Chapter 12 Substance Abuse

The National Institute on Drug Abuse (NIDA) calls drug abuse and addiction “one of America’s most challenging public health problems.”¹ Substance abuse places a tremendous burden on society, affects every aspect of life, and has been called “an equal opportunity destroyer.”¹ It is also an expensive national problem. NIDA estimates that drug abuse and addiction costs the United States more than $500 billion annually.² The cost of drug abuse includes the loss of earning potential of those addicted and the loss of wages of those injured by accidents caused by impaired persons. Included in the societal cost of substance abuse are law enforcement salaries, legal fees, and the cost of maintaining federal prison facilities needed for those incarcerated as a result of drug-related offenses. An estimated 31% of America’s homeless population have addiction issues.¹ NIDA also notes that 50% to 80% of all child maltreatment cases involve some form of substance abuse by the child’s caregivers.¹

An estimated 19.5 million Americans age 12 years and older are current users of illegal drugs. More than 51% of America’s teenagers have at least tried an illegal drug before they leave high school.¹ In 2008 more than 31 million people admitted to driving while under the influence of alcohol at least once in the past year³ (see Chapter 13, Alcohol Abuse). According to the National Survey on Drug Use and Health (NSDUH), current cocaine use gradually declined between 2003 and 2009 among people age 12 years and older (from 2.3 million to 1.6 million).¹⁶

Drug abuse and addiction is a preventable disease, and education on the scope of the problem and available resources in individual communities can assist health care providers in dealing with substance abuse.

Anabolic Steroids

Recent international scandals in professional sports have highlighted the dangers of steroid use. Anabolic-androgenic steroids, sometimes called “roids” or “juice,” are synthetic substances similar to testosterone. While anabolic steroids have legitimate medical uses, they should not be used simply to build up muscle bulk. The most common names of abused anabolic steroids are Andro, oxandrolone (Oxandrin), methandrostenolone (Dianabol), stanozolol (Winstrol), nandrolone decanoate (Deca-Durabolin), and boldenone undecylenate (Equipoise).⁴

Signs and Symptoms

There are many consequences for inappropriately taking steroids. As a whole, excess steroids cause alteration in carbohydrate metabolism (elevated glucose), hyponatremia (leading to fluid retention, hypertension), and hypokalemia.

• Cardiovascular effects: Increases in serum low-density lipoprotein and decreases in high-density lipoprotein levels. Steroids increase atherosclerosis, placing the patients who have taken steroids at risk for a heart attack or stroke.

• Skeletal effects: Hypocalcemia, which can lead to osteoporosis. If taken before puberty is completed, the use of these substances can cause early skeletal maturation.

• Feminization or masculinization effects: Males may have decreasing testicular size along with reduced sperm counts. Men taking steroids may also become bald, develop breasts, and potentially develop prostate cancer. Women taking steroids can grow facial hair while becoming bald, stop menstruating, and develop a permanently deeper voice.

• Mood effects: Extreme mood swings that have led to “roid rage” or violent behavior. Users may have feelings of invincibility, jealousy, and depression that can be followed by suicide attempts.

• Cognitive effects: Memory loss and learning disabilities.

• Immunosuppression may occur.

Therapeutic Interventions

The best treatment is prevention and includes education related to the dangers of steroid abuse. Supportive therapy is also used to gain and maintain homeostasis.

Cocaine

Cocaine is a strong central nervous system stimulant that is highly addictive. NIDA reports that, in 2008, 5.3 million Americans age 12 years and older had abused cocaine in some form.⁵ There are many street names for cocaine, including blow, bump, C, candy, Charlie, coke, flake, rock, snow, and toot.⁵

“Crack,” another street name, is given to the form of cocaine that has been processed to make a rock crystal, which when heated produces vapors that are smoked. The term “crack” refers to the crackling sound produced by the rock as it is heated.

There are three common ways in which cocaine is used.

• Snorting: The powder form of the drug is inhaled through the nose to be absorbed by the nasal membranes

• Smoking: Vapors from burning cocaine are inhaled directly into the lungs for rapid absorption

• Injecting: Drug is put into a syringe and injected directly into the bloodstream

The faster the drug reaches the brain, the more intense the user’s high will be; the duration of the high, however, depends on the route administered and the purity of the cocaine used. To maintain their highs, people who take cocaine will frequently “binge,” a process of ingesting, inhaling, or injecting cocaine several times in rapid succession. Regardless of the route chosen, the person quickly becomes addicted.

Cocaine dealers frequently dilute their product with other substances, both active and inert, to increase or decrease its potency. This dilution process complicates the patient assessment and treatment, as the substances added to the cocaine may be toxic and contribute to the patient’s symptoms.

Signs and Symptoms

Cocaine affects every organ and system in the human body.

• Cardiovascular effects: Constricts blood vessels, elevates blood pressure, and increases heart rate. Acute myocardial infarctions have been reported up to 2 weeks after cocaine use in patients with and without preexisting cardiac disease, some as young as 19 years old.⁶

• Neurotoxicity: Cocaine is the most common stimulant that produces seizures. Other forms of cocaine-induced neurotoxicity include subarachnoid hemorrhage, cerebral infarction, vasculitis, transient ischemic attacks, and toxic delirium.⁷

• Psychiatric and mood disorders: Causes anxiety, irritability, and restlessness and it is not uncommon for these patients who have taken cocaine to have severe paranoia along with auditory hallucinations.

• Other symptoms:

• Dilated pupils

• Increased body temperature

• Abdominal pain and nausea

• Poor appetite and associated malnourishment (chronic use)

Cocaine readily crosses the placenta and is excreted in breast milk for up to 36 hours after use.

Therapeutic Interventions

Interventions are dependent on the patient’s presenting signs and symptoms. Consuming alcohol along with the cocaine causes a synergistic effect, especially on ventricular contraction.⁸ Benzodiazepines are the initial treatment of choice for cocaine-induced chest pain of cardiac origin.

If it is suspected that the patient may have ingested latex packets of cocaine as a “body packer,” an immediate abdominal radiograph will be necessary to determine if any packets are present. Administration of activated charcoal with a cathartic may be used as treatment of this patient; however, whole bowel irrigation may be required to remove the packets. Rarely, endoscopy or surgical removal of these packets is necessary; if the packets rupture, the patient may experience sudden severe cocaine toxicity.

A chest radiograph is important for the patient who inhaled cocaine to determine if a pneumomediastinum is present. This condition is caused when the alveoli rupture secondary to the patient taking deep breaths and holding them as long as possible when smoking cocaine; if a pneumomediastinum is present, it is treated with insertion of a chest tube.

A patient who indicates recent cocaine use and has a fever is at increased risk for complications.

Heroin

NIDA reported that the number of current heroin users in the United States age 12 years and older rose from 153,000 in 2007 to 213,000 in 2008.⁹ In the same year 114,000 first-time heroin users were reported.⁹ Heroin’s street names include brown sugar, dope, H, horse, junk, skag, skunk, smack, and white horse.¹⁰

Heroin is an opiate drug synthesized from morphine. It is a naturally occurring substance extracted from the seed pod of the Asian opium poppy plant. Heroin typically comes in a white or brown powder or as a black, sticky substance known as “black tar” heroin. The substance can be injected, snorted, ingested, or smoked. Injected heroin gives the user the most rapid onset of euphoria in as little as 7 to 8 seconds. Although the other routes of administration have slower onset, the effects last longer. Nearly all reported heroin-related fatalities involve the injected route. As with other illegal substances, dealers dilute the heroin with other substances, which can contribute to the patient’s symptoms and make the diagnosis more difficult.

Signs and Symptoms

The classic triad of heroin use is central nervous system depression, respiratory depression, and miosis.⁹ Assess for any signs and symptoms of chronic abuse. These include redness and swelling of the nares and multiple scars or “track marks” in numerous locations. Drug abuse paraphernalia found among the patient’s belongings (i.e., syringes, bent spoons, bottle caps, and rubber tubing) is another indicator of heroin abuse. Heroin addicts, like all drug abusers, are susceptible to multiple infectious diseases and processes, including human immunodeficiency virus (HIV), hepatitis B and C, endocarditis, and multiple skin abscesses.

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