Crisis Intervention Network: Resources


	Dr. Yeagers Bio: Kenneth Yeager is Director of Quality Assurance at Ohio State University Medical Center. He is a licensed clinical social worker with a Ph.D. in Social Work from Ohio State University. Dr. Yeager has over 15 years experience as an alcoholism and substance abuse therapist conducting individual and group therapy. Drs. Yeager and Roberts are co-editing the Handbook of Practice Based Research and Evaluation to be published by Oxford University Press. Dr. Yeager's Drug Facts Between 1991 and 2001, the use of most major drug types increased among 8th and 10th graders. After 6 years of increases, 8th graders' past month marijuana use began to decrease in 1997, falling to 10.2%. This decline continued through 2001 to 9.2%.¹ Cannabis In 2001, the percentage of Americans reporting marijuana use at least once in the past month was 5.4% of the population age 12 and older.¹ The main active chemical in marijuana is THC (delta-9-tetrahydrocannabinol). Short-term effects of marijuana use include problems with memory and learning, distorted perception, difficulty in thinking and problem solving, loss of coordination, increased heart rate, and anxiety.² Club Drugs The past decade has seen the emergence of a new category of drugs referred to as "Club Drugs." This group of drugs include but are not limited to: MDMA/Ecstasy (methylenedioxymethamphetamine), Rohypnol (flunitrazepam), GHB (gamma hydroxybutyrate), and ketamine (ketamine hydrochloride).³ MDMA/Ecstasy (methylenedioxymethamphetamine): This substance is usually ingested in tablet form, but can also be crushed and snorted, injected. These drugs produce both stimulant and psychedelic effects, MDMA is often used at parties because of the stimulant effect and for the psychosexual effects.⁴ Physical effects may include: nausea, faintness, and significant increases in heart rate and blood pressure. MDMA use can cause hyperthermia, muscle breakdown, seizures, stroke, kidney and cardiovascular system failure, and may lead to death.⁵ Rohypnol, a sedative/tranquilizer, is legally available for prescription in over 50 countries outside of the U.S. and is widely available in Mexico, Colombia, and Europe. Rohypnol and GHB are tasteless and odorless depressants often used as a tool in sexual assaults. These drugs sedate and intoxicate unsuspecting victims, leaving them vulnerable to sexual assault. Physical effects of GHB include: drowsiness, nausea, unconsciousness, seizures, severe respiratory depression, and coma. GHB has increasingly become involved in poisonings, overdoses, date rapes, and fatalities. Cocaine During 2000, there were approximately 926,000 new cocaine users in the United States. The average age of those who first used cocaine during the year was 20 years. This substance can be snorted, smoked, or injected. When snorted, cocaine is inhaled through the nose where it is absorbed into the bloodstream through the nasal tissues, this process is the slowest absorption of the drug with physical limits on the amount of the drug that can be absorbed into the bloodstream. When injected, the cocaine high is more intense and prolonged as the drug directly into the bloodstream.⁶ The physical impact of cocaine use include but are not limited to: constricted blood vessels and increased temperature, heart rate, and blood pressure. While withdrawal from this drug is not life threatening frequently those attempting to decrease cocaine use experience restlessness, anxiousness, irritability, and remarkable mood-swings.⁷ Crack Cocaine Crack is cocaine that has been processed with ammonia or sodium bicarbonate (baking soda) and water to free cocaine from it's sodium base. It is then heated to remove the hydrochloride producing a form of cocaine that can be smoked.⁸ Physical consequences experienced by cocaine smokers Include: acute respiratory problems including coughing, shortness of breath, and severe chest pains with lung trauma and bleeding. Cocaine-related deaths are often a result of cardiac arrest or seizures followed by respiratory arrest.⁹ Heroin Heroin is processed from morphine, a naturally occurring substance extracted from the seedpod of specific varieties of poppy plants. Heroin is a powder varying in color from white to dark brown. Variability in color is due to the presence of impurities, within the drug as a result of the presence of additives or manufacturing process. Heroin can be injected, smoked, or snorted. Within recent years the availability of relatively pure heroin has led to an increased prevalence of snorting cocaine. However, this does not result in a lesser risk for addiction.¹⁰ The initial feelings associated with heroin use is a feeling of euphoria, the short-term effects of heroin include a warm flushing of the skin, a dry mouth, and heavy extremities. Following the initial euphoric feeling, many experience a drowsy state, often feeling drowsy and carefree for several hours.¹¹ Physical effects of prolonged use include: collapsed veins, infection of the heart lining and valves, abscesses, and liver disease. Pulmonary complications, including various types of pneumonia are also a consequence of chronic heroin use. Heroin overdose occurs when the heroin user administers a dose beyond their individualized tolerance level. The result: slow and shallow breathing, convulsions, coma, and possibly death.¹² LSD (lysergic acid diethylamide) LSD is an odorless and colorless substance, which has a slightly bitter taste and is usually ingested orally. It is often added to absorbent paper, such as blotter paper, LSD can also be found in tablets, capsules, and, occasionally, in liquid form. Users report a variety of symptoms from mild hallucinations (both visual and tactile) Some report uncontrollable laughter, and excessive energy. Others report LSD leads to clear thought processes, physical, emotional creative and intellectual stimulation.¹³ Physical effects include dilated pupils, higher body temperature, increased heart rate and blood pressure, sweating, loss of appetite, sleeplessness, dry mouth, and tremors. Sensations and feelings change much more dramatically than the physical signs. The LSD "trip" will vary in length depending on the potency of the "dose" lasting from six to fourteen hours. LSD may trigger long-lasting psychoses, such as schizophrenia or severe depression. It is difficult to determine the extent and mechanism of the LSD involvement in these illnesses, but is believed to be determined by the individual's predisposition to said illnesses.¹⁴ Ephedrine (Ephedra) Ephedrine is derived from the ephedra plant. It is also known as Ma Huang and has been used in China for medicinal purposes for thousands of years. Ephedrine is a stimulant that is used as an ingredient in diet pills, illegal recreational drugs, and legitimate over-the-counter medications to treat congestion and asthma. Ephedrine has a molecular structure similar to amphetamine and is metabolized to norephedrine, which is responsible for the central nervous system stimulating effects of the drug. In 1995, the FDA released an adverse event report on products containing ephedrine alkaloids. The report revealed adverse reactions to ephedrine such as heart attacks, strokes, paranoid psychosis, vomiting, fever, palpitations, convulsions and comas. Today many young adults are abusing this substance as it is available over-the-counter, and can be taken in pill form or by "snorting" the substance. What is more disturbing is the abuse potential of this drug by persons who would never consider abuse of substances. Today, many young athletes in high schools, colleges and professional ranks of play are abusing this substance as it is believed to enhance performance. The end result has been catastrophic. Many unsuspecting persons with comorbid medical conditions such as hypertension are taking ephedra as a dietary supplement without regard to warning labels and are experiencing dangerous medical, psychological and psychiatric side effects (see discussion below-drug induced psychosis.) Currently, the FDA does not currently regulate ephedrine because it is a dietary supplement protected under the Dietary Supplement Health & Education Act of 1994. Pursuant to the Act, the FDA cannot regulate dietary supplements such as ephedrine unless it has been proven to be unsafe. When FDA moved to significantly restrict access to ephedra through a proposed regulation in 1997, an independent report by the General Accounting Office concluded that the available evidence did not support the FDA's proposed restrictions on dosage limits.¹⁵ Drug induced Psychosis Drug induced Psychosis The essential features of a Drug Induced Psychotic Disorder are prominent hallucinations or delusions that are due to the direct physical effects of a drug of abuse, medication or toxin exposure. The presence of a Drug-Induced Psychotic Disorder versus a primary Psychotic Disorder, can be determined by consideration of the onset of symptoms, course and other related factors. Specifically for drugs of abuse there must be sufficient evidence gathered from history of use, physical examination and laboratory findings to document substance dependence, abuse, or intoxication. Differentiation between dependence, abuse or intoxication is defined within the DSM-IV-TR Diagnostic criteria for each drug of abuse. It is not necessary for substance dependency to be present for the diagnosis of drug-induced psychosis. Clinicians must also consider that the current psychotic episode is not better accounted for by the presence of another mental disorder, and that the disturbance does not occur specifically within the course of delirium. (American Psychiatric Association, 2000) Substance-Induced Psychotic Disorders occur within the context of two specifiers: Onset during intoxication and onset during withdrawal. While psychosis occurs within one of the two specifiers symptoms may persist for weeks following onset. The key-differentiating diagnostic factor is that primary psychotic disorders either precede the onset of substance use, or may occur throughout periods of sustained abstinence. Many drugs that have been associated with the onset of psychotic symptoms are: cocaine, amphetamine compounds including methamphetamine, Club drugs including ecstasy, and cannabis. However, it is important to note that all of the aforementioned substances are illegal, with the notable exception of Ephedra. Persons at particular risk are those with a preexisting mental disorder, complicated by an emergent comorbid substance use disorder. Specifically, mentally ill chemical abusers are at particular risk for onset during intoxication, as in the example of an individual with the diagnosis of OCD, who takes a club drug such as ecstasy to "fit in" with his or her high school crowd.¹⁶ Treatment For examples of application of Roberts' Seven-Stage Crisis Intervention Model within substance abuse treatment settings and in combination with Solution Focused and Strengths Perspective see: Yeager, K.R. and Gregoire T.K (2000). Crisis intervention: application of brief solution focused therapy in addictions. In Roberts A.R., Crisis Intervention Handbook. (2nd Ed.) Oxford University Press. New York, N.Y. 440-485. Yeager, K.R., (2000). The roll of intermittent crisis intervention in early recovery from cocaine addiction.Journal of Crisis Intervention and Time Limited Treatment. 5(3) 302-310. Yeager, K.R., (2002). Crisis Intervention With Mentally Ill Chemical Abusers: Brief Treatment and Crisis Intervention Vol. 2, Number 3 Fall 2002 197-216. Sources: ¹National Institute on Drug Abuse, Marijuana Facts Parents Need to Know , November 1998, What is Marijuana, How is Marijuana Used? ²Jones, R. T., (1980). Human effects: An overview In RC. Peterson (Ed.). Marijuana research findings: 1980 54-80 Rockville, MD: National Institute on Drug Abuse. ³Drug Enforcement Administration, Club Drugs: An Update, September 2001. ⁴National Institute on Drug Abuse, Community Drug Alert Bulletin: Club Drugs, December 1999. ⁵National Institute on Drug Abuse, Infofax: Club Drugs, February 2000. ⁶ Substance Abuse and Mental Health Services Administration, 2001 National Household Survey on Drug Abuse, August 2002. ⁷ National Institute on Drug Abuse, Cocaine: Abuse and Addiction, May 1999 ⁸ National Institute on Drug Abuse, Infofacts: Crack and Cocaine, October 2001 ⁹ Drug Enforcement Administration Web site, Drug Descriptions: Cocaine ¹⁰ Drug Enforcement Administration Web site, Drug Descriptions: Heroin ¹¹ National Institute on Drug Abuse, Infofax: Heroin, 2000 ¹² National Institute on Drug Abuse, Research Report: Heroin Abuse and Addiction, 1999 ¹³U.S. Department of Health and Human Services, National Institute on Drug Abuse, Infofax-LSD. ¹⁴ U.S. Department of Justice, Drug Enforcement Administration, LSD in the United States, LSD the Drug. ¹⁵Dietary Supplements: Uncertainties in Analyses Underlying FDA's Proposed Rule on Ephedrine Alkaloids (Letter Report, 07/02/1999, GAO/HEHS/GGD). ¹⁶Roberts, A.R., Yeager, K.R. Seigel, A. (In Press). Obsessive Compulsive Disorder and Comorbid Depression, Substance Abuse and Suicide Attempts: Clinical presentations, assessments and treatment. Brief Treatment and Crisis Intervention. Oxford University Press.

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