Transcript Dangers of Adolescent Drugs of Abuse

Our
Substance
Abuse
Dilemma.
Steven C Blessington, PA-C, EMT-P, MHP
Department of Emergency Medicine
Maine Medical Center, Portland
University of New England, adjunct faculty
Disclosure:
I have no financial disclosures that would be a potential
conflict of interest with this presentation.
IV overdose death

Adam Moser, a resident of Portsmouth NH died at
age 27 on Saturday, Sept. 19, 2015 from an
apparent IV overdose of Fentanyl, an opioid .

Moser was well-known to many Seacoast
residents and beyond for his tuna-fishing exploits
on the National Geographic Channel television
series "Wicked Tuna.”
“Adam Moser: Parents who lost son use
obituary to warn others about drug dangers”
Adam Moser’s parents speak out
Adolescent substance abuse

Most adults who develop a substance use disorder
report having started drug use in adolescence or
young adulthood, so it is important to identify and
intervene in drug use early.

Todays discussion will highlight issues of adolescent
substance abuse looking specifically at several
individual substances of abuse.

The goal is to heighten ones awareness as to the
varied and multitude of abused drugs in our
communities along with signs and symptoms of drug
abuse.
Adolescent substance
abuse

For our young patients any drug use is
cause for concern.

Exposure to dangers from the drug and
associated risky behaviors.

Use or ‘experimentation’ can be a
precursor to repeated/long term drug
use in the future.
Adolescent substance abuse

Adolescents who abuse substances/drugs frequently also
suffer from other conditions.

These may include depression, anxiety disorders, attentiondeficit hyperactivity disorder (ADHD), oppositional defiant
disorder, conduct problems and prior PTSD/sexual abuse.

Identifying and treating these is equally important to treating
the substance abuse
Adolescent substance abuse

Family support is important for an adolescent’s
recovery.

Strengthening family relationships by improving
communication is essential.

In addition, members of the abusers community
can encourage young people who need help to
get into treatment—and support them along the
way.
These community members may
include school counselors, peers,
and case managers, coaches
and school nurses

Adolescent substance abuse

Adolescents identified as having a history of physical,
emotional, and/or sexual abuse should be referred to social
and protective services when appropriate.

Providers must following local regulations and reporting
requirements in your area/state.

Adolescents who use drugs are at increased risk for blood
born pathogen diseases as well as STDs.

These include HIV, hepatitis B and C. herpes, gonorrhea,
chlamydia and syphilis
Adolescent substance abuse

Euphoria/altered mental status associated with use
can alter judgment and decision making

This may increase the likelihood that an adolescent
will engage in unprotected sex and other high-risk
behaviors.

Needle and paraphernalia sharing occurs. Unsafe
tattooing and body piercing practices occur—all
potential routes of virus/bacterial transmission
(MRSA).
Signs of
possible
substance
abuse

Change in peer group

Carelessness with grooming

Decline in academic performance

Missing classes or skipping school

Loss of interest in favorite activities

Changes in eating or sleeping habits

Deteriorating relationships with family and friends

Flat affect/personality changes
Adolescent substance abuse

Parents often underestimate their child’s drug
abuse risk, actual use and seriousness of
addiction.

Parents can enlist the help of:
 primary
 school
 drug
care physician/PA/NP/RN
guidance counselor
abuse treatment provider.
Prescription
Drug
Abuse
Abusing Prescription Drugs

Prescription drug abuse: The act of taking a
medicine in any way that is different from what the
doctor originally prescribed.

Taking medications which were initially prescribed
for another patient.

Taking more mg’s or more tablets than originally
prescribed.

Taking it in a different way than the drug is designed
to be consumed (snorting, injecting etc.)
Prescription drug abuse:

What makes these drugs appealing to some is the
fact that they can have effects similar to illicit drugs
when taken in higher quantities than prescribed, or
in the absence of prescribed symptoms.

Obtainment can often be facilitated without ever
leaving the adolescents house or that of a
friend/co-abuser……Medicine cabinet pharmacy!
Prescription drug abuse:






Opioids (also known as: oxy, percs, happy pills,
hillbilly heroin, OC, or vikes)
Opioids are prescribed for acute and chronic pain.
Over two million people in the US currently abuse
prescription opioids.
Nearly 75% of prescription drug overdoses are
caused by prescription opioids
More deaths than cocaine and heroin combined.
State and federal agencies actively engaged
http://www.drugabuse.gov/publications/drugfacts
Prescription drug abuse

Opioid analgesics such as OxyContin, Oxycodone,
Tylox, Percocet and Vicodin are made from opium,
which comes from the poppy plant. These are semisynthetic (natural plus manmade chemicals).
Fentanyl and methadone are fully synthetic.

Fentanyl is approximately 80 to 100 times more
potent than morphine and roughly 40 to 50 times
more potent than pharmaceutical grade (100%
pure) heroin. (? Adam Moser’s drug potency knowledge ?)

Morphine and codeine (a prodrug/hypermetab)
are two natural products of opium. Morphine,
obtained from the Poppy plant is a precursor
utilized to manufacture opioid prescription drugs
and heroin.
Prescription drug abuse

Different opioids are very similar chemically which is why they
can have effects that are similar to heroin.

A large percentage of young people who inject heroin
reported abusing prescription opioids before starting to use
heroin.

The act of crushing opioid pills to snort or
inject familiarizes the user with methods
similar to injecting and using heroin.
http://www.drugabuse.gov/publications/drugfacts/heroin
Prescription drug abuse

Opioids activate specific transmembrane
neurotransmitter receptors (mu, kappa, delta)

Activation of endogenous mu opioid receptors
results in the prototypic opioid effects of reward,
analgesia and withdrawal

Central nervous system opioid stimulation results in
responses such as analgesia, euphoria, miosis and
respiratory depression.
Stimulation of peripheral mu opioid
receptors in smooth muscle of the
bronchi and intestines results in cough
suppression and opioid-induced
constipation

Prescription drug abuse:

Opioids when used to achieve a euphoric state, and when
taken in high doses or in ways other than prescribed, have
effects similar to heroin.

A progression from pain pills to heroin is not uncommon,
particularly since……….

Heroin has actually become cheaper, more potent and
readily available. The opposite is true with opioids!

Heroin-related overdose deaths increased 286 percent
between 2002 and 2013 . In 2002, 100 people per 100,000
were addicted to heroin but that number had doubled by
2013.
Prescription drug abuse:

Narcotic bowel syndrome NBS — Narcotic bowel
syndrome is characterized by an increase in
abdominal pain associated with continued or
escalating dosages of opioids.

Often severe

Chronic or recurring

Significantly reduced following
medically supervised withdrawal
from the opioids
Prescription drug abuse

It has long been recognized that opiates affect
gastrointestinal motility. These effects, known as
opioid bowel (or gastrointestinal) dysfunction
are manifest as constipation, nausea, bloating,
ileus and often pain.

When pain, moderate to severe, is the
predominant symptom, the condition has been
termed narcotic bowel syndrome (NBS). NBS is
characterized by the progressive and somewhat
paradoxical increase in abdominal pain despite
continued or escalating dosages of narcotics
prescribed in an effort to relieve
the pain.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2074872/
Heroin
Abuse
Heroin (diacetylmorphine)

Heroin is an opioid that is partly manmade and
partly natural. It is made from morphine, a
psychoactive (mind-altering) substance that is
extracted and then refined from the resin of the
opium poppy plant.

Heroin’s color and look depend on how it is made
and what else it may be mixed with. It can be
white or brown powder or a
black, sticky substance
(black tar heroin).
Heroin

Heroin is manufactured from opium poppies
cultivated in four primary source areas: South
America, Southeast and Southwest Asia, and
Mexico.
Heroin

Opium is derived from the poppy plant Papaver somniferum.

Afghanistan is the world’s number one grower and exporter of
opium, supplying 90 percent of the drug to Central Asian and
European markets.

Opium farmers are highly skilled experts at planting, growing,
and harvesting poppy in difficult conditions, often on land
where there is little irrigation and with no fertilizer or pesticides.
It is organic farming out of necessity.

Afghan farmers successfully grew poppy even during a sevenyear drought.
Heroin

Although Afghanistan produces the majority of the world's
heroin, South American heroin has become the most
prevalent type available in the U.S., particularly in the
Northeast, South and Midwest.

During the 1990's, Latin America evolved as the primary
supplier of heroin to the United States, with Mexican heroin
most prevalent west of the Mississippi and Colombian heroin
most prevalent east of it.

The particular form known as "black tar" from Mexico, a less
pure form of heroin, is more commonly found in the western
and southwestern United States. This heroin may be sticky like
roofing tar or hard like coal, with its color varying from dark
brown to black.
Heroin

As we all are aware heroin has become an
epidemic in areas where lots of people
abuse prescription opioid painkillers
(Portland, Lewiston, Bangor)

Heroin is mixed with water and injected with
a needle. Some uses prefer to heat it before
injecting but this is not necessary. It can also
be smoked or snorted
Heroin

Short-term effects of heroin include rapid euphoria and
subdued mentation. For the first several hours after taking
heroin, people may want to rest/sleep, their heart rate and
breathing slow down. When the drug wears off, people may
feel a strong urge to reuse.

Regular heroin use changes
the functioning of the brain.
Repeated use result in:

Tolerance

Dependence

Addiction
Heroin

Activation of the μ-opioid receptor by an agonist
such as morphine causes analgesia and euphoria.
Also sedation, reduced blood pressure, itching,
nausea, decreased respiration, miosis (constricted
pupils), and decreased bowel motility often leading
to constipation (or NBS)

Some of these effects, such as analgesia, sedation,
euphoria, and decreased respiration, tend to lessen
with continued use as tolerance develops. Miosis
and reduced bowel motility tend to persist; little
tolerance develops to these effects
Heroin
Heroin use can cause:

Nausea and Vomiting

Severe itching (pruritis)

Slowed breathing or apnea

Increased risk of HIV and hepatitis (a liver disease) through
shared needles. Skin infections/abscesses (MRSA)

Coma—deep state of unconsciousness

In addition to the effects of the drug itself, heroin bought on
the street often contains a mix of substances, some of which
can be toxic and can occlude blood vessels leading to the
lungs, liver, kidney, or brain. This can cause
hypoxia, necrosis or damage to those organs.

If injected incorrectly (arterially) distal occlusion
and necrosis can result.
Cutaneous abscess
requiring I&D
Area of cellulitis requiring antibiotic coverage
Retained F/B; broken
hypodermic needle
Retained F/B; broken
hypodermic needle
Heroin
Physical signs and symptoms of concern:

A heart murmur may indicate subacute bacterial
endocarditis.

Cervical lymphadenopathy may suggest early viral infection
(HIV). Hepatic enlargement may indicate acute hepatitis; a
small, hard liver is consistent with chronic viral hepatitis due to
hepatitis B or C virus, which is common among injection drug
users who share needles.

Signs of opioid intoxication may include pinpoint pupils,
drowsiness, slurred speech, and impaired cognition.

Signs of acute opioid withdrawal syndrome include watering
eyes, runny nose, yawning, muscle twitching, hyperactive
bowel sounds, and piloerection.
Heroin
Heroin is highly addictive.

For some who become addicted to heroin, seeking and using
the drug may become their primary focus (job
loss/crime/prostitution). Huge socioeconomic variability

The number of people addicted to heroin doubled from
214,000 in 2002 to 517,000 in 2013.

Cessation of use can lead to withdrawal symptoms including:

myalgia

rigors

emesis

insomnia

Restlessness

jerking movements

insurmountable craving for the drug
Heroin

In 2011, 4,397 people died in the United States from
a heroin overdose, an increase of almost 2.5 times
compared to the 1,784 people who died from a
heroin overdose in 2001. In 2013 that number had
increased to nearly 8,500.

For young people (ages 15 to 24), the increase in
the past 10 years has been about 4 times greater.

In Portland this past year Heroin related deaths
surpassed 2014
Inhalant abuse
Inhalant Abuse
The 2010 National Survey on Drug Use and
Health (NSDUH) revealed that the primary
population of inhalant abusers (68%) is under
18 years of age.
 In 2011, 7% of eighth graders reported
inhalant use, along with 4.5% of 10th graders
and 3.2% of 12th graders.
 A young person’s sport!

http://www.medicinenet.com/script/main/art.asp?
Inhalant Abuse

People who use inhalants breathe in the fumes through their
nose or mouth, usually by:

“Sniffing” or “snorting” fumes from containers

Spraying aerosols directly into the nose or mouth (upside
down)

Sniffing or inhaling fumes from substances sprayed or placed
into a plastic or paper bag (“bagging”)

“Huffing” from an inhalant-soaked rag stuffed in the mouth

Inhaling from balloons filled
with nitrous oxide
Inhalant Abuse

Inhalants generally fall into one of four categories:

Volatile solvents are liquids that become a gas at room
temperature. They are found in: Paint thinner, nail polish
remover, degreaser, dry-cleaning fluid, gasoline, and contact
cement. Some art or office supplies, such as correction fluid,
felt-tip marker fluid, and electronic contact cleaner

Aerosols are sprays that contain propellants
and solvents. They include: Spray paint,
hair spray, deodorant spray, vegetable oil
sprays, and fabric protector spray
Inhalant Abuse

Gases may be in household or commercial
products, or used in the medical field to provide
pain relief. They are found in: Butane lighters,
propane tanks, whipped cream dispensers, and
refrigerant gases. Anesthesia, including ether,
chloroform, halothane, and nitrous oxide
(commonly called “laughing gas”).

Nitrites are a class of inhalants used
mainly to enhance sexual experiences.
Organic nitrites include amyl, butyl,
and cyclohexyl nitrites and other related
compounds
Inhalant Abuse

Long-term inhalant use can break down the protective sheath
around nerve fibers in the brain and elsewhere in the body.

Results in muscle weakness, spasms and tremors or even
permanent trouble with basic actions like walking, bending,
and talking. These effects are similar to what happens to
people with multiple sclerosis.

Damage to brain cells. Inhalants also can damage brain cells
often directly as a result of hypoxia. Patients/clients who
repeatedly uses inhalants may be exhibit delayed cognitive
function and demonstrate slowed ability to learn new
concepts

If the cerebellum is affected, it can cause
gait disturbance or coordination problems.
Inhalant Abuse
Serious consequences from inhalant abuse can be:

Asphyxiation—toxic fumes replace oxygen in the lungs so that a
person stops breathing

Suffocation—air is blocked from entering the lungs when inhaling
fumes from a plastic bag placed over the head

Convulsions or seizures—abnormal electrical discharges in the brain

Coma—the brain shuts down all but the most vital functions

Choking and aspiration—inhaling vomit after inhalant use

Injuries—accidents, including driving while
intoxicated. Stumbling and falls from
heights, burns etc.
Inhalant abuse
Serious consequences (cont.)

Heart damage

Liver failure

Muscle weakness

Aplastic anemia—the body produces fewer
blood cells

Nerve damage, which can lead to chronic pain
Bath
Salts
Bath Salts

“Bath salts” is the name given to a family of drugs that have one
or more manmade chemicals related to cathinone.

Street Names: “Bloom,” “Cloud Nine,” “Vanilla Sky,” “White
Lightning,” and “Scarface”

Cathinone is an amphetamine-like stimulant found naturally in the
khat plant. Chemically, they are similar to other amphetamines such
as methamphetamine and to MDMA (Ecstasy or Molly).

Common manmade cathinones found in bath salts include 3,4methylenedioxypyrovalerone (MDPV), mephedrone (“Drone,”
“Meph,” or “Meow Meow”), and methylone, but there are many
others
Bath Salts

Bath salts are usually white or brown crystal-like powder
and are sold in small plastic or foil packages labeled “Not
for Human Consumption.”

Sometimes labeled as “plant food”—or, more recently, as
“jewelry cleaner” or “phone screen cleaner”—they are
sold online and in drug paraphernalia/product stores.

These names or descriptions have nothing to do with the
product. It’s a way for the drug makers to avoid detection
by the Drug Enforcement Administration or local police.

Bath salts can be ingested, snorted,
smoked, or injected.
Bath Salts

Also adolescents believing they are taking drugs such as
MDMA (Molly or Ecstasy) may be getting bath salts
instead.

Methylone, a common chemical in bath salts, has been
substituted for MDMA in capsules sold as Molly in some
areas.

What the adolescent thinks they are buying/ingesting is
often something completely different
Bath Salts
What are the adverse effects associated with Bath Salt use:

Cardiovascular problems such as tachycardia, hypertension and
chest pains can occur.

Emotional symptoms like paranoia, hallucinations, and panic attacks
are frequent.

Patients with the syndrome known as “excited delirium” from taking
bath salts can develop. Also, dehydration, breakdown of muscle
tissue (rhabdomylitis) and acute kidney failure.

Intoxication/overdose from several manmade cathinones in Bath
Salts, including MDPV, mephedrone, methedrone, and butylone
have caused death among some users.

Stimulants are a class of drugs that can boost mood, increase
feelings of well-being, increase energy, and make you more alert—
but they also have dangerous effects including raising heart rate and
blood pressure (tachycardia and hypertension). MI risk!

Methamphetamine (“Meth,” “Speed,” “chalk,” and “tina”; or for
crystal meth, “ice,” “crank,” “glass,” “fire,” and “go fast”) is a very
addictive stimulant drug. It is a manmade, white, bitter-tasting
powder. Sometimes it's made into a white pill or a shiny, white or
clear rock called a crystal.

Most of the meth used in the United States comes from “superlabs”.
Illegal laboratories that make the drug in large quantities. But it is also
made in small labs using cheap, over-the-counter ingredients such as
pseudoephedrine, which is common in cold medicines. Other
chemicals, some of them toxic, are also involved in making
methamphetamine.

Meth-Labs are a mix of volatile, flammable,
toxic and extremely dangerous chemicals
Stimulant abuse

Methamphetamine can be swallowed, snorted,
injected with a needle, or smoked.

“Crystal meth” is a large, usually clear crystal that is
smoked typically in a glass pipe.

Smoking or injecting the drug delivers it very quickly
to the brain, where it produces an immediate and
intense high. (Often compared to the
‘rush’/immediate ‘high’
of crack cocaine……but
is less expensive and
readily available)
Stimulant abuse

Methamphetamine’s ability to release dopamine very quickly
in the brain produces the feelings of extreme pleasure,
sometimes referred to as a “rush” or “flash,” that many users
experience.

Regular use of methamphetamine causes chemical changes
in the brain affecting the dopamine system and adversely
affecting or destroying nerve cells that produce
neurotransmitter such as serotonin
Stimulant abuse

Continued methamphetamine use may cause effects that last for a
long time, even after a person quits using the drug. These effects
include:

Anxiety and confusion

Problems sleeping

Mood swings

Violent behavior

Psychosis (hearing, seeing, or feeling things that are not there)

Skin sores caused by scratching (“meth-face”)

Severe weight loss

Severe dental problems (“meth mouth”)

Problems with thinking, emotion, and memory
Stimulant Abuse

Methamphetamine causes tolerance—when a person needs to take
more of it to get the same high. People who usually eat or snort meth
might start to smoke or inject it to get a stronger, quicker high.

People who are trying to quit using methamphetamine might:

Be fatigued yet insomnic.

Exhibit anxiety.

Exhibit depression.

Feel a very strong craving to
reuse methamphetamine.
Rx Stimulant Abuse

Prescription stimulants are often prescribed for ADHD. When
prescribed by a clinician for a specific health condition, and used
appropriately they can be relatively safe and proven effective.

Taking someone else's prescription drugs or taking the drugs to get
“high” can have serious health risks

There are two commonly abused types of stimulants: amphetamines
(Adderall, Dexadrine) and methylphenidate (Concerta, Methylin,
Ritalin).

Street names might include: skippy, the smart drug, vitamin r, bennies,
black beauties, roses, hearts, speed, or uppers.
Prescription drug abuse:

Note: Prescription stimulants are effective at treating attention
disorders in children and adolescents, but concerns have been
raised that they could make a young person more vulnerable to
developing later substance use disorders.

On balance, the studies conducted so far have found no
differences in later substance use for ADHD-affected children who
received treatment versus those that did not.

Recent studies support that treatment with ADHD medication does
not affect (either negatively or positively) an individual’s risk for
developing a substance use disorder
http://www.drugabuse.gov/publications/principles-adolescent-substance-use-disorder-treatment-researchbased-guide
Stimulant Abuse

Stimulant abuse can be extremely dangerous.
Taking high doses of a stimulant can cause:

Increased blood pressure

Irregular heartbeat

Dangerously high body temperatures

Decreased sleep

Lack of interest in eating, which can lead to poor nutrition

Intense anger or paranoia

Risk for seizures and stroke at high doses

Stimulants should not be mixed with medicines used to treat
depression or over-the-counter cold medicines that contain
decongestants. These mixtures increase the risk for developing
dangerously high blood pressure and irregular heartbeat.
Stimulant abuse

When a person who regularly abuses stimulants
stops taking them, they may experience withdrawal
symptoms. Stimulant withdrawal can cause:

Feelings of fatigue and changes in sleep patterns

Anhedonia

Suicidal ideation

Anxiety and irritability

Depression

Intense drug cravings
Spice Abuse
Spice abuse

Spice is a mix of herbs (shredded plant material) and
manmade chemicals with mind-altering effects. (“K2,” “fake
weed,” “Bliss,” “Black Mamba,” “Bombay Blue,” “Genie,” “Zohai,” “Yucatan
Fire,” “Skunk,” and “Moon Rocks”)

It is often called “synthetic marijuana” because some of the
chemicals in it are similar to ones in marijuana; but its effects
are sometimes very different from marijuana, and frequently
much stronger and unpredictable.

Often labeled “Not for Human Consumption” and disguised as
incense (again as a way to avoid legal recourse).

Sellers of Spice products try to lead people to believe they are
“natural” and therefore harmless; they are neither.
Spice abuse

Most people smoke Spice by rolling it in papers (like with
marijuana or handmade tobacco cigarettes); sometimes,
it is mixed with marijuana. Some users also make it as
an herbal tea for drinking.

Adolescents who have had bad reactions to Spice report
tachycardia, N/V, anxiousness, confusion, and
hallucinations.

Spice can also raise blood pressure and cause less
blood to flow to the heart. In few cases, it has been
linked with heart attack and death.
OTC substance abuse:

Over-the-counter (OTC) drugs such as cough and cold remedies
containing dextromethorphan, that, when taken in very high doses
act on the same receptors as PCP or ketamine, producing similar
dissociative/out-of-body experiences.

‘Purple drank’ is commonly abused by adolescents .

Cough syrup with codeine is mixed with a soft drink and candy
(usually Sprite and Jolly Ranchers). The drink can be also be made
with the over-the-counter medications like Robitussin DM,
(dextromethorphan). Causes hallucinations/dissociative effects. Side
effects include drowsiness, inability to concentrate, slowed physical
activity, nausea, vomiting, and slowed breathing. Lack of
coordination etc………risk of injury

When abused, these drugs cause an increase
dopamine in the brain that is perceived as
pleasurable. Repeated use can lead to
addiction and neuro-chemical changes.
Recognition/Rehabilitation

Interventional programs should include several of
the following approaches:

Educational groups

Individual counseling

Family counseling and education

Recreational activities and team building

Recovery planning for relapse prevention
Recognition/Rehabilitation

Important factors include:

Identifying ‘Risk and Protective factors’ that correlate with the
use of substances and related problems.

Risk factors contribute to the likelihood of problem behaviors.

Protective factors promote health and well-being and build
resiliency.

Both risk and protective, exist in the following domains:
peer/individual, family, school, community, and society.

Effective prevention programs employ multiple strategies in
multiple domains.
Recognition/Rehabilitation

Risk and Protective factors are important in prevention of
substance abuse.

‘Risk factors’ that parents and caregivers may have an impact
on may include:

Friends and peers who are also involved in substance use

Poor family support network/split family/foster care etc

Other family members who abuse substance
•
An important goal is to strengthen protective factors and
reduce risk factors for substance abuse.
Recognition/Rehabilitation
‘Protective factors' that parents and care givers have
a direct impact on:

Strong and positive family bonds;

Parental monitoring of children's activities and peers;

Clear rules of conduct that are consistently enforced within
the family;

Involvement of parents in the lives of their children.
Thank you!