1. Commonly Misused Substances

2. Substances Commonly Used in an At-Risk Manner Alcohol Ethanol, methanol, isopropyl alcohol. Sedative/Hypnotics/Anesthetics Benzodiazepines, barbiturates, anesthetics (Gammahydroxybutyrate (GHB), ketamine). Primarily used orally although ketamine may be injected. Opioids Heroin, oxycodone, morphine, hydromorphone, methadone, fentanyl, codeine, propoxyphene and others. All of these substances maybe used orally, intranasally or by injection. Long acting formulations and patches may be chewed. Stimulants Amphetamines, cocaine, methamphetamine, ephedrine, phencyclidine, methylphenidate. All of these substances may be used orally, intranasally or by injection. SAMHSA, 2005

3. Substances Commonly Used in an At-Risk Manner Hallucinogens LSD, mescaline, psilocybin (mushrooms), phenylcyclidine (PCP), ecstasy, methylenedioxymethamphetamine (MDMA). Cannabis/TetrahydrocannabinolCannabis/Tetrahydrocannabinol (THC) Marijuana. Smoked, vaporized, oral. Steroids Dianabol, nandrolone. Typically by injection. Volatile Substances Toluene, acetone, butane, fluorocarbons. Inhaled (“Huffed”). SAMHSA, 2005 cntinue

4. Sedative/Hypnotic/Anesthetic Benzodiazepines, barbiturates, anesthetics (GHB, ketamine) If injected, Ketamine use may present with Signs/SXS common to injection drug use. NIDA, 2008; Stark, 2009 Signs/SXS of intoxication: Altered consciousness Ataxia Sexual dysfunction Death Confusion Slurred speech Stupor/coma Loss of coordination Dizziness Apnea Memory impairment Weight gain Paradoxical/uncharacteristic behavior Signs/SXS of chronic use: Loss of motivation Poor comprehension Development of tolerance Incoordination Emotional lability Memory impairment Poor task completion Nystagmus with accommodation (barbiturates) Signs/SXS of withdrawal: Severe anxiety Autonomic hyperactivity Insomnia Psychosis Headache Seizure Hypersensitivity to stimuli

5. Opioids Heroin, oxycodone, morphine, hydromorphone, methadone, fentanyl, codeine, propoxyphene NIDA, 2008; Stark, 2009 Signs/SXS of intoxication: Pinpoint pupils Respiratory depression Nausea/vomiting Bradycardia Constipation Coma Relaxed and/or euphoric state ("nodding“) Signs/SXS of chronic use: Sexual dysfunction Amenorrhea Development of tolerance to euphoria/analgesia (but not to pupillary response) Signs/SXS of withdrawal: Yawning Diaphoresis Diarrhea Autonomic hyperactivity Rhinorrhea Nausea/vomiting Tremor Malaise Lacrimation Myalgia Insomnia Anxiety Piloerection Abdominal cramps Dysphoria, Signs/SXS related to route of administration: Injection: Embolis Cellulitis Endocarditis HIV Abscesses Viral hepatitis Foreign body emboli Infections consequences of unsterile injection Fresh needle marks and scaring (track marks) Soft tissue necrosis (with injection of pill forms)

6. Stimulants Amphetamines, Cocaine, Ephedrine, Phencyclidine NIDA, 2008; Stark, 2009 Signs/SXS of intoxication: Hypertension Diaphoresis Fine tremor Muscle spasms Tachycardia Agitation Appetite suppression Chest pain Tachypnea Paranoia Hyperthermia Sexual dysfunction Mydriasis Brisk reflexes Formication Signs/SXS of chronic use: Weight loss Malnutrition Reduced fertility Development of tolerance Signs/SXS of withdrawal: Muscle pain/tremor Hunger Depression/irritability Intense persistent drug seeking behavior No specific withdrawal syndrome but cessation of use may be accompanied by fatigue/malaise Signs/SXS related to route of administration: Intranasal: Rhinorrhea Inhaled: Bronchitis COPD/bronchiectasis Injection: Embolis Septal perforation Pneumonia Abscess formation Eczema localize to nares Dry mouth with poor dentition Burns to the lips and fingers Infections consequences of unsterile injection Skin and soft tissue necrosis with chronic wound formation and adjacent or distant osteomyelitis

7. Hallucinogens LSD, Ecstasy, Mushrooms NIDA, 2008: Stark, 2009 Signs/SXS of intoxication: Tachycardia Nystagmus Nausea Paranoia Dry mouth Ataxia Mood lability Bruxism Hyperreflexia Vomiting Mydriasis Autonomic hyperactivity Visual/auditory hallucinations Signs/SXS of chronic use: Tolerance develops rapidly to LSD, flashbacks may occur long after heavy or prolonged use Signs/SXS of withdrawal: No specific withdrawal syndrome Medical Consequences: Rhabodomyolysis and acute renal failure with large doses, elevated liver enzymes

8. Cannabis Marijuana, tetrahydrocannabinol NIDA, 2008; Stark, 2009 Signs/SXS of intoxication: Euphoria Tachycardia Agitation Dry mouth Poor concentration Anxiety Hunger Memory impairment Toxic psychosis Reddened conjunctivae Paranoia Impaired manual dexterity Hypertension with postural hypotension Signs/SXS of chronic use: Affect disorders Dental caries Cough Chronic bronchitis Signs/SXS of withdrawal: No discrete withdrawal syndrome although cessation of use may be accompanied by disphoria or anxiety Restlessness and irritability Smoked cannabis is a respiratory irritant. No specific consequences associated with oral or vaporized consumption.

9. Volatile Substances Stark, 2009 Signs/SXS of intoxication: Solvent smell Diarrhea Ataxia Nausea Sneezing Dysphoria Vomiting Coughing Disinhibition CNS depression Slurred speech Coma Signs/SXS of chronic use: Nasal sores Fatigue Depression Burns Memory loss Delusions Respiratory problems Weight loss Psychosis Perioral eczema (glue sniffer’s rash) Poor concentration Signs/SXS of withdrawal: Primarily psychological dependence HA Inhalation of volatile substances is associated with sudden death from arrhythmia Drowsiness Chronic liver and renal failure