Handbook of Child and Adolescent Drug and Substance Abuse: Pharmacological, Developmental, and Clinical Considerations

By Louis A. Pagliaro and Ann Marie Pagliaro

• Selected by Choice as a 2013 Outstanding Academic Title

• Language: English
• Publisher: Wiley
• Release date: Nov 15, 2011
• ISBN: 9781118117958

Book preview

Contents

Preface

Acknowledgments

I: Extent of Use and Pharmacological Considerations

1: The Psychodepressants

Introduction

Opiate Analgesics

Sedative-Hypnotics

Volatile Solvents and Inhalants

Chapter Summary

2: The Psychostimulants

Introduction

Amphetamines

Caffeine

Cocaine

Nicotine

Chapter Summary

3: The Psychodelics

Introduction

Amphetamine-Like Psychodelics—The Phenethylamines

Lsd and Lsd-Like Psychodelics—The Indoles, Tryptamines, and Indoles/Tryptamines

Miscellaneous Psychodelics

Chapter Summary

II: Developmental Considerations

4: Explaining Child and Adolescent Use of the Drugs and Substances of Abuse

Introduction

Biological Theories

Psychological Theories

Sociological Theories

Chapter Summary

5: Exposure to the Drugs and Substances of Abuse From Conception Through Childhood

Introduction

Embryonic and Fetal Exposure During Pregnancy: Teratogenesis and Fetotoxicity

Exposure During Breast-Feeding

Exposure to Secondhand Smoke

Exposure by Unintentional Childhood Poisonings

Chapter Summary

6: Effects of the Drugs and Substances of Abuse on Learning and Memory During Childhood and Adolescence

Introduction

Cognitive Input-Output Model of Learning and Memory

Requisites For Optimal Learning: The Core Processes

Memory

Effects of Neurological and Mental Disorders on Learning and Memory: Attention-Deficit/Hyperactivity Disorder; Fetal Alcohol Syndrome/Fetal Alcohol Spectrum Disorder; and Major Depressive Disorder

Chapter Summary

III: Clinical Considerations

7: Detecting Adolescent Use of the Drugs and Substances of Abuse: Selected Quick-Screen Psychometric Tests

Introduction

Importance of Screening

Type 1 and Type 2 Diagnostic Errors

Basic Test Statistics

The Tester and The Test-Taker

Selected Quick-Screen Psychometric Tests

Chapter Summary

8: Dual Diagnosis Among Adolescents

Introduction

Dual Diagnoses Among Adolescents and Young Adults

Tridiagnosis Among Adolescents: Suds and Omds and Hiv

Treatment For Adolescents with Dual Diagnosis

Chapter Summary

9: Preventing and Treating Child and Adolescent Use of the Drugs and Substances of Abuse

Introduction

Primary, Secondary, and Tertiary Prevention

Meta-Interactive Model of Child and Adolescent Use of The Drugs and Substances of Abuse

Chapter Summary

Appendix: Abbreviations Used in the Text

References

Index

About the Authors

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Library of Congress Cataloging-in-Publication Data:

Pagliaro, Louis A.

Handbook of child and adolescent drug and substance abuse: pharmacological, developmental, and clinical considerations / Louis A. Pagliaro and Ann Marie Pagliaro.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-0-470-63906-1 (cloth : alk. paper)

ISBN 978-1-118-11793-4 (ebk)

ISBN 978-1-118-11795-8 (ebk)

ISBN 978-1-118-11794-1 (ebk)

ISBN 978-1-118-10105-6 (obk)

1. Drug and substance abuse—North America. 2. Children—Drug and substance use—North America. 3. Adolescents—Drug and substance use—North America. I. Pagliaro, Ann Marie. II. Title.

[DNLM: 1. Substance-Related Disorders—North America. 2. Adolescent—North America. 3. Child— North America. 4. Pharmaceutical Preparations—North America. WM 270]

RJ506.D78P34 2012

618.92’860097—dc22

2011010982

To all North American children and adolescents. It is our fervent hope that this text will help to bring about a greater awareness and a deeper understanding of the nature and extent of your exposure to and use of the drugs and substances of abuse. We trust that this awareness and understanding will help to stem the growing tide and assuage your associated pain and suffering.

LAP/AMP

Preface

Children and adolescents throughout North America, regardless of age, culture, education, ethnicity, gender, race, religion, sexual orientation, or socioeconomic status, may be exposed to and may actively use the various drugs and substances of abuse (see Figure P.1, Table P.1)¹ in a variety of ways that adversely affect their health, safety, and well-being (see Figure P. 2). Their exposure to and use of these drugs and substances of abuse also may adversely affect the health, safety, and well-being of their families, including siblings, and that of their friends and schoolmates and the larger communities, including the schools and neighborhoods, of which they are a part.² Consequently, all those who work to promote the optimal growth and development of children and adolescents—child and adolescent psychiatrists and psychologists; community health, mental health, and school nurses; family physicians; family therapists; home health-care workers; juvenile justice workers; midwives; pediatric nurse practitioners; pediatricians; pharmacists; school counselors; school psychologists; and social workers—require an unbiased and specialized reference source that presents current research, across the lifespan, concerning the prevalence and characteristics of child and adolescent exposure to and use of the drugs and substances of abuse in North America.

Figure P.1 The Drugs and Substances of Abuse: The Abusable Psychotropicsa

aThe term psychotropics refers to all exogenous substances (i.e., chemicals, including plant products, drugs, and xenobiotics) that: (1) elicit a direct effect on the central nervous system resulting in changes in cognition, learning, memory, behavior, perception, or affect; and (2) are used specifically for these major effects. The psychotropics can be further divided into either abusable or nonabusable psychotropics. The regular, long-term use of the abusable psychotropics is generally associated with the development of physical and/or psychological dependence characterized by (a) the need to use more and more of the drug or substance of abuse in order to achieve desired psychotropic actions (i.e., because of the development of tolerance) and (b) a withdrawal syndrome that occurs with the abrupt discontinuation of its regular, long-term use and that is terminated immediately when use is resumed. The nonabusable psychotropics—anticonvulsants, antidepressants, antiparkinsonians, and antipsychotics (see Table P.1)—while also used for their major psychotropic actions, have not been consistently associated with physical or psychological dependence and thus are not considered in this reference text. The proposed classification presented here has been found to be both accurate and parsimonious. However, because the term abusable psychotropics may be awkward for many readers, we consistently use the more common phrase drugs and substances of abuse to denote this major class of chemicals, drugs, and xenobiotics.

Figure P.2 Patterns of Using the Drugs and Substances of Abuse and Associated Harm

TABLE P.1 The Abusable and Nonabusable Psychotropics

a See Chapters 1, The Psychodepressants, 2, The Psychostimulants, and 3, The Psychodelics for a comprehensive listing and discussion of the abusable psychotropics.

b Some abusable psychotropics (e.g., barbiturates, benozdiazepines) are clinically used as anticonvulsants. However, these listed anticonvulsants are not used as abusable psychotropics.

These health and social care professionals also require a reference text that provides up-to-date clinical pharmacological information about these drugs and substances of abuse and state-of-the-art clinical strategies that focus on: (1) identifying children and adolescents, a priori, who are at risk for using the drugs and substances of abuse; (2) assessing actual or potential harmful patterns of using the drugs and substances of abuse with attention to the personal and social consequences of such use; (3) providing effective treatment for children and adolescents when an active drug or substance use disorder is encountered; and (4) monitoring the efficacy of prevention and treatment approaches that have been implemented.

It is fairly axiomatic that an understanding of the nature and extent of child and adolescent exposure to and use of the drugs and substances of abuse is vital for optimal professional practice among all health and social care providers who have an interest in, and/or provide direct care to, North American children and adolescents. However, a few specific examples are offered to help to support this assertion. For example, this understanding will help to alert:

Juvenile justice workers to patterns of criminal and violent behavior that are associated with the use of particular drugs and substances of abuse, such as the use of gamma-hydroxybutyrate (GHB) and flunitrazepam (Roofies) for the perpetration of date-rape, particularly in the context of parties and raves, or the use of alcohol, amphetamines, cocaine, or phencyclidine (PCP) that can contribute to, or exacerbate, the perpetration of physical assault, including homicide.

Nurses to the accidental injuries and other health consequences, including death, that may be associated with the use of the various drugs and substances of abuse by children and adolescents, such as burns related to the use of the volatile solvent, gasoline, and sudden-sniffing-death associated with the use of the volatile inhalant, glue. It also will alert them, for example, to the need for the prevention of infections (e.g., hepatitis C, human immunodeficiency virus) associated with sharing contaminated intravenous needles and syringes or having unprotected sex with multiple partners—as occurs in the context of sex-for-drug exchanges.

Pharmacists to actual and possible problems such as significant drug interactions, polypharmacy, and illicit patterns of use (e.g., an adolescent selling his legitimate prescription for mixed amphetamines [Adderall®], which he received for the management of his attention-deficit/hyperactivity disorder [A-D/HD], at school to criminal youth gang members; a child who has Type 1 diabetes mellitus [insulin dependent] giving, selling, or trading her injection supplies [i.e., insulin needles and syringes] to siblings, friends, or parents to be used for the injection of their drugs and substances of abuse).

Physicians to rule out the use of drugs and substances of abuse by children and adolescents when formulating diagnoses (e.g., clinical depression; learning disorders; unexplained injuries) and when clinically monitoring therapeutic response (e.g., lack of therapeutic improvement). It also alerts them to the possibility of patients faking signs and symptoms to obtain prescriptions for desired drugs and substances of abuse (e.g., amphetamines; opiate analgesics) and to focus more carefully on the prevention of associated pathology (e.g., teratogenesis, such as the fetal alcohol syndrome [FAS]³ among offspring of adolescent girls who drink alcohol while pregnant).

Psychologists to the need to consider the use of drugs and substances of abuse by children and adolescents as a possible explanation for problem behavior (e.g., amotivational syndrome associated with cannabis use). It also will alert them to consider other mental disorders (e.g., anxiety disorders, major depressive disorder, and psychotic disorders, including cannabis-induced psychosis) that may occur with, or be masked by, the use of various drugs and substances of abuse.

Social workers to investigate high-risk drug or substance of abuse related problems in the home (e.g., child or parental physical, psychological, or sexual abuse; use as a marijuana grow-op or mom-and-pop meth lab) and community (e.g., increased presence and development of criminal youth gangs). It also alerts them to needed action to decrease associated potential harm to children and adolescents, their families, and their communities.

School psychologists and teachers to the effects of child or adolescent use of the drugs and substances of abuse on classroom performance (e.g., inattention; poor learning outcomes; memory impairment) and troublesome schoolyard behavior (e.g., bullying). It also alerts them to recognize that selling drugs and substances of abuse, and related crime and violence, do not stop at the schoolyard fence or even at the school’s main entrance.

Unfortunately, a true understanding of the nature of the use of the drugs and substances of abuse and the characteristics and extent of their use by children and adolescents is not easily gained by those who require this information and would benefit from it. There are many reasons for this situation, including:

1. An overwhelming majority of the published research findings and conclusions reported over the last decade in textbooks and journal articles, as well as over the Internet, provide very little direct attention and insight.⁴

2. Potentially valuable research often presents only equivocal or mixed results in terms of the incidence and consequences.⁵

3. Available published research findings and conclusions do not address children and adolescents in a major way and rarely separate children and adolescents from adults, either in research designs or in conclusions and recommendations.⁶

4. Authors often demonstrate a significantly biased perspective in their conclusions and recommendations. For example, some writers go to extremes in their attempts to inaccurately minimize, or trivialize, the harm associated with using various drugs and substances of abuse,⁷ perhaps, in order to rationalize their own use of these drugs and substances of abuse or to help further the social agenda for the decriminalization/legalization of all drugs and substances of abuse (i.e., these biased views are most often ensconced in a libertarian or secular progressive perspective that those authors are attempting to advance). Other writers may exaggerate associated harm, perhaps to rationalize harsh legal penalties and consequences associated with possession and use of the various drugs and substances of abuse. This latter viewpoint is often laden with moral underpinnings (i.e., that the use of a drug or substance of abuse is not only illegal but immoral—a view most often ensconced in a conservative perspective).⁸

Consequently, health and social care providers desperately require, but do not currently have, ready access to an objective, and subjectively explicit and truthful, reference—a scholarly reference that presents a deep depth and wide breadth of understanding coincident with a timely analysis and synthesis of the available research conclusions and recommendations regarding the status, trends, and individual pharmacology of the drugs and substances of abuse used by children and adolescents throughout North America. This text fills that void for required knowledge (i.e., current and accurate data and informed, reflective interpretation). Thus, this text assists readers to understand the use of the drugs and substances of abuse by children and adolescents in a current and unbiased context that reflects a comprehensive interpretation of the published research and related available information—complete with referenced documentation.

Since we began work on our first textbook, Problems in Pediatric Drug Therapy, which was initially published by Drug Intelligence in 1979, the particular needs of readers and our approach to preparing professional texts for publication have changed dramatically. For example, at that time there was no such thing as a personal computer (PC) or the Internet. The primary challenge for clinicians—our intended audience—was obtaining relevant published research findings that could be appropriately applied in their respective areas of clinical practice. This challenge motivated us in the early 1970s to begin work on our first clinical pharmacology text. At that time, we physically had to go through printed volumes of the Index Medicus, by hand, in order to find needed published journal article citations and, then, literally, go into the medical library stacks (i.e., the storage area for bound copies of published journals from the mid-1800s to date) in order to compile the data for the users of our texts. One difficulty was obtaining some of the most recent journal articles (i.e., those articles that were published over the last year or two) that were often waiting to be bound and added to the stacks. Journals that were waiting to be bound could not be borrowed, or checked out, or removed from the library. Thus, articles had to be read in the circulation area of the library and notes taken on index cards—copy machines had just been invented and were not widely available (1 or 2 per library), and the cost of Xeroxing an article seemed to be, for us at that time, a very high 25 cents per page. Thus, the primary challenge then was to find and access the rather limited amount of published data available (and often well and deeply hidden in the stacks of university medical libraries).

The challenge for us and our readers today has changed from too little available data to too much available data. So, too, has our approach to the preparation of clinical pharmacology and other texts, particularly those focusing solely on the drugs and substances of abuse, changed. We no longer have to physically go into the stacks in order to retrieve relevant data; most journal abstracts and articles can be accessed through numerous Internet sites where they can be read online or printed out immediately at minimal cost. In fact, prepublication copies of relevant research, reviews, and opinions are often available. Having turned in our electric typewriters long ago, we now can write, revise, store, manipulate, and send for immediate access drafts and final copies of texts with a click of a mouse. Thus, as noted, the challenge today is not so much the search for relevant available data of importance for the development of our ideas and texts but, instead, its compilation, sorting, analysis, interpretation, reflection, synthesis, and assimilation into what is most valid and reliable, or true, and most useful for clinical application (i.e., best practices) from a virtual mountain of data—some relevant, much not; some accurate, much not—before it is shared with the reader.

In addition to being of benefit to health and social care professionals, this text also should be of benefit to students who are assimilating knowledge in their respective fields of professional study. Last, but not least, we trust that it also may be of benefit to health and social policy makers (e.g., government officials, such as the Surgeon General; politicians, such as mayors and governors; public health administrators, such as the members of boards of public health or healthcare authorities; and social administrators, such as school principals and public school board members) who must increasingly address both the direct and indirect healthcare and social consequences and costs⁹ associated with the use of the various drugs and substances of abuse by children and adolescents and then appropriately deal with the related adverse impact on all levels and for all segments of North American society.¹⁰

In an effort to meet the identified informational needs of these health and social care professionals, students, and policy makers, this text presents the authors’ distillation and reflective interpretation of the current published clinical literature and available demographic statistical reports addressing the use of the drugs and substances of abuse among children and adolescents in North America. Historical and other relevant published literature (e.g., formalized theories, personal stories and experiences, citations from general review articles, significant textbooks, and helpful related Web sites) also have been used.¹¹

These data have been obtained from a variety of computerized (e.g., PubMed®) and non-computerized database sources utilizing available internet search engines (e.g., BING®; Google®) in order to more accurately reflect the diverse scientific findings, theoretical orientations, and clinically relevant views that exist in the study of why children and adolescents use the drugs and substances of abuse in various ways.¹²

The text is divided into three parts. Part I, Extent of Use and Pharmacological Considerations, contains three chapters: Chapter 1, The Psychodepressants; Chapter 2, The Psychostimulants; and Chapter 3, The Psychodelics. Each of these three chapters presents and discusses the general pharmacology of its respective major class of the drugs and substances of abuse—their mechanisms of action, associated toxicities, and signs and symptoms of overdosage. Particular attention also is given to the prevalence and characteristics of their current use among North American children and adolescents.

Part II, Developmental Considerations, presents three chapters that consider the use of the drugs and substances of abuse by children and adolescents¹³ from a developmental perspective. Chapter 4, Explaining Child and Adolescent Use of the Drugs and Substances of Abuse, presents contemporary theoretical explanations of why children and adolescents use alcohol and other drugs and substances of abuse. Although the preponderance of theorizing has been directed at explaining why children and adolescents drink alcohol and smoke tobacco cigarettes, theories attempting to explain cannabis, cocaine, methylenedioxymethamphetamine (MDMA, ecstasy), and opiate analgesic use, also are included. Major biological (e.g., genetic, neuropharmacological), psychological (e.g., learning, personality), and sociological (e.g., deviance, family systems, sociocultural) theories are addressed. The eclectic (interdisciplinary) and pluralistic (intradisciplinary) theories also are addressed.

Chapter 5, Exposure to the Drugs and Substances of Abuse from Conception Through Childhood, presents and offers detailed information about the potential teratogenic and fetotoxic effects of the drugs and substances of abuse on the developing embryo/fetus and neonate. Chapter 5 also presents a comprehensive overview of the drugs and substances of abuse that are excreted in breast milk and the potential risks to neonates and young infants who are breast-feeding. Also presented in this chapter are the effects of exposing infants, children, and adolescents to passive smoke by parents or primary caregivers who smoke cannabis (marijuana), tobacco cigarettes, cigars, or pipe tobacco, or other drugs and substances of abuse (e.g., crack cocaine) in their presence. Unintentional childhood poisonings involving the drugs and substances of abuse also are addressed in this chapter.

Chapter 6, Effects of the Drugs and Substances of Abuse on Learning and Memory During Childhood and Adolescence, presents and discusses the specific drugs and substances of abuse that can enhance learning and memory (e.g., nicotine [tobacco]) or impair it (e.g., cannabis). A cognitive input-output learning and memory model, which was originally developed by the authors over 30 years ago, is further developed and discussed using specific drugs and substances of abuse as examples in order to facilitate the readers’ understanding of how the use of the specific drugs and substances of abuse by children and adolescents directly affects their learning and memory. In addition, various related disorders (e.g., A-D/HD) are briefly presented and discussed, particularly those that are caused by, or are associated with, the use of the drugs and substances of abuse and significantly affect learning or memory, or both.

Part III, Clinical Considerations, concludes the text with three chapters. Chapter 7, Detecting Adolescent Use of the Drugs and Substances of Abuse: Selected Quick-Screen Psychometric Tests, presents, describes, and discusses several psychometric tests that can be used for detecting the use of specific drugs and substances of abuse by adolescents. Attention is given to the selection and clinical use of these psychometric tests and to their utility and limitations, including their general use, scoring, and associated statistics, such as their measures of sensitivity, specificity, validity, and reliability.

Chapter 8, Dual Diagnosis Among Adolescents, presents an overview of the substance use disorders (SUDs) that may occur concomitantly among adolescents with other mental disorders (OMDs), including anxiety disorders, depressive mood disorders, and psychotic disorders. Also discussed is the relationship between SUDs and sexual or gender identity disorders. The prevalence of these disorders among adolescents and related factors are discussed with emphasis on the importance of accurate diagnosis and the inter-relationship of these co-occurring mental disorders.

Chapter 9, Preventing and Treating Child and Adolescent Use of the Drugs and Substances of Abuse, focuses on specific strategies and programs aimed at preventing the initial use of the drugs and substances of abuse by children and adolescents and treating various levels, or patterns, of use once use has been initiated in order to prevent associated harm. Age-specific primary, secondary, and tertiary prevention strategies, including relapse prevention, are identified and discussed. School-based programs; family therapy; social skills training; Alcoholics Anonymous; therapeutic communities; and short-term residential programs, including age-specific treatment programs, also are discussed. In addition, attention is given to the role that pharmacotherapy plays in treating and managing adolescent SUDs, including: (1) substance-assisted abstinence and substitution (e.g., nicotine [Nicorette®, Nicotrol® for tobacco cessation programs]); (2) antidotes for specific acute overdosage (e.g., naloxone [Narcan®] for opiate analgesic overdosage); (3) treatment of withdrawal syndromes, particularly those associated with the use of the various benzodiazepines (e.g., diazepam [Valium®] to prevent or manage sedative-hypnotic withdrawal syndromes); and (4) abstinence maintenance (e.g., methadone [Dolophine®] for opiate analgesic dependence).

Chapter 9 also presents the Meta-Interactive Model of Child and Adolescent Use of Drugs and Substances of Abuse. This multivariate, interactive model was specifically developed by the authors to facilitate a better understanding among readers of the many interacting variables that have been related to, or have been identified as influencing, the use of drugs and substances of abuse by children and adolescents. Comprised of four major variable dimensions, particular attention is given to the child or adolescent dimension and its interaction with the other three dimensions—the drug or substance of abuse dimension, societal dimension, and time dimension—in order that these interactions can be more fully and properly understood in an actual clinical context.

The backmatter consists of the appendix, which lists abbreviations used in the text, and the reference list, which is a comprehensive, alphabetized listing of all of the published references and other data sources cited in this text. These references are prepared in the standardized format of the American Psychological Association (APA) and listed in alphabetical order by the surname of the primary author. A comprehensive subject index follows. This cross-referenced subject index was carefully constructed by the authors in order to facilitate rapid and accurate retrieval of needed information.

By reading the information presented in this text, health and social care professionals, students, and policy makers alike should better understand the current, unique nature and extent of the exposure to, and use of, the various drugs and substances of abuse by children and adolescents in North America and the associated direct impact on their health, safety, and well-being as well as on that that of their families and their communities. By understanding the extent of child and adolescent exposure to and use of the drugs and substances of abuse, and the associated pharmacological, developmental, and clinical aspects of this exposure and use, health and social care professionals, students, and policy makers should be better able to develop and provide appropriate and effective prevention and treatment services for children and adolescents.

It is our fervent hope that, by using the information presented in this text and working together with children and adolescents and their families and communities, optimal health, safety, and well-being may be achieved for the countless children and adolescents in North America who, in various ways and to various degrees, have been, are, or will be adversely affected by the exposure to and use of the various drugs and substances of abuse.

Louis A. Pagliaro

Ann Marie Pagliaro

2012

Common sense in an uncommon degree,

Which has been derived experientially over time,

Is called wisdom . . .

—Sun Tzu/Pagliaro

¹See related discussion in Chapter 1, The Psychodepressants, Chapter 2, The Psychostimulants, and Chapter 3, The Psychodelics, for specific detailed information regarding these drugs and substances of abuse and their use by North American children and adolescents.

²We now find ourselves in the midst of reaping the whirlwind because of the woeful inattention over the past three decades by society, in general, and the North American governments, in particular, to the serious nature and growing extent of problems associated with the use of the drugs and substances of abuse by children and adolescents. This situation will be examined in depth in the chapters of this text.

³Fetal alcohol syndrome also is commonly referred to in the published literature as the fetal alcohol spectrum disorder (FASD). For additional discussion, see Chapter 5, Exposure to the Drugs and Substances of Abuse from Conception Through Childhood.

⁴Some of these limitations in research design, methods, and dissemination of results are understandable because of the difficulty inherent in obtaining data from children and adolescents. As minors who are identified as a vulnerable population group, children and adolescents require their own consent (and/or assent) to participate in research studies as well as that of their parents or legal guardians and schools or school districts if the research is being conducted in school. In addition, the nature of the very behavior being studied (i.e., use of the drugs and substances of abuse) is generally illegal and, therefore, makes it more difficult to obtain accurate reports of behavior from participants who may fear being arrested or having their parent(s) informed about their illegal behavior.

⁵In addition, these published research studies often conclude with the phrase: more (or additional) research is necessary. Therefore, the use of potentially helpful findings is limited because of the need for study replication or extension into more specific population groups (e.g., boys versus girls, tweens versus teens). In addition, the phrase is rarely followed with specific recommendations for replicating the study or for research questions aimed at extending the reported findings.

⁶In these studies, the population sample, while often including adolescents, is generally age neutral when results are presented (i.e., the subjects may be identified solely as, for example, Americans of Hispanic descent or as 16 years of age and older).

⁷Such authors may use, for example, the accurate but deliberately misleading argument that the harm associated with the use of marijuana in North America would be, in comparison, significantly less than that associated with the use of alcohol (see related discussion in Chapters 1, The Psychodepressants, and 3, The Psychodelics).

⁸On this point, it should be made explicit that we tend to view the use of the various drugs and substances of abuse as being neither good nor bad, neither moral nor immoral. As scientists rooted in several views of science (e.g., positivism, postpositivism, postmodernism) and as expert clinicians, our focus instead is on evaluating the results of these sciences based on their inherent assumptions, research methods, and claims to fact (i.e., their theories and inherent truth). Most important, as subscribers to the scientist-clinician model, we are concerned with the contribution of a study or research program in regard to its ability to further knowledge and understanding that will lead to valuable outcomes for children and adolescents in regard to their use of the drugs and substances of abuse. Thus, we are concerned with the result of the interaction of the use of a particular drug or substance of abuse by a particular child or adolescent in a particular context (e.g., the use of an opiate analgesic, such as morphine, for a child hospitalized with a broken leg to relieve his pain versus the use of morphine by a homeless adolescent girl that results in her death due to an overdosage). Thus, for us, it is not the use of a particular drug or substance of abuse by a particular child or adolescent that is good or bad. Rather, it is the result or outcome of the use of the drug or substance of abuse by a particular child or adolescent in a particular context that is good or bad.

⁹ These costs are: (1) biological (e.g., physical injuries to body systems, such as cirrhosis of the liver related to chronic alcohol use, which is being identified at younger ages, or lung cancer related to tobacco smoking which usually begins during adolescence); (2) psychological (e.g., emotional distress and mental disorders, such as amphetamine-related psychosis or cannabis-related memory impairment); and (3) sociological (e.g., child neglect and family violence related to the use of the drugs and substances abuse, particularly alcohol, cocaine, or methamphetamine, by parents or caregivers).

¹⁰For example, in regard to learning and school achievement (see Chapter 6, Effects of the Drugs and Substances of Abuse on Learning and Memory During Childhood Adolescence).

¹¹It is important to note that this reflective interpretation of the available published data has been performed by the authors in the combined context of over 70 years of academic experience and clinical practice in the fields of pharmacology and psychology specifically dealing with clinical issues related to the use of the drugs and substances of abuse. The authors used this method of analysis and synthesis of these published data (i.e., data produced from the three contemporary views of science—positivism, postpositivism, and postmodernism—that dominate knowledge and its production at the present time) to help to ensure, for the reader, the data’s proper evaluation and the best approximation of truth (i.e., in an earnest attempt to eliminate, or at least minimize, any potential biases).

¹²Hand searches of the available databases were completed to complement the computer searches of relevant databases and to validate and extend the conclusions proffered by the original sources and their suggested leads.

¹³The term adolescence is currently widely defined as the second decade of life and thus includes people who are 10 years of age to 20 years of age. Accordingly, childhood is defined as the first decade of life and thus includes people who are 1 year of age to 10 years of age. However, in regard to developmental abilities and the characteristic patterns of using the drugs and substances of abuse, we also, where necessary and appropriate, use the conventional divisions, including: neonate, covering the first 30 days of life; infant, covering the first year of life; toddler, covering 1 to 3 years of age; preschooler, covering 3 to 5 years of age; child, covering 5 to 12 years of age; preadolescent, 12 to 13 years of age; adolescent, 13 to 18 years of age; and young adult, 19 to 25 years of age. In addition, in order to avoid any additional confusion when presenting research findings, we provide, whenever possible, the specified age ranges for participants in research studies that are cited and also include the reported primary and secondary school grade levels.

Acknowledgments

We wish to acknowledge and express our sincerest gratitude to John Wiley & Sons for our long and positive working relationship that began in the early 1990s. We also would like to express our sincere appreciation to all of the employees at Wiley for their diligent and professional work on this text. Particularly, we would like to acknowledge: Marquita Flemming, the senior editor for this text; her excellent editorial assistants, Fiona Brown and Sherry Wasserman; and Leigh Camp, the production editor for this text. Thank you again to all the staff at John Wiley who worked so hard on this text.

We also wish to acknowledge and express our sincerest thanks to all of the readers of our various texts. For over 30 years, they have been our silent, but essential, partners in our efforts to reduce the incidence of drug and substance abuse in North America and to effectively treat as many patients as possible who are suffering as a result of these disorders. We are confident that you, our readers, will find this text to be the quintessential text on child and adolescent drug and substance abuse in your library and, as such, it will provide you with valuable data and tools to assist you in your professional efforts on behalf of affected children and adolescents and their families.

PART I

Extent of Use and Pharmacological Considerations

CHAPTER 1

The Psychodepressants

INTRODUCTION

The first major group of the drugs and substances of abuse that is discussed in this reference text is the psychodepressants. (See Figure 1.1.) These drugs and substances of abuse can be divided into three major subgroups: (1) opiate analgesics, (2) sedative-hypnotics, and (3) volatile solvents and inhalants. (See Table 1.1.) This chapter presents an overview of each major subgroup of the psychodepressants with attention to the prevalence and characteristics of their use among children and adolescents across North America. It also presents an overview of their general pharmacology—their proposed mechanisms of psychodepressant action and common toxicities, including their propensity for physical and psychological dependence and for overdosage.

Figure 1.1 The Psychodepressants

TABLE 1.1 The Psychodepressants

a Examples of common brand/trade names are provided, when available.

b Partial list. Examples of three to five of the most common street names are provided, when available. See Pagliaro and Pagliaro (2009) for a comprehensive listing of the drugs and substances of abuse and their common street names.

c Usually available as one of the ingredients in a multi-ingredient product (e.g., Empirin® #4; Tylenol® #4).

d Usually available as one of the ingredients in a multi-ingredient product (e.g., Lortab®, Vicodin®).

e In December 2010, the FDA removed propoxyphene from licit production and use within the United States. This action followed a similar move in Europe and was in response to related risk for developing potentially serious, or even fatal, cardiac dysrhythmias associated with propoxyphene use (Gandey, 2010).

f Butalbital is available only in combination products (e.g., Fiorinal®).

g Although not legally produced in North America, flunitrazepam is widely available worldwide under the brand/trade name Rohypnol® It is commonly known and used as a date-rape drug.

h Available as beers, wines, and distilled spirits.

i Usually available by generic name.

j Partial list.

Before beginning this overview, it is important to note that much of the information presented in this chapter in regard to demographics and use statistics, as well as that presented in Chapter 2, The Psychostimulants, and Chapter 3, The Psychodelics, is based on government-supported or sponsored national surveys. While generally constructed to be valid and reliable measurement instruments, these surveys suffer from some noted limitations that may affect the generalizability of their related findings and also bias readers toward trends of use that are significantly lower than they actually are. As such, they may detrimentally influence decisions regarding the need for prevention and treatment programs aimed specifically at children and adolescents. These noted limitations include nonrepresentative, nonstratified sampling flaws that rely very heavily—and in some cases exclusively—on: (1) data obtained from convenience samples of children and adolescents who are attending school and ignore other groups of children and adolescents; and (2) methodological flaws, such as sampling and collecting data solely by telephone contact surveys.

Even when the survey methods are inclusive in terms of sampling techniques, they may suffer from other inherent limitations that require explicit identification and discussion. For example, limitations in sampling methods are relatively common as most surveys generally do not include data from children and adolescents who are usually identified as being at particular high risk for using the drugs and substances of abuse. These children and adolescents include

1. Homeless, runaways, or those living on the streets

2. Absent or truant students or school drop-outs who are not in attendance at the school when the survey is administered

3. Those incarcerated in youth correctional facilities

4. Those living in homes that do not have a land-line telephone¹

5. Those living on American Indian/Canadian Aboriginal reservations and reserves, respectively

Thus, the findings of the national surveys and reports generally tend to underestimate the use of the drugs and substances of abuse by North American children and adolescents. In order to address this limitation of these widely cited national government-supported and sponsored surveys and reports, we have included, whenever possible, the findings of studies and reports that specifically address the generally higher-risk subpopulations of children and adolescents that the large, national surveys often miss or neglect.

OPIATE ANALGESICS

The opiate analgesics comprise a group of natural (e.g., morphine; codeine), semisynthetic (e.g., heroin; hydrocodone [Lortab®]; oxycodone [OxyContin®]), and synthetic (e.g., meperidine [Demerol®]; pentazocine [Talwin®]) derivatives of the opium resin that is obtained from the plant Papaver somniferum—the poppy that causes sleep. One to three weeks after flowering, the opium resin is harvested from the unripe seed pod and dried.² Classified as an herb, Papaver somniferum is indigenous to southeastern Europe and western Asia where it has been widely cultivated for millennia. It also has been introduced to other countries throughout the world by travelers and immigrants. However, climatic conditions similar to those of southeastern Europe and western Asia are required for its successful cultivation.

Prevalence and Characteristics of Opiate Analgesic Use Among North American Children and Adolescents

During the 1990s, the use of prescription opiate analgesics (e.g., hydrocodone [Hycodan®]) rapidly increased among adolescents. In fact, the use of hydrocodone became epidemic in California, where it also was commonly used by movie stars and other celebrities. Traditionally, youth were thought to be at low risk for opiate analgesic use. However, it was during this time that changes in the availability of opiate analgesics and their methods of use (i.e., intranasal insufflation, or snorting) significantly increased their popularity among high school students, particularly in the United States (Pagliaro & Pagliaro, 2009). Today, hydrocodone actively competes with the other opiate analgesics³ for first place.

For example, over 10% of U.S. high school seniors who were surveyed between 2002 and 2006 reported nonmedical use of an opiate analgesic. The majority of these students reported using opiate analgesics to: (1) feel good and get high, (2) see what it’s like, and (3) have a good time with friends (Anderson, 2009). A series of national studies surveyed adolescent use of the drugs and substances of abuse in the United States from 2002 through 2010. These studies found a similar incidence of approximately 13% for reported use of opiate analgesics other than heroin (e.g., hydrocodone [e.g., Vicodin®, a combination product] and oxycodone [OxyContin®]) (Johnston, O’Malley, Bachman et al., 2008, 2010b).⁴ In regard to these same prescription opiate analgesics, the national study of U.S. adolescents conducted by the Partnership for a Drug-Free America (2006) found that: (1) a majority of adolescents (i.e., 62%) reported that opiate analgesics are easily obtained from parents’ medicine cabinets; (2) almost a third of adolescents (32%) reported that opiate analgesics are readily available and easily purchased over the Internet; and (3) a significant percentage of adolescents (i.e., 37%) reported having friends who used opiate analgesics.

The largest group of opiate analgesic users among children and adolescents is street users—children and adolescents who are homeless, or runaways, and living on the street. Heroin is the primary drug of choice. Currently, approximately 40% of the heroin that reaches North America comes from the opium grown in Afghanistan, Burma, Iran, and Pakistan. Most of the opium is processed into heroin in these countries, with the remainder being processed in Italy, primarily in Sicily. Since the early 1990s, the bulk of the remaining heroin that reaches the streets of the United States (about 40%) comes from opium that is grown in the western hemisphere, primarily from the countries of Colombia and Mexico. Mexico alone supplies a significant and increasing proportion of heroin (about 30%) to the United States, primarily in the form of black tar heroin.

In their survey, Johnston, O’Malley, Bachman, et al. (2008) found that 1% of high school students reported having used heroin within the previous 12 months. The incidence of heroin use varies with fluctuations in availability and with continental descent or ethnicity. In this study and most others, North American adolescents of Hispanic descent report a significantly higher incidence of heroin use than do adolescents of other continental descents or ethnicities. For example, over 5% of high school students who were sampled in Arizona and New Mexico in 2007 reported having used heroin (M. P. O’Brien, 2008).⁵ Approximately 1.5% of Americans 18 years of age or older reported having used heroin at least once in their lifetime (Heroin Use USA, 2010).⁶ It is interesting to note that most adults who are regular, long-term heroin users report that they began their heroin use during late adolescence (i.e., around 16 years of age) (Pagliaro, Pagliaro, Thauberger, et al., 1993; Pagliaro & Pagliaro, Clinical Patient Data Files). In comparison, the Partnership for a Drug-Free America (2006), in its nationwide survey of over 7,000 adolescents, found that 5% of their sample reported having tried heroin and 16% reported having a close friend who had used heroin. An apparently related finding is that, since 1999, fewer and fewer adolescents report that they view heroin as a dangerously addictive drug.

Currently, opium and heroin production is at an all-time high. Transshipped from Asian and Colombian sources to North America for distribution at specified geographical locations, heroin is readily available in both higher concentrations and higher purity than it was during the last 4 decades.⁷ Its distribution and commerce in the United States and Canada is largely controlled by ethnically defined criminal gangs.⁸ Much of the actual distribution and street-level sale of this heroin is accomplished by criminal youth gangs, whose members are both more desperate and desirous of the money to be made and less likely, if arrested, to serve any significant jail time because of their ages (Pagliaro & Pagliaro, Clinical Patient Data Files). The ready availability of this high-grade heroin, at relatively low prices, has contributed significantly to an increase in intranasal use (i.e., snorting), particularly among adolescents living in suburban areas.⁹

While the norm for the 1950s, 1960s, 1970s, and 1980s was the intravenous injection of heroin, only approximately 40% of heroin users in North America, men and women alike, now intravenously inject heroin (Pagliaro & Pagliaro, 2009). A re-emerging trend from the 1970s is the more casual, nonintravenous, nondaily, social use of heroin. In the 1970s, this pattern of use was often referred to as chipping (Hanson, 1985). Chipping is a technique in which heroin, rather than being intravenously injected, or mainlined, is subcutaneously injected. However, these more casual heroin users now generally completely avoid needles and syringes by either chasing the dragon (i.e., orally inhaling heroin vapor through a glass tube, or rolled currency, that is held in the mouth) or snorting (i.e., intranasally insufflating the heroin in its powder form). They also may use intranasal instillation, or instill what is known on the street as heroin nose drops¹⁰ into the nostrils in much the same way as they would common nose drops.

Most adolescent heroin users who do not initially inject heroin intravenously but continue to use it usually begin intravenous injection by the time they are young adults. This change in method of use is generally related to both the desired actions associated with heroin use and economics. For example, while desired psychodepressant actions can be achieved with intranasal use, this requires the use of heroin that is higher in purity and concentration and, consequently, more expensive than heroin that can be intravenously injected. Both the desired psychodepressant actions of heroin and a very pleasant rush¹¹ can be achieved with the intravenous injection of lower-quality, and less expensive, heroin.

General Pharmacology

This section discusses the general pharmacology of the opiate analgesics—their apparent mechanisms of psychodepressant action; common toxicities, including their propensity for physical and psychological dependence; and overdosage.

Proposed Mechanism of Psychodepressant Action

The various opiate analgesics primarily achieve their unique and desired psychodepressant actions by acting at specific receptor sites in the brain and the spinal cord. Five major groups of opiate, or endorphin, receptors have been identified: delta, epsilon, kappa, mu, and sigma. Pure opiate analgesic agonists (see Table 1.1) act at the delta, mu, and kappa receptors. These receptors are found in the highest concentrations in the brain stem; cortex; limbic system, including the hypothalamus; midbrain; spinal cord; and thalamus (see Figure 1.2). Acting at the delta receptors, they primarily mediate spinal analgesia. Acting at the mu receptors, specifically the mu 1 and mu 2 receptors, they primarily mediate, respectively, analgesia and various physiologic functions, including: slowing gastrointestinal (GI) motility; causing pupil constriction, or miosis; and depressing respiratory function. The mu 2 receptors also mediate feelings of euphoria and dysphoria and the development of physical dependence (i.e., the development of tolerance to the opiate analgesic agonists and the characteristic opiate analgesic withdrawal syndrome that occurs when they are abruptly discontinued). Kappa receptors mediate analgesia, other than that mediated by the mu 1 receptors; dysphoria; miosis; and respiratory depression. Mixed opiate analgesic agonists/antagonists (e.g., butorphanol [Stadol®], nalbuphine [Nubain®], pentazocine [Talwin®]) appear to act primarily at the kappa receptors. The nausea and vomiting associated with the opiate analgesics are related primarily to their stimulation of the chemoreceptor trigger zone in the medulla oblongata of the brain stem.

Figure 1.2 Opiate Analgesic Receptors and Sites

Common Toxicities

Several significant toxicities, or adverse effects, have been associated with the use of the opiate analgesics—directly related to their pharmacologic actions and indirectly related to their methods of use. Direct toxicities, which can be acute or chronic, affect most body systems, including the cardiovascular, central nervous, GI, and respiratory systems. (See Table 1.2.) Indirect toxicities have been associated particularly with both the intranasal and intravenous use of the opiate analgesics.

TABLE 1.2 Signs and Symptoms of Acute and Chronic Opiate Analgesic Toxicity

Intranasal Use

Intranasal use of the opiate analgesics, which became increasingly prevalent during the 1990s, has been associated with several adverse effects, including: (1) erosion of the lateral nasal walls, nasopharynx, and soft palate; (2) fungal invasion of the nasal surfaces and rhinosinusitis; (3) infections involving the nasal surfaces with associated mucopurulent exudates; and (4) nasal septal perforation. In addition, severe, life-threatening asthma attacks have been associated with intranasal sniffing (snorting) of heroin by people who have preexisting asthma.¹²

Intravenous Use

The adverse effects associated with the intravenous use of the opiate analgesics are often serious, including:

Human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS)

Abscesses and infections at injection sites

Cardiovascular abnormalities, including scarred and collapsed veins

Respiratory abnormalities, including talc granulomas

Hepatitis

Tetanus

(See Table 1.3). These adverse effects and their associated complications are not caused by the opiate analgesics themselves; rather, they are caused by the adulterants used to cut the opiate analgesics for illicit use, nonsterile or shared needles and syringes, and improper injection techniques. It is important to note that if opiate analgesics were ingested, or even smoked or snorted, most of these adverse effects and more serious complications, including those that are life-threatening, would not occur.

TABLE 1.3 Indirect Toxicities Associated With the Intravenous Injection of the Drugs and Substances of Abuse

aOften is a long-term, chronic condition. When affecting the lower extremities, it can be debilitating.

bOften requires removal of the infected body tissue or, depending on the extent of the infection, amputation of the fingers, hand, toes, or foot.

cOften a precursor to cirrhosis of the liver or cancer of the liver (i.e., hepatocellular carcinoma), either of which may be fatal or require liver transplantation. The most common cause of hepatitis C in North America is the sharing of contaminated needles and syringes.

Notes: These toxicities are identified as indirect toxicities because they are not directly associated with the specific pharmacological actions of the specific psychodepressant drug or substance of abuse itself but rather with the general method of administration: intravenous injection.

Commonly used anatomic sites for intravenous injection of the various drugs and substances of abuse, in decreasing order of use, include the antecubital fossa, forearm, hand, foot, leg, breast, groin, and neck (Pagliaro & Pagliaro, Clinical Patient Data Files).

Adulterants (e.g., quinine) and small, unfiltered particles (e.g., powder, talc, and other components of the drug or substance of abuse being injected) significantly contribute to these harmful effects. In addition, unsterile injection equipment, poor methods of injection, and poor hygiene contribute as well.

M. P. O’Brien (2008), reporting for the Community Epidemiology Work Group of the NIDA, found that 2% of U.S. high school students reported lifetime use of illegal injection drugs. As a cross-check of this finding, we note that Johnston, O’Malley, Bachman, et al. (2010b), in their in-school 2010 survey of adolescent use of the drugs and substances of abuse, found that approximately 1% of 8th-grade students, 10th-grade students, and 12th-grade students reported a lifetime prevalence of using a needle to self-administer heroin.

Physical and Psychological Dependence

The development of both physical and psychological dependence has been associated with the long-term, regular use of the opiate analgesics. Thus, the abrupt discontinuation of this pattern of use will result in the opiate analgesic withdrawal syndrome. This syndrome also may occur among regular, long-term users of opiate analgesic agonists (e.g., those users who are physically dependent on heroin or morphine) when an opiate analgesic antagonist (e.g., naloxone [Narcan®]) or a mixed opiate analgesic agonist/antagonist (e.g., pentazocine [Talwin®]) is used. The signs and symptoms of the acute opiate analgesic withdrawal syndrome are listed in Table 1.4. Although this withdrawal syndrome is not usually fatal, generally it should be medically managed with appropriate pharmacotherapy and monitoring, particularly when children and adolescents are involved. For children and adolescents who are undergoing detoxification for physical dependence on opiate analgesics, the gradual discontinuation of the opiate analgesic will help to prevent, or minimize, these signs and symptoms. Unfortunately, following detoxification and treatment, relapse commonly occurs.

TABLE 1.4 Opiate Analgesic Withdrawal Syndrome: Common Signs and Symptoms

Overdosage

Opiate analgesic overdosage requires emergency medical support, particularly for the management of the respiratory depression that is characteristically associated with overdosages involving this subclass of the psychodepressants. Attention also must be given to increasing opiate analgesic elimination. Naloxone (Narcan®), a pure opiate analgesic antagonist, is the specific antidote for the respiratory depression associated with overdosages involving opiate analgesic agonists and mixed opiate analgesic agonist/antagonists. However, it must be administered cautiously to children and adolescents who may be physically dependent on opiate analgesics because the usual dosage of the antagonist may precipitate the opiate analgesic withdrawal syndrome.¹³ Common signs and symptoms of opiate analgesic overdosage are listed in Table 1.5.

TABLE 1.5 Opiate Analgesic Overdosage: Common Signs and Symptoms

It is important to note that many cases of opiate analgesic overdosage also involve other drugs and substances of abuse. For example, psychostimulants (see Chapter 2, The Psychostimulants), such as cocaine and methamphetamine, are concomitantly used, particularly with heroin (i.e., speedball). However, more common, and deadly, is the concomitant use of other psychodepressants, such as alcohol and the benzodiazepines (see Sedative-Hypnotics section for additional related discussion). These psychodepressants potentiate the respiratory depression associated with opiate