Cocaine is a powerfully addictive stimulant drug. The powdered hydrochloride salt form of cocaine can be snorted or dissolved in water and injected. Crack is cocaine base that has not been neutralized by an acid to make the hydrochloride salt. This form of cocaine comes in a rock crystal that is heated to produce vapors, which are smoked. The term “crack” refers to the crackling sound produced by the rock as it is heated.

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How is Cocaine Abused?

Three routes of administration are commonly used for cocaine: snorting, injecting, and smoking. Snorting is the process of inhaling cocaine powder through the nose, where it is absorbed into the bloodstream through the nasal tissues. Injecting is the use of a needle to release the drug directly into the bloodstream. Smoking involves inhaling cocaine vapor or smoke into the lungs, where absorption into the bloodstream is as rapid as by injection. All three methods of cocaine abuse can lead to addiction and other severe health problems, including increasing the risk of contracting HIV and infectious diseases.

The intensity and duration of cocaine’s effects, which include increased energy, reduced fatigue, and mental alertness, depend on the route of drug administration. The faster cocaine is absorbed into the bloodstream and delivered to the brain, the more intense the high. Injecting or smoking cocaine produces a quicker, stronger high than snorting. On the other hand, faster absorption usually means shorter duration of action. The high from snorting cocaine may last 15 to 30 minutes, but the high from smoking may last only 5 to 10 minutes. In order to sustain the high, a cocaine abuser has to administer the drug again. For this reason, cocaine is sometimes abused in binges—taken repeatedly within a relatively short period of time, at increasingly high doses.

Cocaine

Brief Description:
A powerfully addictive drug that is snorted, sniffed, injected, or smoked. Crack is cocaine that has been processed from cocaine hydrochloride to a free base for smoking.
Street Names:
Coke, snow, flake, blow, and many others.
Effects: A powerfully addictive drug, cocaine usually makes the user feel euphoric and energetic. Common health effects include heart attacks, respiratory failure, strokes, and seizures. Large amounts can cause bizarre and violent behavior. In rare cases, sudden death can occur on the first use of cocaine or unexpectedly thereafter.

How Does Cocaine Affect the Brain?
Cocaine is a strong central nervous system stimulant that increases levels of dopamine, a brain chemical associated with pleasure and movement, in the brain’s reward circuit. Certain brain cells, or neurons, use dopamine to communicate. Normally, dopamine is released by a neuron in response to a pleasurable signal (e.g., the smell of good food), and then recycled back into the cell that released it, shutting off the signal between neurons. Cocaine acts by preventing the dopamine from being recycled, causing excessive amounts of dopamine to build up, amplifying the message, and ultimately disrupting normal communication. It is this excess of dopamine that is responsible for cocaine’s euphoric effects. With repeated use, cocaine can cause long-term changes in the brain’s reward system and in other brain systems as well, which may eventually lead to addiction. With repeated use, tolerance to the cocaine high also often develops. Many cocaine abusers report that they seek but fail to achieve as much pleasure as they did from their first exposure. Some users will increase their dose in an attempt to intensify and prolong the euphoria, but this can also increase the risk of adverse psychological or physiological effects.

What Adverse Effects Does Cocaine Have on Health?
Abusing cocaine has a variety of adverse effects on the body. For example, cocaine constricts blood vessels, dilates pupils, and increases body temperature, heart rate, and blood pressure. It can also cause headaches and gastrointestinal complications such as abdominal pain and nausea. Because cocaine tends to decrease appetite, chronic users can become malnourished as well.

Different methods of taking cocaine can produce different adverse effects. Regularly snorting cocaine, for example, can lead to loss of the sense of smell, nosebleeds, problems with swallowing, hoarseness, and a chronically runny nose. Ingesting cocaine can cause severe bowel gangrene as a result of reduced blood flow. Injecting cocaine can bring about severe allergic reactions and increased risk for contracting HIV and other blood-borne diseases. Binge patterns of use may lead to irritability, restlessness, anxiety, and paranoia. Cocaine abusers can suffer a temporary state of full-blown paranoid psychosis, in which they lose touch with reality and experience auditory hallucinations.

Regardless of how or how frequently cocaine is used, a user can experience acute cardiovascular or cerebrovascular emergencies, such as a heart attack or stroke, which may cause sudden death. Cocaine-related deaths are often a result of cardiac arrest or seizure followed by respiratory arrest.

Added Danger: Cocaethylene
When people consume cocaine and alcohol together, they compound the danger each drug poses and unknowingly perform a complex chemical experiment within their bodies. Researchers have found that the human liver combines cocaine and alcohol to produce a third substance, cocaethylene, which intensifies cocaine’s euphoric effects. Cocaethylene is associated with a greater risk of sudden death than cocaine alone.1

What Treatment Options Exist?
Behavioral interventions—particularly, cognitive-behavioral therapy—have been shown to be effective for decreasing cocaine use and preventing relapse. Treatment must be tailored to the individual patient’s needs in order to optimize outcomes—this often involves a combination of treatment, social supports, and other services.

Currently, there are no medications for treating cocaine addiction, so this remains one of NIDA’s top research priorities. Researchers are looking for medications that help alleviate the severe craving experienced by people in treatment for cocaine addiction, as well as medications to counteract other triggers of relapse, such as stress. Several compounds are currently being investigated for their safety and efficacy, including a vaccine that would sequester cocaine in the bloodstream and prevent it from reaching the brain. Research so far suggests that addiction medications are most effective when used as a part of a comprehensive treatment program.

How Widespread is Cocaine Abuse?

www.whitehousedrugpolicy.gov/streetterms/default.asp

1 Harris DS, et al. The pharmacology of cocaethylene in humans following cocaine and ethanol administration. Drug Alcohol Depend 72(2):169–182, 2003.

* These data are from the 2006 Monitoring the Future survey, funded by the National Institute on Drug Abuse, National Institutes of Health, Department of Health and Human Services, and conducted annually by the University of Michigan’s Institute for Social Research. The survey has tracked 12th-graders’ illicit drug use and related attitudes since 1975; in 1991, 8th- and 10th-graders were added to the study. The latest data are online at www.drugabuse.gov.

** “Lifetime” refers to use at least once during a respondent’s lifetime. “Past year” refers to use at least once during the year preceding an individual’s response to the survey. “Past month” refers to use at least once during the 30 days preceding an individual’s response to the survey.

*** NSDUH (formerly known as the National Household Survey on Drug Abuse) is an annual survey of Americans aged 12 and older conducted by the Substance Abuse and Mental Health Services Administration. This survey is available online at www.samhsa.gov and from NIDA at 877-643-2644.

The Truth About Cocaine

Slang-Coke, Dust, Toot, Snow, Blow, Sneeze, Powder, Lines, Rock (Crack)

Cocaine affects your brain. The word “cocaine” refers to the drug in both a powder (cocaine) and crystal (crack) form. It is made from the coca plant and causes a short-lived high that is immediately followed by opposite, intense feelings of depression, edginess, and a craving for more of the drug. Cocaine may be snorted as a powder, converted to a liquid form for injection with a needle, or processed into a crystal form to be smoked.

Cocaine affects your body. People who use cocaine often don’t eat or sleep regularly. They can experience increased heart rate, muscle spasms, and convulsions. If they snort cocaine, they can also permanently damage their nasal tissue.

Cocaine affects your emotions. Using cocaine can make you feel paranoid, angry, hostile, and anxious, even when you’re not high.

Cocaine is addictive. Cocaine interferes with the way your brain processes chemicals that create feelings of pleasure, so you need more and more of the drug just to feel normal. People who become addicted to cocaine start to lose interest in other areas of their life, like school, friends, and sports.

Cocaine can kill you. Cocaine use can cause heart attacks, seizures, strokes, and respiratory failure. People who share needles can also contract hepatitis, HIV/AIDS, or other diseases.

BEFORE YOU RISK IT
Know the law. Cocaine-in any form-is illegal.

Stay informed. Even first-time cocaine users can have seizures or fatal heart attacks.

Know the risks. Combining cocaine with other drugs or alcohol is extremely dangerous. The effects of one drug can magnify the effects of another, and mixing substances can be deadly.

Be aware. Cocaine is expensive. Regular users can spend hundreds and even thousands of dollars on cocaine each week and some will do anything to support their addiction.

Stay in control. Cocaine impairs your judgment which may lead to unwise decisions around sexual activity. This can increase your risk for HIV/AIDS and other diseases, as well as rape and unplanned pregnancy.

KNOW THE SIGNS
How can you tell if a friend is using cocaine? Sometimes it’s tough to tell. But there are signs you can look for. If your friend has one or more of the following warning signs, he or she may be using cocaine or other illicit drugs:

Red, bloodshot eyes
A runny nose or frequently sniffing
A change in eating or sleeping patterns
A change in groups of friends
A change in behavior
Acting withdrawn, depressed, tired, or careless about personal appearance
Losing interest in school, family, or activities he or she used to enjoy
Frequently needing money
What can you do to help someone who is using cocaine? Be a real friend. Save a life. Encourage your friend to stop or seek professional help. For information and referrals, call the National Clearinghouse for Alcohol and Drug Information at 800-729-6686.

Q&A

Q. Is cocaine really still a problem?
A. Yes. While the number of cocaine users has decreased from what was witnessed in the mid-1980′s, there have been nearly 2 million cocaine users every year since 1992.

Q. Isn’t crack less addictive than cocaine because it doesn’t stay in your body very long?
A. No. Both cocaine and crack are powerfully addictive. The length of time it stays in your body doesn’t change that.

Q. Don’t some people use cocaine to feel good?
A. Any positive feelings are fleeting and are usually followed by some very bad feelings, like paranoia and intense cravings. Cocaine may give users a temporary illusion of power and energy, but it often leaves them unable to function emotionally, physically, and sexually.

Cocaine is a powerfully addictive stimulant drug. The powdered hydrochloride salt form of cocaine can be snorted or dissolved in water and injected. Crack is cocaine base that has not been neutralized by an acid to make the hydrochloride salt. This form of cocaine comes in a rock crystal that is heated to produce vapors, which are smoked. The term “crack” refers to the crackling sound produced by the rock as it is heated.

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Other Information Sources

For additional information on cocaine, please refer to the following sources on NIDA’s Web site, www.drugabuse.gov:

Research Report: Cocaine Abuse and Addiction
NIDA Notes: Articles on Cocaine
For a list of street terms used to refer to cocaine and other drugs, visit www.whitehousedrugpolicy.gov/streetterms/default.asp.

1 Harris DS, et al. The pharmacology of cocaethylene in humans following cocaine and ethanol administration. Drug Alcohol Depend 72(2):169–182, 2003.

* These data are from the 2006 Monitoring the Future survey, funded by the National Institute on Drug Abuse, National Institutes of Health, Department of Health and Human Services, and conducted annually by the University of Michigan’s Institute for Social Research. The survey has tracked 12th-graders’ illicit drug use and related attitudes since 1975; in 1991, 8th- and 10th-graders were added to the study. The latest data are online at www.drugabuse.gov.

** “Lifetime” refers to use at least once during a respondent’s lifetime. “Past year” refers to use at least once during the year preceding an individual’s response to the survey. “Past month” refers to use at least once during the 30 days preceding an individual’s response to the survey.

*** NSDUH (formerly known as the National Household Survey on Drug Abuse) is an annual survey of Americans aged 12 and older conducted by the Substance Abuse and Mental Health Services Administration. This survey is available online at www.samhsa.gov and from NIDA at 877-643-2644.

Other References:

1. Samhsa.gov – Cocaine

2. National Institute on Drug Abuse

3. 1998 National Household Survey on Drug Abuse. Substance Abuse and Mental Health Services Administration (SAMHSA), 1998

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Do/have you or a loved one:
fail to keep promises to control or cut down on drinking alcohol?
always need an alcoholic drink after work to unwind?
miss work do excessive drinking?
say that the excessive drinking is due to day to day stress?
said “I’m sorry, it will pass, I swear. I’m not an alcoholic.”
drink to help sleep at night?
say “I just need a pick me up, like alcohol.”
frequently “black out” from excessive drinking?
received a DUI or DWI from alcohol in your system?
been sited for public for public drunkenness or disorderly conduct?
said “It will never happen again.”
These are just a few signs of alcoholism and alcohol abuse. It’s never too late to seek help, so take the first step, for you and your loved ones, and call our 24 hour help line.

Get the Facts On Alcoholism
For many people, the facts about alcoholism are not clear. What is alcoholism, exactly? How does it differ from alcohol abuse? When should a person seek help for a problem related to his or her drinking? The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has prepared this booklet to help individuals and families answer these and other common questions about alcohol problems. The following information explains both alcoholism and alcohol abuse, the symptoms of each, when and where to seek help, treatment choices, and additional helpful resources.

A Widespread Problem
For most people who drink, alcohol is a pleasant accompaniment to social activities. Moderate alcohol use up to two drinks per day for men and one drink per day for women and older people is not harmful for most adults. (A standard drink is one 12-ounce bottle or can of either beer or wine cooler, one 5-ounce glass of wine, or 1.5 ounces of 80-proof distilled spirits.) Nonetheless, a large number of people get into serious trouble because of their drinking. Currently, nearly 14 million Americans 1 in every 13 adults abuse alcohol or are alcoholic. Several million more adults engage in risky drinking that could lead to alcohol problems. These patterns include binge drinking and heavy drinking on a regular basis. In addition, 53 percent of men and women in the United States report that one or more of their close relatives have a drinking problem.

The consequences of alcohol misuse are serious in many cases, life threatening. Heavy drinking can increase the risk for certain cancers, especially those of the liver, esophagus, throat, and larynx (voice box). Heavy drinking can also cause liver cirrhosis, immune system problems, brain damage, and harm to the fetus during pregnancy. In addition, drinking increases the risk of death from automobile crashes as well as recreational and on-the-job injuries. Furthermore, both homicides and suicides are more likely to be committed by persons who have been drinking. In purely economic terms, alcohol-related problems cost society approximately $185 billion per year. In human terms, the costs cannot be calculated.

What Is Alcoholism?
Alcoholism, also known as “alcohol dependence”, is a disease that includes four symptoms:
Craving: A strong need, or compulsion, to drink.
Loss of control: The inability to limit one’s drinking on any given occasion.
Physical dependence: Withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety, occur when alcohol use is stopped after a period of heavy drinking.

Tolerance: The need to drink greater amounts of alcohol in order to “get high.”

People who are not alcoholic sometimes do not understand why an alcoholic can’t just use a little willpower to stop drinking. However, alcoholism has little to do with willpower. Alcoholics are in the grip of a powerful craving, or uncontrollable need, for alcohol that overrides their ability to stop drinking. This need can be as strong as the need for food or water.

Although some people are able to recover from alcoholism without help, the majority of alcoholics need assistance. With treatment and support, many individuals are able to stop drinking and rebuild their lives.

Many people wonder why some individuals can use alcohol without problems but others cannot. One important reason has to do with genetics. Scientists have found that having an alcoholic family member makes it more likely that if you choose to drink you too may develop alcoholism. Genes, however, are not the whole story. In fact, scientists now believe that certain factors in a person’s environment influence whether a person with a genetic risk for alcoholism ever develops the disease. A person’s risk for developing alcoholism can increase based on the person’s environment, including where and how he or she lives; family, friends, and culture; peer pressure; and even how easy it is to get alcohol.

What Is Alcohol Abuse?
Alcohol abuse differs from alcoholism in that it does not include an extremely strong craving for alcohol, loss of control over drinking, or physical dependence. Alcohol abuse is defined as a pattern of drinking that results in one or more of the following situations within a 12-month period:

Failure to fulfill major work, school, or home responsibilities;
Drinking in situations that are physically dangerous, such as while driving a car or operating machinery;
Having recurring alcohol-related legal problems, such as being arrested for driving under the influence of alcohol or for physically hurting someone while drunk; and continued drinking despite having ongoing relationship problems that are caused or worsened by the drinking.
Although alcohol abuse is basically different from alcoholism, many effects of alcohol abuse are also experienced by alcoholics.

What Are the Signs of a Problem?
How can you tell whether you may have a drinking problem? Answering the following four questions can help you find out:
Have you ever felt you should cut down on your drinking?
Have people annoyed you by criticizing your drinking?
Have you ever felt bad or guilty about your drinking?
Have you ever had a drink first thing in the morning (as an “eye opener”) to steady your nerves or get rid of a hangover?
One “yes” answer suggests a possible alcohol problem. If you answered “yes” to more than one question, it is highly likely that a problem exists. In either case, it is important that you see your doctor or other health care provider right away to discuss your answers to these questions. He or she can help you determine whether you have a drinking problem and, if so, recommend the best course of action.
Even if you answered “no” to all of the above questions, if you encounter drinking-related problems with your job, relationships, health, or the law, you should seek professional help. The effects of alcohol abuse can be extremely serious, even fatal, both to you and to others.

The Decision To Get Help
Accepting the fact that help is needed for an alcohol problem may not be easy. But keep in mind that the sooner you get help, the better are your chances for a successful recovery.

Any concerns you may have about discussing drinking-related problems with your health care provider may stem from common misconceptions about alcoholism and alcoholic people. In our society, the myth prevails that an alcohol problem is a sign of moral weakness. As a result, you may feel that to seek help is to admit some type of shameful defect in yourself. In fact, alcoholism is a disease that is no more a sign of weakness than is asthma. Moreover, taking steps to identify a possible drinking problem has an enormous payoff and chance for a healthier, more rewarding life.

When you visit your health care provider, he or she will ask you a number of questions about your alcohol use to determine whether you are having problems related to your drinking. Try to answer these questions as fully and honestly as you can. You also will be given a physical examination. If your health care provider concludes that you may be dependent on alcohol, he or she may recommend that you see a specialist in treating alcoholism. You should be involved in any referral decisions and have all treatment choices explained to you.

Getting Well
Alcoholism Treatment

The type of treatment you receive depends on the severity of your alcoholism and the resources that are available in your community. Treatment may include detoxification (the process of safely getting alcohol out of your system); taking doctor-prescribed medications, such as disulfiram (Antabuse) or naltrexone (ReVia), to help prevent a return (or relapse) to drinking once drinking has stopped; and individual and/or group counseling. There are promising types of counseling that teach alcoholics to identify situations and feelings that trigger the urge to drink and to find new ways to cope that do not include alcohol use. These treatments are often provided on an outpatient basis.
Because the support of family members is important to the recovery process, many programs also offer brief marital counseling and family therapy as part of the treatment process. Programs may also link individuals with vital community resources, such as legal assistance, job training, childcare, and parenting classes.

Alcoholics Anonymous
Virtually all alcoholism treatment programs also include Alcoholics Anonymous (AA) meetings. AA describes itself as a worldwide fellowship of men and women who help each other to stay sober. Although AA is generally recognized as an effective mutual help program for recovering alcoholics, not everyone responds to AA’s style or message, and other recovery approaches are available. Even people who are helped by AA usually find that AA works best in combination with other forms of treatment, including counseling and medical care.

Can Alcoholism Be Cured?
Although alcoholism can be treated, a cure is not yet available. In other words, even if an alcoholic has been sober for a long time and has regained health, he or she remains susceptible to relapse and must continue to avoid all alcoholic beverages. Cutting down on drinking doesn’t work; cutting out alcohol is necessary for a successful recovery.

However, even individuals who are determined to stay sober may suffer one or several slips, or relapses, before achieving long-term sobriety. Relapses are very common and do not mean that a person has failed or cannot recover from alcoholism. Keep in mind, too, that every day that a recovering alcoholic has stayed sober prior to a relapse is extremely valuable time, both to the individual and to his or her family. If a relapse occurs, it is very important to try to stop drinking once again and to get whatever additional support you need to abstain from drinking.

Help for Alcohol Abuse
If your health care provider determines that you are not alcohol dependent but are nonetheless involved in a pattern of alcohol abuse, he or she can help you to: Examine the benefits of stopping an unhealthy drinking pattern.

Set a drinking goal for yourself. Some people choose to abstain from alcohol. Others prefer to limit the amount they drink.
Examine the situations that trigger your unhealthy drinking patterns, and develop new ways of handling those situations so that you can maintain your drinking goal.

Some individuals who have stopped drinking after experiencing alcohol-related problems choose to attend AA meetings for information and support, even though they have not been diagnosed as alcoholic.
Source: NIAAA
24 Hour Free Addiction Helpline.com

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For more information regarding club drugs, Please Call our 24 Hour Helpline Today. 1-866-569-7077

Club drugs* are a pharmacologically heterogeneous group of psychoactive compounds that tend to be abused by teens and young adults at a nightclub, bar, rave, or trance scene. Gamma hydroxybutyrate (GHB), Rohypnol, and ketamine are some of the drugs in this group; so are MDMA (ecstasy) and methamphetamine, which are featured in a separate InfoFacts.

GHB (Xyrem) is a central nervous system (CNS) depressant that was approved by the Food and Drug Administration (FDA) in 2002 for use in the treatment of narcolepsy (a sleep disorder). This approval came with severe restrictions, including its use only for the treatment of narcolepsy, and the requirement for a patient registry monitored by the FDA. GHB is also a metabolite of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA); thus, it is found naturally in the brain, but at concentrations much lower than doses that are abused.
Rohypnol (flunitrazepam) started appearing in the United States in the early 1990s. It is a benzodiazepine (chemically similar to Valium or Xanax), but it is not approved for medical use in this country, and its importation is banned.
Ketamine is a dissociative anesthetic, mostly used in veterinary practice.

Brief Description:

Typically used by teenagers and young adults at bars, clubs, concerts, and parties. The most common club drugs include Ecstasy (MDMA), GHB, Rohypnol, ketamine, methamphetamine, and acid (LSD).

Street Names:

XTC, X (MDMA); Special K, Vitamin K (ketamine); liquid ecstasy, soap (GHB); roofies (Rohypnol).

Effects:

Chronic use of MDMA may lead to changes in brain function. GHB abuse can cause coma and seizures. High doses of ketamine can cause delirium, amnesia, and other problems. Mixed with alcohol, Rohypnol can incapacitate users and cause amnesia.

Statistics and Trends:

The NIDA-funded 2007 Monitoring the Future Study showed that 0.7% of 8th graders, 0.7% of 10th graders, and 1.0% of 12th graders had abused Rohypnol; 0.7% of 8th graders, 0.6% of 10th graders, and 0.9% of 12th graders had abused GHB; and 1.0% of 8th graders, 0.8% of 10th graders, and 1.3% of 12th graders had abused ketamine at least once in the year prior to their being surveyed. Source: Monitoring the Future http://www.monitoringthefuture.org/

How are Club Drugs Abused?
Raves and trance events are generally night-long dances, often held in warehouses. Many who attend raves and trances do not use club drugs, but those who do may be attracted to their generally low cost and the intoxicating highs that are said to deepen the rave or trance experience.

Rohypnol is usually taken orally, although there are reports that it can be ground up and snorted.

GHB and Rohypnol have both been used to facilitate date rape (also known as “drug rape,” “acquaintance rape,” or “drug-assisted” assault). They can be colorless, tasteless, and odorless, and can be added to beverages and ingested unbeknownst to the victim. When mixed with alcohol, Rohypnol can incapacitate victims and prevent them from resisting sexual assault.

GHB also has anabolic effects (it stimulates protein synthesis) and has been sought by bodybuilders to aid in fat reduction and muscle building.

Ketamine is usually snorted or injected intramuscularly.

How do Club Drugs Affect the Brain?

GHB acts on at least two sites in the brain: the GABAB receptor and a specific GHB binding site. At high doses, GHB’s sedative effects may result in sleep, coma, or death. Rohypnol, like other benzodiazepines, acts at the GABAA receptor. It can produce anterograde amnesia, in which individuals may not remember events they experienced while under the influence of the drug.

Ketamine is a dissociative anesthetic, so called because it distorts perceptions of sight and sound and produces feelings of detachment from the environment and self. Ketamine acts on a type of glutamate receptor (NMDA receptor) to produce its effects, similar to those of the drug PCP.1 Low-dose intoxication results in impaired attention, learning ability, and memory. At higher doses, ketamine can cause dreamlike states and hallucinations; and at higher doses still, ketamine can cause delirium and amnesia.

Addictive Potential

Repeated use of GHB may lead to withdrawal effects, including insomnia, anxiety, tremors, and sweating. Severe withdrawal reactions have been reported among patients presenting from an overdose of GHB or related compounds, especially if other drugs or alcohol are involved.

Like other benzodiazepines, chronic use of Rohypnol can produce tolerance and dependence.
There have been reports of people binging on ketamine, a behavior that is similar to that seen in some cocaine- or amphetamine-dependent individuals. Ketamine users can develop signs of tolerance and cravings for the drug.

What Other Adverse Effects do Club Drugs Have on Health?

Uncertainties about the sources, chemicals, and possible contaminants used to manufacture many club drugs make it extremely difficult to determine toxicity and associated medical consequences.

Coma and seizures can occur following use of GHB. Combined use with other drugs such as alcohol can result in nausea and breathing difficulties. GHB and two of its precursors, gamma butyrolactone (GBL) and1,4 butanediol (BD), have been involved in poisonings, overdoses, date rapes, and deaths.

Rohypnol may be lethal when mixed with alcohol and/or other CNS depressants.

Ketamine, in high doses, can cause impaired motor function, high blood pressure, and potentially fatal respiratory problems.

What Treatment Options Exist?

There is very little information in scientific literature about treatment for persons who abuse or are dependent upon club drugs.

There are no GHB detection tests for use in emergency rooms, and as many clinicians are unfamiliar with the drug, many GHB incidents likely go undetected. According to case reports, however, patients who abuse GHB appear to present both a mixed picture of severe problems upon admission and good response to treatment, which often involves residential services.
Treatment for Rohypnol follows accepted protocols for any benzodiazepine, which may consist of a 3- to 5-day inpatient detoxification program with 24-hour intensive medical monitoring and management of withdrawal symptoms, since withdrawal from benzodiazepines can be life-threatening.
Patients with a ketamine overdose are managed through supportive care for acute symptoms, with special attention to cardiac and respiratory functions.

How Widespread is Club Drug Abuse?
Monitoring the Future (MTF) Survey**

According to results of the 2007 MTF survey, 0.7 percent of students in the 8th grade reported past-year*** use of GHB, as did 0.6 percent and 0.9 percent of students in grades 10 and 12, respectively. This is consistent with use reported in 2006.

Past-year use of ketamine did not change significantly from 2006 to 2007—use was reported by 1.0 percent of 8th-graders, 0.8 percent of 10th-graders, and 1.3 percent of 12th-graders in 2007.

There was no significant change in the illicit use of Rohypnol from 2006 to 2007, according to 2007 MTF results, which report consistently low levels of Rohypnol use since the drug was added to the survey in 1996. Annual prevalence of use stands now at around 0.5 percent in all three grades surveyed.

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* For more information about club drugs, visit www.clubdrugs.gov, www.teens.drugabuse.gov, and www.backtoschool.drugabuse.gov; or call NIDA at 877-643-2644. For street terms searchable by drug name, street term, cost and quantities, drug trade, and drug use, visit http://www.whitehousedrugpolicy.gov/streetterms/default.asp.

** These data are from the 2007 Monitoring the Future survey, funded by the National Institute on Drug Abuse, National Institutes of Health, Department of Health and Human Services, and conducted annually by the University of Michigan’s Institute for Social Research. The survey has tracked 12th-graders’ illicit drug use and related attitudes since 1975; in 1991, 8th- and 10th-graders were added to the study. The latest data are online at www.drugabuse.gov.

*** “Past year” refers to use at least once during the year preceding an individual’s response to the survey. “Past month” refers to use at least once during the 30 days preceding an individual’s response to the survey. “Lifetime” refers to use at least once during a respondent’s lifetime.

1 Maeng S, Zarate CA Jr. The role of glutamate in mood disorders: Results from the ketamine in major depression study and the presumed cellular mechanism underlying its antidepressant effects. Curr Psychiatry Rep 9(6):467–474, 2007.

2 Maxwell JC, Spence RT. Profiles of club drug users in treatment. Subst Use Misuse 40(9–10):1409–1426, 2005.

3 Jansen KL, Darracot-Cankovic R. The nonmedical use of ketamine, part two: A review of problem use and dependence. J Psychoactive Drugs 33(2):151–158, 2001.

4 Smith KM, Larive LL, Romanelli F. Club Drugs: Methylenedioxymethamphetamine, flunitrazepam, ketamine hydrochloride, and γ–hydroxybutyrate. Am J Health-Syst Pharm 59(11):1067–1076, 2002.

Other References:

1. Samhsa.gov – Cocaine

2. National Institute on Drug Abuse

3. 1998 National Household Survey on Drug Abuse. Substance Abuse and Mental Health Services Administration (SAMHSA), 1998

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How is MDMA Abused?
MDMA is taken orally as a capsule or tablet. It was initially popular among white adolescents and young adults in the nightclub scene or at weekend-long dance parties known as raves. However, the profile of the typical MDMA user has changed, and the drug now affects a broader range of ethnic groups. MDMA is also popular among urban gay males—some report using MDMA as part of a multiple-drug experience that includes marijuana, cocaine, methamphetamine, ketamine, and other legal and illegal substances.

How does MDMA Affect the Brain?
MDMA exerts its primary effects in the brain on neurons that use the chemical serotonin to communicate with other neurons. MDMA binds to the serotonin transporter, which is responsible for removing serotonin from the synapse (or space between adjacent neurons) when the signal between neurons needs to be terminated. MDMA also causes excessive release of serotonin and has similar but less potent effects on neurons that contain dopamine and norepinephrine. The serotonin system plays an important role in regulating mood, aggression, sexual activity, sleep, and sensitivity to pain.

MDMA can produce confusion, depression, sleep problems, drug craving, and severe anxiety. These problems can occur soon after taking the drug or, sometimes, even days or weeks after taking MDMA. In addition, chronic users of MDMA perform more poorly than nonusers on certain types of cognitive or memory tasks, although some of these effects may be due to the use of other drugs in combination with MDMA. Research in animals indicates that MDMA can be harmful to the brain—one study in nonhuman primates showed that exposure to MDMA for only 4 days caused damage to serotonin nerve terminals that was still evident 6 to 7 years later.1 Although similar neurotoxicity has not been shown definitively in humans, the wealth of animal research indicating MDMA’s damaging properties strongly suggests that MDMA is not a safe drug for human consumption. This is currently an area of active research.

Brief Description:

A drug that has stimulant and psychodelic properties. It is taken orally as a capsule or tablet.

Street Names:

XTC, X, Adam, hug, beans, love drug.

Effects:

Short-term effects include feelings of mental stimulation, emotional warmth, enhanced sensory perception, and increased physical energy. Adverse health effects can include nausea, chills, sweating, teeth clenching, muscle cramping, and blurred vision.

Addictive Potential

For some people, MDMA can be addictive.2 A survey of young adult and adolescent MDMA users found that 43 percent of those who reported ecstasy use met the accepted diagnostic criteria for dependence, as evidenced by continued use despite knowledge of physical or psychological harm, withdrawal effects, and tolerance (or diminished response).3 These results are consistent with those of similar studies in other countries that also suggest a high rate of MDMA dependence among users.4 MDMA abstinence-associated withdrawal symptoms include fatigue, loss of appetite, depressed feelings, and trouble concentrating.2

What Other Adverse Effects does MDMA Have on Health?

MDMA can also be dangerous to overall health and, on rare occasions, lethal. MDMA can have many of the same physical effects as other stimulants such as cocaine and amphetamines. These include increases in heart rate and blood pressure, which present risks of particular concern for people with circulatory problems or heart disease; and other symptoms such as muscle tension, involuntary teeth clenching, nausea, blurred vision, faintness, and chills or sweating.

In high doses, MDMA can interfere with the body’s ability to regulate temperature. On rare but unpredictable occasions, this can lead to a sharp increase in body temperature (hyperthermia), which can result in liver, kidney, and cardiovascular system failure, and death. MDMA can interfere with its own metabolism (breakdown within the body); therefore, potentially harmful levels can be reached by repeated MDMA administration within short periods of time.

Other drugs that are chemically similar to MDMA, such as MDA (methylenedioxyamphetamine, the parent drug of MDMA) and PMA (paramethoxyamphetamine, associated with fatalities in the United States and Australia),5 are sometimes also sold as ecstasy. These drugs can be neurotoxic or create additional health risks to the user. Furthermore, ecstasy tablets may be adulterated with other substances, such as ephedrine (a stimulant); dextromethorphan (DXM, a cough suppressant); ketamine (an anesthetic used mostly by veterinarians); caffeine; cocaine; and methamphetamine. Although the combination of MDMA with one or more of these drugs may be inherently dangerous, users might also combine these with other substances such as marijuana and alcohol, putting themselves at even higher risk.

What Treatment Options Exist?
There are no specific treatments for MDMA abuse and addiction. The most effective treatments for drug abuse and addiction in general are cognitive-behavioral interventions that are designed to help modify the patient’s thinking, expectancies, and behaviors, and to increase skills in coping with life’s stressors. Drug abuse recovery support groups may be effective in combination with behavioral interventions to support long-term, drug-free recovery. There are currently no pharmacological treatments for addiction to MDMA.

1-866-569-7077

* For more information, please visit www.clubdrugs.org and www.teens.drugabuse.gov. For street terms searchable by drug name, street term, cost and quantities, drug trade, and drug use, visit www.whitehousedrugpolicy.gov/streetterms/default.asp.

** These data are from the 2006 Monitoring the Future survey, funded by the National Institute on Drug Abuse, National Institutes of Health, Department of Health and Human Services, and conducted annually by the University of Michigan’s Institute for Social Research. The survey has tracked 12th-graders’ illicit drug use and related attitudes since 1975; in 1991, 8th- and 10th-graders were added to the study. The latest data are online at www.drugabuse.gov.

*** “Lifetime” refers to use at least once during a respondent’s lifetime. “Past year” refers to use at least once during the year preceding an individual’s response to the survey. “Past month” refers to use at least once during the 30 days preceding an individual’s response to the survey.

**** NSDUH (formerly known as the National Household Survey on Drug Abuse) is an annual survey of Americans age 12 and older conducted by the Substance Abuse and Mental Health Services Administration. Copies of the latest survey are available at www.samhsa.gov and from NIDA at 877-643-2644.

1 Ricaurte GA, McCann UD. Experimental studies on 3,4-methylenedioxymethamphetamine (MDMA, “ecstasy”) and its potential to damage brain serotonin neurons. Neurotox Res 3(1):85–99, 2001.

2 Stone AL, Storr CL, Anthony JC. Evidence for a hallucinogen dependence syndrome developing soon after onset of hallucinogen use during adolescence. Int J Methods Psychiatr Res 15:116–130, 2006.

3 Cottler LB, Womack SB, Compton WM, Ben-Abdallah A. Ecstasy abuse and dependence among adolescents and young adults: Applicability and reliability of DSM-IV criteria. Human Psychopharmacol 16:599–606, 2001.

4 Leung KS, Cottler LB. Ecstasy and other club drugs: A review of recent epidemiological studies. Curr Opin Psychiatry 21:234–241, 2008.

5 Kraner JC, McCoy DJ, Evans MA, Evans LE, Sweeney BJ. Fatalities caused by the MDMA-related drug paramethoxyamphetamine (PMA). J Anal Toxicol 25(7):645–648, 2001.

Other References:

1. Samhsa.gov – Cocaine

2. National Institute on Drug Abuse

3. 1998 National Household Survey on Drug Abuse. Substance Abuse and Mental Health Services Administration (SAMHSA), 1998

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How is Heroin Abused?
Heroin can be injected, snorted/sniffed, or smoked—routes of administration that rapidly deliver the drug to the brain. Injecting is the use of a needle to release the drug directly into the bloodstream. Snorting is the process of inhaling heroin powder through the nose, where it is absorbed into the bloodstream through the nasal tissues. Smoking involves inhaling heroin smoke into the lungs. All three methods of administering heroin can lead to addiction and other severe health problems.

How Does Heroin Affect the Brain?

Heroin enters the brain, where it is converted to morphine and binds to receptors known as opioid receptors. These receptors are located in many areas of the brain (and in the body), especially those involved in the perception of pain and in reward. Opioid receptors are also located in the brain stem—important for automatic processes critical for life, such as breathing, blood pressure, and arousal. Heroin overdoses frequently involve a suppression of respiration.

After an intravenous injection of heroin, users report feeling a surge of euphoria (“rush”) accompanied by dry mouth, a warm flushing of the skin, and a heaviness of the extremities. Following this initial euphoria, the user goes “on the nod,” an alternately wakeful and drowsy state. Mental functioning becomes clouded. Users who do not inject the drug may not experience the initial rush, but other effects are the same.

With regular heroin use, tolerance develops. This means the abuser must use more heroin to achieve the same intensity of effect. Eventually, chemical changes in the brain can lead to addiction.

Heroin

Brief Description:

An addictive drug that is processed from morphine and usually appears as a white or brown powder.

Street Names:

Smack, H, ska, junk, and many others.

Effects:

Short-term effects include a surge of euphoria followed by alternately wakeful and drowsy states and cloudy mental functioning. Associated with fatal overdose and- particularly in users who inject the drug-infectious diseases such as HIV/AIDS and hepatitis.

What Other Adverse Effects Does Heroin Have on Health?

Heroin abuse is associated with serious health conditions, including fatal overdose, spontaneous abortion, and—particularly in users who inject the drug—infectious diseases, including HIV/AIDS and hepatitis. Chronic users may develop collapsed veins, infection of the heart lining and valves, abscesses, and liver or kidney disease. Pulmonary complications, including various types of pneumonia, may result from the poor health of the abuser, as well as from heroin’s depressing effects on respiration. In addition to the effects of the drug itself, street heroin often contains toxic contaminants or additives that can clog the blood vessels leading to the lungs, liver, kidneys, or brain, causing permanent damage to vital organs.

Chronic use of heroin leads to physical dependence, a state in which the body has adapted to the presence of the drug. If a dependent user reduces or stops use of the drug abruptly, they may experience severe symptoms of withdrawal. These symptoms, which can begin as early as a few hours after the last drug administration, include restlessness, muscle and bone pain, insomnia, diarrhea and vomiting, cold flashes with goose bumps (“cold turkey”), kicking movements (“kicking the habit”), and other symptoms. Users also experience severe craving for the drug during withdrawal, precipitating continued abuse and/or relapse. Major withdrawal symptoms peak between 48 and 72 hours after the last dose and typically subside after about a week; however, some individuals may show persistent withdrawal symptoms for months. Although heroin withdrawal is considered less dangerous than alcohol or barbiturate withdrawal, sudden withdrawal by heavily dependent users who are in poor health is occasionally fatal.

Heroin abuse during pregnancy, together with related factors like poor nutrition and inadequate prenatal care, has been associated with adverse consequences including low birthweight, an important risk factor for later developmental delay. If the mother is regularly abusing the drug, the infant may be born physically dependent on heroin and could suffer from serious medical complications requiring hospitalization.

What Treatment Options Exist?
A range of treatments exist for heroin addiction, including medications and behavioral therapies. Science has taught us that when medication treatment is integrated with other supportive services, patients are often able to stop using heroin (or other opiates) and return to stable and productive lives.

Treatment often begins with medically assisted detoxification, to help patients withdraw from the drug safely. Medications such as clonidine and, now, buprenorphine can be used to help minimize symptoms of withdrawal. However, detoxification alone is not treatment and has not been shown to be effective in preventing relapse—it is merely the first step.

Medications to help prevent relapse include:

Methadone, which has been used for more than 30 years to treat heroin addiction. It is a synthetic opiate medication that binds to the same receptors as heroin; but when taken orally, as dispensed, it has a gradual onset of action and sustained effects, reducing the desire for other opioid drugs while preventing withdrawal symptoms. Properly prescribed methadone is not intoxicating or sedating, and its effects do not interfere with ordinary daily activities. At the present time, methadone is only available through specialized opiate treatment programs.
Buprenorphine is a more recently approved treatment for heroin addiction (and other opiates). It differs from methadone in having less risk for overdose and withdrawal effects, and importantly, it can be prescribed in the privacy of a doctor’s office.
Naltrexone is approved for treating heroin addiction but has not been widely utilized because of compliance issues. It is an opioid receptor blocker, which has been shown to be effective in highly motivated patients. It should only be used in patients who have already been detoxified in order to prevent severe withdrawal symptoms. Naloxone is a shorter acting opioid receptor blocker, used to treat cases of overdose.

For pregnant heroin abusers, methadone maintenance combined with prenatal care and a comprehensive drug treatment program can improve many of the detrimental maternal and neonatal outcomes associated with untreated heroin abuse. Preliminary evidence suggests that buprenorphine also is a safe and effective treatment during pregnancy, although infants exposed to either methadone or buprenorphine prenatally may require treatment for withdrawal symptoms. For women who do not want or are not able to receive pharmacotherapy for their heroin addiction, detoxification from opiates during pregnancy can be accomplished with medical supervision, although potential risks to the fetus and the likelihood of relapse to heroin use should be considered.

There are many effective behavioral treatments available for heroin addiction—usually in combination with medication. These can be delivered in residential or outpatient settings. Examples are: contingency management, which uses a voucher-based system where patients earn “points” based on negative drug tests, which they can exchange for items that encourage healthy living; and cognitive-behavioral therapy, designed to help modify a patient’s expectations and behaviors related to drug abuse, and to increase skills in coping with various life stressors.

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Other Information Sources
For additional information on heroin, please refer to the following sources on NIDA’s Web site, www.drugabuse.gov:

Heroin Abuse—Research Report Series
Various issues of NIDA Notes (search by “heroin” or “opiates”)
For a list of street terms used to refer to heroin and other drugs, visit www.whitehousedrugpolicy.gov/streetterms/default.asp.

1 These data are from the 2007 Monitoring the Future survey, funded by the National Institute on Drug Abuse, National Institutes of Health, DHHS, and conducted annually by the University of Michigan’s Institute for Social Research. The survey has tracked 12th-graders’ illicit drug use and related attitudes since 1975; in 1991, 8th- and 10th-graders were added to the study. The latest data are online at www.drugabuse.gov.

2 “Lifetime” refers to use at least once during a respondent’s lifetime. “Past year” refers to use at least once during the year preceding an individual’s response to the survey. “Past month” refers to use at least once during the 30 days preceding an individual’s response to the survey.

3 NSDUH (formerly known as the National Household Survey on Drug Abuse) is an annual survey of Americans age 12 and older conducted by the Substance Abuse and Mental Health Services Administration. Copies of the latest survey are available at www.samhsa.gov and from NIDA at 877-643-2644.

Other References:

1. Samhsa.gov – Cocaine

2. National Institute on Drug Abuse

3. 1998 National Household Survey on Drug Abuse. Substance Abuse and Mental Health Services Administration (SAMHSA), 1998

How is Marijuana Abused?
Marijuana is usually smoked as a cigarette (joint) or in a pipe. It is also smoked in blunts, which are cigars that have been emptied of tobacco and refilled with marijuana. Since the blunt retains the tobacco leaf used to wrap the cigar, this mode of delivery combines marijuana’s active ingredients with nicotine and other harmful chemicals. Marijuana can also be mixed in food or brewed as a tea. As a more concentrated, resinous form it is called hashish, and as a sticky black liquid, hash oil.* Marijuana smoke has a pungent and distinctive, usually sweet-and-sour odor.

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How Does Marijuana Affect the Brain?
Scientists have learned a great deal about how THC acts in the brain to produce its many effects. When someone smokes marijuana, THC rapidly passes from the lungs into the bloodstream, which carries the chemical to the brain and other organs throughout the body.

THC acts upon specific sites in the brain, called cannabinoid receptors, kicking off a series of cellular reactions that ultimately lead to the “high” that users experience when they smoke marijuana. Some brain areas have many cannabinoid receptors; others have few or none. The highest density of cannabinoid receptors are found in parts of the brain that influence pleasure, memory, thoughts, concentration, sensory and time perception, and coordinated movement.

Not surprisingly, marijuana intoxication can cause distorted perceptions, impaired coordination, difficulty in thinking and problem solving, and problems with learning and memory. Research has shown that marijuana’s adverse impact on learning and memory can last for days or weeks after the acute effects of the drug wear off.2 As a result, someone who smokes marijuana every day may be functioning at a suboptimal intellectual level all of the time.

Research on the long-term effects of marijuana abuse indicates some changes in the brain similar to those seen after long-term abuse of other major drugs. For example, cannabinoid withdrawal in chronically exposed animals leads to an increase in the activation of the stress-response system3 and changes in the activity of nerve cells containing dopamine.4 Dopamine neurons are involved in the regulation of motivation and reward, and are directly or indirectly affected by all drugs of abuse.

Brief Description:
The most commonly used illegal drug in the U.S. The main active chemical is THC.
Street Names:
Pot, ganga, weed, grass, and many others.
Effects: Short-term effects include memory and learning problems, distorted perception, and difficulty thinking and solving problems.

Addictive Potential
Long-term marijuana abuse can lead to addiction; that is, compulsive drug seeking and abuse despite its known harmful effects upon social functioning in the context of family, school, work, and recreational activities. Long-term marijuana abusers trying to quit report irritability, sleeplessness, decreased appetite, anxiety, and drug craving, all of which make it difficult to quit. These withdrawal symptoms begin within about 1 day following abstinence, peak at 2–3 days, and subside within 1 or 2 weeks following drug cessation.5

Marijuana and Mental Health
A number of studies have shown an association between chronic marijuana use and increased rates of anxiety, depression, suicidal ideation, and schizophrenia. Some of these studies have shown age at first use to be a factor, where early use is a marker of vulnerability to later problems. However, at this time, it not clear whether marijuana use causes mental problems, exacerbates them, or is used in attempt to self-medicate symptoms already in existence. Chronic marijuana use, especially in a very young person, may also be a marker of risk for mental illnesses, including addiction, stemming from genetic or environmental vulnerabilities, such as early exposure to stress or violence. At the present time, the strongest evidence links marijuana use and schizophrenia and/or related disorders6. High doses of marijuana can produce an acute psychotic reaction, and research suggests that in vulnerable individuals, marijuana use may be a factor that increases risk for the disease.

What Other Adverse Effect Does Marijuana Have on Health?
Effects on the Heart
One study found that an abuser’s risk of heart attack more than quadruples in the first hour after smoking marijuana.7 The researchers suggest that such an outcome might occur from marijuana’s effects on blood pressure and heart rate (it increases both) and reduced oxygen-carrying capacity of blood.

Effects on the Lungs
Numerous studies have shown marijuana smoke to contain carcinogens and to be an irritant to the lungs. In fact, marijuana smoke contains 50 to 70 percent more carcinogenic hydrocarbons than tobacco smoke. Marijuana users usually inhale more deeply and hold their breath longer than tobacco smokers do, which further increases the lungs’ exposure to carcinogenic smoke. Marijuana smokers show dysregulated growth of epithelial cells in their lung tissue, which could lead to cancer;8 however, a recent case-controlled study found no positive associations between marijuana use and lung, upper respiratory, or upper digestive tract cancers.9 Thus, the link between marijuana smoking and these cancers remains unsubstantiated at this time.

Nonetheless, marijuana smokers can have many of the same respiratory problems as tobacco smokers, such as daily cough and phlegm production, more frequent acute chest illness, a heightened risk of lung infections, and a greater tendency toward obstructed airways. A study of 450 individuals found that people who smoke marijuana frequently but do not smoke tobacco have more health problems and miss more days of work than nonsmokers.10 Many of the extra sick days among the marijuana smokers in the study were for respiratory illnesses.

Effects on Daily Life
Research clearly demonstrates that marijuana has the potential to cause problems in daily life or make a person’s existing problems worse. In one study, heavy marijuana abusers reported that the drug impaired several important measures of life achievement including physical and mental health, cognitive abilities, social life, and career status.11 Several studies associate workers’ marijuana smoking with increased absences, tardiness, accidents, workers’ compensation claims, and job turnover.

What Treatment Options Exist?
Behavioral interventions, including cognitive behavioral therapy and motivational incentives (i.e., providing vouchers for goods or services to patients who remain abstinent) have shown efficacy in treating marijuana dependence. Although no medications are currently available, recent discoveries about the workings of the cannabinoid system offer promise for the development of medications to ease withdrawal, block the intoxicating effects of marijuana, and prevent relapse.

The latest treatment data indicate that in 2006 marijuana was the most common illicit drug of abuse and was responsible for about 16 percent (289,988) of all admissions to treatment facilities in the United States. Marijuana admissions were primarily male (73.8 percent), White (51.5 percent), and young (36.1 percent were in the 15–19 age range). Those in treatment for primary marijuana abuse had begun use at an early age: 56.2 percent had abused it by age 14 and 92.5 percent had abused it by age 18.**

How Widespread is Marijuana Abuse?
According to the National Survey on Drug Use and Health, in 2006, 14.8 million Americans age 12 or older used marijuana at least once in the month prior to being surveyed, which is similar to the 2005 rate. About 6,000 people a day in 2006 used marijuana for the first time—2.2 million Americans. Of these, 63.3 percent were under age 18.***

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* For street terms searchable by drug name, street term, cost and quantities, drug trade, and drug use, visit: http://www.whitehousedrugpolicy.gov/streetterms/default.asp.

** These data are from the Treatment Episode Data Set (TEDS) Highlights – 2006: National Admissions to Substance Abuse Treatment Services (Office of Applied Studies, DASIS Series: S-40, DHHS Publication No. SMA 08-4313, Rockville, MD, 2008), funded by the Substance Abuse and Mental Health Services Administration. The latest data are available at 800-729-6686 or online at www.samhsa.gov.

*** Results from the 2006 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H–32, DHHS Publication No. SMA 07-4293 Rockville, MD, 2007). NSDUH is an annual survey conducted by the Substance Abuse and Mental Health Services Administration. Copies of the latest survey are available from the National Clearinghouse for Alcohol and Drug Information at 800-729-6686.

**** These data are from the 2007 Monitoring the Future survey, funded by the National Institute on Drug Abuse, National Institutes of Health, DHHS, and conducted annually by the University of Michigan’s Institute for Social Research. The survey has tracked 12th graders’ illicit drug use and related attitudes since 1975; in 1991, 8th and 10th graders were added to the study. The latest data are online at www.drugabuse.gov.

1 Herkenham M, Lynn A, Little MD, et al. Cannabinoid receptor localization in the brain. Proc Natl Acad Sci, USA 87(5):1932–1936, 1990.

2 Pope HG, Gruber AJ, Hudson JI, Huestis MA, Yurgelun-Todd D. Neuropsychological performance in long-term cannabis users. Arch Gen Psychiatry 58(10):909–915, 2001.

3 Rodríguez de Fonseca F, Carrera MRA, Navarro M, Koob GF, Weiss F. Activation of corticotropin-releasing factor in the limbic system during cannabinoid withdrawal. Science 276(5321):2050–2054, 1997.

4 Diana M, Melis M, Muntoni AL, Gessa GL. Mesolimbic dopaminergic decline after cannabinoid withdrawal. Proc Natl Acad Sci, USA 95(17):10269–10273, 1998.

5 Budney AJ, Vandrey RG, Hughes JR, Thostenson JD, Bursac Z. Comparison of cannabis and tobacco withdrawal: Severity and contribution to relapse. J Subst Abuse Treat, e-publication ahead of print, March 12, 2008.

6 Moore TH, Zammit S, Lingford-Hughes A, et al. Cannabis use and risk of psychotic or affective mental health outcomes: A systematic review. Lancet 370 (9584):319–328, 2007.

7 Mittleman MA, Lewis RA, Maclure M, Sherwood JB, Muller JE. Triggering myocardial infarction by marijuana. Circulation 103(23):2805–2809, 2001.

8 Tashkin DP. Smoked marijuana as a cause of lung injury. Monaldi Arch Chest Dis 63(2):92–100, 2005.

9 Hashibe M, Morgenstern H, Cui Y, et al. Marijuana use and the risk of lung and upper aerodigestive tract cancers: Results of a population-based case-control study. Cancer Epidemiol Biomarkers Prev 15(10):1829–1834, 2006.

10 Polen MR, Sidney S, Tekawa IS, Sadler M, Friedman GD. Health care use by frequent marijuana smokers who do not smoke tobacco. West J Med 158(6):596–601, 1993.

11Gruber AJ, Pope HG, Hudson JI, Yurgelun-Todd D. Attributes of long-term heavy cannabis users: A case control study. Psychological Med 33(8):1415–1422, 2003.

Other References:

1. Samhsa.gov – Cocaine

2. National Institute on Drug Abuse

3. 1998 National Household Survey on Drug Abuse. Substance Abuse and Mental Health Services Administration (SAMHSA), 1998

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Methamphetamine

Brief Description:
An addictive stimulant that is closely related to amphetamine, but has longer lasting and more toxic effects on the central nervous system. It has a high potential for abuse and addiction.
Street Names:
Speed, meth, chalk, ice, crystal, glass.
Effects:
Increases wakefulness and physical activity and decreases appetite. Chronic, long-term use can lead to psychotic behavior, hallucinations, and stroke.

How is Methamphetamine Abused?
Methamphetamine is a white, odorless, bitter-tasting crystalline powder that easily dissolves in water or alcohol and is taken orally, intranasally (snorting the powder), by needle injection, or by smoking.

How Does Methamphetamine Affect the Brain?
Methamphetamine increases the release of very high levels of the brain chemical dopamine, which is involved in motivation, the experience of pleasure, and motor function, and is a common mechanism of action for most drugs of abuse.

Chronic methamphetamine abuse significantly changes how the brain functions. Noninvasive human brain imaging studies have shown alterations in the activity of the dopamine system that are associated with reduced motor performance and impaired verbal learning.1 Recent studies in chronic methamphetamine abusers have also revealed severe structural and functional changes in areas of the brain associated with emotion and memory,2,3 which may account for many of the emotional and cognitive problems observed in chronic methamphetamine abusers.

Long-term methamphetamine abuse can also lead to addiction—a chronic, relapsing disease, characterized by compulsive drug seeking and use, and accompanied by chemical and molecular changes in the brain. Some of these changes persist long after methamphetamine abuse is stopped, and some reverse after sustained periods of abstinence (e.g., 2 years).4

What Other Adverse Effects Does Methamphetamine Have on Health?
Taking even small amounts of methamphetamine can result in increased wakefulness, increased physical activity, decreased appetite, increased respiration, rapid heart rate, irregular heartbeat, increased blood pressure, and hyperthermia.

Long-term methamphetamine abuse has many negative consequences, including extreme weight loss, severe dental problems, anxiety, confusion, insomnia, mood disturbances, and violent behavior. Chronic methamphetamine abusers can also display a number of psychotic features, including paranoia, visual and auditory hallucinations, and delusions (for example, the sensation of insects creeping under the skin).

Also, transmission of HIV and hepatitis B and C can be consequences of methamphetamine abuse. Among abusers who inject the drug, HIV and other infectious diseases can be spread through contaminated needles, syringes, and other injection equipment that is used by more than one person. The intoxicating effects of methamphetamine, regardless of how it is taken, can also alter judgment and inhibition and lead people to engage in unsafe behaviors. Methamphetamine abuse may also worsen the progression of HIV and its consequences. Studies of methamphetamine abusers who are HIV positive indicate that the HIV causes greater neuronal injury and cognitive impairment compared with HIV-positive people who do not use the drug.5,6

What Treatment Options Exist?
Currently, the most effective treatments are behavioral. For example, the Matrix Model, a comprehensive behavioral treatment approach that combines behavioral therapy, family education, individual counseling, 12-Step support, drug testing, and encouragement for nondrug-related activities, has been shown to be effective in reducing methamphetamine abuse.7 Contingency management interventions, which provide tangible incentives in exchange for engaging in treatment and maintaining abstinence, have also been shown to be effective.8 There are no medications at this time approved to treat methamphetamine addiction; however, this is an active area of research for NIDA.

How Widespread is Methamphetamine Abuse?
National Survey on Drug Use and Health

**
In 2006, there were an estimated 731,000 current users of methamphetamine aged 12 or older (0.3 percent of the population). Of the 259,000 people who used methamphetamine for the first time in 2006, the mean age at first use was 22.2 years, which is up considerably from the mean age of 18.6 in 2005. From 2005 to 2006, lifetime methamphetamine abuse increased among those 26 and older, particularly among those 26–34 years of age.

Other Information Resources

For more information on the effects of methamphetamine abuse and addiction, visit www.drugabuse.gov/drugpages/methamphetamine.html.

To find publicly funded treatment facilities by state, visit www.findtreatment.samhsa.gov.

For street terms searchable by drug name, street term, cost and quantities, drug trade, and drug use, visit: www.whitehousedrugpolicy.gov/streetterms/default.asp.

* These data are from the 2007 Monitoring the Future survey funded by the National Institute on Drug Abuse, National Institutes of Health, DHHS, and conducted by the University of Michigan’s Institute for Social Research. The study has tracked 12th graders’ illicit drug abuse and related attitudes since 1975; in 1991, 8th and 10th graders were added to the study. The latest data are online at www.drugabuse.gov.

** The National Survey on Drug Use and Health (formerly known as the National Household Survey on Drug Abuse) is an annual survey conducted by the Substance Abuse and Mental Health Services Administration. Findings from the latest survey are available at www.samhsa.gov.

1 Volkow ND, Chang L, Wang GJ, et al. Association of dopamine transporter reduction with psychomotor impairment in methamphetamine abusers. Am J Psychiatry 158:377–382, 2001.

2 London ED, Simon SL, Berman SM, et al.. Mood disturbances and regional cerebral metabolic abnormalities in recently abstinent methamphetamine abusers. Arch Gen Psychiatry 61:73–84, 2004.

3 Thompson PM, Hayashi KM, Simon SL, et al. Structural abnormalities in the brains of human subjects who use methamphetamine. J Neurosci 24:6028–6036, 2004.

4 Wang GJ, Volkow ND, Chang L, et al. Partial recovery of brain metabolism in methamphetamine abusers after protracted abstinence. Am J Psychiatry 161:242–248, 2004.

5 Chang L, Ernst T, Speck O, Grob CS. Additive effects of HIV and chronic methamphetamine use on brain metabolite abnormalities. Am J Psychiatry 162:361–369, 2005.

6 Rippeth JD, Heaton RK, Carey CL, et al. Methamphetamine dependence increases risk of neuropsychological impairment in HIV infected persons. J Int Neuropsychol Soc 10:1–14, 2004.

7 Rawson RA, Marinelli-Casey P, Anglin MD, et al. A multi-site comparison of psychosocial approaches for the treatment of methamphetamine dependence. Addiction 99:708–717, 2004.

8 Roll JM, Petry NM, Stitzer ML, et al. Contingency management for the treatment of methamphetamine use disorders. Am J Psychiatry 163:1993–1999, 2006.

Other References:

1. Samhsa.gov – Cocaine

2. National Institute on Drug Abuse

3. 1998 National Household Survey on Drug Abuse. Substance Abuse and Mental Health Services Administration (SAMHSA), 1998

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Patients, healthcare professionals, and pharmacists all have roles in preventing the abuse1 of and addiction to prescription medications. For example, patients should follow the directions for use carefully, learn what effects and side effects the medication could have, and inform their doctor/pharmacist whether they are taking other medications [including over-the-counter (OTC) medications or health supplements], since these could potentially interact with the prescribed medication. The patient should read all information provided by the pharmacist. Physicians and other healthcare providers should screen for past or current substance abuse in the patient during routine examination, including asking questions about what other medications the patient is taking and why. Providers should note any rapid increases in the amount of a medication needed or frequent requests for refills before the quantity prescribed should have been finished, as these may be indicators of abuse.

Similarly, some OTC medications, such as cough and cold medicines containing dextromethorphan, have beneficial effects when taken as recommended, but they can also be abused and lead to serious adverse health consequences. Parents should be aware of the potential for abuse of these medications, especially when consumed in large quantities, which should signal concern and the possible need for intervention.

Prescription Medications (Including Oxycontin)

Brief Description:

Prescription drugs that are abused or used for nonmedical reasons can alter brain activity and lead to dependence. Commonly abused classes of prescription drugs include opioids (often prescribed to treat pain), central nervous system depressants (often prescribed to treat anxiety and sleep disorders), and stimulants (prescribed to treat narcolepsy, ADHD, and obesity).

Street Names:

Commonly used opioids include oxycodone (OxyContin), propoxyphene (Darvon), hydrocodone (Vicodin), hydromorphone (Dilaudid), meperidine (Demerol), and diphenoxylate (Lomotil). Common central nervous system depressants include barbiturates such as pentobarbital sodium (Nembutal), and benzodiazepines such as diazepam (Valium) and alprazolam (Xanax). Stimulants include dextroamphetamine (Dexedrine) and methylphenidate (Ritalin).

Effects:

Long-term use of opioids or central nervous system depressants can lead to physical dependence and addiction. Taken in high doses, stimulants can lead to compulsive use, paranoia, dangerously high body temperatures, and irregular heartbeat.

Commonly Abused Prescription Medications
Although many prescription medications can be abused, the following three classes are most commonly abused:

Opioids—usually prescribed to treat pain.
CNS Depressants—used to treat anxiety and sleep disorders.
Stimulants—prescribed to treat ADHD and narcolepsy.

Opioids
What are Opioids?
Opioids are commonly prescribed because of their effective analgesic, or pain-relieving, properties. Studies have shown that properly managed medical use of opioid analgesic compounds (taken exactly as prescribed) is safe, can manage pain effectively, and rarely causes addiction.

Among the compounds that fall within this class are hydrocodone (e.g., Vicodin), oxycodone (e.g., OxyContin—an oral, controlled-release form of the drug), morphine, fentanyl, codeine, and related medications. Morphine and fentanyl are often used to alleviate severe pain, while codeine is used for milder pain. Other examples of opioids that can be prescribed to relieve pain include propoxyphene (Darvon); hydromorphone (Dilaudid); and meperidine (Demerol), which is used less often because of its side effects. In addition to their effective pain-relieving properties, some of these medications can be used to relieve severe diarrhea (for example, Lomotil, also known as diphenoxylate) or severe coughs (codeine).

How are Opioids Abused?
Opioids can be taken orally, or the pills may be crushed and the powder snorted or injected. A number of overdose deaths have resulted from the latter routes of administration, particularly with the drug OxyContin, which was designed to be a slow-release formulation. Snorting or injecting opioids results in a rapid release of the drug into the bloodstream, exposing the person to high doses and causing many of the reported overdose reactions.

How do Opioids Affect the Brain?
Opioids act by attaching to specific proteins called opioid receptors, which are found in the brain, spinal cord, and gastrointestinal tract. When these compounds attach to certain opioid receptors in the brain and spinal cord, they can effectively change the way a person experiences pain.

In addition, opioid medications can affect regions of the brain that mediate what one perceives as pleasure, resulting in the initial euphoria or sense of well-being that many opioids produce. Repeated abuse of opioids can lead to addiction—a chronic, relapsing disease, characterized by compulsive drug seeking and abuse despite its known harmful consequences.

What Adverse Effects Can be Associated with Opioids?
Opioids can produce drowsiness, cause constipation, and, depending upon the amount taken, depress breathing. Taking a large single dose could cause severe respiratory depression or death.

These medications are only safe to use with other substances under a physician’s supervision. Typically, they should not be used with alcohol, antihistamines, barbiturates, or benzodiazepines. Because these substances slow breathing, their combined effects could lead to life-threatening respiratory depression.

What Happens When you Stop Taking Opioids?
Patients who are prescribed opioids for a period of time may develop a physical dependence on them, which is not the same as addiction. Repeated exposure to opioids causes the body to adapt, sometimes resulting in tolerance (that is, more of the drug is needed to achieve the desired effect compared to when it was first prescribed) and withdrawal symptoms upon abrupt cessation of drug use. Thus, individuals taking prescribed opioid medications should not only be given these medications under appropriate medical supervision, but should also be medically supervised when stopping use in order to reduce or avoid withdrawal symptoms. Symptoms of withdrawal can include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps (“cold turkey”), and involuntary leg movements.

Are there Treatments for Opioid Addiction?
Individuals who abuse or are addicted to prescription opioid medications can be treated. Initially, they may need to undergo medically supervised detoxification to help reduce withdrawal symptoms—however, that is just the first step. Options for effectively treating addiction to prescription opioids are drawn from research on treating heroin addiction. Behavioral treatments combined with medications have proven effective. Currently used medications are:

Methadone, a synthetic opioid that eliminates withdrawal symptoms and relieves craving, has been used for more than 30 years to successfully treat people addicted to heroin.
Buprenorphine, another synthetic opioid, is a more recently approved medication for treating addiction to heroin and other opiates. It can be prescribed in a physician’s office and has a better safety profile than methadone.
Naltrexone is a long-acting opioid receptor blocker that can be employed to help prevent relapse. It is not widely used, however, because of poor compliance, except in highly motivated individuals (e.g., physicians at risk of losing their medical license). It should be noted that this medication can only be used for someone who has already been detoxified, since it can produce severe withdrawal symptoms in a person continuing to abuse opioids.
Naloxone is a short-acting opioid receptor blocker that counteracts the effects of opioids and can be used to treat overdoses.

CNS Depressants
What are CNS Depressants?
CNS depressants (e.g., tranquilizers, sedatives) slow normal brain function. In higher doses, some CNS depressants can be used as general anesthetics or pre-anesthetics.

CNS depressants can be divided into three groups, based on their chemistry and pharmacology:

Barbiturates, such as mephobarbital (Mebaral) and sodium pentobarbital (Nembutal), are used as preanesthetics, promoting sleep.
Benzodiazepines, such as diazepam (Valium), alprazolam (Xanax), and estazolam (ProSom), can be prescribed to treat anxiety, acute stress reactions, panic attacks, convulsions, and sleep disorders. For the latter, benzodiazepines are usually prescribed only for short-term relief of sleep problems because of the development of tolerance and risk of addiction.
Newer sleep medications, such as zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta), are now more commonly prescribed to treat sleep disorders. These medications are non-benzodiazepines that act at a subset of the benzodiazepine receptors and appear to have a lower risk for abuse and addiction.

How are CNS Depressants abused?
CNS depressants are usually taken orally, sometimes in combination with other drugs or to counteract the effects of other licit or illicit drugs (e.g., stimulants).

How do CNS Depressants Affect the Brain?
Most of the CNS depressants have similar actions in the brain—they enhance the actions of the neurotransmitter gamma-aminobutyric acid (GABA). Neurotransmitters are brain chemicals that facilitate communication between brain cells. GABA works by decreasing brain activity. Although different classes of CNS depressants work in unique ways, it is ultimately their ability to increase GABA activity that produces a drowsy or calming effect.

What Adverse Effects Can Be Associated with CNS Depressants?
Despite their beneficial effects for people suffering from anxiety or sleep disorders, barbiturates and benzodiazepines can be addictive and should be used only as prescribed.

CNS depressants should not be combined with any medication or substance that causes drowsiness, including prescription pain medicines, certain OTC cold and allergy medications, or alcohol. If combined, they can slow both the heart and respiration, which can be fatal.

What Happens When you Stop Taking CNS Depressants?
Discontinuing prolonged use or abuse of high doses of CNS depressants can lead to serious withdrawal symptoms. Because it works by slowing the brain’s activity, when one stops taking a CNS depressant, this activity can rebound to the point that seizures can occur. Someone who is either thinking about ending their use of a CNS depressant, or who has stopped and is suffering withdrawal, should seek medical treatment.

Are there Treatments for Addiction to CNS Depressants?
In addition to medical supervision during withdrawal, counseling in an inpatient or outpatient setting can help people who are overcoming addiction to CNS depressants. For example, cognitive-behavioral therapy has been used successfully to help individuals in treatment for abuse of benzodiazepines. This type of therapy focuses on modifying a patient’s thinking, expectations, and behaviors while simultaneously increasing their skills for coping with various life stressors.

Stimulants
What are Stimulants?
Stimulants such as amphetamines (Adderal, Dexedrine) and methylphenidate (Concerta, Ritalin) have chemical structures that are similar to key brain neurotransmitters called monoamines, which include dopamine and norepinephrine—stimulants increase the levels of these chemicals in the brain and body. This, in turn, increases blood pressure and heart rate, constricts blood vessels, increases blood glucose, and opens up the pathways of the respiratory system. Stimulants increase alertness, attention, and energy; and because they increase dopamine, they can produce a sense of euphoria.

Historically, stimulants were used to treat asthma and other respiratory problems, obesity, neurological disorders, and a variety of other ailments. As their potential for abuse and addiction became apparent, the use of stimulants began to wane. Now, stimulants are prescribed for treating only a few health conditions, most notably ADHD, narcolepsy, and, in some instances, depression that has not responded to other treatments.

How are Stimulants Abused?
Stimulants may be taken orally, but some abusers crush the tablets, dissolve them in water, and inject the mixture; complications can arise from this because insoluble fillers in the tablets can block small blood vessels. Stimulants have been abused for both “performance enhancement” and recreational purposes (i.e., to get high).

How Do Prescription Stimulants Affect the Brain?
All stimulants work by increasing dopamine levels in the brain. Dopamine is a brain chemical (neurotransmitter) associated with pleasure, movement, and attention. The therapeutic effect of stimulants is achieved by slow and steady increases of dopamine that are similar to the natural production of this chemical by the brain. The doses prescribed by physicians start low and increase gradually until a therapeutic effect is reached. However, when taken in doses and routes other than those prescribed, stimulants can increase brain dopamine in a rapid and highly amplified manner—as do most other drugs of abuse—disrupting normal communication between brain cells, producing euphoria, and increasing the risk of addiction.

What Adverse Effects Can Be Associated with Stimulant Abuse?
The consequences of stimulant abuse can be extremely dangerous. Taking high doses of a stimulant can result in an irregular heartbeat, dangerously high body temperatures, and/or the potential for cardiovascular failure or seizures. Taking high doses of some stimulants repeatedly over a short period of time can lead to hostility or feelings of paranoia in some individuals.

Stimulants should not be mixed with antidepressants, which may enhance the effects of a stimulant, or OTC cold medicines containing decongestants, which may cause blood pressure to become dangerously high or lead to irregular heart rhythms.

Are there Treatments for Stimulant Addiction?
Treatment of addiction to prescription stimulants is based on behavioral therapies proven effective for treating cocaine or methamphetamine addiction. At this time, there are no proven medications for the treatment of stimulant addiction.

Depending on the patient’s situation, the first step in treating prescription stimulant addiction may be to slowly decrease the drug’s dose and attempt to treat withdrawal symptoms. This process of detoxification could then be followed with one of many behavioral therapies. Contingency management, for example, improves treatment outcomes by enabling patients to earn vouchers for drug-free urine tests; the vouchers can be exchanged for items that promote healthy living. Cognitive-behavioral therapies—which teach patients skills to recognize risky situations, avoid drug use, and cope more effectively with problems—are proving beneficial. Recovery support groups may also be effective in conjunction with a behavioral therapy.

Dextromethorphan (DXM)
What is DXM?
Dextromethorphan is the active cough suppressant found in OTC cough and cold medications. When taken in recommended doses, these medications are safe and effective.

How is DXM Abused?
DXM is taken orally. In order to experience the mind-altering effects of DXM, excessive amounts of liquid or gelcaps must be consumed. The availability and accessibility of these products make them a serious concern, particularly for youth, who tend to be their primary abusers.

What are the Consequences Associated with the Abuse of DXM?
In very large quantities, DXM can cause effects similar to that of ketamine and PCP by affecting similar sites in the brain. These effects can include impaired motor function, numbness, nausea/vomiting, and increased heart rate and blood pressure. On rare occasions, hypoxic brain damage has occurred due to the combination of DXM with decongestants often found in these medications.

What are the Trends in the Abuse of Prescription Drugs and Cough Medicine?
Past-month nonmedical use of prescription-type drugs among young adults aged 18 to 25 increased from 5.4 percent in 2002 to 6.4 percent in 2006. This was primarily due to an increase in pain reliever use, which was 4.1 percent in 2002 and 4.9 percent in 2006. However, nonmedical use of tranquilizers also increased over the 5-year period, from 1.6 to 2.0 percent.

Among persons aged 12 or older who used pain relievers nonmedically in the past 12 months, 55.7 percent reported that they got the drug most recently used from someone they knew and that they did not pay for it. Another 19.1 percent reported that they obtained the drug from one doctor. Only 3.9 percent purchased the pain reliever from a drug dealer or other stranger, and only 0.1 percent reported buying the drug on the Internet. Among those who reported getting the pain reliever from a friend or relative for free, 80.7 percent reported in a followup question that the friend or relative had obtained the drug from just one doctor.

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Other Information Sources
For more information on addiction to prescription medications, visit http://www.drugabuse.gov/drugpages/prescription.html.

1. A common vocabulary has not been established in the field of prescription drug abuse. Because much of the survey data collected in this area refer to nonmedical use of prescription drugs, this definition of “abuse,” rather than that of the Diagnostic and Statistical Manual of Mental Disorders (DSM), is used. Also, because physical dependence to prescription medications can develop during medically supervised appropriate use, the term “addiction” is used to reflect dependence as defined by the DSM.

2. These data are from the 2007 Monitoring the Future survey, funded by the National Institute on Drug Abuse, National Institutes of Health, Department of Health and Human Services, and conducted annually by the University of Michigan’s Institute for Social Research. The survey has tracked 12th-graders’ illicit drug use and related attitudes since 1975; in 1991, 8th- and 10th-graders were added to the study. The latest data are online at www.drugabuse.gov.

3. “Lifetime” refers to use at least once during a respondent’s lifetime. “Past year” refers to use at least once during the year preceding an individual’s response to the survey. “Past month” refers to use at least once during the 30 days preceding an individual’s response to the survey.

4 NSDUH (formerly known as the National Household Survey on Drug Abuse) is an annual survey of Americans age 12 and older conducted by the Substance Abuse and Mental Health Services Administration. Copies of the latest survey are available at www.samhsa.gov and from NIDA at
877-643-2644.

Other References:

1. Samhsa.gov – Cocaine

2. National Institute on Drug Abuse

3. 1998 National Household Survey on Drug Abuse. Substance Abuse and Mental Health Services Administration (SAMHSA), 1998