-type scales, which are used to first rate the extent to which various behaviors are conducted, and then to rerate each item as to how competently it was practiced. Psychometric evaluation of the CTACS in the context of a drug addiction study has been generally positive (Liese et al., 1995), and this measure warrants broader evaluation.