Rhode Island Substance Abuse

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The following course content

Introduction   

Substance abuse is described as “a pattern of using a substance (drug) that causes significant problems or distress” (1). As of 2020, 37.309 million Americans were currently using illegal drugs (2). Medical professionals are on the front lines of recognizing, treating and providing support to individuals who suffer from substance abuse. This Rhode Island Substance Abuse course will walk you through the different types of substances abused, the prevalence of that abuse, the symptoms one experiences while using that substance, overdose symptoms, and how to counteract an overdose. You will also learn about substance abuse in adolescents, and prevention methods currently being used to combat substance abuse in adolescents. 

Alcohol

Alcohol abuse is the second most common type of substance abuse, with the first being tobacco use (3). While many individuals in the United States can drink alcohol and it is not considered abuse, there are some individuals whose drinking causes harm or distress. In the case of alcohol use disorder, harm or distress is described as alcohol leading to health problems, or trouble while at home, work, school or with law enforcement (3).   

There are several signs and symptoms of alcohol use disorder that help one to determine if their loved one needs help. As health care providers, it is important to understand the signs and symptoms to properly help and treat those who are experiencing alcohol use disorder. Symptoms can range from mild to severe, depending on the number of symptoms experienced (5) and include: 

1. Unable to limit the amount of alcohol consumed 
2. Wanting to decrease the amount consumed, but being unsuccessful 
3. Spending a large amount of time obtaining alcohol, drinking alcohol, or recovering from alcohol use 
4. Having a strong craving or urge to drink alcohol 
5. Not completing major obligations at work, school or home due to alcohol use 
6. Continuing to drink alcohol even though you know it is causing problems physically, at work, home, or in relationships 
7. No participating in social activities or work-related functions to consume alcohol  
8. Developing a tolerance to alcohol so more is needed to elicit the same effect 
9. Experiencing symptoms of withdrawal, such as, nauseas, sweating and shaking when you are not drinking
   

While the above signs and symptoms are typically ones that do not have a medical component attached, alcohol use disorder impacts nearly every organ and system in the body. This widespread impact can have a detrimental effect on an individual suffering from alcohol use disorder (4) such as: 

1. Neurologic
   – Ischemic stroke
   – Hemorrhagic stroke
2. Cardiac
   – Cardiomyopathy
   – Arrhythmias
   – Ischemic heart disease
   – Hypertension
3. Lung
   – Acute respiratory distress syndrome
   – Pneumonia
4. Liver
   – Steatosis
   – Steatohepatitis
   – Fibrosis
   – Cirrhosis
   – Alcohol associated hepatitis
   – Liver cancer
5. Pancreas
   – Acute and chronic pancreatitis
6. Gastrointestinal
   – Gut leakiness
   – Microbial dysbiosis
   – Colorectal cancer

Clear patterns have emerged between alcohol use disorder and increased risk for certain types of cancers (4): 

1. Head and neck cancer
   – Oral cavity
   – Pharynx
   – Larynx
2. Esophageal Cancer
3. Liver Cancer
4. Breast
5. Colorectal Cancer
   

Knowing the effects of chronic alcohol use on the body is important in understanding the treatment methods that will be needed. Treatment options range from spiritual to medical, with many individuals utilizing more than one option (6).  

1. Detox and withdrawal
   – This treatment option is typically done in an inpatient setting. Treatment begins with detoxification, which leads to withdrawal symptoms. These symptoms can be medically managed, and occasionally require sedating medications. Detox and withdrawal generally take 2 to 7 days.
2. Psychological counseling
   – This treatment option will help the individual better understand their problem with alcohol and provide support on the psychological aspects of alcohol use disorder. This type of treatment can be done individually or in a group setting.
3. Oral medications
   – Disulfiram is a medication that helps to curb one’s want for alcohol. While the drug doesn’t remove the urge to drink, it will produce a physical reaction to consuming alcohol in the form of flushing, nausea, vomiting and headaches.
   – Naltrexone is used to block the good feelings alcohol causes, which can aid in recovery.
   – Acamprosate is used to help curb cravings of alcohol and is generally used in combination with Naltrexone.
4. Injected medication
   – Vivitrol is the injected version of Naltrexone and is injected once a month. Injected medications may be easier, or more consistently used than oral medications.
5. Medical treatment
   – As we’ve learned, alcohol use disorder comes with a large amount of health concerns. These concerns typically require medical treatment in the form of medication, surgery, outpatient care, etc.
6. Spiritual practice
   – It has been shown that individuals involved in some type of spiritual practice find it easier to maintain recovery.

Marijuana

Marijuana, also known as cannabis, weed or pot, refers to the dried flowers, leaves, stems and seeds of the cannabis plant. In one cannabis plant there are over 100 compounds ranging from tetrahydrocannabinol (THC) to cannabidiol (CBD) (7). While THC and CBD have the same molecular structure, the difference in how the atoms are arranged accounts for the different effects on the body. THC is the main psychoactive compound in cannabis, which produces the high sensation, while CBD, although psychoactive, does not produce the high sensation (8). 

Marijuana is the most used federally illegal drug in the United Stated. In 2019, the CDC reported that 48.2 million, or ~18% of Americans have used marijuana at least once. There are several ways to use marijuana, including: smoking in joints, blunts, or bongs, vaping via electronic vaporizing devices, mixing or infusing into foods or drinks, or inhaling oil concentrates (7).  

There are many health risks associated with using marijuana, in any form. It is estimated that 3 in 10 people who use marijuana have marijuana use disorder (7).  

The risks include: 

Brain Health

Since marijuana is a psychoactive drug, the main effect is on brain function. Marijuana specifically affects the parts of the brain responsible for memory, learning, attention, decision making, coordination, emotions and reaction time.  

Heart Health 

Marijuana is known to make the heart beat faster, which can make blood pressure higher immediately after use. This can lead to an increased risk of stroke, heart disease or vascular disease. 

Lung Health 

Inhaled marijuana can cause damage to lung tissues and small blood vessels, as well as scarring to the lung. More research is being done to understand the effects of secondhand marijuana smoke. 

Mental Health 

While the relationship is not fully understood, marijuana has been linked to social anxiety, depression and schizophrenia. 

Unintentional Poisoning 

There is a greater risk for unintentional poisoning with edibles (marijuana baked or put into food or drinks) than with inhaled marijuana. This risk is because children can easily mistake food with marijuana in it. In some instances, emergency medical care has been required. 

As marijuana becomes legal, and readily available across many states, teenagers are gaining better access to it. The CDC reports that 37% of high school students in the United States have reported using marijuana. This use can come with impacts to their developing brains, resulting in (7): 

1. Difficulty thinking and problem-solving 
2. Problems with memory and learning 
3. Reduced coordination 
4. Difficulty maintaining attention 
5. Problems with school and social life 

Prescription Medicines

Prescription drug abuse is classified as the abuse of a prescription medication that is taken in a way not intended by the prescriber. This abuse can be by the person who the drug was initially prescribed for, or from someone taking another person’s prescription medication. The National Center for Drug Abuse Statistics show that 6% of Americans over the age of 12 abuse prescriptions in a year, and 12% of prescription drug abusers are addicted. This is perpetuated by 4 out of 5 pharmacy filled prescriptions being opioids (10).  

Prescription medication is sectioned off into three categories: opioids, anti-anxiety medications/sedatives/hypnotics, and stimulants. Signs and symptoms of prescription drug abuse vary depending on the type of drug used (9). Opioids are a type of medication that is used to treat pain. These medications usually contain oxycodone or hydrocodone. Opioids are the leading cause of drug overdose death, with 74.8% of drug overdose death being from Opioids (11).  

The signs of symptoms of opioid drug abuse include (9): 

1. Constipation 
2. Nausea 
3. Feeling high 
4. Slowed breathing rate 
5. Drowsiness 
6. Confusion 
7. Poor coordination 
8. Increased dose needed for pain relief 
9. Worsening or increased sensitivity to pain with higher doses
   

Anti-anxiety medication, sedatives and hypnotics are used to treat anxiety and sleep disorders. Some medications used for these disorders are alprazolam (Xanax), diazepam (Valium), and zolpidem (Ambien). 

The signs and symptoms of drug abuse by these types of medications are (9): 

1. Drowsiness 
2. Confusion 
3. Unsteady walking 
4. Slurred speech 
5. Poor concentration 
6. Dizziness 
7. Problems with memory 
8. Slowed breathing
   

Stimulants are a type of medication used to treat attention-deficit/hyperactivity disorder (ADHD) and certain sleep disorders. Some medications used to treat these disorders include methylphenidate (Ritalin, Concerta, and others), dextroamphetamine-amphetamine (Adderall XR, Mydayis) and dextroamphetamine (Dexedrine).  

Signs and symptoms of drug abuse by these types of medications are (9): 

1. Increased alertness 
2. Feeling high 
3. Irregular heartbeat 
4. High blood pressure 
5. High body temperature 
6. Reduced appetite 
7. Insomnia 
8. Agitation 
9. Anxiety 
10. Paranoia 
    

Medical complications differ depending on the type of medication abused. Opioids can decrease respiratory rate with the potential for breathing to stop altogether. They can also cause a coma, and lead to death. Anti-anxiety/sedatives/hypnotics can cause memory problems, low blood pressure and slowed breathing. Like opioids, they can also lead to coma or death. Abrupt withdrawal of these medications can lead to an overactive nervous system and seizures. Stimulants can increase the bodies temperature, produce heart problems, high blood pressure, seizures or tremors, hallucinations, aggressiveness, and paranoia (9).  

Opioids can be reversed with a medication called Naloxone. This medication works by binding to the opioid receptors, then reversing and blocking the effects of other opioids. It is used to restore an individual’s breathing and can be given through injection or nasal spray. If Naloxone is given outside of a medical facility, emergency personnel should be contacted immediately (18).  

Methamphetamine

Methamphetamine is a highly addictive, man-made, central nervous system stimulant. This drug increases heart rate, body temperature, respiration, and blood pressure. It also enhances one’s energy, attention, focus, pleasure, and excitement (12). It has commonly been referred to as meth, ice, speed, and crystal. Research has shown that 2.5 million Americans aged 12 or older reported using methamphetamine within the past year. 53% of those individuals met diagnostic criteria for methamphetamine use disorder, but less than 1 in 3 received substance use treatment within the past year (13).  

There are four ways methamphetamine can be used: smoking, swallowing (pill), snorting, or injecting the powder that has been dissolved in water or alcohol. While methamphetamine produces a high quickly, it also fades quickly. This produces what is called and “binge and crash” pattern of use. This type of use is where an individual will take the drug every few hours for several days at a time, resulting in lack of food and sleep (14). 

There is a substantial amount of long-term health effects from methamphetamine use. Those who inject methamphetamine are at a higher risk for contracting infectious diseases like HIV and hepatitis C.  

Other long-term problems include (14): 

1. Extreme weight loss 
2. Severe dental problems 
3. Intense itching which can lead to skin sores and infection from scratching 
4. Anxiety 
5. Changes in brain structure and function
   – Changes have been noted to the brain’s dopamine system which has resulted in problems with coordination and verbal learning.
   – Severe changes have also been noted to the areas of the brain that deal with emotion and memory 
6. Confusion and memory loss 
7. Sleeping problems 
8. Violent behavior 
9. Paranoia 
10. Hallucinations
    

Due to the effect methamphetamine has on the body, an overdose often leads to a stroke, heart attack, or organ problems. Because of this, it is imperative health care providers restore blood flow to the affected part of the brain for a stroke, restore blood flow to the heart in the event of a heart attack, or treat the organ issues that present (14). Treatment for methamphetamine use disorder focuses on cognitive-behavioral therapy and motivational incentives, such as vouchers or small cash rewards that encourage individuals to remain drug-free. There is currently no FDA approved medication to treat a methamphetamine addiction (14).

Cocaine

Cocaine is a highly addictive stimulant drug that is derived from the leaves of the coco plant that is native to South America. Dealers of cocaine may add in other drugs to the cocaine, such as amphetamine or synthetic opioids, like fentanyl. Adding in synthetic opioids can be especially dangerous and lead to overdose and even death (15). Over 5 million Americans reported current cocaine use in 2020, with nearly 1 in 5 overdose deaths reported (13). 

There are several ways in which cocaine can be used: in powder form it can be snorted or rubbed into an individual’s gums, the powder can be dissolved and injected into the bloodstream, or if the cocaine is in crystal form, it can be heated and smoked. Injecting cocaine produces a faster and more intense high but is short-lasting. Cocaine affects the brain by increasing the amount of dopamine produced. This increase of dopamine floods the brain’s reward circuit, which reinforces drug-taking behavior. Repeated cocaine use can lead to the brain’s reward circuit becoming less sensitive, which leads to individuals taking stronger and more frequent doses to achieve the same high as before (15).  

The effects of cocaine are felt almost immediately and can disappear within a few minutes to an hour. There are several health effects from using cocaine (15): 

1. Extreme happiness and energy 
2. Mental alertness 
3. Hypersensitivity to sight, sound, and touch 
4. Irritability 
5. Paranoia 
6. Constricted blood vessels 
7. Dilated pupils 
8. Nausea 
9. Increase in body temperature and blood pressure 
10. Increased or irregular heartbeat 
11. Tremors/muscle twitches 
12. Restlessness 
    

There are several long-term effects of cocaine use. These effects can range from common, to being dependent on the method of use (15) 

1. Malnourished due to a decreased appetite 
2. Movement disorders 
3. Irritability 
4. Restlessness 
5. Auditory hallucinations 
6. Snorting cocaine
   – Loss of smell
   – Nosebleeds
   – Frequent runny nose
   – Problems with swallowing 
7. Smoking cocaine
   – Cough
   – Asthma
   – Respiratory distress
   – Higher risk for infections like pneumonia 
8. Consuming cocaine by mouth
   – Severe bowel decay due to reduced blood flow 
9. Injecting cocaine
   – Increased risk of contracting HIV, hepatitis B and C, and other blood-borne diseases
   – Skin or soft tissue infections
   – Scarring or collapsed veins
   

A cocaine overdose is similar to that of a methamphetamine overdose, with the inclusion of seizures. Like methamphetamine, it is critical that health care providers restore blood flow to the heart and brain in the event of a heart attack or stroke. If an individual presents with a seizure due to a cocaine overdose, the first action to be taken is to stop the seizure. Cocaine mirrors that of methamphetamine use in terms of increased dopamine in the brain. This leads to an addictive nature, as well as needing more drug overtime to produce the same high (15).  

Unfortunately, there is no FDA medication approved to treat cocaine use disorder.  

There are several behavioral therapy options available (15): 

1. Cognitive-behavioral therapy 
2. Contingency management or motivational incentives 
3. Therapeutic communities
   – These are residences in which people can recover from substance use disorders with other individuals who understand their addiction, all while being drug-free 
4. Community based recovery groups 

Heroin

Heroin is a type of drug made from morphine, which is derived from the seed pod of opium poppy plants (16). According to the CDC, over 19% of all opioid overdose deaths in 2020 involved the use of heroin (17). Heroin can be found as a white or brown powder, or a black tar like substance. Like cocaine and methamphetamine, heroin can be injected into the bloodstream, snorted, or heated and smoked. Additionally, some individuals mix heroin with cocaine, or alcohol. This created an even higher risk for an overdose, and potentially death (16).  

The effects of heroin on the body are like those of prescribed opioids. When heroin reaches the brain, it is turned into morphine, which binds to opioid receptors. This causes the user to feel what is described as a rush, or a pleasurable sensation. How intense the rush is, is determined by how much drug has been taken and how quickly it attaches itself to the opioid receptor (16).   

Along with the rush, there are several short-term effects that people may experience when using heroin (16): 

1. Dry mouth 
2. Warm, flushing of the skin 
3. Heaving feeling in their arms and legs 
4. Nausea 
5. Vomiting 
6. Severe itching 
7. Clouded mental functioning 
8. Being in a back-and-forth state of consciousness and semi-consciousness
   

Individuals with heroin use disorder may experience some of the following long term health effects (16): 

1. Insomnia 
2. Collapsed or damaged veins from injecting the drug 
3. Damaged tissues on the inside of the nose due to snorting the drug 
4. Infection in the lining of the heart and the valves 
5. Abscesses 
6. Constipation and stomach cramping 
7. Liver and kidney disease 
8. Lung complications, like pneumonia 
9. Mental disorders like depression and antisocial personality disorder 
10. Sexual dysfunction in men 
11. Irregular menstrual cycle in women 
12. Increased risk for blood borne diseases such as HIV and hepatitis C 

Heroin overdoses, along with opioid overdoses, have been increasing in the United States. A heroin overdose depresses one’s heart rate as well as breathing, leading to hypoxia. However, Naloxone is a medication that can reverse opioid overdoses, if given the correct way. Naloxone can be injected or snorted and has recently been approved for over the counter dispense in several states (18).  

Those who suffer from heroin use disorder have a wider variety of treatments at their disposal. Behavioral therapies include cognitive-behavioral therapy as well asl contingency management. It has been shown that these behavioral therapies work best when used in-conjunction with medications.  

There are three different types of medications available to those with heroin use disorder (16):

Methadone

This is an opioid receptor full agonist, which means it attaches itself to and actives an opioid receptor to help ease withdrawal symptoms of heroin cravings  

Buprenorphine

This is an opioid receptor partial agonist, which means it attaches itself to and partially activates opioid receptors to help ease withdrawal symptoms and heroin cravings 

Naltrexone

This is an opioid receptor antagonist, which means it prevents heroin from binding to opioid receptors, blocking the effects 

Hallucinogens

Hallucinogenic drugs are described as a group of drugs that alter a person’s awareness of their surroundings, thoughts, and feelings (19). In 2019 it was estimated that 5.5 million people in the United States used hallucinogens within that past year (20). Hallucinogenic drugs are split into two categories: classic hallucinogens and dissociative drugs. Like the name suggests, both types of hallucinogens can cause the user to experience hallucinations, but dissociative drugs can also cause the user to feel out of control or disconnected from their body (19).  

Common classic hallucinogens include (19):

D-lysergic acid diethylamide (LSD)

Considered one of the most powerful mind-altering chemicals. This drug is a clear or white odorless material, made from lysergic acid. Lysergic acid is found on fungus that will grow on rye and other grains.

4-phosphoryloxy-N, N-dimethyltryptamine (Psilocybin)

This hallucinogenic is also referred to “magic mushrooms” or “shrooms” since it is found on certain types of mushrooms in South America, Mexico, and the United States.

Mescaline (Peyote)

Peyote comes from a small, spineless cactus, but may also be synthetic. While it is illegal in the United States, it can be used in religious ceremonies in the Native American Church.

N, N-dimethyltryptamine (DMT)

A chemical found in some Amazonian plants. It can be made into a tea called Ayahuasca or smoked if synthetically made.

251-NBOMe

This is a synthetic hallucinogen that is like LSD and MDMA but is more potent. It was originally developed for use in brain research. It has also been referred to as “N Bomb” or “251”.

Common dissociative drugs include (19):

Phencyclidine (PCP)

This drug was initially developed for surgery in the 1950’s, but due to its serious side effects it is no longer used. It can be found in several forms, such as: tablets, liquid, and white crystal powder.

Ketamine

This drug is used as an anesthetic for both humans and animals and is typically stolen or sold illegally from veterinary offices. Ketamine comes in powder, pills, or liquid form.

DXM (Dextromethorphan)

This drug is used as a cough suppressant and muscus-clearing ingredient in over-the-counter cold and cough medicines. It can be found in syrup, tablet or gel capsule form.

Saliva divinorum (Salvia)

This is a plant that is common to southern Mexico and Central and South America. It’s leaves or typically chewed, or the juice that is extracted from them is drank. Saliva can also be inhaled.

The short- and long-term side effects of hallucinogens are different depending on the type and category of hallucinogenic used. Short-term side effects for classic hallucinogens are (19):

1. Hallucinations 
2. Increased heart rate 
3. Nausea 
4. Intensified feelings and sensory experiences 
5. Changes in sense of time 
6. Increased blood pressure, breathing and body temperature 
7. Loss of appetite 
8. Dry mouth 
9. Sleep problems 
10. Uncoordinated movements 
11. Excessive sweating 
12. Panic  
13. Paranoia 
14. Psychosis
    

There are two specific long-term side effects of classic hallucinogens. These side effects are typically seen in individuals with a history of mental illness but can happen to anyone (19).

Persistent Psychosis

• This refers to a series of continuing mental problems that include:
• Visual disturbances
• Disorganized thinking
• Paranoia
• Mood changes

Hallucinogen Persisting Perception Disorder (HPPD)

This is a recurrence of certain drug experiencs like hallucinations or visual disturbances. These typically happen without warning and can occur any time after drug use.

Antidepressants and antipsychotic medicals have been used to improve an individual’s mood, as well as treat psychosis. Behavioral therapies have been used to help individuals cope with fear or confusion associated with visual disturbances.

Short-term side effects for dissociative drugs have been known to appear within a few minutes of taking the drug and can last hours or days. If the dosage is low, dissociative drugs can cause the following effects (19):

1. Numbness
2. Disorientation and loss of coordination
3. Hallucinations
4. Increase in the user’s blood pressure, heart rate and body temperature

If higher doses of dissociative drugs are taken the following side effects may occur (19):

1. Memory loss
2. Panic and anxiety attacks
3. Seizures
4. Psychotic symptoms
5. Amnesia
6. Inability to move
7. Mood swings
8. Trouble breathing

The long-term side effects of dissociative drugs are still being researched. However, repeated and prolonged use of PCP has been known to result in addiction. The following long-term effects may continue for a year or more after the drug use stops (19): 

1. Speech problems
2. Memory Loss
3. Weight Loss
4. Anxiety
5. Depression and suicidal thoughts

Most classic hallucinogen use will not result in an overdose but tend to have extremely unpleasant experiences when taken in higher doses. There have been some serious medical emergencies and fatalities that have been reported by 251-NBOMe. Overdose becomes more likely with dissociative drugs. High doses of PCP have been known to cause seizures, coma, and death (19).  

Due to the nature of hallucinogens, there is a high risk of bodily harm due to the alteration of the user’s perception and mood (19):

1. Users could attempt things they wouldn’t normally do when not under the influence, such as jumping out of a window or off a building. 
2. Users could experience a profound sadness or feeling of hopelessness leading to suicidal feelings and/or suicidal actions. 
3. Psilocybin users could accidently consume a poisonous mushroom that look like psilocybin, which can result in severe illness or death. 

Substance Abuse in Adolescents

Substance abuse and opioid overdose deaths are beginning to affect school systems. In 2017, 2.2 million adolescents between the ages of 12-17 stated they were currently using illicit substances (21).

Brain growth and development, particularly during one’s adolescent years, has been highly studied and reviewed. One area of the brain that is still developing during adolescents is the prefrontal cortex. This area of the brain is responsible for allowing one to assess situations, make decisions, and keep emotions and desires under control (21). Because this area of the brain is still developing, it places adolescents at an increased risk of trying drugs and continuing them (21).

Substance use during one’s adolescent years has the potential to create several long-term negative effects. It is estimated that 90% of individuals with addictions began using substances during their adolescent years (22). There are several factors that can lead to substance use. These risk factors include family history of addiction, mental health concerns, behavioral or impulse control problems, exposure to trauma, and environmental factors (22).

Multiple studies have shown that the science of prevention may affect the probability of later problems (23). The main goal in adolescent substance abuse prevention is to reduce risk factors and overall enhance/reinforce protective factors (23). Depending on the addiction, medication may be used in combination with a form of behavioral therapy or counseling.

There are several types of behavioral therapies:

Cognitive-Behavioral Therapy

Helps individuals recognize, avoid and cope with situations in which they may use drugs.

Contingency Management

Uses positive reinforcement for attending counseling sessions, remaining drug-free, or taking prescribed medications.

Motivational Enhancement Therapy

Focuses on strategies that make the most of an individual’s readiness to change their current behavior and enter treatment.

Family Therapy

Focuses on utilizing the family to address influences on drug patterns and improve overall family function.

Twelve-Step Facilitation

Delivered in 12-week sessions. There are no medical treatments, but allow the individual to social and complementary support.

Follows 12 steps of acceptance, surrender, and active involvement in recovery

Conclusion

Substance abuse in the United States is on the rise, with many hospitals and health care centers seeing an increase in patients. Understanding the different types of substances used, their short- and long-term symptoms, overdose symptoms, and medication options will help prepare you to care for these individuals. It is equally important to understand the behavioral therapy options for those with substance use disorders, and advocate for them while they are in your care.

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