Medication Abuse Handouts by Rand L. Kannenberg

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  • 1. MEDICATION ABUSE: Over-the-Counter & Prescription Drug Abuse & Dependence Rand L. Kannenberg, M.A., LAC, CCM, CCS
  • 2. Table of Contents
    • Dedication i
    • Acknowledgements ii
    • OTC and prescription drug statistics in the U.S. 1
    • About the Presenter 2
    • Program Description 3
    • Objectives 4
    • Agenda and Outline 5
    • Schedules of controlled substances with accepted medical use 6
    • Opioids and morphine derivatives 7-13
    • Video #1 “Opioids” 14
    • Opioids and sleep disordered breathing syndromes 15
    • CNS depressants 16-18
    • Video #2 “Benzos” 19
    • Dissociative anesthetics 20
    • Stimulants 21-24
    • Anabolic steroids 25
    • Cold and cough medications 26
    • Video #3 “DXM” 27
    • Weight loss pills 28-29
    • Sleeping aids 30
    • Online or e-pharmacies 31-32
    • Minors ordering on the Internet 33
    • Street use 34
    • “ Pill mills” 35
    • Identifying drug-seeking patients 36
    • Case Study 1 37
    • Case Study 2 38
    • “ Opiophobia” (underprescribing painkillers) 39
    • Characteristics of overprescribing physicians 40
    • How to approach physicians with concerns 41
    • Types of fraudulent prescriptions 42
    • Characteristics of forged prescriptions 43
    • Other warning signs 44
  • 3.
    • Prescription fraud prevention techniques 45
    • How to destroy unwanted medications 46
    • Reasons for drug testing 47
    • Types of drug testing 48
    • Detection periods 49
    • Alternatives to controlled drugs for anxiety 50
    • Alternatives to controlled drugs for insomnia 51
    • Alternatives to controlled drugs for ADHD 52
    • Alternatives to controlled drugs for pain 53
    • Suboxone versus Methadone or LAAM 54
    • Warning signs of impaired professionals 55
    • Guidelines for writing prescriptions 56
    • Do these three things when writing prescriptions 57
    • “ Clinical Sobriety Checklist” (CSC) ™ for medications 58
    • Prescription drug interview questions 59-60
    • CAGE questionnaire for prescription drugs 61
    • Drug addiction test 62-66
    • Substance dependence screening 67
    • Substance abuse screening 68
    • Substance intoxication effects 69-71
    • Benzodiazepine withdrawal symptom questionnaire 72
    • Clinical Opiate Withdrawal Scale (with example pictures) 73-87
    • Stimulant withdrawal checklist 88
    • Inpatient medical detoxification criteria checklists 89-91
    • Social detoxification criteria 92
    • Outpatient/home detoxification options 93-95
    • Rapid detoxification 96
    • The “4 Ds” of quitting medications 97
    • Relapse prevention exercises 98-99
    • Goal setting exercises 100-101
    • “ National Medicine Abuse Awareness Month” 102
    • References 103-106
  • 4. Dedication
    • Jay Balchunas
    • Task Force Officer
    • January 18, 1970 - November 5, 2004
    • “ On October 29, 2004, Task Force Officer John “Jay” Balchunas was fatally wounded in Milwaukee, Wisconsin. He died from his injuries on November 5, 2004. Officer Balchunas was conducting surveillance as part of the Department of Justice/FBI Fall Threat Initiative prior to the national elections.
    • Task Force Officer Balchunas was employed as a Narcotics Bureau Special Agent within the State of Wisconsin, Division of Criminal Investigation (DCI). Prior to joining the State DCI, Task Force Officer Balchunas worked as a Milwaukee Police Officer for seven years and a Marquette University Public Safety Officer before that. Additionally, Task Force Officer Balchunas was a dedicated Volunteer Firefighter with the New Berlin Fire Department, achieving the rank of Lieutenant.
    • On the evening of October 29th, while walking to his car, Task Force Officer Balchunas was accosted by two assailants. A struggle ensued and one of the assailants shot Officer Balchunas in the abdomen. He underwent several surgeries before succumbing to his injuries on November 5, 2004. Task Force Officer Balchunas was engaged to be married in the fall of 2005 and is survived by his fiancée, Luann Vogel, his parents, Don and Mary Kay, his brother Dan, and his sister, Linda.”
    • DEA
  • 5. Acknowledgements
    • I would like to thank my new employers and friends in the field of medical education/professional development for their incredible support and encouragement and in our respective personal lives as we attempt to end the pain and suffering of patients, clients and other people across the country:
    • Tristan Colonna ,
    • President of MEDS-PDN
    • from Eau Claire, Wisconsin;
    • and
    • Kristine Scheel ,
    • Program Planner of MEDS-PDN
    • from Waukesha, Wisconsin.
    • Thanks also to my eldest daughter,
    • Corrie Kannenberg
    • University of Colorado at Boulder
    • for editing and proofreading this, my sixteenth seminar manual since I first started speaking on addiction in 1995.
  • 6. Statistics
    • Non-medical use of prescription medications ranks second only behind marijuana in terms of illicit drug use in the U.S.
    • Approximately 15 million Americans report using a prescription drug for non-medical reasons at least once a year.
    • An estimated 48 million people 12 and older (20% of the population) have used prescription drugs for non-medical reasons at least once in their lifetimes.
    • Nearly 14% of adolescents and more than 17% of adults over 60 have abused prescription drugs.
    • 10% of teenagers ages 12-17 have abused cough medicine to get high.
    • The number of first time misusers of tranquilizers went up nearly 50%.
    • ER visits related to abusing pain killers alone have increased almost 165%.
    • 5.2 million persons are nonmedical users of prescription pain killers.
    • Among 12 th graders, 9.5% have used Vicodin® and 5.0% have used OxyContin® without a prescription the past year.
    • 55.7% of misusers of pain relievers report that they obtain them from a friend or relative for free.
    • Office of National Drug Control Policy (ONDCP)
    • National Institute on Drug Abuse (NIDA)
    • The Partnership for a Drug-Free America ™
    • National Survey on Drug Use and Health (NSDUH)
    • Substance Abuse and Mental Health Services Administration (SAMHSA)
  • 7. About the Presenter
    • Rand Kannenberg has been the Executive Director of Criminal Justice Addiction Services in Lakewood, Colorado since 1995. Additionally, he is a credentialed consultant with physicians in the emergency department and on the medical units at a Denver area medical center where he serves as the addiction preceptor. Mr. Kannenberg has provided nearly 400 substance abuse and corrections advanced-level training and continuing education workshops in 44 states as well as Italy, Puerto Rico and South Africa. In addition to speaking at seminars and other educational events, he has a private clinical practice specializing in forensic drug and alcohol assessments. Mr. Kannenberg is a Licensed Addiction Counselor, a Certified Case Manager, and an approved education provider by both NBCC and NAADAC.
    • Mr. Kannenberg is a Public Health Champion of the Year recipient as well as a Distinguished Career Award nominee. He has authored Sociotherapy for Sociopaths in 2003 and Case Management Handbook for Clinicians in 2004. NAADAC News ’ reviews of these publications included, “Kannenberg’s fresh approach to treating psychoactive chemical abusing sociopaths should be in every counselor’s arsenal when treating a client of this nature,” and “Even if new to the profession or a seasoned veteran, this book is a helpful resource to all addiction counselors…An Addiction treatment facility’s library is not complete without the book.” Mr. Kannenberg and his work has been featured in numerous scholarly journals, academic and scientific research papers and reports, as well as in the local and national news media. CBS stated that his program is “credited with reducing the number of repeat drug offenders in three states.” Both ABC and NBC referred to him as an expert. And The Denver Business Journal reported, “Rand Kannenberg is a Licensed Addiction Counselor who gets called into the hospital when patients arrive with drug problems.”
  • 8. Program Description
    • Recognize the three classes of commonly abused prescribed medications.
    • Cite the three over-the-counter drugs used for non medical reasons.
    • Name the three ways to identify and prevent drug-seeking patients.
    • Take home three instruments for screening medication abuse and dependence.
    • Take home three tools for the assessment and evaluation of medication withdrawal.
    • Take home three clinical exercises for drug free goal setting and relapse prevention.
  • 9. Objectives
    • List the most commonly abused prescription and over-the-counter drugs
    • Describe effective prevention techniques for the different types of fraudulent and forged prescriptions
    • Describe the warning signs of health care workers and other professionals impaired by medications
    • Summarize the alternatives to controlled drugs to treat various medical and psychological problems
    • Identify and explain the differences between medication abuse and medication dependence
    • Describe the effects of medication intoxication and how to administer written scales for withdrawal
    At the end of this seminar the participant will be able to:
  • 10. Agenda & Outline
    • Part I
    • Social Implications: Community and Professionals
    • Part II
    • Clinical Strategies: Assessment and Treatment
  • 11. Schedule II. (A) The drug or other substance has a high potential for abuse. (B) The drug or other substance has a currently accepted medical use in treatment in the United States or a currently accepted medical use with severe restrictions. (C) Abuse of the drug or other substances may lead to severe psychological or physical dependence. Schedule III. (A) The drug or other substance has a potential for abuse less than the drugs or other substances in schedules I and II. (B) The drug or other substance has a currently accepted medical use in treatment in the United States. (C) Abuse of the drug or other substance may lead to moderate or low physical dependence or high psychological dependence. Schedule IV. (A) The drug or other substance has a low potential for abuse relative to the drugs or other substances in schedule III. (B) The drug or other substance has a currently accepted medical use in treatment in the United States. (C) Abuse of the drug or other substance may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in schedule III. Schedule V. (A) The drug or other substance has a low potential for abuse relative to the drugs or other substances in schedule IV. (B) The drug or other substance has a currently accepted medical use in treatment in the United States. (C) Abuse of the drug or other substance may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in schedule IV. U.S. Drug Enforcement Administration (DEA) Schedules of controlled substances
  • 12. Opioids & morphine derivatives hydrocodone (Schedules II, III, V) Examples Hydrocodone with Acetaminophen, Vicodin®, Vicoprofen®, Tussionex®, Lortab®, Tussend®, Hycodan®, Anexsia® Nicknames vike, Watson-387 Route of Administration swallowed Desired Outcomes pain relief, euphoria Adverse Reactions drowsiness, nausea, constipation, confusion, sedation, respiratory arrest, unconsciousness, coma, constricted pupils, slow and shallow breathing, clammy skin, convulsions, possible death National Institute on Drug Abuse (NIDA) U.S. Drug Enforcement Administration (DEA)
  • 13. Opioids & morphine derivatives oxycodone (Schedule II) Examples Roxicet®, Oxycodone with Acetaminophen, OxyContin®, Endocet®, Percocet®, Percodan®, Tylox®, Roxicodone® Nicknames Oxy, O.C., killer Route of Administration swallowed, snorted, injected Desired Outcomes pain relief, euphoria Adverse Reactions drowsiness, nausea, constipation, confusion, sedation, respiratory arrest, unconsciousness, coma, constricted pupils, slow and shallow breathing, clammy skin, convulsions, possible death National Institute on Drug Abuse (NIDA) U.S. Drug Enforcement Administration (DEA)
  • 14. Opioids & morphine derivatives
    • codeine (Schedules II, III, V)
    • Examples
    • Empirin® with Codeine, Fiorinal® with Codeine, Fioricet® with Codeine, Robitussin A-C®, Acetaminophen, Guaifenesin or Promethazine (Phenergan®) with Codeine, Tylenol® with Codeine, morphine methyl ester, methyl morphine, Didrate® and Parzone® (dihydrocodeine), Papaverine® and Noscapine® (Codeine and Isoquinoline Alkaloid), Cosanyl®, Cheracol®, Cerose®, Pediacof®
    • Nicknames
    • Captain Cody, schoolboy
    • Route of Administration
    • injected, swallowed
    • Desired Outcomes
    • pain relief, euphoria
    • Adverse Reactions
    • drowsiness, nausea, constipation, confusion, sedation, respiratory arrest, unconsciousness, coma, constricted pupils, slow and shallow breathing, clammy skin, convulsions, possible death
    • National Institute on Drug Abuse (NIDA)
    • U.S. Drug Enforcement Administration (DEA)
  • 15. Opioids & morphine derivatives morphine (Schedules II, III) Examples Duramorph®, MS-Contin®, Roxanol®, Oramorph SR®, RMS® Nicknames M, Miss Emma, monkey, white stuff Route of Administration injected, swallowed, smoked Desired Outcomes pain relief, euphoria Adverse Reactions drowsiness, nausea, constipation, confusion, sedation, respiratory arrest, unconsciousness, coma, constricted pupils, slow and shallow breathing, clammy skin, convulsions, possible death National Institute on Drug Abuse (NIDA) U.S. Drug Enforcement Administration (DEA)
  • 16. Opioids & morphine derivatives hydro-morphone (Schedule II) Examples Dilaudid ®, dihydromorphinone Nicknames Dust, Juice, Smack, D, Footballs Route of Administration swallowed, injected Desired Outcomes pain relief, euphoria Adverse Reactions drowsiness, nausea, constipation, confusion, sedation, respiratory arrest, unconsciousness, coma, constricted pupils, slow and shallow breathing, clammy skin, convulsions, possible death National Institute on Drug Abuse (NIDA) U.S. Drug Enforcement Administration (DEA)
  • 17. Opioids & morphine derivatives opium (Schedules II, III, V) Examples laudanum, paregoric, papaver somniferum, extracts/fluid/poppy/tincture/granulated/powdered/raw, Parepectolin®, Kapectolin PG®, Kaolin®, Pectin P.G.® Nicknames big O, black stuff, block, gum, hop Route of Administration swallowed, smoked Desired Outcomes pain relief, euphoria Adverse Reactions drowsiness, nausea, constipation, confusion, sedation, respiratory arrest, unconsciousness, coma, constricted pupils, slow and shallow breathing, clammy skin, convulsions, possible death National Institute on Drug Abuse (NIDA) U.S. Drug Enforcement Administration (DEA)
  • 18. Opioids & morphine derivatives other narcotics (Schedules II, III, IV) Examples Actiq®, Duragesic®, Sublimaze®, Fentanyl®, Demerol®, methadone, Darvon®, Darvocet®, Stadol®, Talwin®, Paregoric®, Buprenex®, propoxyphene, Propacet®, Innovar®, Mepergan®, pethidine Nicknames Apache, China girl, China white, dance fever, friend, goodfella, jackpot, murder 8, TNT, Tango and Cash Route of Administration swallowed, injected, smoked, snorted Desired Outcomes pain relief, euphoria Adverse Reactions drowsiness, nausea, constipation, confusion, sedation, respiratory arrest, unconsciousness, coma, constricted pupils, slow and shallow breathing, clammy skin, convulsions, possible death National Institute on Drug Abuse (NIDA) U.S. Drug Enforcement Administration (DEA)
  • 19. Video #1 “Opioids” (3 minutes & 8 seconds) “ Prescription Drugs: Killing More Than Pain”
  • 20.
    • 75% of chronic pain patients taking daily opioids have “sleep disordered breathing syndromes”
    • obstructive sleep apnea
        • (loud snoring usually related to obesity and other health problems)
    • central sleep apnea
        • (breathing stops during sleep)
    • Versus estimates of only 2% to 5% observed in general population.
    • Suggests:
    • 1.) Opioids impact brain control of respirations and breath size; and
    • 2.) Chronic pain patients taking daily opioids have “higher risk of morbidity and mortality”
    • Pain Medicine
  • 21. CNS depressants barbiturates (Schedules II, III, IV) Examples (methohexital) Brevital®, (thiamyl) Surital®, (thiopental) Pentothal®, (amobarbital) Amyta®, (pentobarbital) Nembutal®, (secobarbital) Seconal®, (amobarbital/secobarbital) Tuinal®, (butalbital) Fiorina®, (butabarbital) Butisol®, (talbutal) Lotusate®, (aprobarbital) Alurate®, (phenobarbital) Luminal®, (mephobarbital) Mebaral® Nicknames barbs, reds, red birds, phennies, tooies, yellows, yellow jackets Route of Administration injected, swallowed Desired Outcomes reduced pain and anxiety; feeling of well-being; lowered inhibitions Adverse Reactions slowed pulse and breathing, lowered blood pressure, poor concentration/fatigue, confusion, impaired coordination/memory/judgment, respiratory depression and arrest, death, sedation, drowsiness/depression, unusual excitement, fever, irritability, poor judgment, slurred speech, dizziness, life-threatening withdrawal National Institute on Drug Abuse (NIDA) U.S. Drug Enforcement Administration (DEA)
  • 22. CNS depressants
    • benzodiazepines (Schedule IV)
    • Examples
    • (estazolam) ProSom®, (flurazepam) Dalmane®, (temazepam) Restoril®, (triazolam) Halcion®, (midazolam) Versed®, (alprazolam) Xanax®, (chlordiazepoxide) Librium®, (clorazepate) Tranxene®, (diazepam) Valium®, (halazepam) Paxipam®, (lorazepam) Ativan®, (oxazepam) Serax®, (prazepam) Centrax®, (quazepam) Doral®, (clonazepam) Klonopin®
    • Nicknames
    • candy, downers, sleeping pills, tranks
    • Route of Administration
    • injected, swallowed
    • Desired Outcomes
    • reduced pain and anxiety, feeling of well being, lowered inhibitions
    • Adverse Reactions
    • slowed pulse and breathing, lowered blood pressure, poor concentration/fatigue, confusion, impaired coordination/memory/judgment, respiratory depression and arrest, death, sedation, drowsiness/dizziness, life-threatening withdrawal
    • National Institute on Drug Abuse (NIDA)
    • U.S. Drug Enforcement Administration (DEA)
  • 23. CNS depressants
    • flunitrazepam
    • Example
    • Rohypnol ( only manufactured and sold legally in Latin America and Europe )
    • Nicknames
    • forget-me pill, Mexican Valium, R2, Roche, roofies, roofinol, rope, rophies
    • Route of Administration
    • injected, swallowed, snorted
    • Desired Outcomes
    • reduced pain and anxiety; feeling of well-being; lowered inhibitions
    • Adverse Reactions
    • slowed pulse and breathing, lowered blood pressure, poor concentration/fatigue, confusion, impaired coordination/memory/judgment, respiratory depression and arrest, death, visual and gastrointestinal disturbances, urinary retention, memory loss for the time under the drug's effects, associated with sexual assaults
    • National Institute on Drug Abuse (NIDA)
    • U.S. Drug Enforcement Administration (DEA)
  • 24. Video #2 “Benzos” (2 minutes & 46 seconds) “ Prescription Drugs: Killing More Than Pain”
  • 25. Dissociative anesthetics
    • Ketamine (Schedule III)
    • Examples
    • Ketalar ®, Ketalar SV ®, Ketaset®, Vetalar®, Vetaket®
    • Nicknames
    • cat Valium, K, Special K, vitamin K, jet, super acid, green
    • Route of Administration
    • injected, snorted, smoked
    • Desired Outcomes
    • "K-Hole," an "out of body," or "near-death" experience
    • Adverse Reactions
    • increased heart rate and blood pressure, impaired motor function, numbness, nausea/vomiting, delirium, depression, respiratory depression and arrest, amnesia, long-term memory and cognitive difficulties, used as a date-rape drug
    • National Institute on Drug Abuse (NIDA)
    • U.S. Drug Enforcement Administration (DEA)
  • 26. Stimulants
    • amphetamines (Schedule II)
    • Examples
    • Adderall®, Adderall XR®, Dexedrine®, Dextrostat®, Biphetamine®, Durophet ® , Obetrol ®
    • Nicknames
    • bennies, black beauties, crosses, hearts, LA turnaround, speed, truck drivers, uppers
    • Route of Administration
    • swallowed, snorted, injected, smoked
    • Desired Outcomes
    • awake, alert, active, aware, appetite suppression, energy, euphoria, excitement, enthusiasm, enhancement of the senses
    • Adverse Reactions
    • hallucinations, delusions, picking at the skin, preoccupation with one's own thoughts, violent and erratic behavior, increased heart rate, high blood pressure, increased metabolism, irregular heart beat, weight loss, heart failure, nervousness, insomnia, rapid breathing, tremors, loss of coordination; irritability, anxiousness, restlessness, delirium, panic, impulsive behavior
    • Criminal Justice Addiction Services
    • National Institute on Drug Abuse (NIDA)
    • U.S. Drug Enforcement Administration (DEA)
  • 27. Stimulants cocaine (Schedule II) Examples Cocaine hydrochloride Nicknames blow, bump, C, candy, Charlie, coke, crack, flake, rock, snow, toot Route of Administration swallowed, snorted, injected, smoked Desired Outcomes awake, alert, active, aware, appetite suppression, energy, euphoria, excitement, enthusiasm, enhancement of the senses Adverse Reactions dysphoric crash, death from respiratory failure, strokes, heart failure, increased heart rate, high blood pressure, increased metabolism, irregular heart beat, weight loss, nervousness, insomnia, increased temperature, chest pain, nausea, abdominal pain, seizures, headaches, malnutrition, panic attacks Criminal Justice Addiction Services National Institute on Drug Abuse (NIDA) U.S. Drug Enforcement Administration (DEA)
  • 28. Stimulants methamphetamine (Schedule II) Example Desoxyn® Nicknames chalk, crank, crystal, fire, glass, go fast, ice, meth, speed Route of Administration swallowed, snorted, injected, smoked Desired Outcomes awake, alert, active, aware, appetite suppression, energy, euphoria, excitement, enthusiasm, enhancement of the senses Adverse Reactions inability to sleep, loss of appetite and weight, thin/gaunt, increased sensitivity to noise, agitation, restlessness, irritability, aggressiveness, dizziness, confusion, impaired judgment, diarrhea and gastrointestinal complaints, difficulty breathing, headaches, tremors or seizures, nausea and vomiting, numbness, profuse sweating, chills, muscle cramping, pain and tenderness, dehydration, low magnesium level, low potassium level, grossly dilated pupils, chest pain, increased or decreased heart rate, increased blood pressure, fever or hyperthermia, impaired speech and language, mania, psychosis with hallucinations and delusions, anxiety, panic, fear of impending doom, depression and suicidal ideation, poor hygiene and body malodor, missing teeth, bleeding gums, infected gums, dental caries/decay/cavities, dry mouth, removed enamel, teeth grinding, skin aging and damage, dryness, roughness, wrinkles, broken veins, dermatitis around the mouth, skin ulceration and infection, acne or sores, hair loss from repetitious pulling Criminal Justice Addiction Services National Institute on Drug Abuse (NIDA) U.S. Drug Enforcement Administration (DEA)
  • 29. Stimulants methylphenidate (Schedule II) Examples Ritalin®, Methylin®, Concerta® Nicknames JIF, MPH, R-ball, Skippy, the smart drug, vitamin R Route of Administration swallowed, snorted, injected Desired Outcomes awake, alert, active, aware, appetite suppression, energy, euphoria, excitement, enthusiasm, enhancement of the senses Adverse Reactions increased heart rate, high blood pressure, increased metabolism, irregular heart beat, weight loss, heart failure, nervousness, insomnia Criminal Justice Addiction Services National Institute on Drug Abuse (NIDA) U.S. Drug Enforcement Administration (DEA)
  • 30. Anabolic steroids (Schedule III)
    • Examples
    • (oxymetholone) Anadrol®, (oxandrolone) Oxandrin®, (methandrostenolone) Durabolin®, (stanozolol) Winstrol®, (testosterone cypionate) Depo- Testosterone®, (boldenone undecylenate) Equipoise®, (nandrolone decanoate) Deca-Durabolin®, (nandrolone phenpropionate) Durabolin®
    • Nicknames
    • roids, juice, arnolds, gym candy, pumpers, cycling, stacking, pyramiding, weight trainers
    • Route of Administration
    • injected, swallowed, applied to skin
    • Desired Outcomes
    • no intoxication effects excluding a general sense of feeling good about self while taking the medication(s), increased size and strength of muscles, improved appearance, improved endurance, and decrease recovery time between workouts
    • Adverse Reactions
    • elevated blood pressure and cholesterol levels, severe acne, premature balding, reduced sexual function, testicular atrophy in males, prostate cancer in males, reduced sperm production in males, abnormal breast development in males (gynecomastia), masculinizing effects in females (more body hair including development of beard, deeper voice, smaller breasts, fewer menstrual cycles), enlargement of the clitoris in females, may prematurely stop the lengthening of bones resulting in stunted growth in adolescents, psychotic reactions, manic episodes, feelings of anger or hostility, aggression, violent behavior, blood clotting, liver cysts and cancer, kidney cancer
    • National Institute on Drug Abuse (NIDA)
    • U.S. Drug Enforcement Administration (DEA)
  • 31. Dextromethorphan (DXM)
    • Examples
    • Alka-Seltzer Plus Cold & Cough Medicine®, Coricidin HBP Cough and Cold®, Dayquil LiquiCaps®, Dimetapp DM®, Robitussin® cough products, Sudafed® cough products, Triaminic® cough syrups, Tylenol Cold® products,Vicks 44 Cough Relief® products, Vicks NyQil LiquiCaps®
    • Nicknames
    • Candy, CCC, Dex, DM, Drex, DXM, Red Devils, Robo, Robo-fizzing (if mixed with sodas or alcohol), Rojo, Skittles, Syrup, Triple-C, Tussin, Vitamin D
    • Route of Administration
    • swallowed
    • Desired Outcomes
    • auditory and visual hallucinations, dissociation, euphoria, heightened perceptual awareness, lethargy, mania, perceptual distortion
    • Adverse Reactions
    • abdominal pain, blurred vision, brain damage, confusion, death, dehydration, disorientation, delusions, dizziness, double vision, drowsiness, dry mouth, dry skin, dysphoria, fever, flaky skin, flushing of face, headache, hot flashes, impaired judgment, involuntary muscle movement, itchy skin, loss of consciousness, loss of physical coordination, memory problems, nausea, numbness of fingers and toes, panic attacks, paranoia, poor mental performance, profuse sweating, rapid heart beat, rigid motor tone, seizures, slurred speech, tremors, vomiting
    • Substance Abuse and Mental Health Services Administration (SAMHSA)
    • The Partnership for a Drug-Free America ™
    • Tennessee Association of Alcohol and Drug Abuse Services (TAADAS)
    • Community Anti-Drug Coalitions of America
    • U.S. Drug Enforcement Administration (DEA)
  • 32. Video #3 “DXM” (1minute & 50 seconds)
    • “ The OTC: Battling the Over-the-Counter High”
  • 33. Weight loss pills Examples bitter orange, chitosan, chromium, conjugated linoleic acid (CLA), county mallow (heartleaf), ephedra, green tea extract, guar gum, hoodia Nicknames same as above Route of Administration swallowed Desired Outcomes decrease appetite, block absorption of dietary fat, reduce fat, build muscle, increase calorie and fat metabolism, increase the feeling of fullness Adverse Reactions constipation, bloating, diarrhea, indigestion, high blood pressure, heart rate irregularities, sleeplessness, seizures, heart attacks, strokes, death, vomiting, flatulence Mayo Clinic
  • 34.
    • Alli 60 mg (over-the-counter, reportedly 85% as effective as Xenical 120 mg which has required a prescription since 1999 ).
    • Made by GlaxoSmithKline.
    • Made available in 2007.
    • Company advertising states that users may expect 50% more weight loss than by dieting alone (i.e., 15 pounds instead of 10 pounds).
    • Blocks the breakdown and absorption of fat in the intestine.
    • May cause diarrhea, loose oily stools and loss of bowel control when fatty foods are ingested.
    • New users are encouraged to wear dark pants and carry a change of underwear and other clothes with them when they first start taking Alli.
    • http://www.myalli.com/
  • 35. Sleeping aids
    • Examples
    • (doxylamine) Unisom® Sleeptabs ™ , (diphenhydramine) Benadryl®, AllerMax®, Banophen®, Diphenhist®, Genahist®, (dimenhydrinate) Dramamine®, Calm-X®, Dimetabs®, Triptone® Nicknames
    • sleepers, downers, sleeping pills
    • Route of Administration
    • swallowed
    • Desired Outcomes
    • sleep
    • Adverse Reactions
    • agitation, nervousness, excitability, not able to sleep, blurred vision, dizziness or fainting spells, irregular heartbeat, palpitations, chest pain, muscle or facial twitches, pain or difficulty passing urine, seizures, drowsiness, dizziness, dry mouth, headache, loss of appetite, stomach upset, nausea, vomiting, diarrhea, constipation, confusion, restlessness, incoordination, ringing in the ears, persistent and unusual rash or hives, wheezing, weakness, reddening of the skin, sensitivity to light
    • Drug Digest
  • 36. Online or e-pharmacies fax broadcasting/blasting
    • “ individuals in need of prescription drugs…”
    • “ without a doctor’s recommendation…”
    • “ by simply answering a set of questions…”
    • “ save time and money because you don’t have to go to your doctor and the pharmacy…”
    • “ the cheapest prescription drugs on the Internet…”
    • “ Ultram,
    • Soma,
    • Fioricet,
    • Prozac,
    • Buspar,
    • are the different drugs that are included in our weekly specials…”
    • “ 90 quantity for $51.99 and $84.99 for 180 quantity…”
    • http://www.suremedlink.com
  • 37. http://www.suremedlink.com
  • 38. Minors ordering on the Internet
    • Web sites to watch for:
    • www.erowid.org
    • www.dextroverse.org
    • www.lycaeum.org
    • www.myspace.com/dextromethorphan
    • and many thousands of others!
    • Community Anti-Drug Coalitions of America
  • 39. Street use
    • “ pharming”
    • (taking handfuls of known or unknown tablets, capsules, powders and syrups in one sitting)
    • U.S. Drug Enforcement Administration (DEA)
  • 40. “Pill mills”
    • (Internet pharmacies that provide controlled substances illegally)
    • DEA uses web crawler/data mining technology to identify, investigate and prosecute these so-called "pill mills"
    • They are addressed in the “White House's National Drug Control Strategy Focuses on Prescription Drug Safety”
    • U.S. Drug Enforcement Administration (DEA)
  • 41. Identifying Drug-Seeking Patients
    • Escalating use
    • (a pattern of overuse or escalation of use by the patient)
    • “ Doctor shoppers”
    • (patients who use at least two physicians, frequent emergency departments, call or go in off hours on nights/weekends/holidays, and/or claim to be from “out of town”)
    • “ Scams”
    • (applying enough pressure that a physician who initially says “no” to a medication or a refill eventually changes the answer to a “yes” because it’s easier to write the prescription than confronting the patient)
    • American Family Physician
  • 42. Case Study 1
    • The client is a 33-year-old white and Native American Indian female referred by her private probation officer for a court ordered substance abuse evaluation. She is on probation for two years for felony possession of a controlled substance (Vicodin®). She is also on probation in another county for two years for felony prescription fraud (Vicodin®). She has lost custody of her children, is unemployed (only fired after the second conviction discussed below), is required to take non opioid pain medications only, is required to attend 12 step Narcotics Anonymous (NA) Meetings, has random and unannounced urine drug screens and attends weekly outpatient substance abuse therapy sessions.
    • She was first prescribed Vicodin® after having breast enhancement surgery. She took it as directed and never requested any refills. She was prescribed it again three years later for a hysterectomy and later that same year for rectal surgery. She “liked the feeling it gave [her]. It decreased [her] anxiety and made [her] feel calmer.” She and her husband moved in with his parents for five months while they were building a house. He left her and the children there alone for two weeks of business and hunting trips back to back. She had conflict with her in laws.
    • At the time she was working as an office manager for a neurologist and used his DEA number and called in the first false prescription to a Safeway® pharmacy. She took one tablet every four to five hours for three weeks, then one every two hours for three weeks, two every four hours for two to three weeks and finally two every two to three hours for three months. She called or faxed in approximately 15 prescriptions using four pharmacies (Target®, Safeway® and two others she won’t name because she has not yet been charged in those crimes). She initially ordered bottles with 30 tablets. She then increased to 60 tablets.
  • 43. Case Study 2
    • The patient is a 43-year-old white female referred by her attending physician on the medical unit at a local hospital. She is five days post operative with a lap assisted total abdominal colectomy and ileocectomy. A consultation was ordered with this clinician because the patient is increasingly confused and hallucinating. Her medical problems are secondary to a history of purging and laxative abuse (taking as many as 20-30 doses of laxatives a day since the age of 20 to lose weight or have a bowel movement). As a result of the laxative abuse she had slow transit constipation for years.
    • Three days after her surgery numerous prescription medications were located in her room and it was assumed that she was taking some or all of them on her own (Ativan®, Tylenol® with codeine, Vicodin®, Valium®, Ambien® and Klonopin®) in addition to what was being ordered by the hospitalist, the surgeon and administered by the nursing staff.
    • She receives the medications listed above from four physicians who do not know that other providers are treating the same patient for her lupus, fibromyalgia, osteoporosis, and arthritis. Her divorce is pending. Her 16-year-old recently ran away from a group home. Her 11-year-old lives with his father and her 6-year-old is currently staying with the patient’s sister. The patient was terminated from her job as a certified public school Kindergarten teacher for missing work. The employer had documentation that the patient had been diagnosed with Bipolar Disorder but she did not respond to corrective action plans. She reportedly took the following medications from various unknown prescribers: Seroquel®, Effexor®, Lamictal® and Adderall XL®.
    • At the time of the exam she was naked below the waist, had perplexed expression, her speech was nonsensical, she was hallucinating, and she was disoriented to person/place/date.
    • She was diagnosed with Opioid and Sedative/Hypnotic/Anxiolytic Withdrawal Delirium (provisionally, ruling out Delirium related to medical conditions).
  • 44. “Opiophobia”
    • “ Many health care providers underprescribe painkillers because they overestimate the potential for patients to become addicted to medications such as morphine and codeine. Although these drugs carry a heightened risk of addiction, research has shown that providers' concerns that patients will become addicted to pain medication are largely unfounded. This fear of prescribing opioid pain medications is known as ‘opiophobia .’”
    • National Institute on Drug Abuse (NIDA)
  • 45. Characteristics of overprescribing physicians
    • “The 4 Ds” from the AMA:
    • 1.) dated
    • (out of date regarding knowledge of pharmacology, differential diagnoses and management of various conditions);
    • 2.) duped
    • (vulnerable to manipulative patients);
    • 3.) dishonest
    • (willing to write prescriptions for controlled substances in exchange for money or other favors); and
    • 4.) disabled
    • (impaired with a medical condition, psychiatric illness and/or chemical dependency)
    • American Family Physician
  • 46. How to approach physicians with concerns
    • Start with provider first. If not successful, then:
    • Report to in house impairment program if available. If not available, then:
    • Report to chief of appropriate clinical service. If at an office based practice instead, then:
    • Refer to external impaired program. If not available, or if a complaint is required first, then:
    • Report to state licensing board.
    • “ Impaired Professionals”
  • 47. Types of fraudulent prescriptions
    • stolen legitimate prescription pads with prescriptions written for real or fictitious patients;
    • physician prescriptions that have been altered by the patient;
    • prescription pads with a legitimate physician printed but with a different call back number answered by the patient or an accomplice;
    • patients calling in their own prescriptions using their own phone number as a call back confirmation;
    • patients using scanners or copiers to copy legitimate physician prescriptions; and
    • patients using computers to create prescriptions for nonexistent or legitimate physicians.
    • Office of Diversion Control
  • 48. Characteristics of forged prescriptions
    • looks “too good” – handwriting too legible;
    • quantities, directions or dosages differ from what is usual, customary and reasonable;
    • does not comply with acceptable standard abbreviations or appears to be a “textbook presentation;”
    • appears to be photocopied;
    • directions written in full with no abbreviating; and
    • written in more than one color ink or in more than one handwriting.
    • Office of Diversion Control
  • 49. Other warning signs
    • significantly more prescriptions or larger quantities from one prescriber compared to what is received from his or her peers in the area;
    • patients requesting refills daily, weekly or biweekly if the prescription was for a month;
    • patients with prescriptions for antagonistic substances at the same time (i.e., depressants and stimulants on the same day or on close dates);
    • patients dropping off or picking up prescriptions for other people;
    • a number of patients with the same or similar prescription (even from the same physician in some cases) presenting at the same time or one after another; and
    • patients not from the local area showing up with prescriptions from the same physician.
    • Office of Diversion Control
  • 50. Prescription fraud prevention techniques
    • know the prescriber and his or her signature;
    • know the prescriber’s DEA registration number;
    • know the patient or ask for identification;
    • check that the date on the prescription is recent;
    • call the prescriber for verification or clarification if any question or concern;
    • call the local police or sheriff department if a forged, altered or counterfeited prescription is suspected;
    • call the state pharmacy board; and
    • contact the DEA at:
    • http://www.usdoj.gov/dea/submit_tip_form.htm
    • (877) RXAbuse or (877) 792-2873
    • Office of Diversion Control
  • 51.
    • Don’t flush unwanted or leftover medications!
    • Do:
    • crush or dissolve tablets or capsules in warm water;
    • mix with kitty litter, coffee grounds or dog waste;
    • place in sealed plastic bag in covered trash can;
    • remove and destroy prescription bottle label before discarding.
    • Or:
    • ask if pharmacy or local hazardous materials site accept leftover medications.
    • U.S. Department of Health and Human Services,
    • Substance Abuse and Mental Health Services Administration
  • 52. Reasons for drug testing
    • to establish a drug free workplace for prospective and current employees;
    • when any use on-the-job (or an employee coming to work under the influence of substances) is suspected;
    • after an employee accident or injury that may involve substances; and/or
    • to support employees currently or formerly involved in impaired professional programs.
    • Drug Test Coordinators, Inc.
  • 53. Types of drug testing
    • Pre-employment (part of application process)
    • Random (“neutral selection” of employees or all employees)
    • For-Cause (same as “probable cause” and “reasonable suspicion”)
    • Periodic Announced (regularly scheduled annual exams)
    • Post-Accident (on-the-job vehicle or other work related incident)
    • Rehabilitation (part of treatment program and/or before return to work)
    • Safety-Sensitive (testing of employees with safety-sensitive job duties)
    • Drug Test Coordinators, Inc.
  • 54. Detection periods
    • amphetamines * 1-3 days
    • (may not be detectable in urine until 4-6 hours after use)
    • barbiturates (short acting) 1 day
    • barbiturates (intermediate and long acting) 1-3 weeks
    • benzodiazepines 5-7 days
    • cocaine * 1-3 days
    • (may not be detectable in urine until 2-6 hours after use)
    • opioids 1-3 days
    • (may not be detectable in urine until 2-6 hours after use)
    • *prescription medications versus illicit forms of same or similar substances
    • “ Impaired Professionals”
    • Food and Drug Administration (FDA)
  • 55. Alternatives to controlled drugs for anxiety
    • Most antidepressants
    • (buspirone) Buspar®
    • Anticonvulsants: (valproic acid) Depakote® and (gabapentin) Neurontin®
    • Selected (antihypertensives) beta blockers
    • Atypical neuroleptics: (olanzapine) Zyprexa®, (quetipine) Seroquel®, (risperidone) Risperdal®
    • (hydroxyzine) Vistaril® or Atarax ®
    • American Family Physician
  • 56. Alternatives to controlled drugs for insomnia
    • Sedating antidepressants: trazodone (Desyrel®), doxepin (Sinequan®), amitriptyline (Elavil®), nefazodone (Serzone®), mirtazepine (Remeron®)
    • American Family Physician
  • 57. Alternatives to controlled drugs for ADHD
    • (pemoline) Cylert®
    • (bupropion) Wellbutrin®
    • (desipramine) Norpramin®
    • (venlafaxine) Effexor®
    • (clonidine) Catapres®
    • Selective serotonin reuptake inhibitors
    • American Family Physician
  • 58. Alternatives to controlled drugs for pain
    • nonsteroidal anti-inflammatory drugs
    • acetaminophen
    • antidepressants
    • anticonvulsants
    • steroids
    • muscle relaxants
    • American Family Physician
  • 59. Suboxone ® versus Methadone or LAAM
    • (buprenorphine HCI/
    • naloxone HCI dihydrate)
    • a “partial agonist”
    • has Naloxone in it to prevent people from crushing and injecting it which would cause instant withdrawal instead of intoxication
    • may cause respiratory depression and death if injected and/or if combined with benzodiazepines or other CNS depressants
    • preferred over Methadone for patients addicted to prescription opioids (instead of heroin)
    • sublingual tablets (that are slow to dissolve with bad taste)
    • negative side effects/adverse reactions commonly reported more than placebo: headache, pain, nausea and sweating
    • must be in opioid withdrawal before starting and must have empty stomach
    • blocks effects of all other opioids but Fentanyl®
    • only available from physicians who have completed Reckitt Benckiser Pharmaceutical, Inc. training. They are listed at:
    • http://www.suboxone.com
    • Suboxone.com
  • 60. Warning signs of impaired professionals
    • Deterioration of personal hygiene
    • Increased absence from professional functions or duties
    • Emotionally labile
    • Appears sleep deprived
    • Increased evidence of professional errors
    • Shows a decreased concern for patient well being
    • Unexplained “personal problems”
    • Increased patient complaints
    • “ Impaired Professionals”
  • 61. Guidelines for Writing Prescriptions
    • Building an alliance with the patient (informed consent means informing the patient of potential for physical dependency with certain medications)
    • How to document in the medical record (how the action to use medication was chosen; that the patient was informed, consented, and was competent to make the decision)
    • Duty to warn related to driving errors (patients must be informed of the risk of driving while taking certain medications, combining alcohol with certain medications, and both discussions should be documented in the record)
    • Using medication conjointly with therapies (use medication only as part of an overall treatment plan with other forms of therapy, including, but not limited to physical therapy, biofeedback, cognitive behavioral treatment, or even bibliotherapy)
    • American Family Physician
  • 62. Do these 3 things when writing prescriptions
    • Prescribe only the exact amount until the next appointment;
    • Write out the number (e.g., “thirty” instead of “30”); and
    • Use only one pharmacy and only one physician in the practice or program to write the refills (i.e., “one-doctor/one pharmacy” treatment plan).
    American Family Physician
  • 63. “Clinical Sobriety Checklist” (CSC)™ for medications
    • (Every blank in all three sections must be checked.)
    • (AA)
      • _____awake
      • _____alert
    • (Ox4)
      • _____oriented to person
      • _____oriented to place
      • _____oriented to time
      • _____oriented to events
    • (Walking/Talking)
      • _____exhibits stable gait without ataxia
      • (i.e., is coordinated and balance is steady when standing or moving)
      • _____conversive without slurred speech
      • (i.e., communicates and word
      • pronunciation is clear when speaking)
    • “ These guidelines are intended to be tools to facilitate clinical decision making. They are not the standard of care for each patient. No guideline can anticipate every situation, and the [clinician] should deviate from the guidelines when clinical judgment so indicates.” [1]
    • Adapted from “Clinical pathway for intoxicated patients,” Brown University. Retrieved from the World Wide Web at http://brown.edu/Administration/Emergency_Medicine/emr/pages/etoh.htm July 29, 2007.
    • Copyright 2007 Rand L. Kannenberg
    • All rights reserved. 1] “Clinical pathway for intoxicated patients.”
  • 64. _____legal, illegal, prescription and over-the-counter substance(s) used; _____amount/route of administration/frequency/duration of use; _____when started using; _____why using/used; _____last use; _____blood alcohol level and time; _____breath test result and time; _____urine drug screen results and time; _____CIWA score and time; _____COWS score and time; _____CAGE score; Kannenberg Prescription drug interview questions
  • 65. _____history of blackouts; _____history of intoxication or withdrawal delirium; _____history of intoxication or withdrawal seizures; _____history of substance induced psychosis, mania, anxiety or depression; _____longest time clean/sober, _____history of addiction treatment; _____history of addiction support; _____history of addiction education; _____history of substance related legal problems; _____history of physical problems as a result of using; and _____problems at home, work or school as a result of using. Kannenberg
  • 66.
    • CAGE Questionnaire
    • for Prescription Drugs
    • Medication dependence is likely if the patient gives 2 or more positive answers:
    • Have you ever felt you should C UT down your use of prescription drugs?
    • Have people A NNOYED you by criticizing your use of prescription drugs?
    • Have you ever felt bad or G UILTY about your use of prescription drugs?
    • Have you ever used prescription drugs as a way to “get going” first thing in the morning ( E YE- opener)?
    • Ewing
  • 67. Drug addiction test
    • Alcohol and Drug Addiction Test
    • Gorski and Kelley
  • 68.
    • Use to feel better: I use alcohol or drugs to get away from things that bother me or are hard to face.
    • Use to solve most problems : I use alcohol or drugs to try to solve most of my problems and things that bother me.
    • It takes more : It takes more or stronger kinds of alcohol or drugs to get the same feelings than it used to.
    • Memory loss : Sometimes after I have been using, I do not remember what happened.
    • Sneaking : Sometimes I hide from other people how much I'm using or drinking. This might be because I do not want people to know or because I do not want to share.
    • Dependence : I rarely do anything for fun unless I use alcohol or drugs.
    • Fast start : I use stronger alcohol or drugs or use a lot quickly at first to get a "good start."
    • Feel guilty : I feel guilty about using alcohol or drugs or about the things that I do when I use.
    • Do not listen : Other people complain or try to talk to me about my using but I do not listen.
    • Regular blackouts : I do not remember what happened and I get into trouble when I use alcohol or drugs.
    • 11. Excuses : I use problems in my life as an excuse for using alcohol or drugs. I feel that I have to use to deal with these problems.
    • 12. Using more than others : I use more than most people, so I hang around people who use as much or more so that I feel that I fit in.
    Yes No
  • 69. 21. Neglect food : I do not eat healthy foods or eat at regular times, especially when I'm using. 22. Resentment : I feel like other people are out to get me, and I feel angry a lot. 23. Withdrawal : I need a drink or a drug in the morning or else I get the shakes or sweats because I feel terrible. 24. Can't make decisions : I can't make decisions about even small things. I just wait until things happen. 19. Work and money troubles : I have problems on the job, owe money or can't work at all because of my using. 20. Avoid friends and family : I avoid old friends and family that do not use—unless I need something from them. 18. Make changes : I change jobs, move, or leave a relationship to try to make my life better, but it doesn't make any difference. 17. Give up other things : I've stopped doing things that I used to do that didn't involve using alcohol or drugs. 16. Control : I try to control my use, but it doesn't work. 15. Promises : I promise to get my life in order and do better. I mean it, but it doesn't work out that way. 14. Show off : I show off or get pushy with other people to feel better and prove that I am okay. 13. Feel bad : I feel bad about how my using hurts other people, but I don't know what to do about it.
  • 70. 37. Confinement : I have been in jails and mental wards because of my using. 36. Desperation : I am willing to do anything to get better. 35. I'm lost : I don't try to pretend my life is normal. I know I am an addict or an alcoholic. I believe that things will never change. 34. Turn to God : I want God or religion to save me from my life. 33. Using is everything : Getting something to use, using, and getting over using are my whole life. 32. Give up : I don't try to change anything. I just wait to see what happens. 31. Afraid : I feel like something terrible might happen to me, people are out to get me, and I have to be on guard at all times. 30. Major damage : Even when I'm not using, I have a hard time thinking, remembering, and doing things that used to be easy. 29. Find someone worse : I try to use with people who are worse off than I am so that I feel better. 28. Use all the time : I use whenever I can, and I don't try to have a normal life. 27. Over the line : I do things I said I would never do or things that do not reflect the way I was raised. 26. Decrease in amount to get high : It takes less for me to get high or doesn't matter how much I use because I can't get the effect I want. 25. Health problems : I am sick, have lost a lot of weight, or feel physically bad most of the time.
  • 71. Scoring Sheet for Alcohol and Drug Addiction Test Early Stage Addiction Count up the number of yes answers you checked in questions 1–12 and write the number below. Number of checks for questions 1–12 _____ If you have one or more checks in this section, there is a possibility that you are addicted to alcohol or drugs. This means that you use alcohol or drugs to try to solve problems and to make yourself feel better. While using alcohol or drugs will not really make things better, it will feel like it does. If you have any checks in this section, you have a possibility of becoming addicted if you keep using. The closer your score is to 12, the higher your chance of addiction. Middle Stage Addiction Count up the number of yes answers you checked in questions 13–24 and write the number below. Number of checks for questions 13–24 ____ Any number of checks in this section means that you are addicted and have started to have bad things happen to you because of your addiction. During this stage, you may try to do things to control your addiction. Some of these may work for a while, but not for long. For questions 13–24, the closer your score is to 12, the more addicted you are, and the worse things will get if you do not get help. Late Stage Addiction Count up the number of yes answers you checked in questions 25–37 and write the number below. Number of checks for questions 25–37 ____ Any number of checks in this section means that you are in the late stage of addiction. During this stage, you may have given up and thought that you could not do anything to change. Serious life problems, such as being sick, or going to jail or a mental ward, have happened or will happen to you if you do not try to get help. For questions 25–37, the closer your score is to 13, the more addicted you are. Your chances of dying are high if you continue to use.
  • 72. Substance dependence screening
    • (requires 3 or more of the following in 12 consecutive months):
    • Increased Tolerance;
    • Withdrawal;
    • Increased Quantity or Duration;
    • Persistent Desire but Inability to Decrease or Discontinue Use;
    • Increased Time to Obtain or Recover;
    • Social/Occupational/Recreational Impairment;
    • Continued Use Despite Awareness of Related Physical or Psychological Problems.
    • American Psychiatric Association (APA)
  • 73. Substance abuse screening
    • (requires 1 or more of the following in 12 consecutive months):
    • Recurrent Use Resulting in Social/Occupational/Educational Problems;
    • Recurrent Use in Physically Hazardous Situations;
    • Recurrent Substance-Related Legal Problems;
    • Continued Use Despite Awareness of Related Social or Interpersonal Problems.
    • American Psychiatric Association (APA)
  • 74. Opioid Intoxication
    • A. Recent use of an opioid. 
    • B. Clinically significant maladaptive behavioral or psychological changes (e.g., initial euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, impaired judgment, or impaired social or occupational functioning) that developed during, or shortly after, opioid use. 
    • C. Pupillary constriction (or pupillary dilation due to anoxia from severe overdose) and one (or more) of the following signs, developing during, or shortly after, opioid use: 
    • (1) drowsiness or coma  (2) slurred speech  (3) impairment in attention or memory
    • D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder. Specify if:  With Perceptual Disturbances
    • American Psychiatric Association (APA)
  • 75. Sedative, Hypnotic, or Anxiolytic Intoxication
    •  
    • A. Recent use of a sedative, hypnotic, or anxiolytic. 
    • B. Clinically significant maladaptive behavioral or psychological changes (e.g., inappropriate sexual or aggressive behavior, mood lability, impaired judgment, impaired social or occupational functioning) that developed during, or shortly after, sedative, hypnotic, or anxiolytic use. 
    • C. One (or more) of the following signs, developing during, or shortly after, sedative, hypnotic, or anxiolytic use: 
    • (1) slurred speech  (2) incoordination  (3) unsteady gait  (4) nystagmus  (5) impairment in attention or memory  (6) stupor or coma 
    • D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.
    • American Psychiatric Association (APA)
  • 76. Stimulant Intoxication
    • A. Recent use of a stimulant.
    • B. Clinically significant maladaptive behavioral or psychological changes (e.g., euphoria or affective blunting; changes in sociability; hypervigilance; interpersonal sensitivity; anxiety, tension, or anger; stereotyped behaviors; impaired judgment; or impaired social or occupational functioning) that developed during, or shortly after, use of a stimulant.
    • C. Two (or more) of the following, developing during, or shortly after, use of a stimulant:
        • tachycardia (resting heart rate of over 100 beats per minute) or bradycardia (heart rate of under 60 beats per minute)
        • Pupillary dilation
        • Elevated or lowered blood pressure
        • Perspiration or chills
        • Nausea or vomiting
        • Evidence of weight loss
        • Psychomotor (thought and physical movements) agitation or retardation
        • Muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias (irregular heart contraction)
        • Confusion, seizures, dyskinesias (bad or abnormal movements), dystonias (involuntary, sustained muscle contractions), or coma
    • The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.
    • American Psychiatric Association (APA)
  • 77. Benzodiazepine withdrawal symptom questionnaire
    • Feeling unreal
    • Very sensitive to noise
    • Very sensitive to light
    • Very sensitive to smell
    • Very sensitive to touch
    • Peculiar taste in mouth
    • Pains in muscles
    • Muscle twitching
    • Shaking or trembling
    • Pins and needles
    • Dizziness
    • Feeling faint
    • Feeling sick
    • Feeling depressed
    • Sore eyes
    • Feeling that things are moving when they are still
    • Seeing or hearing things that are not really there (hallucinations)
    • Unable to control your movements
    • Loss of memory
    • Loss of appetite
    Each moderate score is given a rating of 1 and each severe score a rating of 2. The maximum score possible is 40, unless of course additional symptoms are included. Note also whether the symptoms occurred when the tablets were reduced or stopped, or if the symptoms occurred when the tablets were the same. If the individual attains an overall score above 20 seek specialist medical help. If the individual endorses a number of severe symptoms seek specialist medical help. If the individual reports a number of new symptoms seek specialist medical help. Tyrer, Murphy and Riley
  • 78.   For each item, write in the number that best describes the patient’s signs or symptom.  Rate on just the apparent relationship to opiate withdrawal.  For example, if heart rate is increased because the patient was jogging just prior to assessment, the increase pulse rate would not add to the score.   WESSON, Donald R., CNS Medications Development, Oakland, California; Medications Development Committee, American Society of Addiction Medicine. LING, Walter, Integrated Substance Abuse Programs, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles. Clinical Opiate Withdrawal Scale (COWS)   Patient’s Name:___________________________                         Date: ______________
  • 79. Resting Pulse Rate :  (record beats per minute)                    Measured after patient is sitting or lying for one minute. 0 pulse rate 80 or below 1 pulse rate 81-100 2 pulse rate 101-120 4 pulse rate greater than 120
    • Sweating:
    • Over past ½ hour not accounted for by room temperature or patient activity.
            • 0 no report of chills or flushing
            • 1 subjective report of chills or flushing
            • 2 flushed or observable moistness on face
            • 3 beads of sweat on brow or face
            • 4 sweat streaming off face
  • 80. http://www.aic.cuhk.edu.hk/web8/Horners_sweating.jpg
  • 81.
    • Restlessness:
    • Observation during assessment.
      • 0 able to sit still
      • 1 reports difficulty sitting still, but is able to do so
      • 3 frequent shifting or extraneous movements of legs/arms
      • 5 Unable to sit still for more than a few seconds
    • Pupil Size:
      • 0 pupils pinned or normal size for room light
      • 1 pupils possibly larger than normal for room light
      • 2 pupils moderately dilated
      • 5 pupils so dilated that only the rim of the iris is visible
  • 82. http://www.opt.indiana.edu/ecco/graphics/dilate.jpg
  • 83.
    • Bone or Joint Aches:
    • If patient was having pain previously,
    • only the additional component attributed to opiates withdrawal is scored.
          • 0 not present
          • 1 mild diffuse discomfort
          • 2 patient reports severe diffuse aching of joints/ muscles
          • 4 patient is rubbing joints or muscles and is unable to sit still
          • because of discomfort
    • Runny Nose or Tearing:
    • Not accounted for by cold symptoms or allergies.
      • 0 not present
      • 1 nasal stuffiness or unusually moist eyes
      • 2 nose running or tearing
      • 4 nose constantly running or tears streaming down cheeks
  • 84. http://images.jupiterimages.com/common/detail/39/98/23119839.jpg
  • 85. http://www.kellogg.umich.edu/theeyeshaveit/symptoms/images/tearing.jpg
  • 86.
    • GI Upset:
    • Over last ½ hour.
        • 0 no GI symptoms
        • 1 stomach cramps
        • 2 nausea or loose stool
        • 3 vomiting or diarrhea
        • 5 Multiple episodes of diarrhea or vomiting
    • Tremor:
    • Observation of outstretched hands.
        • 0 No tremor
        • 1 tremor can be felt, but not observed
        • 2 slight tremor observable
        • 4 gross tremor or muscle twitching
  • 87. http://www.brainexplorer.org/brain-images/tremor.jpg
  • 88.
    • Yawning:
    • Observation during assessment.
        • 0 no yawning
        • 1 yawning once or twice during assessment
        • 2 yawning three or more times during assessment
        • 4 yawning several times/minute
  • 89. http://www.abc.net.au/science/news/img/health/yawning071204.jpg
  • 90.
    • Anxiety or Irritability:
      • 0 none
      • 1 patient reports increasing irritability or anxiousness
      • 2 patient obviously irritable or anxious
      • 4 patient so irritable or anxious that participation in the assessment is difficult
    • Gooseflesh Skin:
        • 0 skin is smooth
        • 3 piloerection of skin can be felt or hairs standing up on arms
        • 5 prominent piloerection
  • 91. http://content.answers.com/main/content/wp/en/2/23/Goose_bumps.jpg
  • 92.       Score: 5-12 = mild; 13-24 = moderate; 25-36 = moderately severe; more than 36 = severe withdrawal                                   Total scores   with observer’s initials
  • 93. Stimulant withdrawal checklist
    • A. Cessation of (or reduction in) stimulant use that has been heavy and prolonged.
    • B. Dysphoric mood and two (or more) of the following physiological changes, developing within a few hours to several days after Criterion A:
        • Fatigue
        • Vivid, unpleasant dreams
        • Insomnia or hypersomnia (an excessive amount of sleepiness)
        • Increased appetite
        • Psychomotor retardation or agitation
    • C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
    • The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.
    • American Psychiatric Association (APA)
  • 94. Adult Inpatient Medical Detoxification Admission Criteria Checklist
    • Opioids
    • The patient is acutely intoxicated; OR
    • The patient meets the criteria for another opioid induced disorder listed in the current edition of the Diagnostic and Statistical Manual; OR
    • The patient is experiencing severe withdrawal (Clinical Opiate Withdrawal Scale is greater than 36); OR
    • There is evidence that severe withdrawal is imminent; AND
    • The patient has been unsuccessful at a less intensive level of service (or such a level is not currently an option because of safety); AND
    • If the patient is voluntary, he or she has arranged for longer term treatment after inpatient medical detoxification; AND
    • The patient requires close monitoring for a coexisting or co-occurring physical, emotional, behavioral, and/or cognitive condition; AND
    • The patient does not require a medical admission; AND
    • The patient does not require an inpatient psychiatric admission.
    • Exempla West Pines Behavioral Health Services
  • 95. Adult Inpatient Medical Detoxification Admission Criteria Checklist
    • Sedatives, Hypnotics, Anxiolytics
    • The patient is acutely intoxicated; OR
    • The patient meets the criteria for another sedative, hypnotic or anxiolytic induced disorder listed in the current edition of the Diagnostic and Statistical Manual; OR
    • The patient is in severe withdrawal; OR
    • There is evidence that severe withdrawal is imminent; AND
    • The patient is not responsive to appropriate efforts to maintain the dose of the substance(s) at therapeutic levels; AND
    • There is evidence that the patient is in danger of seizures upon withdrawal; AND
    • The patient requires close monitoring for a coexisting or co-occurring physical, emotional, behavioral, and/or cognitive condition; AND
    • The patient does not require a medical admission; AND
    • The patient does not require an inpatient psychiatric admission.
    • Exempla West Pines Behavioral Health Services
  • 96. Adult Inpatient Medical Detoxification Admission Criteria Checklist
    • Stimulants
    • The patient is acutely intoxicated; OR
    • The patient meets the criteria for another stimulant induced disorder listed in the current edition of the Diagnostic and Statistical Manual; OR
    • The patient is in severe withdrawal; OR
    • There is evidence that severe withdrawal is imminent; AND
    • The patient requires close monitoring for a coexisting or co-occurring physical, emotional, behavioral, and/or cognitive condition; AND
    • The patient does not require a medical admission; AND
    • The patient does not require an inpatient psychiatric admission.
    • Exempla West Pines Behavioral Health Services
  • 97. Social detoxification exclusion criteria
    • Blood Pressure must be less than 180/110
    • Pulse must be less than 130
    • Temperature must be less than 102.5 degrees
    • Respirations must be less than 30
    • Arapahoe House Detox-West
  • 98. OFFICE-BASED OUTPATIENT WITHDRAWAL TECHNIQUES USING (CLONIDINE) CATAPRES® FOR OPIATES
    • CATAPRES® SUBSTITUTION
    • FOR OPIOID WITHDRAWAL AT HOME
    • 1. Oral 2. Patch
    • The clonidine patch comes in three strengths (#1, #2, #3) and delivers over one week the equivalent of a daily dose of oral clonidine.
    • Go to http://www.txpsych.org/guidelineopiates.htm for dosing guidelines.
    • 3. Other useful medications for symptom control
    • Lomotil® for diarrhea Kaopectate® after a loose stool Pro-Banthine® or Bentyl® for abdominal cramps Tylenol® for headache Feldene® or Naprosyn® for back, joint, and bone pain Mylanta® for indigestion Phenergan® suppositories for nausea Atarax® for nausea Librium® for anxiety Benadryl® or Restoril® for sleep Sinequan® for insomnia, anxiety, dysphoria
    • Go to http://www.txpsych.org/guidelineopiates.htm for dosing guidelines.
    • Federation of Texas Psychiatry
    • Kleber
  • 99. OFFICE-BASED OUTPATIENT WITHDRAWAL TECHNIQUES USING (DIAZEPAM) VALIUM® OR (CLONAZEPAM) KLONOPIN® FOR ANXIOLYTICS/SEDATIVES/HYPNOTICS
    • VALIUM® OR KLONOPIN® SUBSTITUTION FOR ANXIOLYTIC/SEDATIVE/HYPNOTIC WITHDRAWAL AT HOME
    • Sporadic or intermittent use of anxiolytic/sedative/hypnotics may not require a withdrawal regimen. These techniques are best suited for the chronic user (a patient who has been on a relatively stable dose continuously for six months or more). The longer-acting clonazepam can be used rather than diazepam (5 mg of diazepam = 1 mg of clonazepam).
    • Go to http://www.txpsych.org/guidelinesanxiolyticsedativehypnotic.htm for dosing guidelines.
    • Federation of Texas Psychiatry
    • Alexander and Perry
    • Schweize and Rickels
    • Dupont
    • Benzer, Smith, and Miller
  • 100. OFFICE-BASED OUTPATIENT WITHDRAWAL TECHNIQUES FOR COCAINE AND AMPHETAMINES
    • NO SPECIFIC SUBSTITUTES FOR STIMULANT WITHDRAWAL AT HOME ARE AVAILABLE
    • The following may be used to treat the symptoms only:
    • benzodiazepines- brief use to decrease anxiety, agitation, or insomnia
    • neuroleptics- useful for agitation, paranoid symptoms, hallucinations, or delusions
    • Federation of Texas Psychiatry
    • Fischman
    • Fischman and Haney
  • 101. Rapid detoxification
    • “ Rapid opioid detoxification with opioid antagonist [naltrexone, a derivative of naloxone] induction using general anesthesia has emerged as an expensive , potentially dangerous , unproven approach to treat opioid dependence…
    • These data do not support the use of general anesthesia for …rapid opioid antagonist induction .”
    • American Medical Association
  • 102. The “4 Ds” of quitting medications
    • Deep breaths
    • (to deal with the tension from no longer using medication: with mouth closed and shoulders relaxed, inhale slowly and deeply through the nose, to the count of 7, pushing the stomach out; hold the breath to the count of 7; exhale slowing through pursed lips to the count of 7; repeat this cycle 3-5 times)
    • Drink water
    • (to remove the medication from your system: drink 8-10 glasses of water a day for at least a week, avoiding caffeinated beverages if possible)
    • Delay
    • (to handle the temptation to use medication: wait out a craving or urge to use medication at least 1 minute, finding that it goes away whether or not the medication is used after no more than 5 minutes)
    • Do something else
    • (to handle the psychological and/or physical desire to use medication: do other activities instead (review your most important reasons for quitting, talk to yourself, exercise, doodle, work on a hobby or crossword puzzle, take a shower, etc.)
    • American Lung Association (ALA) of Minnesota
  • 103.
    • Relapse Prevention
    • Exercise No. 1: Why Do I Want To Change?
    • Purpose . In this exercise, you will look at why you want to change. It is important to ask yourself this question. If you only want to escape the problems that you are facing right now, this workbook will not help you. If you want to change your life, it will.
    • Instructions . Complete the following sentences.
    • The reason I decided to try to get sober and clean this time is . . . (Tell what happened that made you seek help, such as job, health, or legal problems.)
    • Unless I really want to give up alcohol and drugs, I will not get better. Things might get better for a short time, but this will not last. I want to change because . . .
    Gorski and Kelley
  • 104.
    • Exercise No. 2: Reasons for Relapse
    • Purpose . This exercise will show you why you have trouble with recovery. By knowing this, you will know more about what you need to change.
    • When someone is having trouble staying sober and clean, it is because that person is having trouble with one of four major areas of recovery:
    • Acceptance of their disease : People who are having trouble accepting their disease believe they can still use alcohol or drugs and learn to control their use.
    • Unable to stabilize : Every time they try to stop using, they become sick, feel crazy, or cannot think about anything except drugs or alcohol. Therefore, they use alcohol or drugs to feel better.
    • Cannot get comfortable being sober : When they stop using, they do not know how to change the way they live so they can enjoy sobriety.
    • Relapse : They get sober and clean, they attend AA or NA meetings and enjoy sobriety, but then something happens, and they become unhappy and start to use again.
    • Instructions . Answer the following questions.
    • True False
    • ________ I believe that I can learn to drink or use drugs and control my use so that it will not hurt me.
    • ________ I know that I should not use alcohol or drugs at all, but every time I try to quit, I get sick and feel crazy, so I use alcohol or drugs to feel better.
    • ________ I know I cannot use alcohol or drugs, but when I quit for a while, I always end up using again.
    • ________ I know I cannot use alcohol or drugs, and I attend AA or NA and do everything I can to stay sober and clean. Sometimes I get very happy in recovery, but I still end up using again.
    Gorski and Kelley
  • 105.  
  • 106.  
  • 107. “ National Medicine Abuse Awareness Month ” set by the United States Senate for every August starting in 2007.
  • 108. References and Resources
    • “ Addiction: Part II. Identification and Management of the Drug-Seeking Patient,” American Family Physician, The American Academy of Family Physicians, April, 2000.
    • Alexander B. and Perry P. “Detoxification from benzodiazepines: Schedules and strategies.” Journal of Substance Abuse Treatment, Vol 8, pp.9-17, 1991.
    • American Lung Association (ALA) of Minnesota. “Tobacco Free Teens” ™. Adapted from ALA’s “Freedom from Smoking”®.
    • American Medical Association. “Anesthesia-Assisted vs Buprenorphine-or Clonidine-Assisted Heroin Detoxification and Naltrexone Induction A Randomized Trial.” Eric D. Collins, MD; Herbert D. Kleber, MD; Robert A. Whittington, MD; Nicole E. Heitler, MA, The Journal of the American Medical Association (JAMA). 2005;294:903-913.
    • American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.
    • American Society of Addiction Medicine, http://www.asam.org/.
    • “ A Pharmacist’s Guide to Prescription Fraud,” Office of Diversion Control, U.S. Department of Justice, Drug Enforcement Administration. Retrieved from the World Wide Web at http://www.deadiversion.usdoj.gov on July 20, 2007.
    • Arapahoe House Detox-West, 4643 Wadsworth Blvd., Wheat Ridge, CO 80033.
    • Benzer DO, Smith DE and Miller NS. “Detoxification from benzodiazepine use: Strategies and schedules for clinical practice.” Psychiatric Annals. 25(3) pp 180-185, 1995.
    • “ Biographies of DEA Agents and Employees Killed in Action.” Retrieved from the World Wide Web at http://www.dea.gov/agency/10bios.htm on December 6, 2007.
    • Clinical Opiate Withdrawal Scale (COWS), Wesson, Donald R., CNS Medications Development, Oakland, California; Medications Development Committee, American Society of Addiction Medicine; Ling, Walter, Integrated Substance Abuse Programs, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles.
    • “ Clinical pathway for intoxicated patients,” Brown University. Retrieved from the World Wide Web at http://brown.edu/Administration/Emergency_Medicine/emr/pages/etoh.htm July 29, 2007.
    • Community Anti-Drug Coalitions of America. Retrieved from the World Wide Web at http://www.doseofprevention.org on November 28, 2007.
  • 109.
    • Criminal Justice Addiction Services, 7475 W. 5th Ave., #150F, Lakewood, CO 80226-1673, (303) 232-0767, rtkannenberg@juno.com, http://ourworld.compuserve.com/homepages/criminaljustice.
    • Drug Digest. Express Scripts. Retrieved from the World Wide Web at http://www.drugdigest.org/ on December 5. 2007.
    • Drugs of Abuse. U.S. Drug Enforcement Administration (DEA), Office of Diversion Control, 2401 Jefferson Davis Highway, Alexandria, VA 22301. Retrieved from the World Wide Web at http://www.usdoj.gov/dea/pubs/abuse/index.htm on November 29, 2007.
    • Drug Test Coordinators, Inc. Retrieved from the World Wide Web at http://www.drugesting.com on November 21, 2007.
    • Dupont RL. “A practical approach to benzodiazepine discontinuation.” J. Psychiatric. Res. Vol 24 Suppl. 2 pp 81-90, 1990.
    • Ewing, JA, “Detecting Alcoholism: The CAGE Questionnaire” JAMA 252: 1905-1907, 1984. (Revised for prescription drugs.)
    • Exempla West Pines Behavioral Health Services, Source: Document #: 05-WPGM-3434-01, Version #:2, Effective Date: 7/01/05. 3400 Lutheran Pkwy., Wheat Ridge, CO 80033.
    • Fischman, M.W. “Pharmacologic Management of Cocaine Abuse and Dependence.” 1999 CME Monograph series sponsored by Dannemiller Memorial Educational Foundation and Alpha and Omega Worldwide LLC, 2000.
    • Fischman, MW and Haney M. “Neurobiology of Stimulants.” In Galanter M and Kleber H.D. Textbook of Substance Abuse Treatment (2nd edition), American Psychiatric Press, Inc pp 21-31, 1999.
    • Food and Drug Administration (FDA) Facts on Demand. Shelf number 2209. Retrieved from the World Wide Web at http://www.feda.goc.cdrh on May 23, 2007.
    • Goose bumps (image). Retrieved from the World Wide Web at http://content.answers.com/main/content/wp/en/2/23/Goose_bumps.jpg on July 22, 2007.
    • Gorski, Terence T. and Kelley, John M. (1999). Substance Abuse and Mental Health Services Administration, Public Health Service, U.S. Department of Health and Human Services.
    • “ Impaired Professionals.” Retrieved from the World Wide Web at www.psychiatry.ufl.edu/aec/courses/501/impairedprofessionals.pdf on November 29, 2007.
    • Kannenberg, Rand L. Criminal Justice Addiction Services, 7475 W. 5th Ave., #150F, Lakewood, CO 80226-1673, (303) 232-0767, rtkannenberg@juno.com, http://ourworld.compuserve.com/homepages/criminaljustice.
    • Kannenberg, Rand L. (2002). Sociotherapy for Sociopaths: Resocial Group. A Group Treatment Curriculum for Adults with Antisocial Behavior and Substance Abuse . Eau Claire, WI: PESI HealthCare, LLC.
  • 110.
    • Kleber HS Opioids: “Detoxification.” In Galanter M and Kleber HD. Textbook of substance abuse treatment , 2nd edition, The American Psychiatric Press Washington, DC 1999, pp 251-269.
    • Mayo Clinic. ”Weight-loss pills: What can diet aids do for you?” Mayo Foundation for Medical Education and Research. Retrieved from the World Wide Web at http://www.mayoclinic.com/health/weight-loss/HQ01160 on December 5, 2007.
    • Myalli. Retrieved from the World Wide Web at http://www.myalli.com/ on November 6, 2007.
    • National Institute on Drug Abuse (NIDA) “Research Report – Prescription Drugs: Abuse and Addiction.” NIH Publication No. 01-4881, Revised August 2005.
    • “ National Survey on Drug Use and Health (NSDUH): National Findings.” 2006. SAMHSA.
    • Office of National Drug Control Policy (ONDCP). Retrieved from the World Wide Web on November 6, 2007 at http:// www.whitehousedrugpolicy.gov
    • Physicians’ Desk Reference ® (PDR®). (6th ed.). (2003). New York: Pocket Books.
    • “ PRACTICE GUIDELINES: OFFICE-BASED OUTPATIENT WITHDRAWAL TECHNIQUES: A GUIDE .” Federation of Texas Psychiatry. 401 West 15th Street, Suite 675, Austin, Texas 78701.
    • “ Prescription Drugs: Abuse and Addiction: Pain and Opiophobia.” Research Report Series. National Institute on Drug Abuse (NIDA). Retrieved from the World Wide Web at http://www.nida.nih.gov/ResearchReports/Prescription/Prescription6a.html on November 23, 2007.
    • “ Prescription Drugs: Killing More Than Pain.” 2005. VHS225. Community Anti-Drug Coalitions of America (CADCA) and Multijurisdictional Counterdrug Task Force Training (MCTFT) Program, St. Petersburg College; SAMHSA’s National Clearinghouse for Alcohol & Drug Information.
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    • Schedules of Controlled Substances. TITLE 21 - FOOD AND DRUGS CHAPTER 13 - DRUG ABUSE PREVENTION AND CONTROL SUBCHAPTER I - CONTROL AND ENFORCEMENT Part A - Introductory Provisions - Sec. 802. Definitions.
    • Schweizer E and Rickels K. “Benzodiazepine dependence and withdrawal: A review of the syndrome and its clinical management.” Acta. Psychiatry. Scand. 98 (suppl.393) pp 95-101, 1998.
    • Selected Prescription Drugs with Potential for Abuse. National Institute on Drug Abuse (NIDA). Revised April 2005.
    • “ Sleep-Disordered Breathing and Chronic Opioid Therapy” by Lynn R. Webster, MD; Youngmi Choi, MD, PhD; Himanshu Desai, MD; Linda Webster, RPSGT; and Brydon J. B. Grant, MD. OnlineEarly Articles: 30-Jul-2007. Pain Medicine . American Academy of Pain Medicine (AAPM).
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    • on July 27, 2007.
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    • Tennessee Association of Alcohol and Drug Abuse Services (TAADAS). Call the Tennessee REDLINE at (800) 889-9789 or (615) 780-5901.
    • “ The OTC: Battling the Over-The-Counter High.” 2004. VHS223. Community Anti-Drug Coalitions of America (CADCA) and Multijurisdictional Counterdrug Task Force Training (MCTFT) Program, St. Petersburg College; SAMHSA’s National Clearinghouse for Alcohol & Drug Information.
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    • WESSON, Donald R., CNS Medications Development, Oakland, California; Medications Development Committee, American Society of Addiction Medicine. LING, Walter, Integrated Substance Abuse Programs, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles.
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