4/14/05njm

**Q. What types of drug testing are indicated in pregnancy?**

A. Universal screening questions **AND** targeted biochemical clinical
testing. See details

**Background**

Abuse of alcohol and drugs is a major health problem for American women
across differences in socioeconomic status, race, ethnicity, and age,
and it is costly to individuals and to society. We should learn and use
a protocol for universal screening questions, brief intervention,
further assessment -- the 5 P's - that walk a provider through to
clearly linked and defined steps, and referral to treatment in order to
provide patients and their families with medical care that is
state-of-the-art, comprehensive, and effective.

There are significant ethical issues involved, so one must be aware of
the common ethical dilemmas related to drug and alcohol use that arise
in the clinical setting. My suggestion is to have a frank discussion of
the issues with your Native board before proceeding with any policy.

How will this help the issue versus just call attention in a negative
way? There should be a clear linked process from screening to treatment
needs to be articulated.

This topic has to the potential to be a very complicated issue,
especially from a political standpoint. My advice is to keep your
policy/procedure as simple as possible and well within the realm of
clinical practice and based on your population.

**Different indications for drug testing**

NB: Not all drug 'testing' is 'screening'

First, let us not confuse overlapping issues, e.g., there are at least
4-5 separate issues

A.)

Clinically indicated drug testing of pregnant mother - this is not drug
screening, it is testing the mother because she bleeding, changing her
cervix, need to know for anesthesia and medications, etc\....

B.)

Targeted Drug testing - this is performed after the verbal 5 P's or 4
P's, IHS No. 866, or a CAGE-like screen. The verbal screens may be
confirmatory, qualitative, or quantitative.

If the pregnant patient answers yes to the questions, then you ask her
to submit a biochemical test.

If she says No, then you document that fact, as well.

C.)

Universal screening - screening all comers based on some common
characteristic, e.g., all patients presenting to this clinic, or that
L/D unit.

This type of testing is reserved for areas where the Native Board has
approved it. As it is, exposures may be hidden, or clinically obvious.
This modality would only be indicated if there were good treatment
modalities and referral systems in place when one obtains a positive
result.

D.)

Clinically indicated drug testing of an infant - this is not drug
screening of the infant; this is testing of an infant because he/she is
sick.

Yes this last method also secondarily implies something about the
mother, but the infant is a dependent individual and needs to be tested
be primarily for infant reasons. Maternal autonomy is discussed below.

E.)

See Other issues below

**So, the short answers are:**

1.) All Indian Health centers should be documenting the standard verbal
universal screening questions as per Indian Health and ACOG
recommendations. (below)

2.) There should be targeted biochemical testing based on clinical
indications.

3.) Screening, for without clinical indications is reserved for Native
Board approval of guideline

**A. Here is what the Indian Health Manual states**

[Chemical Abuse Assessment and Counseling]{.underline} -Screening for
alcohol or substance abuse will be completed at the initial visit.
Counseling and education should be provided to all patient6 as to the
effect these substance6 have upon the women\'s health and the
development of the fetus. A management plan should be developed by a
multidiscipline team for all identified abusers

IHS Manual, Part 3: Chapter 13 - Maternal Child Health, 3:13.2 F (2) f

<http://www.ihs.gov/PublicInfo/Publications/IHSManual/Part3/pt3chapt13/pt3chpt13.htm>

**B. Here are the ACOG Resources**

At-risk drinking and illicit drug use: ethical issues in obstetric and
gynecologic practice. ACOG Committee Opinion No. 294. American College
of Obstetricians and Gynecologists. Obstet Gynecol 2004;103:1021--31.

**Non - ACOG Members**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15121596>

**ACOG Members**

<http://www.acog.org/publications/committee_opinions/co294.cfm>

Substance Abuse ACOG Technical Bulletin, No. 194, July 1994

**ACOG Members**
<http://www.acog.org/publications/educational_bulletins/btb194.htm>

**Are there good verbal screening tools?**

The 5 P's and the 4 P's are very straightforward approaches to
documentation

(both instruments below -- see Other Resources)

Here is one good instrument on an IHS form

**Indian Health [Prenatal assessment Form: ETOH, substances,
DV](http://www.psc.gov/forms/IHS/ihs-866.pdf)**

<http://www.psc.gov/forms/IHS/ihs-866.pdf>

By the way, a CAGE instrument may not be all that an effective tool for
adolescents. There may better perinatal screens that while less invasive
at first, get at the issue of use in the context of family paradigm.
Contact: Judith Thierry <Judith.Thierry@ihs.gov>

Knight JR, Sherritt L, Harris SK, Gates EC, Chang G. Validity of brief
alcohol screening tests among adolescents: a comparison of the AUDIT,
POSIT, CAGE, and CRAFFT. Alcohol Clin Exp Res. 2003 Jan;27(1):67-73.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12544008>

**What are the clinical Indications for Drug Screening in Pregnancy ?**

**Here is a compendium of all various maternal clinical indications**

No prenatal care

Late prenatal care after 24 weeks gestation

Incomplete prenatal care (\<4 visits by 3^rd^ trimester)

Abruptio placentae

Intrauterine fetal death

History of substance abuse in this pregnancy

Preterm labor (Not POOC)

IUGR, intrauterine growth restriction 'of no obvious cause',

Previously known drug or alcohol abuse

Unexplained congenital anomalies

Current signs and symptoms of acute intoxication

# Neonatal indications 

History of substance abuse in this pregnancy

Preterm labor (Not POOC)

Placental abruption

Unexplained neonatal depression, seizures, jitteriness or possible
neonatal

abstinence syndrome

**Informed consent**

Some centers have chosen to get verbal consent for all testing, both
screening and clinically indicated. In those settings, pregnant women
and postpartum mothers are informed that a biochemical test will be
evaluated based on their standard guidelines. Written consent is not
required. If the patient refuses to allow a maternal biochemical test,
then that request should be noted and honored. Parents do not have a
legal right to decline a medically indicated infant biochemical testing.

**Please see University of New Mexico Urine Drug Monitoring Guidelines**

<http://www.ihs.gov/MedicalPrograms/MCH/m/documents/UNMScr.doc>

**Please see DRAFT OB Generic Department Guidelines**

<http://www.ihs.gov/MedicalPrograms/MCH/m/documents/ScrOBdraft.doc>

**Here are some slightly more involved answers:**

As there are a significant percentage of patients who use illicit drug
use that are not discovered in a verbal screening program, there could a
simple elegance of process and public health dividend from universal
drug screening in pregnancy.

Making a universal drug screening program work in any setting is really
dependent on the local Native prerogatives. When presented with this
topic, e.g., universal biochemical testing, some tribal boards reject it
because it is thought to label all our local Native women as somehow
tainted with a question of drug abuse. On the other hand, in areas with
significant current negative drug impacts, e.g., current Methamphetamine
use, a local tribal board may have a completely different response.

A center would only embark on this type of enterprise, if they had good
treatment resources to refer the patient.

 

**The Ethical Rationale for Universal Screening Questions, Brief
Intervention, and Referral to Treatment**

Support for universal screening questions, brief intervention, and
referral to treatment is derived from 4 basic principles of ethics.
These principles are 1) beneficence, 2) non-malfeasance, 3) justice, and
4) respect for autonomy.

**Ethics of Drug Testing**

Since positive results have implications for patients that transcend
their health, they should give informed consent prior to testing. When
there is no suspicion of substance abuse, random checks of a patient\'s
urine for substances are unethical. A false-positive from such testing
might have devastating consequences for the patient and clinician. The
patient\'s medical records are confidential, and protection of her
rights is of the utmost importance.

Medical circumstances occasionally arise in which this consent is
considered unnecessary or unobtainable. Patients who are in a stupor,
unconscious, or show obvious signs of intoxication need to be tested in
order to direct further medical interventions.

Substance Abuse ACOG Technical Bulletin, No. 194, July 1994

ACOG Members
<http://www.acog.org/publications/educational_bulletins/btb194.htm>

As clinically indicated drug screening is an accepted practice, one
should also take care to use an appropriate set of possible indications
in their drug screening policy. According to the American Academy of
Pediatrics\' statement on neonatal drug withdrawal, maternal
characteristics that suggest a need for biochemical screening of the
neonate include no prenatal care, previous unexplained fetal demise,
precipitous labor, abruptio placentae, hypertensive episodes, severe
mood swings, cerebrovascular accidents, myocardial infarction, and
repeated spontaneous abortions. Infant characteristics that may be
associated with maternal drug use include preterm birth, unexplained
intrauterine growth restriction, neuro-behavioral abnormalities,
congenital abnormalities, atypical vascular incidents, myocardial
infarction, and necrotizing enterocolitis in otherwise healthy term
infants. The legal implications of testing and the need for maternal
consent vary from state to state; therefore, physicians should be aware
of local laws that may influence regional practice

At-risk drinking and illicit drug use: ethical issues in obstetric and
gynecologic practice. ACOG Committee Opinion No. 294. American College
of Obstetricians and Gynecologists. Obstet Gynecol 2004;103:1021--31.

<http://www.acog.org/publications/committee_opinions/co294.cfm>

**State Responses to Substance Abuse Among Pregnant Women**

The Alan Guttmacher Institute

<http://www.agi-usa.org/pubs/ib_006.html>

Several other instruments have been developed that can be very useful as
brief screening tests in the office and can be integrated into a patient
intake questionnaire. The most widely known of these is a four-question
screening test known as the CAGE questionnaire. This questionnaire has a
91% sensitivity and 77% specificity for detecting problem drinking. One
positive response indicates reason for concern; two positive responses
indicate that a problem is likely.

The CAGE questions are shown in the box below

See also the 5 P's and 4 P's, below

**Other issues**

**Issues to discuss with your Native Board**

What is our facility's role in rehabilitation versus public safety / law
enforcement? The emphasis on medical/behavioral intervention, rather
than law enforcement/social services may be intertwined, especially
since many tribes

a\) don\'t even have a statute making this drug illegal

b\) have limited options for treatment

c\) have limited options in the law enforcement/social services arena as
well.

Society may have different attitudes about social services for alcohol
abusing moms versus methamphetamine abusing pregnant adults, or adults
with dependent children.

The referral system may be overwhelmed with the volume of cases, and
there may be limited resources for foster care. Lastly, society's
attitudes about various substances of abuse, e.g., a society may be
\"scared\" by the new drug like methamphetamine, but one the other hand
quite tolerant with alcohol, with which they are familiar.

As a medical provider it is important to keep up an ongoing dialogue
with your tribal board to maximize the therapeutic options. There needs
to be a balance between options that involve the legal system as those
are sometimes the only way patients will enter into therapy.

Here is a good resource to help one appreciate some of these larger
societal issues.

Documentary \"G\" on Methamphetamine abuse

This is the documentary produced on the reservation with Navajo men and
women speaking about their experiences with meth, as well as Dr. Tom
Drouhard, local TCRHCC surgeon, Mr. Greg Adair from Criminal
Investigations in Tuba City, and Vice President Frank Dayish.

See ordering information below

**Don't forget tobacco, etc....**

While the above does not focus on tobacco abuse, per se, it may confound
birth outcomes along with drug use, alcohol and violence issues.

**Other Resources**

**American Academy of Pediatrics\' statement on neonatal drug
withdrawal**

Maternal characteristics that suggest a need for biochemical screening
of the neonate

No prenatal care

Previous unexplained fetal demise

Precipitous labor

Abruptio placentae

Hypertensive episodes

Severe mood swings

Cerebrovascular accidents

Myocardial infarction

Repeated spontaneous abortions

Preterm birth

Unexplained intrauterine growth restriction

Infant neuro-behavioral abnormalities

Congenital abnormalities

Infant atypical vascular incidents

Infant myocardial infarction

Necrotizing enterocolitis in otherwise healthy term infants

Neonatal drug withdrawal. American Academy of Pediatrics Committee on
Drugs

\[published erratum appears in Pediatrics 1998;102:660\]. Pediatrics
1998;101:1079--88.

**5 P\'s**

1\. Do either of your parents have a problem with using alcohol or
drugs?

**Yes, No, or No answer**

2\. Do any of your friends (peers) have a problem with drugs or alcohol?

**Yes, No, or No answer**

3\. Does your partner have a problem with drug or alcohol use?

**Yes, No, or No answer**

4\. Before you knew you were pregnant (past) how often did you drink
beer,

wine, wine coolers, or liquor?

**Not at all, rarely, sometimes, frequently**

5\. In the past month (present) how often did you drink beer, wine, wine

coolers or liquor?

**Not at all, rarely, sometimes, frequently**

Kennedy C, Finkelstein N, Hutchins E, Mahoney Improving screening for
alcohol use during pregnancy: the Massachusetts ASAP program. Matern
Child Health J. 2004 Sep;8(3):137-47.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15503394>

**4 P\'s**

1\. Did either of your parents ever have a problem with drinking or
using drugs?

**Answers = Yes or No**

2\. Does your partner have any problem with drinking or using drugs?

**Answers = Yes or No**

3\. Have you ever drunk alcohol?

**Answers = Yes or No**

4\. In the month before you knew you were pregnant, how many beers did
you drink?

**Answer = Quantity**

5\. In the month before you knew you were pregnant, how many cigarettes
did you smoke?

**Answer = Quantity**

Developed by Ira Chasnoff, MD.

An article will be published in the next few months on use of this
screen with pregnant women in publicly funded clinics and some of the
findings, to be published in the Journal of Perinatology. Lead author:
Ira Chasnoff, MD

**Psychologic and Physical Findings**

**Resources:**

At-risk drinking and illicit drug use: ethical issues in obstetric and
gynecologic practice. ACOG Committee Opinion No. 294. American College
of Obstetricians and Gynecologists. Obstet Gynecol 2004;103:1021--31.

**Non - ACOG Members**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15121596>

**ACOG Members**

<http://www.acog.org/publications/committee_opinions/co294.cfm>

Substance Abuse ACOG Technical Bulletin, No. 194, July 1994

**ACOG Members**

<http://www.acog.org/publications/educational_bulletins/btb194.htm>

Neonatal drug withdrawal. American Academy of Pediatrics Committee on
Drugs

\[published erratum appears in Pediatrics 1998;102:660\]. Pediatrics
1998;101:1079--88.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9614425>

**Indian Health [Prenatal assessment Form: ETOH, substances,
DV](http://www.psc.gov/forms/IHS/ihs-866.pdf)**

<http://www.psc.gov/forms/IHS/ihs-866.pdf>

**State Responses to Substance Abuse Among Pregnant Women**

The Alan Guttmacher Institute.

<http://www.agi-usa.org/pubs/ib_006.html>

**UpToDate - Designer drugs in adults (highlights below)\***

<http://www.uptodateonline.com/application/topic.asp?file=genr_med/11925&type=A&selectedTitle=1~31>

**UpToDate: Sedative and stimulant abuse in adults (highlights
below)\*\***

<http://www.uptodateonline.com/application/topic.asp?file=genr_med/24018&type=A&selectedTitle=2~31>

**Methamphetamine Abuse: Fact or Fiction?**

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ListservMethPowerpoint.ppt>

Knight JR, Sherritt L, Harris SK, Gates EC, Chang G. Validity of brief
alcohol screening tests among adolescents: a comparison of the AUDIT,
POSIT, CAGE, and CRAFFT. Alcohol Clin Exp Res. 2003 Jan;27(1):67-73.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12544008>

**IHS Manual, Part 3: Chapter 13 - Maternal Child Health**

3:13.2 F (2) f

[Chemical Abuse Assessment and Counseling]{.underline} -Screening for
alcohol or substance abuse will be completed at the initial visit.
Counseling and education should be provided to all patient6 as to the
effect these substance6 have upon the women\'s health and the
development of the fetus. A management plan should be developed by a
multidiscipline team for all identified abusers

IHS Manual, Part 3: Chapter 13 - Maternal Child Health

<http://www.ihs.gov/PublicInfo/Publications/IHSManual/Part3/pt3chapt13/pt3chpt13.htm>

**Q.** Can we test pregnant patients that have clinical indications for
drug testing? Can we screen pregnant patients?

**A.** This is a very complex issue that determined in large part by
local laws and regulations. Here is how one Area has approached the
problem.

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/perintl_drug_tstg.doc>

# 

# The IHS Primary Care Provider, Part 2 of January 1995, Volume 20, Number 1

# Letter to the Editor

<http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/Ihsproj1.asp>

**Video**

**Documentary \"G\" on Methamphetamine abuse**

This is the documentary produced on the reservation with Navajo men and
women speaking about their experiences with meth, as well as Dr. Tom
Drouhard, local TCRHCC surgeon, Mr. Greg Adair from Criminal
Investigations in Tuba City, and Vice President Frank Dayish.

The video is now out and has a presenter\'s guide that accompanies it.

The easiest way to order it is to go to:

a\. [[www.tcrhcc.org]{.underline}](../www.tcrhcc.org)

b\. go to programs

c\. go to health promotion program

d\. scroll down to \"G\" methamphetamine on Navajo Nation and at the
very bottom of the screen

look for ORDER FORM

e\. Download order form and send back via (fax or mail) to Community
Health.

f\. cost: \$25.00 for VHS, \$30 for DVD

Contact for questions: Diana Hu <diana.hu@tcimc.ihs.gov>

Buchi KF et al Changing prevalence of prenatal substance abuse in Utah.
Obstet Gynecol. 2003 Jul;102(1):27-30.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12850602>

**ACOG Members**

<http://www.greenjournal.org/cgi/content/full/102/1/27>

Smith, L et al Effects of Prenatal Methampetamine Exposure on Fetal
Growth and Drug Withdrawal Symptoms in Infants Born at Term. *J Dev
Behav Pediatr 24:17-23, 2003.*

<http://www.isp.state.id.us/DEC_Conference/documents/EffectsofPrenatalMethamphetamineAbstract.doc>

ABSTRACT. To determine fetal growth and the incidence of withdrawal
symptoms in term infants exposed to methamphetamine in utero, we
retrospectively identified neonates whose mothers used methamphetamine
during pregnancy and matched them to unexposed newborns. Exclusion
criteria included multiple and preterm gestations. Although there were
no differences in infant growth parameters between the
methamphetamine-exposed and methamphetamine-unexposed neonates,
methamphetamine exposure throughout gestation was associated with
decreased growth relative to infants exposed only for the first two
trimesters. In addition, there were significantly more small for
gestational age infants in the methamphetamine group compared with the
unexposed group. Methamphetamine-exposed infants whose mothers smoked
had significantly decreased growth relative to infants exposed to
methamphetamine alone. Withdrawal symptoms (as determine by a previously
reported scoring system) requiring pharmacologic intervention were
observed in 4% of methamphetamine-exposed infants. These preliminary
findings indicate that methamphetamine use is associated with growth
restriction in infants born at term.

**Drug Court Practitioner Fact Sheet**

[NATIONAL DRUG COURT
INSTITUTE](http://www.ndci.org/publications/methamphetamine_factsheet.pdf)

<http://www.ndci.org/publications/methamphetamine_factsheet.pdf>

**Drug Policy Information Clearinghouse: Fact Sheet**

<http://www.whitehousedrugpolicy.gov/publications/factsht/methamph/>

Methamphetamine abuse during pregnancy can cause prenatal complications
such as increased rates of premature delivery and altered neonatal
behavior patterns, such as abnormal reflexes and extreme irritability,
and may be linked to congenital deformities. Methamphetamine abuse,
particularly by those who inject the drug and share needles, can
increase users\' risks of contracting HIV/AIDS and hepatitis B and C.

**What are the risks of Methamphetamine in Pregnancy?**

**Michigan Women's Commission**

<http://www.michigan.gov/documents/publications_methamphetamine_8902_7.pdf>

**Methamphetamine in Pregnancy**

**Colorado Alliance for Drug Endangered Children**

<http://www.colodec.org/decpapers/methandpregnancy.htm>

**The Legal Status of the Fetus: Implications for Medical Personnel**

<http://www.reproductiverights.org/pub_art_fetalrights.html>

**Groups challenge criminal drug testing during pregnancy: AMA News**

<http://www.ama-assn.org/amednews/2000/09/11/prsd0911.htm>

## Supreme Court Rejects Maternal Drug Tests March 21, 2001

In a 6 to 3 decision, the Supreme Court has held that public hospitals
may not test pregnant women for drug use and release the results to law
enforcement without the patient's consent or a warrant. The case arose
from a South Carolina Public Hospital's policy of drug testing pregnant
women who exhibited certain symptoms linked to substance abuse.

<http://www.privacy.org/archives/000672.html>

**THE POLITICS OF PREGNANCY: POLICY DILEMMAS IN THE MATERNAL-FETAL
RELATIONSHIP** Women & Politics Volume: 13 Issue: 3/4 1994

[http://www.haworthpress.com/store/Toc_views.asp?TOCName=J014v13n03_TOC&desc=Volume%3A%2013%20Issue%3A%203%2F4](http://www.haworthpress.com/store/Toc_views.asp?TOCName=J014v13n03_TOC&desc=Volume%3A 13 Issue%3A 3%2F4)

**\* UpToDate: Designer drugs in adults**

<http://www.uptodateonline.com/application/topic.asp?file=genr_med/11925&type=A&selectedTitle=1~31>

**Clinical effects** --- The physiologic and psychologic effects of the
various amphetamine analogs are similar; some drugs also possess mild
hallucinogenic effects. These psychedelic effects are the reason that
glow-in-the-dark chemical \"light sticks\" and laser light shows are so
popular with \"ravers\" and at clubs where amphetamine analogs are being
used.

Users usually experience a heightened energy level, increased ability to
concentrate, and feelings of euphoria, relaxation, empathy, closeness
with others and enhanced sense of pleasure. They may be impulsive,
paranoid, and have increased risk-taking behavior.

Similar to other amphetamines, designer amphetamines suppresses
appetite, thirst, and the need to sleep, so much so that some users
suffer from dehydration and heat exhaustion. Many users combine designer
amphetamine use with \"smart drinks\" (drinks containing amino acid
mixtures) in an attempt to maintain hydration and counteract some of the
untoward effects. In some cases, however, fluid intake is markedly
increased, possibly resulting in symptomatic hyponatremia

.

Other effects include tachycardia, hypertension, hyperthermia, tremors,
and pupillary dilatation. The cardiovascular effects of MDMA (1.5 mg/kg)
were documented in a double-blind, placebo controlled trial and include
increased mean heart rate (by 28 beats per minute), systolic blood
pressure (by 25 mmHg), diastolic blood pressure (by 7 mmHg), and cardiac
output (by 2 L per minute).

The effects of MDEA (140 mg), demonstrated in a double-blind
placebo-controlled crossover study, include long-lasting increases in
serum cortisol, prolactin, systolic blood pressure, and heart rate as
well as increased psychomotor drive, feelings of relaxation, diminished
anxiety, and depressed mood.

**Adverse effects** --- Adverse effects of amphetamine analog designer
drugs may be due to host factors (eg, overexertion), impurities in the
drugs, or excessive doses. In addition, the drug tablets are often mixed
with other substances, including other amphetamines,
[ketamine](http://www.uptodateonline.com/application/topic.asp?file=drug_a_k/138198&drug=true),
[ephedrine](http://www.uptodateonline.com/application/topic.asp?file=drug_a_k/92312&drug=true),
and LSD. The relative contributions of each of these variables to
amphetamine analog toxicity is not known since there are no controlled
studies and the ingested dose is usually not known.

Life-threatening adverse effects that have been reported include
hepatitis, cerebral infarction, drug-induced hyperthermia, arrhythmias,
hypertensive crisis, myocardial infarction, cardiomyopathy,
cardiovascular collapse, seizures, aplastic anemia, hepatotoxicity, and
respiratory failure. Fatalities have occurred from the above
complications, from overdoses that often involve other drugs, and from
accidental injuries that occur while under the influence.

Other reported adverse reactions include include nausea, jaw clenching,
bruxism, blurred vision, anxiety, agitation, obtundation,
hallucinations, muscle cramping, tachycardia, hyperthermia,
pneumomediastinum, excessive sweating, panic disorder, and psychosis.

**\*\*Sedative and stimulant abuse in adults**

<http://www.uptodateonline.com/application/topic.asp?file=genr_med/24018&type=A&selectedTitle=2~31>

**Acute intoxication** ---The acutely intoxicated stimulant user should
be approached in a subdued manner; never speak in a loud voice or move
quickly, never approach the patient from behind, and try to avoid
touching the patient unless absolutely sure it is safe to do so.

Treatment of acute amphetamine intoxication (assuming no hepatic
dysfunction) includes acidification of the urine with [ammonium
chloride](http://www.uptodateonline.com/application/topic.asp?file=drug_a_k/14855&drug=true),
up to 4 g orally, four times daily. Seizures can be treated with
[diazepam](http://www.uptodateonline.com/application/topic.asp?file=drug_a_k/77469&drug=true).
[Haloperidol](http://www.uptodateonline.com/application/topic.asp?file=drug_a_k/120995&drug=true)
or other antipsychotics may be used for management of acute psychotic
reactions..

Treatment of acute cocaine intoxication is rarely necessary since it is
such a short-acting drug. The exceptions are cases of acute psychotic
reactions.

MDMA may be associated with severe acute toxicity, including fulminant
hyperthermia, seizures, disseminated intravascular coagulation,
rhabdomyolysis, acute renal failure, and hepatotoxicity. It may also
cause acute rises in systolic and diastolic blood pressure, heart rate,
and myocardial oxygen consumption. In addition, tablets of the drug are
often mixed with other substances that cause toxicity, including
amphetamines,
[ketamine](http://www.uptodateonline.com/application/topic.asp?file=drug_a_k/138198&drug=true),
[ephedrine](http://www.uptodateonline.com/application/topic.asp?file=drug_a_k/92312&drug=true),
and LSD.
[Dantrolene](http://www.uptodateonline.com/application/topic.asp?file=drug_a_k/71438&drug=true)
has been used with questionable efficacy in patients with severe
symptoms due to MDMA intoxication, and also has been associated with
hepatotoxicity.

**Chronic use** --- High-dose stimulant use over long periods of time
causes neurophysiologic changes in brain systems, which can take months
to resolve after cessation of stimulant use. As an example, a study in
twins found that after at least one year of abstinence, abusing twins
had deficits in attention and motor skills compared with nonabusing
twins. Brain imaging of
[methamphetamine](http://www.uptodateonline.com/application/topic.asp?file=drug_l_z/160126&drug=true)
users has shown structural deficits including gray-matter deficits in
the cingulate, limbic, and paralimbic cortices, and significant
reductions in hippocampal volume.

Development of tolerance suggests that the user is at risk for
developing dependence on stimulants. Controlled use shifts to compulsive
use when users attain increased access to these drugs and escalate
dosage, or when they switch to a more rapid route of administration,
such as from insufflation to smoking or intravenous injection. The
absence of a daily use pattern does not indicate less impairment, since
stimulant dependence is characterized by binges, or \"runs,\" of intense
use alternating with periods of decreased use or short periods of
abstinence without intention to quit permanently. Addicts report that
during binges virtually all thoughts are focused upon stimulants.
Addicts continue to use stimulants to avoid the depressed mood that
occurs when the effects wear off. Acute tolerance causes rapid dose
escalation until drug supplies are exhausted.

According to estimates by the National Institute on Drug Abuse (NIDA),
only 10 to 15 percent of those who initially try stimulants
(specifically cocaine) intranasally become abusers. No set of
characteristics has been identified that predict whether a recreational
user will become chemically dependent.

  **Symptoms** --- The clinical features of chronic stimulant use
include depression, fatigue, poor concentration, and mild parkinsonian
features such as myoclonus (inappropriate, spontaneous muscle
contractions), tremor, or bradykinesia (slowing of movements). Patients
presenting with these signs should be suspected of stimulant abuse and
screened carefully. Long-term
[methamphetamine](http://www.uptodateonline.com/application/topic.asp?file=drug_l_z/160126&drug=true)
dependence can cause neurotoxicity even in patients who are no longer
users.

Chronic use of MDMA can lead to a paranoid psychosis that is clinically
indistinguishable from schizophrenia; it is usually reversible after a
prolonged drug-free state. There is a considerable body of animal data
and now at least one human study which suggests that MDMA use (possibly
in conjunction with cannabis) can lead to cognitive decline in otherwise
healthy young people. The neurotoxicity occurs with typical recreational
doses of ecstasy.

The long-term medical sequelae of crack cocaine use include pulmonary
dysfunction, arrhythmias, myocardial infarction, cardiomyopathy, and
paranoia. The smokable free-based form of
[methamphetamine](http://www.uptodateonline.com/application/topic.asp?file=drug_l_z/160126&drug=true)
(\"ice\") has similar effects to crack, but may last 10 times as long.

Cocaine use may also be associated with ischemic stroke.

 **Abstinence syndrome** --- An abstinence syndrome can occur with
chronic stimulant use that is characterized by symptoms that are more
subtle and complex than those previously associated with drug
withdrawal. The \"crash,\" or drastic reduction in mood and energy,
starts 15 to 30 minutes after cessation of a stimulant binge. Addicts
experience craving, depression, anxiety, and paranoia. The craving for
stimulants decreases over one to four hours and is replaced by a craving
for sleep and rejection of further stimulant use. Hypersomnolence lasts
eight hours to four days. Sleep is punctuated by brief awakenings during
which the addict experiences hyperphagia (\"the munchies\"). Then begins
a protracted dysphoric syndrome in which the addict experiences
anhedonia, boredom, anxiety, generalized malaise, problems with memory
and concentration, and occasional suicidal ideation. This induces severe
craving that may lead to resumption of stimulant use and a vicious cycle
of recurrent binges.

Intermittent conditioned craving can last months to years after the last
stimulant use, and is gradually extinguished over time. The severity and
duration of withdrawal depends upon the intensity of the preceding
months of chronic abuse and the presence of predisposing psychiatric
disorders, which amplify withdrawal symptoms.