2002Self-Assessment Exercise XXVI. Substance abuse [Return to Category List] Questions Question 28. Answer.

A TRUE statement about the use of alcohol among high school students is that: A. alcohol is abused less commonly than marijuana

B. fewer than 25% of 9th graders report that they drank alcohol during the preceding 30 days C. D. E. males are twice as likely as females to report episodic heavy drinking most teenage drinkers become problem drinkers as adults the major health consequence in this age group is accidental injury or death Answer.

Question 75.

The mother of a 16-year-old boy is concerned that her son is using marijuana. His grades have dropped slightly, and he is less active in after-school activities. When he returns home after a night out with friends, his clothes often smell of tobacco, although he denies tobacco use himself. Of the following, a TRUE statement regarding marijuana use is that: A. B. C. D. E. behavioral consequences include hyperalertness and increased energy decreased appetite and nausea are the major gastrointestinal side effects it is associated with gynecomastia physical findings include bradycardia and constricted pupils withdrawal effects occur with both occasional and chronic use

Question 125. Answer. A 15-year-old boy is brought to the emergency department after having been found unresponsive at a party. On physical examination, he is comatose and has the following vital signs: respiratory rate, 10 breaths/min; heart rate, 64 beats/min; blood pressure, 96/50 mm Hg; and temperature, 97F (36.1C). His pupils are miotic. Of the following, these findings are MOST suggestive of: A. amphetamine overdose

B. C. D. E.

barbiturate overdose cocaine overdose lysergic acid diethylamide (LSD) ingestion phencyclidine ingestion

Question 192. Answer. A 16-year-old boy is brought to the emergency department after a party. He has dilated pupils, conjunctival injection, and visual hallucinations. In addition, he is anxious and agitated and has feelings of panic and depression. Of the following, these findings are MOST consistent with ingestion of: A. B. C. D. E. barbiturates benzodiazepines ethanol lysergic acid diethylamide (LSD) opiates

Question 240. Answer. A 17-year-old boy is brought to the emergency department by friends. He is agitated and disoriented. Vital signs include a blood pressure of 170/100 mm Hg, heart rate of 120 beats/min, and a temperature of 100.5F (38C). Shortly after arrival, he experiences a generalized seizure. You suspect a cocaine overdose. Of the following, the MOST appropriate medication to administer is: A. B. C. D. E. diazepam haloperidol nifedipine nitroprusside phenytoin

Answers Critique 28. Preferred Response: E

[View Question] Alcohol is the most common substance abused by young people in the United States. According to the Centers for Disease Control and Prevention 1999 Youth Risk Behavior

Surveillance, more than 80% of high school students had ever used alcohol compared with 70% who had ever tried cigarettes and 47% who had ever used marijuana. Current alcohol use, defined as one or more drinks in the preceding month, was reported by 50% of the students, including 40% of 9th graders and 60% of l2th graders. Episodic heavy drinking, defined as five or more drinks on one or more occasions in the preceding month, was reported by 31% of the students, including 20% of 9th grade females and almost 22% of 9th grade males and 28% of females and 35% of males in the 12th grade. One third of the students reported that in the preceding month they had ridden with a driver who had been drinking alcohol, and 14% of females and 31% of males in the 12th grade reported driving in the preceding month after drinking alcohol. Acute alcohol ingestion affects motor coordination and causes visual disturbances. The speech may become slurred and the gait ataxic. Although alcohol is a depressant, it also causes disinhibition, manifesting as giddiness, talkativeness, or belligerence and aggression. An idiosyncratic intoxication, most common in young males, presents as a sudden behavioral change of marked aggression, impulsiveness, and assaultive behavior associated with the consumption of relatively small amounts of alcohol. Occasionally an adolescent may present with confusion and stupor, symptoms of severe intoxication. Very high alcohol levels are associated with respiratory depression, coma, and death. Signs of physiologic addiction (eg, withdrawal seizures and delirium tremens) are seen infrequently in adolescents. Although many adolescents are binge drinkers, drinking to become intoxicated, the majority do not become alcoholics. Patients who have conduct disorders and those who have a strong family history of alcoholism are especially at risk for alcoholism. Adolescents who are problem drinkers often have an antecedent comorbid depression. Indicators of a developing substance abuse or drinking problem include labile moods, withdrawal, irritability, irresponsibility, decline in school performance, and a shift in friends to peers who are also substance users. The primary consequences of alcohol use in adolescents are injuries or death due to associated trauma and violence. Alcohol is a frequent contributing factor in motor vehicle accidents, drownings, homicides, and suicides as well as premature sexual activity and date rape. References: Fishman M, Bruner A, Adger H Jr. Substance abuse among children and adolescents. Pediatr Rev. 1997;18:394-403 Schwartz B, Alderman EM. Substances of abuse. Pediatr Rev. 1997; 18:204-215 State and Local Youth Risk Behavior Surveillance System Coordinators. Youth risk behavior surveillanceUnited States, l999. MMWR Morb Mortal Wkly Rep. 2000;49(SS-5):13-14, 1718, 38, 60 Takahashi A, Franklin J. Alcohol abuse. Pediatr Rev. 1996;17:39-45 Critique 75. Preferred Response: C

[View Question] Marijuana continues to be one of the mostly widely used illicit substances among teenagers in the United States. According to 1999 survey data from the Centers for Disease Control and Prevention, approximately 50% of 12th graders report using the substance at some time in their lives, and about 25% are current users. Marijuana use can have both physiologic and behavioral consequences. Effects of acute intoxication should be distinguished from the major medical consequences often associated with heavy marijuana use. Acute physical findings include conjunctival reddening, dry mouth and throat, tachycardia, dilated pupils, and sleepiness. Auditory and visual distortions also may occur, as might an acute distortion of time. It is very common for the appetite to increase. Marijuana use may affect the pulmonary, cardiovascular, endocrine, and immune system. Pulmonary effects are seen primarily in chronic or heavy users and include bronchitis, increased sputum production, bronchoconstriction, and wheezing. Cardiovascular effects include tachycardia and a mild decrease in exercise tolerance. Endocrine dysfunction, such as antagonistic effects on insulin and an increase in anovulatory menstrual cycles, can be seen in heavy users. In addition, gynecomastia and male infertility (as a result of a decrease in sperm count and motility) may occur. Behavioral consequences of marijuana use may involve intellectual and social difficulties. Short-term use can result in a decrease in reading comprehension and problemsolving. Long-term use may lead to an impairment of memory, learning ability, and perception. Socially, marijuana use has been correlated with truancy, poor academic achievement, and poor interpersonal skills. However, a cause-and-effect relationship is difficult to prove because heavy users often have pre-existing behavioral problems. Additional high-risk behaviors such as tobacco and other illicit drug use commonly are associated with marijuana use. Withdrawal effects usually occur only with prolonged marijuana use and consist of irritability; sleep disturbances; nausea, vomiting, and diarrhea; tremor; and nystagmus. No specific treatment is indicated. References: Fishman M, Bruner A, Adger H Jr. Substance abuse among children and adolescents. Pediatr Rev. 1997;18:394-403 Neinstein LS, Heischober BS, Pinsky D. Marijuana. In: Neinstein LS, ed. Adolescent Health Care: A Practical Guide. 3rd ed. Baltimore, Md: Williams & Wilkins; 1996:1032-1038 Schwartz B, Alderman EM. Peripheral brain: substances of abuse. Pediatr Rev. 1997;18:204215 Critique 125. Preferred Response: B

[View Question]

The differential diagnosis of unresponsiveness encompasses many disorders, including hypoor hyperglycemia, a postictal state following a seizure, toxic ingestion, psychiatric or neurologic disease, hemodynamic compromise, and trauma. When an adolescent is brought to the emergency department in a comatose state, one of the most likely causes is a toxic ingestion, although the substance(s) responsible for the comatose state may not be known immediately. The unresponsive, hypothermic, hypotensive boy in the vignette, who also has respiratory depression and miosis, most likely has ingested an overdose of barbiturates, opiates, or other sedative/hypnotics. Barbiturates exert their depressive effect by enhancing the action of gamma aminobutyric acid (GABA), the primary inhibitory central nervous system neurotransmitter, and by decreasing excitatory amino acid response and calcium conductance. Short-acting barbiturates such as secobarbital (eg, reds, red devils, F-40s, pinks, pink ladies) or pentobarbital (eg, yellow jackets, Abbotts, Mexican yellows) are used illicitly to reduce anxiety, decrease inhibitions, and treat unwanted side effects of stimulants or other substances of abuse. Illicit barbiturate use by adolescents has risen gradually in recent years, as has the use of marijuana, cocaine, and LSD. For example, 5.5% of high school seniors reported ever having used barbiturates in 1992, increasing to 9.8% in 1999. All barbiturates are potentially addictive and may cause an abstinence syndrome when discontinued. A daily dose of 600 mg to 800 mg of a short-acting barbiturate for 1 month or more will cause physiologic dependence. Higher doses create a stronger dependence and more serious abstinence symptoms. Within 24 hours of discontinuing a short-acting barbiturate, an addicted individual experiences withdrawal symptoms such as weakness, tremors, sweating, insomnia, agitation, delusions, psychosis, seizures, and hyperthermia. Although an overdose of amphetamines, cocaine, LSD, or phencyclidine could produce coma, findings on physical examination differ significantly from those of barbiturate intoxication. Patients intoxicated with any of these substances generally have tachycardia, hypertension, hyperthermia, and dilated pupils. References: Amitai Y, Oehme F, Heath AJ, McCarron MM. Barbiturates-short acting. In: Toll LL, Hurlbut KM, eds. Poisindex System. Englewood, Co: Micromedex, Inc; expires 12/2000. Available at: www. micromedex.com. Coupey SM. Barbiturates. Pediatr Rev. 1997;18:260-265 Johnston LD, Bachman JG, OMalley PM, Schulenberg JE, Wallace J. Monitoring the future: a continuing study of American youth. 1999. Available at: http://www.monitoringthefuture.org. Schwartz B, Alderman EM. Substances of abuse. Pediatr Rev. 1997; 18:204-215 Critique 192. Preferred Response: D

[View Question] The combination of visual hallucinations, anxiety, panic, and depression are suggestive of use of a hallucinogen, such as lysergic acid diethylamide (LSD). Hallucinogens are compounds that, in nontoxic doses, cause distortions in perceptions without loss of consciousness. Agents traditionally classified as hallucinogens include LSD, mescaline, psilocybin, morning glory, nutmeg, and jimson weed. It is important to recognize, however, that hallucinations also may be produced by phencyclidine (PCP), cocaine, marijuana, and amphetamine derivatives such as methylenedioxymethamphetamine (MDMA, Ecstasy.) The use of hallucinogens by adolescents peaked in 1979, when approximately 18% of high school seniors reported ever having tried one of these substances. In 1999, 14% of high school seniors reported having used a hallucinogen; 12% had used LSD, 3% PCP, and 8% MDMA. The mechanism of action of hallucinogens varies with the agent used. LSD is a sympathomimetic and, therefore, some of the earliest symptoms and signs (beginning within minutes of ingestion) are nausea, flushing, chills, dilated pupils, tachycardia, and hypertension. LSD is concentrated in the visual cortex and limbic and reticular activating systems where it binds to serotonin receptors, producing central nervous system effects within 15 to 20 minutes. Visual or auditory hallucinations are typical, and patients may experience synesthesias, which represent sensory confusion in which colors are heard or smells seen. Some users experience a sense that they or others are aging rapidly; others develop paranoia, depression, panic, and anxiety. Severe toxicity may produce coma, respiratory arrest, hyperpyrexia, coagulopathy, or seizures. Long-term consequences of LSD use include flashbacks, personality changes, depressive symptoms, or psychosis. Despite these adverse effects, hallucinogens, including LSD, do not appear to produce physical dependence or a withdrawal state. Intoxication with barbiturates, benzodiazepines, ethanol, or opiates produces sedation, not agitation, and is not associated with hallucinations. Furthermore, depressants (eg, barbiturates, benzodiazepines) and opiates cause miotic pupils, decreased body temperature, and decreased blood pressure, not signs of sympathetic stimulation, as seen in the adolescent in the vignette. References: Hurlbut KM, Joliff H, Hall AH, Fish SS, Rumack BH. LSD. In: Toll LL, Hurlbut KM, eds. Poisindex System. Englewood, Co: Micromedex, Inc; expires 12/2000. Available at: www.micromedex.com. Johnston LD, Bachman JG, OMalley PM, Schulenberg JE, Wallace J. Monitoring the future: a continuing study of American youth. 1999. Available at: http://www.monitoringthefuture.org. Schwartz B, Alderman EM. Substances of abuse. Pediatr Rev. 1997; 18:204-215 Werner MJ. Hallucinogens. Pediatr Rev. 1993;14:466-472 Critique 240. Preferred Response: A

[View Question] Symptoms and signs of acute cocaine overdose include agitation, fever, tachycardia, hypertension, and seizures. This potent central nervous system (CNS) and cardiac stimulant usually is administered by insufflating (snorting), although it may be injected intravenously or smoked (free-based). Cocaine inhibits neuronal uptake of dopamine, norepinephrine, and serotonin and stimulates pleasure centers in the brain. Its use is potentially addictive, with the mode of administration possibly influencing this potential. For example, freebasing appears to create more drug craving than intravenous injection or insufflation. Cocaine produces a continuum of dose-related effects ranging from mild intoxication to overdose. At lower doses, for example, the individual experiences euphoria and overconfidence; at higher doses, there may be aggressive or violent behavior with paranoia or psychosis. Although a relationship between dose and clinical effect has been observed, it should be recognized that death due to cocaine ingestion may occur regardless of the dose ingested, the blood level of cocaine, or the route of administration. An acute cocaine overdose, such as that experienced by the boy presented in the vignette, may produce a number of life-threatening complications involving the CNS, cardiovascular, and pulmonary systems that require careful patient monitoring and supportive care. Seizures are managed best with a benzodiazepine (eg, diazepam); if seizures persist, phenobarbital followed by phenytoin may be administered. Cocaineinduced hypertension has been associated with little morbidity or mortality, usually is shortlived, and may be followed by significant hypotension. For these reasons, pharmacologic treatment, usually with nitroprusside rather than nifedipine, is reserved for those patients experiencing a hypertensive emergency who have evidence of end-organ injury. Haloperidol is useful in the management of patients who have symptoms of psychosis. References: Schwartz B, Alderman EM. Substances of abuse. Pediatr Rev. 1997; 18:204-215 Weisman RS, Kulig K, Hurlbut KM, Fish SS, Krenzelok EP, Becker CE. Cocaine. In: Toll LL, Hurlbut KM, eds. Poisindex System. Englewood, Co: Micromedex, Inc; expires 12/2000. Available at: www. micromedex.com. Wootten J, Miller SI. Cocaine: a review. Pediatr Rev. 1994;15:89-92 2002Self-Assessment Exercise XXVI. Substance abuse [Return to Category List] Questions [Print Directions] Question 29. Answer.

You are counseling a group of adolescents about the adverse effects of smoking, including an increased incidence of chronic lung disease, cancer, and cardiovascular disease. You explain that smoking has many other negative effects. Of the following, the MOST significant adverse physiologic consequence of smoking is A. B. C. D. E. increased appetite and obesity increased muscle tension memory loss nausea and vomiting peptic ulcer disease Answer.

Question 72.

Tobacco smoking results in the rapid development of physiologic addiction to nicotine. Withdrawal from such an addiction can be difficult and is characterized by a variety of signs and symptoms. Of the following, the feature MOST typical of withdrawal from nicotine addiction is A. B. C. D. E. increased appetite increased catecholamine levels increased metabolic rate somnolence tachycardia

Question 109. Answer. You are discussing common presentations of intentional overdose with a group of third year medical students. When discussing opioid toxicity, your MOST likely statement would be that A. B. C. D. E. deep tendon reflexes become more pronounced hypertension occurs pulmonary edema may develop respiratory drive is preserved symptoms include an increase in body temperature

Question 145. Answer.

A 15-year-old boy is found wandering the streets and is brought by ambulance to the emergency department. He is tremulous, sweating, confused, and hyperactive. His pupils are dilated, equal, and reactive. He has no nystagmus. Other findings on physical examination include tachycardia and mild hypertension. Of the following, the MOST likely diagnosis is A. B. C. D. E. ingestion of phencyclidine inhalation of cannabis overdose of a tricyclic antidepressant overdose of amphetamine overdose of diazepam

Question 182. Answer. A 19-year-old girl is brought to the emergency department by ambulance. Her roommate found her unresponsive in their college dormitory room. The roommate states that the patient and her boyfriend had just broken up. The patient is very hard to arouse, and her speech is slurred. A urine toxicology screen is positive for barbiturates. Of the following, the MOST likely finding in this patient is A. B. C. D. E. hyperreflexia hypertension hypothermia pinpoint pupils widened QRS interval on electrocardiography

Question 221. Answer. You are discussing common street drugs with a group of medical students. A TRUE statement regarding the drugs classified as hallucinogens is that A. B. C. deaths due directly to ingestion of lysergic acid diethylamide (LSD) are common flashbacks are uncommon in phencyclidine (PCP) users LSD is a dissociative anesthetic, causing diminished pain sensation when ingested

D. PCP produces signs of inebriation, including nystagmus and slurred speech, at small doses E. the effects of hallucinogens are generally cholinergic, causing bradycardia and pupillary constriction

Answers Critique 29. Preferred Response: E

[View Question] The major physiologic effects of smoking are caused by nicotine, the addicting substance in cigarettes. Inhaled nicotine reaches the brain within 7 seconds of inhalation. Its effects include alertness, muscle relaxation, facilitation of memory or attention, decreased appetite, and decreased irritability. Nausea and vomiting are common in those who have not developed tolerance, but uncommon once tolerance and addiction have developed. Although inhaled nicotine does not produce the pleasurable feelings experienced with addictive drugs such as morphine, withdrawal from smoking causes a variety of unpleasant effects, which can stimulate the smoker to continue the habit. The major long-term physiologic consequences of smoking are chronic lung disease, cancer, and cardiovascular disease. Smoking not only leads to formation of duodenal ulcers, but it slows ulcer healing and increases the rate of recurrence. Secondhand smoke has chronic effects on children, including an increased incidence of middle ear disease, upper respiratory tract infections, asthma, and pneumonia. Women who smoke have an increased incidence of stillbirths, preterm births, and low-birthweight infants. Further, their infants weigh an average of 200 g less than infants of nonsmoking mothers. References: Miller NS, Cocores JA. Nicotine dependence: diagnosis, chemistry, and pharmacologic treatments. Pediatr Rev. 1993;14:275-279 Motil KJ. Peptic ulcer disease. In: McMillan JA, DeAngelis CD, Feigin RD, Warshaw JB, eds. Oski's Pediatrics: Principles and Practice. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999:1646-1652 Place R. Tobacco. Pediatr Rev. 1997;18:441 Critique 72. Preferred Response: A

[View Question] When tobacco is smoked, nicotine enters the body through inhalation, rapidly producing effects in the brain. There may be a brief period of mild-to-moderate euphoria, but tolerance to this effect quickly develops. Addiction to nicotine does not depend on the pleasurable feelings induced by the drug, but rather on the adverse effects produced by smoking cessation. Withdrawal of nicotine in the addicted user produces a variety of physiologic responses that include insomnia and sleep disturbances, headache, gastrointestinal disturbances, decreased catecholamine levels, decreased metabolic rate, decreased heart rate, tremor, increased coughing, irritability, anxiety, depression, difficulty in concentrating,

increased appetite, and weight gain. These effects are suppressed by the resumption of nicotine use. Smoking cessation programs are less effective in adolescents than adults. Factors that have been associated with increased success include emphasizing both short- and longterm risks, counseling, pharmacotherapy to counteract effects of withdrawal, anticipatory guidance regarding physiologic withdrawal symptoms, and peer support. References: Miller NS, Cocores JA. Nicotine dependence: diagnosis, chemistry, and pharmacologic treatments. Pediatr Rev. 1993;14:275-279 Place R. Tobacco. Pediatr Rev. 1997;18:441 Critique 109. Preferred Response: C

[View Question] Opiate overdose typically presents with a classic toxidrome of symptoms, including depressed mental status, respiratory depression, and severely constricted (miotic) pupils. Opiates exert their effect by binding to opioid receptors in the central nervous system, thereby causing central nervous system depression. Examples of opiates include heroin, morphine, meperidine, codeine, oxycodone, methadone, propoxyphene, and fentanyl. Common effects of opiate ingestion include euphoria, analgesia, slowed comprehension, and decreased reflexes. Blood pressure and body temperature are mildly decreased. Constipation and urinary retention are common. With severe overdose, stupor proceeding to coma, hypotension, bradycardia and circulatory collapse, respiratory arrest, pulmonary edema, and seizures (especially with meperidine and propoxyphene) occur. Arrhythmias may also occur with propoxyphene overdose. References: Alderman EM. Opiates. Pediatr Rev. 1997;18:122-126 Fishman M, Bruner A, Adger H Jr. Substance abuse among children and adolescents. Pediatr Rev. 1997;18:394-403 Osterhoudt KC, Shannon M, Henretig FM. Toxicologic emergencies. In: Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2000:887-942 Schwartz B, Alderman EM. Peripheral brain: substances of abuse. Pediatr Rev. 1997;18:204215 Critique 145. Preferred Response: D

[View Question] The adolescent described in the vignette is demonstrating classic signs of acute amphetamine overdose. Common street names include uppers, speed, ice, crystal, and the designer drug ecstasy. Routes of administration include oral, smoking, snorting, and rarely, intravenous. Amphetamines have a sympathomimetic effect. The presentation is similar to that of cocaine use. With an acute overdose, coma, circulatory collapse, hypertensive crisis, seizures, hyperthermia, arrhythmias, and cerebral hemorrhage may occur. Although similar in some ways to the presentation of amphetamine ingestion, phencyclidine intoxication is characterized by both vertical and horizontal nystagmus and in high doses, muscle rigidity. Ingestion of tricyclic antidepressants and diazepam usually leads to somnolence and central nervous system depression. Cardiac arrhythmias are also common with tricyclic antidepressant ingestion. Cannabis causes euphoria, drowsiness, and impaired coordination. Although patients may be mildly tachycardic, sweating and tremulousness are not seen. References: Ellenhorn MJ, Schonwald S, Ordog G, Wasserberger J. Amphetamines and designer drugs. In: Ellenhorn's Medical Toxicology: Diagnosis and Treatment of Human Poisoning. 2nd ed. Baltimore, Md: Williams & Wilkins; 1997:340-355 Osterhoudt KC, Shannon M, Henretig FM. Toxicologic emergencies. In: Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2000:887-942 Schwartz B, Alderman EM. Peripheral brain: substances of abuse. Pediatr Rev. 1997;18:204215 Critique 182. Preferred Response: C

[View Question] Barbiturates such as thiopental, secobarbital, and phenobarbital are sedative/hypnotics that reversibly depress the activity of all excitable tissues. Most of the effects of these agents are on the central nervous system, but cardiovascular depression also may occur with significant ingestions. Barbiturates are known as downers and are taken by drug users to counteract cocaine-induced tension and anxiety. Because benzodiazepines are readily available, barbiturates have been become less popular drugs of abuse. Central nervous system effects of barbiturate overdose include sedation, ataxia, slurred speech, hypotonia, impaired mentation and memory, and diminished reflexes. With severe overdose, stupor, coma, hypotension, cardiac or respiratory arrest, and hypothermia may occur. Pupils are usually of normal size, but they may be mildly constricted. Electrocardiography does not demonstrate a widened QRS interval, as is seen in severe tricyclic antidepressant overdose.

References: Ellenhorn MJ, Schonwald S, Ordog S, Wasserberger J. Sedative-hypnotic drugs. In: Ellenhorn's Medical Toxicology: Diagnosis and Treatment of Human Poisoning. 2nd ed. Baltimore, Md: Williams & Wilkins; 1997:684-711 Osterhoudt KC, Shannon M, Henretig FM. Toxicologic emergencies. In: Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2000:887-942 Schwartz B, Alderman EM. Peripheral brain: substances of abuse. Pediatr Rev. 1997;18:204215 Critique 221. Preferred Response: D

[View Question] Multiple drugs are classified as hallucinogens, and they exert their effect through various mechanisms. Important hallucinogens of abuse include D-lysergic acid diethylamide tartrate (LSD), peyote, mescaline, psychedelic mushrooms (psilocybin), phencyclidine (PCP), and in large doses, marijuana delta-9-tetrahydrocannabinol (THC.) In recent years, LSD use has made a comeback. One-time experimental use in high school seniors has been reported at 12%. LSD, known as acid, is commonly available as blotter paper, which usually is ingested. Its mechanism of action is inhibition of the release of serotonin. Intoxication with LSD leads to changes in perception, thinking, arousal, emotions, and self-image. Users experience significant alteration in visual perception, resulting in brightened colors, halos around objects, and distortion of shapes and sizes. Thought becomes illogical, time is distorted, sensory input magnifies, and vigilance is decreased, leading to potentially dangerous actions. The somatic effects of LSD and most other hallucinogens are sympathomimetic, resulting in dilated pupils, tachycardia, and hypertension. Severe overdose can lead to coma. Death from LSD overdose is rare. Bad trips also can occur, characterized by an extremely negative response that causes terror, panic, and extreme agitation. Flashbacks, or periodic hallucinatory imaging, can occur multiple times per day for months or years after use. Treatment of LSD overdose is primarily supportive and consists of providing a quiet environment with a supportive person to talk down the patient. PCP, also known as angel dust, is a dissociative anesthetic with analgesic, stimulant, depressant, and hallucinogenic properties. It is available in powder, tablet, and rock crystal form and often is mixed with plant material, such as oregano or marijuana. Effects of intoxication include illusions, hallucinations, and such signs of inebriation as ataxia, slurred speech, and nystagmus. With larger doses, catatonia and muscular rigidity may occur. Tachycardia and hypertension are common. At extremely high doses, seizures, arrhythmias, respiratory arrest, and rhabdomyolysis can be seen. Flashbacks occur more commonly than in LSD users. Patients who have taken PCP must be monitored closely

because behavior can be violent and unpredictable, but the use of physical restraints should be avoided because struggling may lead to rhabdomyolysis and myoglobinuria. Treatment of the severely intoxicated patient includes stabilization of vital signs, treatment of life-threatening events, and gastrointestinal decontamination if the drug was ingested orally. Chemical restraint with benzodiazepines or major tranquilizers may be necessary. References: Fishman M, Bruner A, Adger H Jr. Substance abuse among children and adolescents. Pediatr Rev. 1997;18:394-403 Osterhoudt KC, Shannon M, Henretig FM. Toxicologic emergencies. In: Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. 4th ed. Philadelphia, Pa: Lippincott Williams & Williams; 2000:887-942 Schwartz B, Alderman EM. Peripheral brain: substances of abuse. Pediatr Rev. 1997;18:204215 Schwartz RH. LSD makes a comeback. Contemp Pediatr. 1996;13:71-81 2000Self-Assessment Exercise XXVI. Substance abuse [Return to Category List] Questions [Print Directions] Question 74. Answer.

A 17-year-old boy is brought to the emergency department by police after he exhibited bizarre and combative behavior at a school dance. Upon presentation, he appears very agitated and states that the lights in the room are flashing too quickly. Physical examination reveals flushing, tachycardia, sweating, a blood pressure of 166/100 mm Hg, and horizontal and vertical nystagmus. Of the following, the MOST appropriate management is A. B. C. D. E. acidification of the urine administration of haloperidol administration of naloxone administration of phenothiazine administration of physostigmine

Question 204. Answer.

A 15-year-old boy is brought to your office by his mother because she suspects he is using drugs. She reports that he is hanging out with a "new crowd" and always is fatigued. During your interview alone with the adolescent you discover that he is ingesting alcohol almost daily but denies use of other illicit substances. As a result of this alcohol use, he is MOST likely to develop A. B. C. D. E. cerebellar ataxia cirrhosis delirium tremens gastritis peripheral neuropathy

Answers Critique 74 Preferred Response: B

[View Question] The adolescent described in the vignette is displaying signs and symptoms consistent with an acute hallucinogen overdose, specifically phencyclidine (PCP). Phencyclidine and lysergic acid diethylamide (LSD) are the two hallucinogens used most commonly by adolescents. Others include peyote, mescaline, and psychedelic mushrooms. The effects from PCP are dose-dependent and can cause severe psychiatric disturbances, including distortion of body image, paranoia, agitation, auditory and visual hallucinations, and combative violent behavior. Additional effects are euphoria, dysphoria, or catatonia. Other side effects of PCP can be categorized into those that are sympathomimetic (tachycardia, hypertension, hyperreflexia), cholinergic (miosis, flushing, diaphoresis), and cerebellar (vertical and horizontal nystagmus, ataxia, dysarthria). With high doses, rhabdomyolysis, renal failure, unresponsiveness, hypoventilation, seizures, arrhythmias, and death may occur. The management of acute hallucinogen overdose is primarily supportive and should be directed at reducing stimulation, especially in the agitated combative patient. Attempting to talk down the patient is not effective for those who have ingested PCP. A benzodiazepine such as midazolam may be used for sedation. Haloperidol should be administered in the psychotic or severely agitated patient; phenothiazines should be avoided because they may cause hypotension. Other treatment modalities include decontamination of the gastrointestinal tract with gastric lavage and charcoal, although the risk of charcoal aspiration may outweigh its benefit. The urine should not be acidified in an attempt to enhance secretion; an acid urine will precipitate myoglobin and potentiate renal failure if rhabdomyolysis is present. Further, because restraints may worsen rhabdomyolysis, they should be used only if absolutely

necessary in the violent patient. Seizures, hypertension, and hyperthermia also may require treatment with appropriate medications or a cooling blanket, respectively. Physostigmine and naloxone have no role in the management of an acute hallucinogen overdose. It is not unusual for an adolescent who has a history of substance abuse to have a comorbid psychiatric condition. However, distinguishing between the two is often difficult when a patient is using the illicit substance. Therefore, the adolescent should be reevaluated for the presence of a psychiatric disorder after 2 to 4 weeks of abstinence. In the adolescent who has severe or chronic symptoms, however, a tentative diagnosis and early empiric treatment may be necessary. References: Fishman M, Bruner A, Adger H Jr. Substance abuse among children and adolescents. Pediatr Rev. 1997;18: 394-403 Schwartz B, Alderman EM. Substances of abuse. Pediatr Rev. 1997;18:204-215 Wasserman GS. Substances of abuse: cocaine, phencyclidine, and sympathomimetics. In: Barkin RM, ed. Pediatric Emergency Medicine: Concepts and Clinical Practice. 2nd ed. St Louis, Mo: Mosby-Year Book, Inc; 1997:564-567 Critique 204 Preferred Response: D

[View Question] Alcohol is the most common substance of abuse used by young people. Nationwide, more than 80% of high school seniors report having used alcohol at some time in their lives. Even more alarming is the number of youth who binge drink (consume five or more drinks in a row, presumably to achieve intoxication). According to the Centers for Disease Control and Prevention's 1997 Youth Risk Behavior Surveillance, one third of high school students surveyed had at least five drinks of alcohol on more than one occasion during the preceding month. This binge drinking is reported by 25% of 9th graders, 30% of 10th graders, and approximately 40% of 11th and 12th graders. Significant health risks are associated with alcohol use: motor vehicle crashes, violence, and other injuries due to intoxication. In addition, alcohol abuse often is linked to other high-risk behaviors, such as early sexual activity, illicit drug use, and delinquency. Unlike in adults, the medical consequences of alcohol use or abuse in adolescents are uncommon. It is believed that this is related to fewer years of alcohol consumption. Although rarely seen, medical disorders can include esophagitis, gastritis, peptic ulcer disease, hepatitis, cirrhosis, and pancreatitis. Consequences of alcohol use or abuse in this age group are more likely to manifest as physical trauma from accidents or as an accidental or nonaccidental overdose. The signs and symptoms of acute alcohol toxicity at low doses are motor incoordination, slurred speech, visual disturbance, and ataxia. Other findings include flushed skin, excessive sweating, sluggish normal-size pupils, nausea, vomiting, and hypoglycemia. At higher doses,

a progression of neurologic symptoms can occur from irritability to stupor and coma. In fatal intoxications, a decreased respiratory drive can lead to respiratory arrest. The adolescent in the vignette is most likely to develop gastritis as a result of his alcohol use. Cerebellar ataxia, cirrhosis, and peripheral neuropathy are more severe medical sequelae that result from years of alcohol exposure. Delirium tremens are associated with severe alcohol withdrawal and rarely are seen in adolescents. Less severe forms of withdrawal, however, can be seen in teenagers, with symptoms such as sweating, chills, tremor, autonomic hyperactivity, nausea, and irritability. References: Fishman M, Bruner A, Adger H Jr. Substance abuse among children and adolescents. Pediatr Rev. 1997;18: 394-403 Mydler TT, Wasserman GS. Alcohols (ethanol, isopropanol, and methanol) and ethylene glycol. In: Barkin RM, ed. Pediatric Emergency Medicine: Concepts and Clinical Practice. 2nd ed. St Louis, Mo: Mosby-Year Book, Inc; 1997:539-544 Schwartz B, Alderman EM. Substances of abuse. Pediatr Rev. 1997;18:204-215 Takahashi A, Franklin J. Alcohol abuse. Pediatr Rev. 1996;17:39-45 Youth risk behavior surveillance-United States, 1997. MMWR Morb Mortal Wkly Rep. 1998;47:12 2111Self-Assessment Exercise XXVI. Substance abuse [Return to Category List] Questions [Print Directions] Question 51. Answer.

The mother of a 17-year-old boy reports to you that she suspects her son is using cocaine. A. B. C. D. E. bradycardia conjunctival injection nasal septal perforation needle tracks pinpoint pupils

Question 149. Answer. During a preparticipation sports physical examination, a 16-year-old boy tells you that he and his friends occasionally use drugs.

Which of the following illicit substances is MOST commonly used by adolescents in the United States? A. B. C. D. E. Amphetamines Cocaine Lysergic acid diethylamide (LSD) Marijuana Phencyclidine (PCP)

Question 234. Answer. You are talking with a 17-year-old boy who has a chronic history of substance abuse and has agreed to enter a drug treatment program. A urine drug screen is required prior to entry. He last used marijuana and secobarbital 1 week ago. If a urine drug screen is performed today, it is MOST likely to reveal

Barbiturates A. B. C. D. E. Inconclusive Negative Negative

Cannabinoid Inconclusive Negative Positive

Positive Negative Positive Positive

Answers Critique 51 Preferred Response: C

[View Question] Cocaine is one of the most addictive substances known. Its effects are dose-dependent and vary with the route of administration. It is derived from the leaves of the coca bush, Erythroxylon coca, which is indigenous to Bolivia, Colombia, Java, and Peru. When administered, cocaine causes the increased release and decreased reuptake of biogenic amines, resulting in central and peripheral nervous system stimulation, local anesthesia, and vasoconstriction. General effects of cocaine intoxication are hyperalertness, a sense of well-being, decreased fatigue and hunger, increased energy and confidence, and a feeling of euphoria.

At higher doses, agitation, anxiety, and irritability occur. Violent and aggressive behavior, which may be accompanied by paranoia and toxic psychosis, may be seen at even higher doses. Life-threatening complications of cocaine intoxication include convulsions, stroke, cardiac arrhythmias, subarachnoid hemorrhage, and hyperthermia; these are not always dose-related. The cardiovascular signs associated with cocaine use include tachycardia (not bradycardia) and hypertension. Eye findings include dilated pupils (not pinpoint pupils). Conjunctival injection is a nonspecific finding that is not commonly associated with cocaine use, but can be a sign of alcohol or marijuana abuse. There are essentially three routes of administration of cocaine: insufflation ("snorting"), intravenous injection, and freebasing or smoking. Insufflation, the most common mode of administration, has its onset of action of 5 minutes, peaks approximately 10 minutes later, and has a duration of action of 1 hour or less. Initially, about 20% to 30% of the drug is absorbed through the nasal mucosa, but this percentage decreases with successive use because of the drug's vasoconstrictive properties. Complications associated with snorting include chronic nasal congestion, perforation or ulceration of the nasal septum, and epistaxis. Accordingly, of the options listed, the most suggestive sign of cocaine use is septal perforation. Because cocaine hydrochloride is water-soluble, it is mixed with water prior to intravenous (IV) injection. When taken intravenously, the onset of action of cocaine is 45 seconds, the peak is reached within 30 seconds to 2 minutes, and the duration of action is about 15 minutes. Several complications can occur following IV administration, including needle track marks, cellulitis, phlebitis, endocarditis, pulmonary emboli, hepatitis, and acquisition of human immunodeficiency virus infection from shared needles. Smoking cocaine delivers the drug via the intrapulmonary route. It can be smoked in chunks or "rocks" in pipes or in the "freebase" form, commonly known as "crack". The onset of action by this route is very rapid, and the duration of the "high" is very short-lived. Thus, it is hypothesized that this route may be more addictive than the other two routes of administration. Medical complications of "freebasing" cocaine are related to the use of other volatile substances, which lead to explosions or burns. In addition, the effects of smoking can cause pulmonary sequelae such as alveolar rupture and emphysema. References: Brown RT, Coupey RT. Illicit drugs of abuse. Adolescent Medicine: State of the Art Reviews. 1993;4:321-340 Fishman M, Bruner A, Adger H Jr. Substance abuse among children and adolescents. Pediatrics in Review. 1997;18:394-403 Schwartz B, Alderman EM. Substances of abuse. Pediatrics in Review. 1997;18:204-215 Wootton J, Miller SI. Cocaine: a review. Pediatrics in Review. 1994;15:89-93

Critique 149

Preferred Response: D

[View Question] A large variety of illicit substances are tried and used by adolescents. Most adolescents use drugs to achieve pleasure, relieve emotional strain, and help with social interactions. In addition, they may use drugs to fit in with their peer group or as self-medication for an undiagnosed psychiatric condition. Among adolescents, marijuana is the most widely used illicit drug. More adolescents have tried marijuana than any other illicit substance except alcohol. Although there was a documented 33% decline in the prevalence of marijuana use from 1975 to 1989, a national survey in 1995 reported more than 40% of high school seniors had used marijuana at some point in their lives, 35% reported use in the past year, 21% reported some use in the past month, and 5% reported using it on a daily basis. Use of stimulants and inhalants also seems to be on the rise among adolescents, but it has not reached the popularity of marijuana use. Amphetamines, which are stimulants, produce a sense of well-being and heightened awareness as well as an increase in energy and decrease in social inhibition. Cocaine is similar to amphetamines in its effect, but its use has declined. Inhalants (eg, spray paint, glue) also are sometimes used to get high, especially among younger high school students. The use of phencyclidine hydrochloride (PCP), which is a true hallucinogen, reportedly is declining. However, lysergic acid diethylamide (LSD) use has not shown a decline in recent years, and anecdotal reports suggest its use may be on the rise. It is important to note that the adolescents participating in surveys reporting drug use are those who have stayed in school and that the rate of alcohol and drug use in school dropouts is likely to be significantly higher. Clinicians should be aware of the widespread prevalence of illicit drug use among adolescents to provide appropriate counseling and treatment. References: Brown RT, Coupey SM. Illicit drugs of abuse. Adolescent Medicine: State of the Art Reviews. 1993;4:321-340 Fishman M, Bruner A, Adger H Jr. Substance abuse among children and adolescents. Pediatrics in Review. 1997;18:394-403 O'Malley PM, Johnston LD, Bachman JG. Adolescent substance use and addictions: epidemiology, current trends, and public policy. Adolescent Medicine: State of the Art Reviews. 1993;4:227-248 Takahashi A, Franklin J. Alcohol abuse. Pediatrics in Review. 1996;17:39-45 Critique 234 Preferred Response: C

[View Question] Urine drug screening can detect the presence of drugs of abuse such as marijuana, amphetamines, methamphetamine, barbiturates, cocaine metabolites, and opiates. The duration of a positive result for any drug in the urine depends upon several factors: the halflife of the individual drug; the timing of the test sample in relation to drug use; the physical condition of the person being tested, especially hydration status; and the quantity and frequency of substance use. Cannabis, the most frequently used illicit drug, generally can be detected in the urine through its metabolites for 2 to 3 days following casual use. Some experts have claimed that cannabis can be detected in the urine for 5 days following a single use and for 10 days following casual use. Approximately 20% of adolescents who have used the drug daily will continue to excrete measurable amounts of the metabolites for 1 month or more after cessation of use. Passive inhalation of marijuana smoke by an individual in a ventilated room of average size or an open area does not produce a positive urine test. The duration of a positive result for barbiturates in the urine depends on the specific duration of action of the barbiturate. A very short-acting barbiturate (secobarbital) can be detected for approximately 24 hours, intermediate-acting barbiturates (amobarbital) for 2 to 3 days, and long-acting ones (phenobarbital) for more than 7 days. Accordingly, if the boy described in the vignette has a chronic history of substance abuse and last used marijuana and a short-acting barbiturate 1 week ago, the cannabinoid is more likely to be detected in the urine than the barbiturate. Interpretation of the results of urine drug screening involves the careful consideration of three factors: 1) the possibility of the specimen being adulterated, 2) the cutoff level of the assay being used, and 3) the use of other foods or medications that can interfere with the assay or give a false-positive result. Random urine drug screening is not recommended to determine drug use in adolescents, especially at the sole request of the parent. Drug testing furnishes no information on the patterns of drug use or abuse and does not verify mental or physical impairment or dependency. Involuntary testing also violates the legal rights of informed consent in the competent adolescent. A thorough physical examination and psychosocial assessment remain the most proficient way to elicit drug use in an adolescent and to determine if drug treatment is indicated. References: Neal W, Alderman E. Urine drug screening. Pediatrics in Review. 1996;17:51-52 Schwartz B, Alderman EM. Substances of abuse. Pediatrics in Review. 1997;18:204-215 Schwartz RH. Testing for drugs of abuse: controversies and techniques. Adolescent Medicine: State of the Art Reviews. 1993;4:353-370 2111Self-Assessment Exercise

XXVI. Substance abuse [Return to Category List] Questions [Print Directions] Question 22. Answer.

The mother of a 12-year-old girl is worried because she found five bottles of typewriter correction fluid in her daughter's bedroom. She also has noticed that her daughter sometimes has paint stains on her hands. The girl's school performance has deteriorated over the past month. You suspect that the child is abusing inhalants. Among the following, the MOST likely consequence of chronic abuse of inhalants is A. B. C. D. E. cardiac arrhythmia cerebral hemorrhage encephalopathy pneumothorax respiratory acidosis

Question 266. Answer. You are evaluating a hostile, combative adolescent boy in the emergency department. Physical examination reveals sinus tachycardia and tremulousness. The adolescent denies taking any drugs. Of the following, the BEST management of this patient includes screening for A. B. C. D. E. alcohol barbiturates cocaine inhalants narcotics

Answers Critique 22 Preferred Response: C

[View Question] Inhalant abuse is defined as the intentional inhalation of a volatile substance such as model glue, spray paint, typewriter correction fluid, or gasoline to achieve a euphoric state. Virtually any hydrocarbon can have mind-altering effects when inhaled in large doses. The peak age of inhalant abuse is 14 to 15 years, with onset occurring as early as 6 to 8 years.

Annual surveys of high school seniors have shown that 15% to 20% have ever used inhalants, and 5% to 10% have used them in the past year. However, these numbers underestimate the real prevalence of inhalant abuse because school dropouts and younger students are more likely to abuse inhalants than high school seniors. Although inhalant abuse occurs in all ethnic and socioeconomic groups, it is more common among poor children and adolescents, especially those of Hispanic and Native American background. Volatile hydrocarbons may be inhaled directly from a container, plastic bag, or saturated rag. The effects of inhalant abuse have been described as a "quick drunk" because the symptoms resemble alcohol intoxication. The immediate effects are similar to the early stages of anesthesia: initial euphoria is followed by drowsiness, disinhibition, lightheadedness, and agitation. With increasing intoxication, individuals may develop ataxia, dizziness, and disorientation. In extreme intoxication, abusers exhibit generalized muscle weakness, dysarthria, nystagmus, and hallucinations or disruptive behavior. Several hours after use, abusers often complain of headaches and lethargy, similar to an alcohol hangover. Psychosocial effects include school failure, delinquency, and increased risk-taking behavior . The primary organic morbidity following chronic abuse is an encephalopathy due to central nervous system damage. Inhalants are highly lipophilic, which explains their distribution to organs rich in lipids such as the brain. Clinical signs of central nervous system damage due to inhalants include loss of cognitive and cerebellar function. Computed tomography studies have demonstrated loss of brain mass following chronic inhalant abuse; magnetic resonance imaging has shown white matter degeneration. Other neurologic effects of inhalant abuse include peripheral neuropathy, cranial neuropathy, symptoms of parkinsonism, and visual loss. Abuse of toluene during pregnancy results in an embryopathy that is similar to fetal alcohol syndrome. Death is rare in the course of acute inhalant intoxication and usually is due to either asphyxia or cardiac arrhythmia. Suffocation also can occur when the mode of inhalation is via a plastic bag placed over the nose and mouth. The loss of inhibition associated with inhalant abuse leads to impulsive, risk-taking behavior that also can result in death from falls, hypothermia, and fires. Death from aspiration may occur because of a depressed level of consciousness and loss of protective airway reflexes. Cardiac arrhythmias leading to death in patients who are abusing inhalants have been termed "sudden sniffing death syndrome." Death occurs when the user is startled during inhalation by either a hallucination or an environmental event. Because the inhalants sensitize the myocardium to epinephrine, the sudden surge of this hormone after being startled results in a fatal cardiac arrhythmia. Sudden sniffing death can occur during initial experimentation or any subsequent use. In one study of deaths due to inhalant abuse, 22% of those who died had no history of previous inhalant abuse. Respiratory acidosis may occur with inhalant abuse, but more commonly a hyperchloremic metabolic acidosis occurs due to distal renal tubular dysfunction. Other findings include hypokalemia, hypocalcemia, and other electrolyte disturbances. Inhalants also are hepatotoxic, and elevated levels of plasma liver enzymes are common. Although hydrocarbons are pulmonary irritants, their abuse usually is not associated with pulmonary

toxicity. Both pneumothorax and cerebral hemorrhage typically are signs of cocaine abuse rather than inhalant abuse. Parents and physicians should suspect inhalant abuse whenever a child or adolescent is found with inhalants and there is no valid reason for their possession. The conspicuous odor of the inhalant also may be evident because most hydrocarbons are excreted via the lungs. Additional clues may include stained clothing, flecks of paint or glitter on the face, and perioral rashes. Urine drug screens are not helpful in confirming the use of inhalants because they do not detect these chemicals. References: Abbott PJ, Trujillo M. Special populations--special concerns: Hispanics. In: Kinney J, ed. Clinical Manual of Substance Abuse. 2nd ed. St Louis, Mo: Mosby-Year Book, Inc; 1996:197207 American Academy of Pediatrics, Committee on Substance Abuse and Committee on Native American Child Health. Inhalant abuse. Pediatrics. 1996;97:420-423 Esmail A, Meyer L, Pottier A, Wright S. Deaths from volatile substance abuse in those under 18 years: results from a national epidemiological study. Arch Dis Child. 1993;69:356-360 MacKenzie RG, Kipke MD. Substance use and abuse. In: Friedman SB, Fisher M, Schonberg SK, eds. Comprehensive Adolescent Health Care. St Louis, Mo: Quality Medical Publishing, Inc; 1992:765-786 Pearson MA, Hoyme HE, Seaver LH, Rimsza ME. Toluene embryopathy: delineation of the phenotype and comparison with fetal alcohol syndrome. Pediatrics. 1994;93:211-215 Sharp CW, Rosenberg NL. Volatile substances. In: Lowinson JH, Ruiz P, Millman RB, eds. Substance Abuse: A Comprehensive Textbook. 2nd ed. Baltimore, Md: Williams & Wilkins; 1992:303-327 Critique 266 Preferred Response: C

[View Question] Tachycardia, tremulousness, and combative behavior in an adolescent is suggestive of cocaine intoxication. This central nervous system stimulant prevents reuptake of neuronal catecholamines, principally norepinephrine, which results in excessive levels of catecholamines in the blood. These high catecholamine concentrations produce tachycardia, hypertension, pupillary dilation, agitation, and tremulousness. Ingestion of other central nervous system stimulants, such as amphetamine and ephedrine, can cause similar symptoms. Alcohol is a central nervous system depressant, although at low doses it has behavioral stimulant properties, and combative behavior may occur in some patients. Tremulousness is not a common feature of acute ethanol intoxication, although chronic

alcoholism and alcohol withdrawal may be associated with tremors. Blood, saliva, or breath samples are used for alcohol screening because alcohol is not detected easily in the urine. The effects of inhalant abuse have been described as a "quick drunk" because the symptoms resemble alcohol intoxication. Volatile hydrocarbons may be inhaled directly from a container, plastic bag, or saturated rag. The immediate effects are similar to the early stages of anesthesia: initial euphoria is followed by drowsiness, disinhibition, lightheadedness, and agitation. With increasing intoxication, individuals may develop ataxia, dizziness, and disorientation. In extreme intoxication, abusers exhibit generalized muscle weakness, dysarthria, nystagmus, and hallucinations or disruptive behavior. Several hours after use, abusers often complain of headaches and lethargy, similar to an alcohol hangover. Barbiturates are central nervous system depressants. Low doses cause mild sedation characterized by fatigue, sleepiness, and yawning. Other symptoms include ataxia, hypotonia, lateral nystagmus, and orthostatic hypotension. In high doses, respiratory depression and coma may occur. Similar symptoms and signs are seen with other sedatives and hypnotics, such as benzodiazepines, carbamates, and glutethimide. Symptoms and signs of narcotic abuse include pupillary constriction, drowsiness, slurred speech, and respiratory depression. Initial euphoria typically is followed by apathy, dysphoria, and psychomotor agitation or retardation. Tremulousness and tachycardia are not common features. Although cocaine appears to be the most likely drug to have caused the symptoms and signs noted in the patient in the vignette, drug screening should not be limited to this drug because an overdose may involve a combination of agents. Also, the symptoms and signs of acute intoxication may be similar for different drugs. The patient's history may not be reliable in this situation. Street drugs often are misrepresented and contaminated with other drugs with the result that an adolescent may have ingested a different drug than he or she thought. Also, it is common for an adolescent to deny taking any drug even when acutely symptomatic. Accordingly, drug screening for multiple drugs of abuse is necessary in evaluating the adolescent who is suspected of using illicit drugs. References: Brown RT, Coupey SM. Illicit drugs of abuse. Adolescent Medicine: State of the Art Reviews. 1993;4:321-340 Frances A, Pincus HA, First MB. Diagnostic and Statistical Manual of Mental Disorders-IV. Washington, DC: American Psychiatric Association; 1994:175-272 MacKenzie RG, Kipke MD. Substance use and abuse. In: Friedman SB, Fisher M, Schonberg SK, eds. Comprehensive Adolescent Health Care. St Louis, Mo: Quality Medical Publishing, Inc; 1992:765-786 Schwartz RH. Testing for drugs of abuse: controversies and techniques. Adolescent Medicine: State of the Art Reviews. 1993;4:353-370

Sharp CW, Rosenberg NL. Volatile substances. In: Lowinson JH, Ruiz P, Millman RB, eds. Substance Abuse: A Comprehensive Textbook. 2nd ed. Baltimore, Md: Williams & Wilkins; 1992:303-327 Takahashi A, Franklin J. Alcohol abuse. Pediatrics in Review. 1996;17:39-45