Alcohol and drugs week 9


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  • Stimulant Fact Sheet Text: Amphetamines Stimulants is a name given to several groups of drugs that tend to increase alertness and physical activity. The groups include pharmaceuticals such as amphetamines and the street drugs commonly called "uppers" or "speed," and cocaine . The more widely abused stimulants are amphetamines and cocaine. Cocaine has limited commercial use and its sale and possession are strictly controlled. Amphetamines are sometimes prescribed by physicians, and their availability makes them prime candidates for misuse. Used properly, amphetamines increase alertness and physical ability. They are often prescribed to counter the effects of narcolepsy, a rare disorder marked by episodes of uncontrollable sleep, and to help children with minimal brain dysfunction. Amphetamines increase the heart and respiration rates, increase blood pressure, dilate the pupils of the eyes, and decrease appetite. Other side effects include anxiety, blurred vision, sleeplessness, and dizziness. Abuse of amphetamines can cause irregular heartbeat and even physical collapse. A common form of abuse of amphetamines is by people who use them to counter the effects of sleeping pills ( barbiturates ) taken the night before. This roller coaster effect is damaging to the body. While amphetamine users may feel a temporary boost in self-confidence and power, the abuse of the drug can lead to delusions, hallucinations, and a feeling of paranoia. These feelings can cause a person to act in bizarre fashion, even violently. In most people, these effects disappear when they stop using the drug. Amphetamines are stolen or acquired through scams involving pharmacists or physicians who are duped into writing prescriptions for the drugs. These illegally acquired drugs are either sold as is or reduced to yellowish crystals that can be ingested in a number of ways, including sniffing and by injection. Another means of illegal sale of amphetamines involves "look-alike" drugs produced in illicit laboratories. One danger in these look-alikes is that the potency may vary from batch to batch. A person accustomed to using a weak look-alike may unwittingly suffer an overdose taking the same volume of a stronger look-alike. Symptoms Amphetamines are psychologically addictive. Users become dependent on the drug to avoid the "down" feeling they often experience when the drug's effect wears off. This dependence can lead a user to turn to stronger stimulants such as cocaine, or to larger doses of amphetamines to maintain a "high". People who abruptly stop using amphetamines often experience the physical signs of addiction, such as fatigue, long periods of sleep, irritability, and depression. How severe and prolonged these withdrawal symptoms are depends on the degree of abuse. That boost we get from that morning cup of coffee is the result of the caffeine that naturally occurs in coffee. Caffeine is a common stimulant and is found not only in coffee and tea, but also in soft drinks and other foods. It can also be bought over-the-counter in tablet form. Too much caffeine can cause anxiousness, headaches, and the "jitters." Caffeine is also addictive and a person who abruptly stops drinking coffee may experience withdrawal symptoms. Caffeine: FACT SHEET CAFFEINE AND YOUR HEALTH Caffeine is consumed as a natural part of coffee, tea, chocolate and certain flavours (e.g. those derived from kola and guarana). The best way for consumers to avoid any adverse effects from caffeine is to become familiar with the many sources of this substance, to read product labels and to moderate consumption of caffeine-containing products. Caffeine exhibits a number of biological effects resulting from its diuretic and stimulant properties. Research1 has shown that some sensitive individuals experience side effects such as insomnia, headaches, irritability and nervousness. As with any substance, there can be numerous other contributing factors, but Canada's Guidelines to Healthy Eating advises consumers that limiting caffeine is a wise precaution. A recent review2 undertaken by Health Canada has considered the numerous studies dealing with caffeine and its potential health effects. It has re-confirmed that for the average adult, moderate daily caffeine intake at dose levels of 400-450 mg/day is not associated with any adverse effects. Data has shown, however, that women of childbearing age and children may be at greater risk from caffeine. Consequently, as a precautionary measure, Health Canada has developed additional guidelines for these two groups. The following recommended maximum caffeine intake levels are based on the most current research available. RECOMMENDED MAXIMUM CAFFEINE INTAKE LEVELS FOR CHILDREN AND WOMEN OF CHILDBEARING AGE Children* 4 - 6 years 45 mg/day 7 - 9 years 62.5 mg/day 10 - 12 years 85 mg/day Women who are planning to become pregnant, pregnant women and breast feeding mothers**   300 mg/day *Using the recommended intake of 2.5 milligrams per kilogram of body weight per day and based on average body weights of children (Health and Welfare Canada, 1990), based on "behavioural effects". **Based on possible adverse effects on some factors of reproduction and development. 1 Health and Welfare Canada, 1990. Nutrition Recommendations. 2 Effects of Caffeine on Human Health, P. Nawrot, S. Jordan, J. Eastwood, J. Rotstein, A. Hugenholtz and M. Feeley, Food Additives and Contaminants, 2003, Vol. 20, No. 1, pg. 1-30. The web version of this page also contains a table that lists caffeine content of common food and drink Caffeine Myths and Facts Caffeine myth or caffeine fact? It's not always easy to know. Chances are you have some real misperceptions about caffeine. For starters, do you know the most common sources of caffeine? Well, maybe two of the sources aren't too hard to name -- coffee and tea leaves. But did you know kola nuts and cocoa beans are also included among the most common caffeine sources? And do you know how much caffeine content can vary from food to food? Turns out it's quite a lot actually, depending on the type and serving size of a food or beverage and how it's prepared. Caffeine content can range from as much as 160 milligrams in some energy drinks to as little as 4 milligrams in a 1-ounce serving of chocolate-flavored syrup. Even decaffeinated coffee isn't completely free of caffeine. Caffeine is also present in some over-the-counter pain relievers, cold medications, and diet pills. These products can contain as little as 16 milligrams or as much as 200 milligrams of caffeine. In fact, caffeine itself is a mild painkiller and increases the effectiveness of other pain relievers. Caffeine Myth No. 1: Caffeine Is Addictive This one has some truth to it, depending on what you mean by "addictive." Caffeine is a stimulant to the central nervous system, and regular use of caffeine does cause mild physical dependence. But caffeine doesn't threaten your physical, social, or economic health the way addictive drugs do. (Although after seeing your monthly spending at the coffee shop, you might disagree!) If you stop taking caffeine abruptly, you may have symptoms for a day or more, especially if you consume two or more cups of coffee a day. Symptoms of withdrawal from caffeine include: headache fatigue anxiety irritability depressed mood difficulty concentrating No doubt, caffeine withdrawal can make for a few bad days. However, caffeine does not cause the severity of withdrawal or harmful drug-seeking behaviors as street drugs or alcohol. For this reason, most experts don't consider caffeine dependence an addiction. Caffeine Myth No. 2: Caffeine Is Likely to Cause Insomnia Your body quickly absorbs caffeine. But it also gets rid of it quickly. Processed mainly through the liver, caffeine has a relatively short half-life. This means it takes about four to five hours, on average, to eliminate half of it from your body. After eight to 10 hours, 75% of the caffeine is gone. For most people, a cup of coffee or two in the morning won't interfere with sleep at night. Consuming caffeine later in the day, however, can interfere with sleep. If you're like most people, your sleep won't be affected if you don't consume caffeine at least six hours before going to bed. Your sensitivity may vary, though, depending on your metabolism and the amount of caffeine you regularly consume. People who are more sensitive may not only experience insomnia but also have caffeine side effects of nervousness and gastrointestinal upset. Decongestants Definition Decongestants are medicines used to relieve nasal congestion (stuffy nose). Purpose A congested or stuffy nose is a common symptom of colds and allergies. This congestion results when membranes lining the nose become swollen. Decongestants relieve the swelling by narrowing the blood vessels that supply the nose. This reduces the blood supply to the swollen membranes, causing the membranes to shrink. These medicines do not cure colds or reverse the effects of histamines-chemicals released as part of the allergic reaction. They will not relieve all of the symptoms associated with colds and allergies, only the stuffiness. When considering whether to use a decongestant for cold symptoms, keep in mind that most colds go away with or without treatment and that taking medicine is not the only way to relieve a stuffy nose. Drinking hot tea or broth or eating chicken soup may help. There are also adhesive strips can be placed on the nose to help widen the nasal passages, making breathing through the nasal passages a bit easier when congestion is present. Precautions Decongestant nasal sprays and nose drops may cause a problem called rebound congestion if used repeatedly over several days. When this happens, the nose remains stuffy or gets worse with every dose. The only way to stop the cycle is to stop using the drug. The stuffiness should then go away within about a week. Anyone who shows signs of severe rebound congestion should also contact his or her physician. Do not use decongestant nasal sprays for more than three days. Decongestants taken by mouth should not be used for more than seven days. If the congestion has not gone away in this time, or if the symptoms are accompanied by fever, call a physician. Do not use a decongestant nasal spray after the product's expiration date. If the product has become cloudy or discolored, throw it away and do not use it. Do not share droppers or spray bottles with anyone else, as this could spread infection. Do not let droppers and bottle tips touch countertops or other surfaces. Some decongestants cause drowsiness. People who takes these drugs should not drive, use machines or do anything else that might be dangerous until they have found out how the drugs affect them. In general, older people may be more sensitive to the effects of decongestants and may need to take lower doses to avoid side effects. People in this age group should not take long-acting (extended release) forms of decongestants unless they have previously taken a short-acting form with no ill effects. Children may also be more sensitive to the effects of decongestants. Before giving any decongestant to a child, check the package label carefully. Some of these medicines are too strong for use in children. Serious side effects are possible if they are given large amounts of these drugs or if they swallow nose drops, nasal spray or eye drops. If this happens, call a physician or poison center immediately. Special conditions People with certain medical conditions or who are taking certain other medicines can have problems if they take decongestants. Before taking these drugs, be sure to let the physician know about any of these conditions: PREGNANCY In studies of laboratory animals, some decongestants have had unwanted effects on fetuses. However, it is not known whether such effects also occur in people. Women who are pregnant or who plan to become pregnant should check with their physicians before taking decongestants. BREASTFEEDING Some decongestants pass into breast milk and may have unwanted effects on nursing babies whose mothers take the drugs. Women who are breastfeeding should check with their physicians before using decongestants. If they need to take the medicine, it may be necessary to bottle feed the baby with formula while taking it. OTHER MEDICAL CONDITIONS Anyone with heart or blood vessel disease, high blood pressure, diabetes, enlarged prostate, or overactive thyroid should not take decongestants unless under a physician's supervision. The medicine can increase blood sugar in people with diabetes. It can be especially dangerous in people with high blood pressure, as it may increase blood pressure. Before using decongestants, people with any of these medical problems should make sure their physicians are aware of their conditions: Glaucoma, history of mental illness. Decongestants may have a variety of side effects, and may also interact with other medications the patient is taking. Side effects The most common side effects from decongestant nasal sprays and nose drops are sneezing and temporary burning, stinging, or dryness. These effects are usually temporary and do not need medical attention. If any of the following side effects occur after using a decongestant nasal spray or nose drops, stop using the medicine immediately and call the physician: increased blood pressure headache fast, slow, or fluttery heartbeat nervousness dizziness nausea sleep problems The most common side effects of decongestants taken by mouth are nervousness, restlessness, excitability, dizziness, drowsiness, headache, nausea, weakness, and sleep problems. Anyone who has these symptoms while taking decongestants should stop taking them immediately. Patients who have these symptoms while taking decongestants should call the physician immediately: increased blood pressure fast, irregular, or fluttery heartbeat severe headache tightness or discomfort in the chest breathing problems fear or anxiety hallucinations trembling or shaking convulsions (seizures) pale skin painful or difficult urination Other side effects may occur. Anyone who has unusual symptoms after taking a decongestant should get in touch with his or her physician. Interactions with other medicines Decongestants may interact with a variety of other medicines. When this happens, the effects of one or both of the drugs may change or the risk of side effects may be greater. Do not take decongestants at the same time as these drugs: Monoamine oxidase inhibitors (MAO inhibitors) such as phenzeline (Nardil) or tranylcypromine (Parnate), used to treat conditions including depression and Parkinson's disease. Do not take decongestants at the same time as a MAO inhibitor or within two weeks of stopping treatment with an MAO inhibitor unless a physician approves. Other products containing the same or other decongestants Caffeine. In addition, anyone who takes decongestants should let the physician know all other medicines he or she is taking. Among the drugs that may interact with decongestants are: tricyclic antidepressants such as imipramine (Tofranil) or desipramine (Norpramin) the antidepressant maprotiline (Ludiomil) amantadine (Symmetrel) amphetamines medicine to relieve asthma or other breathing problems methylphenidate (Ritalin) appetite suppressants other medicine for colds, sinus problems, hay fever or other allergies beta-blockers such as atenolol (Tenormin) and propranolol (Inderal) digitalis glycosides, used to treat heart conditions The list above does not include every drug that may interact with decongestants. Be sure to check with a physician or pharmacist before combining decongestants with any other prescription or nonprescription (over-the-counter) medicine. Risks Anyone considering taking a decongestant should take a close look at the labels of any already in their medicine cabinet. In 2000, the Food and Drug Administration prohibited over-the-counter sales of medicines containing the decongestant phenylpropanolamine. The medicine is associated with an increased risk of stroke in people ages 18 to 49, especially women. Many cold remedies contained this medicine. Contact a pharmacist if there is any question about the ingredients in a medication. Over-the-counter remedies containing phenylpropanolamine should be discarded. Medline Plus Health Information. U.S. National Library of Medicine. Methamphetamine What are the street names/slang terms for Methamphetamine? Chalk, Crank, Croak, Crypto, Crystal, Fire, Glass, Meth, Tweek , White Cross. What is Methamphetamine ?Methamphetamine is an addictive stimulant that strongly activates certain systems in the brain. What does it look like?Meth is a crystal-like powdered substance that sometimes comes in large rock-like chunks. When the powder flakes off the rock, the shards look like glass, which is another nickname for meth. Meth is usually white or slightly yellow, depending on the purity. How is it used?Methamphetamine can be taken orally, injected, snorted, or smoked. What are its short-term effects?Immediately after smoking or injection, the user experiences an intense sensation, called a " rush " or "flash," that lasts only a few minutes and is described as extremely pleasurable. Snorting or swallowing meth produces euphoria - a high, but not a rush. After the initial "rush," there is typically a state of high agitation that in some individuals can lead to violent behavior. Other possible immediate effects include increased wakefulness and insomnia, decreased appetite, irritability/aggression, anxiety, nervousness, convulsions and heart attack.RushA surge of pleasure that rapidly follows administration of some drugs. (National Institute on Drug Abuse) What are its long-term effects?Meth is addictive, and users can develop a tolerance quickly, needing larger amounts to get high. In some cases, users forego food and sleep and take more meth every few hours for days, 'binging' until they run out of the drug or become too disorganized to continue. Chronic use can cause paranoia, hallucinations, repetitive behavior (such as compuslively cleaning, grooming or disasembling and assembling objects), and delusions of parasites or insects crawling under the skin. Users can obsessively scratch their skin to get rid of these imagined insects. Long-term use, high dosages, or both can bring on full-blown toxic psychosis (often exhibited as violent, aggressive behavior). This violent, aggressive behavior is usually coupled with extreme paranoia. Meth can also cause strokes and death.ToleranceA condition in which higher doses of a drug are required to produce the same effect as experienced initially; often leads to physical dependence. (National Institute on Drug Abuse) Psychosis (A mental disorder characterized by symptoms such as delusions or hallucinations that indicate an impaired conception of reality. (National Institute on Drug Abuse)) Ritalin What are the street names/slang terms for Ritalin?Kibbles and bits, Pineapple. What is Ritalin?Ritalin, the trade name for methylphenidate, is a medication prescribed for children with an abnormally high level of activity or with attention-deficit hyperactivity disorder (ADHD) and is also occasionally prescribed for treating narcolepsy. It stimulates the central nervous system, with effects similar to but less potent than amphetamines and more potent than caffeine. Ritalin has a notably calming effect on hyperactive children and a "focusing" effect on those with ADHD. When taken as prescribed, Ritalin is a valuable medicine. Further, research funded by the National Institute of Mental Health has shown that people with ADHD do not get addicted to their stimulant medications at treatment dosages. Because of its stimulant properties, however, in recent years there have been reports of its abuse by people for whom it is not a medication. These prescription tablets can create powerful stimulant effects and serious health risks when crushed and then snorted like cocaine , or injected like heroin . Treatment Planned activities designed to change some pattern of behavior(s) which has led to substance use problems, and medications that help with withdrawal symptoms, craving, and preventing relapse. Typical activities for the treatment of alcoholism and/or drug dependence include detoxification, individual or group counseling for the addicted person, education and counseling for the family, and a structured residential program for those who have been unsuccessful in abstinence in less structured settings. (Join Together) What does it look like? Ritalin is in pill or tablet form. How is it used? Ritalin is in pill or tablet form. What are its short-term effects? Ritalin (methylphenidate) is a central nervous system stimulant, similar to amphetamines in the nature and duration of its effects. It is believed that it works by activating the brain stem arousal system and cortex. Pharmacologically, it works on the neurotransmitter dopamine , and in that respect resembles the stimulant characteristics of cocaine . Short-term effects can include nervousness and insomnia, loss of appetite, nausea and vomiting, dizziness, palpitations, headaches, changes in heart rate and blood pressure (usually elevation of both, but occasionally depression), skin rashes and itching, abdominal pain, weight loss, and digestive problems, toxic psychosis , psychotic episodes, drug dependence syndrome, and severe depression upon withdrawal . NeurotransmitterA chemical produced by neurons to carry messages to other neurons. (National Institute on Drug Abuse Glossary for Teens) What are its long-term effects? High doses of stimulants produce a predictable set of symptoms that include loss of appetite (may cause serious malnutrition), tremors and muscle twitching, fevers, convulsions, and headaches (may be severe), irregular heartbeat and respirations (may be profound and life threatening), anxiety, restlessness, paranoia, hallucinations, and delusions, excessive repetition of movements and meaningless tasks, and formicaton (sensation of bugs or worms crawling under the skin). Ritalin Part II Ritalin, Methylphenidate, is a medication prescribed for individuals (usually children) who have attention-deficit hyperactivity disorder (ADHD), which consists of a persistent pattern of abnormally high levels of activity, impulsivity, and/or inattention that is more frequently displayed and more severe than is typically observed in individuals with comparable levels of development. The pattern of behavior usually arises between the ages of 3 and 5, and is diagnosed during the elementary school years due to the child’s excessive locomotor activity, poor attention, and/or impulsive behavior. Most symptoms improve during adolescence or adulthood, but the disorder can persist or present in adults. It has been estimated that 3–7 percent of school-age children have ADHD. Methylphenidate also is occasionally prescribed for treating narcolepsy. Health Effects Methylphenidate is a central nervous system (CNS) stimulant. It has effects similar to, but more potent than, caffeine and less potent than amphetamines. It has a notably calming and “focusing” effect on those with ADHD, particularly children. Recent research at Brookhaven National Laboratory may begin to explain how methylphenidate helps people with ADHD. The researchers used positron emission tomography (PET—a noninvasive brain scan) to confirm that administering normal therapeutic doses of methylphenidate to healthy, adult men increased their dopamine levels. The researchers speculate that methylphenidate amplifies the release of dopamine, a neurotransmitter, thereby improving attention and focus in individuals who have dopamine signals that are weak.1 Methylphenidate is a valuable medicine, for adults as well as children with ADHD.2, 3, 4 Treatment of ADHD with stimulants such as Ritalin and psychotherapy help to improve the abnormal behaviors of ADHD, as well as the self-esteem, cognition, and social and family function of the patient.2 Research shows that individuals with ADHD do not become addicted to stimulant medications when taken in the form and dosage prescribed by doctors. In fact, it has been reported that stimulant therapy in childhood is associated with a reduction in the risk for subsequent drug and alcohol use disorders.5, 6 Also, studies have found that individuals with ADHD treated with stimulants such as methylphenidate are significantly less likely than those who do not receive treatment to abuse drugs and alcohol when they are older.7 Because of its stimulant properties, however, in recent years there have been reports of abuse of methylphenidate by people for whom it is not prescribed. It is abused for its stimulant effects: appetite suppression, wakefulness, increased focus/attentiveness, and euphoria. Addiction to methylphenidate seems to occur when it induces large and fast dopamine increases in the brain. In contrast, the therapeutic effect is achieved by slow and steady increases of dopamine, which are similar to the natural production by the brain. The doses prescribed by physicians start low and increase slowly until a therapeutic effect is reached. That way, the risk of addiction is very small.8 When abused, the tablets are either taken orally or crushed and snorted. Some abusers dissolve the tablets in water and inject the mixture; complications can arise from this because insoluble fillers in the tablets can block small blood vessels. Trends in Ritalin Abuse Monitoring the Future (MTF) Survey * Each year, MTF assesses the extent of drug use among adolescents and young adults nationwide. MTF 2004 data on annual** use indicate that 2.5 percent of 8th-graders abused Ritalin, as did 3.4 percent of 10th-graders and 5.1 percent of 12th-graders. Other Studies ADHD has been more frequently reported in boys than in girls; however, in the last year, the frequency among girls has greatly increased.9 A large survey at a public university showed that 3 percent of the students had used methylphenidate during the past year.10 Other Information Sources Because stimulant medicines such as methylphenidate do have potential for abuse, the U.S. Drug Enforcement Administration (DEA) has placed stringent, Schedule II controls on their manufacture, distribution, and prescription. For example, DEA requires special licenses for these activities, and prescription refills are not allowed. The DEA web site is . States may impose further regulations, such as limiting the number of dosage units per prescription. Adderall Amphetamine-Dextroamphetamine (am FEH ta meen/deck stroe am FEH ta meen) Adderall, Adderall XR What is the most important information I should know about Adderall? Use caution when driving, operating machinery, or performing other hazardous activities. Adderall may cause dizziness, blurred vision, or restlessness, and it may hide the symptoms of extreme tiredness. If you experience these effects, avoid hazardous activities.• Adderall is habit forming. Physical and psychological dependence may occur with the use of this medication, and withdrawal effects may occur if you stop taking it suddenly after several weeks of continuous use. Talk to your doctor about stopping this medication gradually.• Do not crush or chew the extended-release form of Adderall (Adderall XR). If swallowing the capsules is difficult, a capsule can be opened and the entire contents sprinkled on a small amount of applesauce. The mixture should be consumed immediately, and not saved for later use. The mixture should be swallowed whole, without chewing the sprinkled beads. The dose of a single capsule should not be divided. What is Adderall? • Adderall is a stimulant and appetite suppressant. It stimulates the central nervous system (nerves and brain) by increasing the amount of certain chemicals in the body. This increases heart rate and blood pressure and decreases appetite, among other effects.• Adderall is used to treat narcolepsy and attention deficit disorder with hyperactivity (ADHD).• Adderall may also be used for purposes other than those listed in this medication guide. What should I discuss with my healthcare provider before taking Adderall? • Do not take Adderall if you     ·have heart disease or high blood pressure;     ·have arteriosclerosis (hardening of the arteries);     ·have glaucoma;     ·have taken a monoamine oxidase inhibitor (MAOI) such as isocarboxazid (Marplan), tranylcypromine (Parnate), or phenelzine (Nardil) in the last 14 days; or     ·have a history of drug or alcohol abuse.• Before taking this medication, tell your doctor if you have     ·thyroid problems;     ·an anxiety disorder;     ·epilepsy or another seizure disorder; or     ·diabetes.• You may not be able to take Adderall, or you may require a dosage adjustment or special monitoring during treatment if you have any of the conditions listed above.• Adderall is in the FDA pregnancy category C. This means that it is not known whether it will be harmful to an unborn baby. Do not take Adderall without first talking to your doctor if you are pregnant or could become pregnant during treatment.• Adderall passes into breast milk and may affect a nursing baby. Do not take Adderall without first talking to your doctor if you are breast-feeding a baby. What happens if I overdose? • Seek emergency medical attention.• Symptoms of an Adderall overdose include restlessness, tremor, rapid breathing, confusion, hallucinations, panic, aggressiveness, nausea, vomiting, diarrhea, an irregular heartbeat, and seizures. What should I avoid while taking Adderall? • Use caution when driving, operating machinery, or performing other hazardous activities. Adderall may cause dizziness, blurred vision, or restlessness, and it may hide the symptoms of extreme tiredness. If you experience these effects, avoid hazardous activities.• Do not take Adderall late in the day. A dose taken too late in the day may cause insomnia. What are the possible side effects of Adderall? • If you experience any of the following serious side effects, stop taking Adderall and seek emergency medical attention:     ·an allergic reaction (difficulty breathing; closing of the throat; swelling of the lips, tongue, or face; or hives);     ·an irregular heartbeat or very high blood pressure (severe headache, blurred vision); or     ·hallucinations, abnormal behavior, or confusion.• Other, less serious side effects may be more likely to occur. Continue to take Adderall and talk to your doctor if you experience     ·restlessness or tremor;     ·anxiety or nervousness;     ·headache or dizziness;     ·insomnia;     ·dryness of the mouth or an unpleasant taste in the mouth;     ·diarrhea or constipation; or     ·impotence or changes in sex drive.• Adderall is habit forming. Physical and psychological dependence may occur with the use of this medication, and withdrawal effects may occur if you stop taking it suddenly after several weeks of continuous use. Talk to your doctor about stopping this medication gradually.• Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome. What other drugs will affect Adderall? • Do not take Adderall if you have taken a monoamine oxidase inhibitor (MAOI) such as isocarboxazid (Marplan), tranylcypromine (Parnate), or phenelzine (Nardil) in the last 14 days.• Before taking Adderall, tell your doctor if you are taking any of the following medicines:     ·insulin or another medicine to treat diabetes;     ·guanethidine (Ismelin) or reserpine (Diutensin-R);     ·doxazosin (Cardura), terazosin (Hytrin), prazosin (Minipress), or guanadrel(Hylorel);     ·a phenothiazine such as chlorpromazine (Thorazine);     ·lithium (Lithobid, Lithonate, Eskalith, others);     ·haloperidol (Haldol); or     ·a tricyclic antidepressant such as amitriptyline (Elavil), amoxapine (Asendin), doxepin (Sinequan), nortriptyline (Pamelor), imipramine (Tofranil), clomipramine (Anafranil), protriptyline (Vivactil), or desipramine (Norpramin).• You may not be able to take Adderall, or you may require a dosage adjustment or special monitoring during treatment if you are taking any of the medicines listed above.• Drugs other than those listed here may also interact with Adderall. Talk to your doctor and pharmacist before taking any prescription or over-the-counter medicines, including herbal products. Cocaine Description: A powerfully addictive drug that is
  • Methamphetamine Brief Description: An addictive stimulant that is closely related to amphetamine, but has longer lasting and more toxic effects on the central nervous system. It has a high potential for abuse and addiction. Street Names: Speed, meth, chalk, ice, crystal, glass. Effects: Increases wakefulness and physical activity and decreases appetite. Chronic, long-term use can lead to psychotic behavior, hallucinations, and stroke. Statistics and Trends: According to the 2002 National Survey on Drug Use and Health , about 12 million Americans have tried methamphetamine. Cocaine Cocaine is a powerfully addictive stimulant drug. The powdered, hydrochloride salt form of cocaine can be snorted or dissolved in water and injected. Crack is cocaine that has not been neutralized by an acid to make the hydrochloride salt. This form of cocaine comes in a rock crystal that can be heated and its vapors smoked. The term "crack" refers to the crackling sound heard when it is heated.* Regardless of how cocaine is used or how frequently, a user can experience acute cardiovascular or cerebrovascular emergencies, such as a heart attack or stroke, which could result in sudden death. Cocaine-related deaths are often a result of cardiac arrest or seizure followed by respiratory arrest. Health Hazards Cocaine is a strong central nervous system stimulant that interferes with the reabsorption process of dopamine, a chemical messenger associated with pleasure and movement. The buildup of dopamine causes continuous stimulation of “receiving” neurons, which is associated with the euphoria commonly reported by cocaine abusers. Physical effects of cocaine use include constricted blood vessels, dilated pupils, and increased temperature, heart rate, and blood pressure. The duration of cocaine's immediate euphoric effects, which include hyperstimulation, reduced fatigue, and mental clarity, depends on the route of administration. The faster the absorption, the more intense the high. On the other hand, the faster the absorption, the shorter the duration of action. The high from snorting may last 15 to 30 minutes, while that from smoking may last 5 to 10 minutes. Increased use can reduce the period of time a user feels high and increases the risk of addiction. Some users of cocaine report feelings of restlessness, irritability, and anxiety. A tolerance to the "high" may develop—many addicts report that they seek but fail to achieve as much pleasure as they did from their first exposure. Some users will increase their doses to intensify and prolong the euphoric effects. While tolerance to the high can occur, users can also become more sensitive to cocaine's anesthetic and convulsant effects without increasing the dose taken. This increased sensitivity may explain some deaths occurring after apparently low doses of cocaine. Use of cocaine in a binge, during which the drug is taken repeatedly and at increasingly high doses, may lead to a state of increasing irritability, restlessness, and paranoia. This can result in a period of full-blown paranoid psychosis, in which the user loses touch with reality and experiences auditory hallucinations. Other complications associated with cocaine use include disturbances in hearth rhythm and heart attacks, chest pain and respiratory failure, strokes, seizures and headaches, and gastrointestinal complications such as abdominal pain and nausea. Because cocaine has a tendency to decrease appetite, many chronic users can become malnourished. Different means of taking cocaine can produce different adverse effects. Regularly snorting cocaine, for example, can lead to loss of sense of smell, nosebleeds, problems with swallowing, hoarseness, and a chronically runny nose. Ingesting cocaine can cause severe bowel gangrene due to reduced blood flow. People who inject cocaine can experience severe allergic reactions and, as with any injecting drug user, are at increased risk for contracting HIV and other blood-borne diseases. Added Danger: Cocaethylene When people mix cocaine and alcohol consumption, they are compounding the danger each drug poses and unknowingly forming a complex chemical experiment within their bodies. NIDA-funded researchers have found that the human liver combines cocaine and alcohol and manufactures a third substance, cocaethylene, that intensifies cocaine's euphoric effects, while potentially increasing the risk of sudden death. Treatment The widespread abuse of cocaine has stimulated extensive efforts to develop treatment programs for this type of drug abuse. One of NIDA's top research priorities is to find a medication to block or greatly reduce the effects of cocaine, to be used as one part of a comprehensive treatment program. NIDA-funded researchers are also looking at medications that help alleviate the severe craving that people in treatment for cocaine addiction often experience. Several medications are currently being investigated for their safety and efficacy in treating cocaine addiction. In addition to treatment medications, behavioral interventions—particularly cognitive behavioral therapy—can be effective in decreasing drug use by patients in treatment for cocaine abuse. Providing the optimal combination of treatment and services for each individual is critical to successful outcomes. Extent of Use Monitoring the Future (MTF) Survey ** MTF assesses the extent and perceptions of drug use among 8th, 10th, and 12th grade students nationwide. There was only one statistically significant change in cocaine use measured between 2003 and 2004. Tenth-graders reported an increase in 30-day*** use of powder cocaine, from 1.1 percent in 2003 to 1.5 percent in 2004. Overall annual cocaine use increased in each grade from the early 1990s until 1998 or 1999 and has subsequently stabilized or declined somewhat. Among 12th-graders, the rate increased from 3.1 percent in 1992 to 6.2 percent in 1999, declined significantly to 5.0 percent in 2000, and remained stable through 2003 at 4.8 percent. Among 10th-graders, the rate increased from 1.9 percent in 1992 to 4.9 percent in 1999. In 2004, 3.7 percent of 10th-graders reported annual cocaine use, significantly below the peak in 1999, though year-to-year changes were not significant. Among 8th-graders, 1.1 percent reported annual cocaine use in 1991, a figure that increased to 3.0 percent in 1996, hovered around that point for several years, then dropped to 2.0 percent in 2004—significantly below the 1996 high point. Eighth-graders reported a significant decrease in perceived availability of both crack and powder cocaine in 2004. Twelfth-graders, however, reported a significant increase in perceived availability of both crack and cocaine in 2004. Community Epidemiology Work Group (CEWG) **** Cocaine/crack was endemic in almost all 21 CEWG areas in 2002. Rates of emergency department (ED) mentions were higher for cocaine than for any other drug in 17 CEWG areas. ED rates increased significantly between 2001 and 2002 in Baltimore, and were highest in Chicago, Philadelphia, Atlanta, Baltimore, Miami, Newark, Detroit, and New York. Cocaine-related death mentions in 2001 were particularly high in Chicago, Baltimore, Dallas, Newark, San Antonio, Atlanta, Boston, Denver, San Francisco, and New York, as measured by one Federal data source. Reports from local medical examiner data named Detroit, Philadelphia, Miami, and Phoenix as sites with the highest rates of cocaine-related deaths from 2000 through 2002. Primary cocaine treatment admissions were high in 9 of the 21 CEWG areas reporting treatment data in 2003 (Atlanta, Miami, New Orleans, St. Louis, Washington, DC, Philadelphia, Texas, Detroit, and Illinois). Nearly half of adult male arrestees in Atlanta, New Orleans, and Chicago tested positive for cocaine in 2003. Nationwide, 61,594 kilograms of cocaine were seized by the DEA in 2002, 3.6 percent more than in 2001 and 35.9 percent more than in 1995. National Survey on Drug Use and Health (NSDUH) ***** In 2003, 34.9 million Americans age 12 and over reported lifetime use of cocaine, and 7.9 million reported using crack. About 5.9 million reported annual use of cocaine, and 1.4 million reported using crack. About 2.3 million reported 30-day use of cocaine, and 604,000 reported using crack. The percentage of youth ages 12 to 17 reporting lifetime use of cocaine was 2.6 percent in 2003. Among young adults ages 18 to 25, the rate was 15 percent, showing no significant difference from the previous year. However, there was a statistically significant decrease in the rate of lifetime crack use among females in the 12 to 17 age bracket.
  • Tolerance and dependence Regular use of amphetamines induces tolerance to some effects, which means that more and more of the drug is required to produce the desired effects. Tolerance does not develop to all effects at the same rate, however; indeed, there may be increased sensitivity to some of them. Chronic users may also become psychologically dependent on amphetamines. Psychological dependence exists when a drug is so central to a person's thoughts, emotions, and activities that the need to continue its use becomes a craving or compulsion. Experiments have shown that animals, when given a free choice, will readily operate pumps that inject them with cocaine or amphetamine. Animals dependent on amphetamines will work hard to get more of the drug. Physical dependence occurs when the body has adapted to the presence of the drug, and withdrawal symptoms occur if its use is stopped abruptly. The most common symptoms of withdrawal among heavy amphetamine users are fatigue, long but troubled sleep, irritability, intense hunger, and moderate to severe depression, which may lead to suicidal behavior. Fits of violence may also occur. These disturbances can be temporarily reversed if the drug is taken again.
  • Illicit Drug Use During Pregnancy Nearly 3 percent of pregnant women use illicit drugs such as marijuana, cocaine, Ecstasy and other amphetamines, and heroin, according to a 2003 study by the Centers for Disease Control and Prevention. These and other illicit drugs may pose various risks for unborn babies and pregnant women. Some of these drugs can cause a baby to be born too small or to have withdrawal symptoms, birth defects , or learning or behavioral problems. However, because most pregnant women who use illicit drugs also use alcohol and tobacco (which also pose risks to unborn babies), it often is difficult to determine which health problems are caused by a specific illicit drug. What are the risks with use of cocaine during pregnancy? Cocaine use during pregnancy can affect a pregnant woman and her unborn baby in many ways. During the early months of pregnancy, it may increase the risk of miscarriage. Later in pregnancy, it can trigger preterm labor (labor that occurs before 37 weeks of pregnancy) or cause the baby to grow poorly. As a result, cocaine-exposed babies are more likely than unexposed babies to be born with low birthweight (less than 5½ pounds). Low-birthweight babies are 20 times more likely to die in their first month of life than normal-weight babies, and face an increased risk of lifelong disabilities such as mental retardation and cerebral palsy. Cocaine-exposed babies also tend to have smaller heads, which generally reflect smaller brains. Some studies suggest that cocaine-exposed babies are at increased risk of birth defects, including urinary-tract defects and, possibly, heart defects. Cocaine also may cause an unborn baby to have a stroke, which can result in irreversible brain damage or a heart attack, and sometimes death. Cocaine use also may cause the placenta to pull away from the wall of the uterus before labor begins. This condition, called placental abruption , can lead to extensive bleeding and can be fatal for both mother and baby. (Prompt cesarean delivery, however, can prevent most deaths.) Babies who were regularly exposed to cocaine before birth may score lower than unexposed babies on tests given at birth to assess the newborn’s physical condition and overall responsiveness. They may not do as well as unexposed babies on measures of motor ability, reflexes, attention and mood control, and they appear less likely to respond to a human face or voice. Babies who are regularly exposed to cocaine before birth sometimes have feeding difficulties and sleep disturbances. As newborns, some are jittery and irritable, and they may startle and cry at the gentlest touch or sound. Therefore, these babies may be difficult to comfort and may be described as withdrawn or unresponsive. Other cocaine-exposed babies “turn off” surrounding stimuli by going into a deep sleep for most of the day. Generally, these behavioral disturbances are temporary and resolve over the first few months of life. Some studies suggest that cocaine-exposed babies have a greater chance of dying of sudden infant death syndrome (SIDS). However, other studies suggest that poor health practices that often accompany maternal cocaine use (such as use of other drugs) also may play a major role in these deaths. What is the long-term outlook for babies who were exposed to cocaine before birth? Some studies suggest that most children who are exposed to cocaine before birth have normal intelligence. This is encouraging, in light of earlier predictions that many of these children would be severely brain damaged. A 2002 study at Harvard Medical School and Boston University found that children up to age 2 who were heavily exposed to cocaine before birth scored just as well on tests of infant development as lightly exposed or unexposed children. However, other studies suggest that cocaine may sometimes affect mental development, possibly lowering IQ levels. A 2002 study at Case Western Reserve University found that cocaine-exposed 2-year-olds were twice as likely as unexposed children from similar low socioeconomic backgrounds to have significant delays in mental development (14 percent and 7 percent, respectively). It is not known whether these children will continue to have learning problems when they reach school age. Studies are inconclusive regarding the risk of learning and behavioral problems. Studies from the National Institute on Drug Abuse suggest that most adolescents who were exposed to cocaine before birth seem to function normally. However, some may have subtle impairments in the ability to control emotions and focus attention that could put them at risk of behavioral and learning problems. Other studies suggest that cocaine exposure may adversely affect language abilities. Researchers continue to follow cocaine-exposed children through their teen years to clarify their long-term outlook.     What are the risks with use of Ecstasy and other amphetamines during pregnancy? The use of Ecstasy has increased dramatically in recent years. To date there have been few studies on how the drug may affect pregnancy. One small study did find a possible increase in congenital heart defects and, in females only, of a skeletal defect called clubfoot . Babies exposed to Ecstasy before birth also may face some of the same risks as babies exposed to other types of amphetamines. Another commonly abused amphetamine is methylamphetamine, also known as speed, ice, crank and crystal meth. Some, but not all, studies suggest that this drug may cause an increased risk of birth defects, including cleft palate , and heart and limb defects. It also appears to contribute to pregnancy complications including maternal high blood pressure  which can slow fetal growth and cause other complications for mother and baby), premature delivery, and excessive bleeding in the mother following delivery. After birth, babies who were exposed to amphetamines appear to undergo withdrawal-like symptoms, including jitteriness, drowsiness and breathing problems. What is the long-term outlook for babies exposed to Ecstasy and other amphetamines before birth? The long-term outlook for these children is not known. One very small study (only 12 children) found that 7- and 8- year-old children who were exposed to Ecstasy before birth had altered levels of a specific brain chemical. However, it is not known whether this has any effect on learning or behavior, as there was no evidence of problems in these children. One recent animal study did find that rats that were exposed to Ecstasy during the period that corresponds to the third trimester of human pregnancy suffered life-long deficits in memory and learning. It is not yet known whether this will hold true for exposed children. How can a woman protect her baby from the dangers of illicit drugs? Birth defects and other problems caused by illicit drugs are completely preventable. The March of Dimes advises women who use illicit drugs to stop before they become pregnant or to delay pregnancy until they believe they can avoid the drug completely throughout pregnancy. The March of Dimes also encourages pregnant women who use illicit drugs (with the exception of heroin) to stop using the drug immediately, because of the harm continued drug use may cause. Women who use heroin should consult their health care provider or a drug treatment center about methadone treatment. Does the March of Dimes support research on illicit drug use during pregnancy? The March of Dimes has supported a number of research grants aimed at learning more about the effects of drug exposure during pregnancy. For example, a recent grantee was seeking to determine how prenatal cocaine exposure may alter brain development in ways that can affect learning and memory, in order to develop better treatments for any cocaine-related developmental problems. The March of Dimes also produces a variety of educational materials that inform pregnant women and others of the dangers of cocaine and other drugs during pregnancy.
  • Text Version of Caffeine and Athletics: Introduction to caffeine Caffeine is a mild stimulant that occurs naturally in at least 63 plant species. Caffeine can be found in the leaves, stems, seeds, and roots of these various plants. Caffeine is part of the methylxanthine family. It consists of a xanthine molecule with three methyl groups attached to it. Caffeine can be found in many products like sodas, tea, and coffee, but it also occurs in several other products such as prescription medications, diuretics, and pain relievers. Caffeine’s widespread use and popularity have caused many people to view the substance as an addictive drug. Thus making caffeine the most inexpensive and readily available drug known to man. Then on the other hand there are people who view caffeine as a helpful stimulant that increases the individual’s concentration and awareness as well as many other physical traits. The important thing to remember is that caffeine’s affects vary based on the person, the amount ingested, the frequency of consumption, and individual metabolism. ( )   Purpose of Caffeine in Athletics Caffeine has many specific benefits for different types of athletes. Though much of the research on caffeine in athletics is inconclusive, there are many athletes that believe the substance can enhance their physical as well as mental performance. It is supposed that caffeine can improve the athlete’s endurance in sports where long-term stamina is needed. These sports include cycling, running, and even soccer. In an experiment to study the effects of caffeine as an ergogenic aid, 6 regular caffeine users were monitored while they exercised until exhaustion. During this double blind, placebo test, the athletes were given pills an hour before the exercise trial. The results were that those who received caffeine before the exercise performed more efficiently than those who received the placebo. (Graham, 1998) This shows the importance of caffeine in endurance sports such as cycling, running, and soccer which require a great deal of physical stamina in order to compete successfully. Studies also show that caffeine has very little affect on athletes requiring quick burst of energy such as sprinters and swimmers. Also caffeine has been known to decrease fatigue in athletes, which plays a physical as well as psychological role in the performance of an athlete. Caffeine’s mental appeal is just as trendy as its physical purpose. Caffeine has been proven to stimulate the central nervous system. Caffeine stimulates the Central Nervous System at high levels, like the medulla and cortex, and even has the ability to reach the spinal cord in larger doses. The effect of caffeine in the cortex is a clearer thought process and also can rid the body of fatigue. This gives people a greater ability of concentration for 1-3 hours. For athletes competing in sports where quick thinking and rapid reactions are necessary, caffeine can provide a huge edge. However, these results are much more inconsistent than the experiments done on caffeine in endurance sports. ( )   How caffeine works, in theory In athletics three theories have been presented that support caffeine’s use in athletics. The first theory focuses on caffeine’s ability to cause the body to burn more fat and fewer carbohydrates. Glycogen is the principle fuel for muscles, but fat is the most abundant resource that the body uses for energy. Caffeine enters the body and forces the working muscles to utilize as much fat as possible. This delays the immediate depletion of glycogen. Studies show that in the first fifteen minutes of exercise caffeine has the potential to reduce the loss of glycogen by fifty percent. When this happens, the saved glycogen can be used for the remainder of the workout where normally it would be entirely depleted. ( ) However, a study involving 9 trained athletes set out to provide proof of caffeine’s ability to work as an ergogenic aid before and during the workout. “In this study involving a 2 hour cycle endurance test, Ivey et al. (1979) found that 250mg of caffeine 1hour before the test and another 250mg total divided in doses every 15 minutes during the test led to higher work output throughout the test” (Dews, p.89) This study resulted in a 7 percent average increase in total output among the athletes. By consuming caffeine during high endurance activities, it is possible to increase the total output. The second theory deals with the prospect of caffeine enhancing the athlete’s mental focus. Caffeine has been proven to be a recognized stimulant to the central nervous system. By slowing substances used to stop neuronal firing, caffeine can quicken reactions and increase mental awareness. And finally, caffeine may have the ability to strengthen muscle contractions. By transferring calcium, sodium, and potassium in the cells, membrane permeability increases. This in turn results in more powerful muscle contractions. Scientist Gene Spiller has performed many studies in order to confirm this belief. “In a double blind, placebo controlled experiment where caffeine was isolated, caffeine was found to increase muscular force output at low frequencies of electrical stimulation (10 to 50Hz). There was no significant change at higher frequencies of electrical stimulation like 100Hz” (Spiller, 1998). This reflects the belief that caffeine has the ability to create more forceful muscle contractions. Once again, all three of these theories are subject to many different factors, and the precise process by which caffeine affects the body is unknown. ( ) Caffeine Controversy This being the summer of the 2000 Olympics, it is relevant to know that caffeine is one of the many drugs that will not be permitted during the summer games. The International Olympic Committee (IOC) presently lists caffeine as a banned substance. It is difficult to believe that a substance consumed by over 75% of Americans everyday, is placed in a category, which includes harmful drugs such as steroids and cocaine. Urinary test above 12mg/liter (8 cups of coffee) is perceived by the IOC as a deliberate attempt by an athlete to gain an advantage on the competition. ( ) Side Effects of Caffeine Caffeine presents many side effects to regular users and also moderate consumers. At one point many researchers looked to link caffeine with heart disease and cancer. Also many studies have shown that blood pressure is increased with the consumption of caffeine, but the results of these studies vary. For the most part these beliefs have been put to rest due to extensive testing. Currently there is no evidence that links caffeine to cancer, cardiovascular disease, or high blood pressure. However, caffeine causes many side effects that can still cause many problems among athletes as well as the regular person. These side effects include sleep deprivation, nausea, cramping, anxiety, fatigue, headaches, and gastrointestinal instability. For athletes, caffeine has more disastrous effects that may affect performance. These side effects include muscle tightness, muscle cramping, and dehydration. The threat of any of these problems during competition is enough to make any athlete think twice before using caffeine in a major event. ( ) Diuretic Effect Caffeine consumption has been proven to cause major changes occurring to the kidneys known as the diuretic effect. Caffeine increases the blood flow in the kidneys and at the same time inhibits the reabsorption of sodium and water. Also caffeine has been known to weaken the detrusor muscles in the bladder, which provokes the need to urinate. This poses many problems to athletes participating in long-term endurance activities. On one hand this can cause the need to urinate, but combined with other aspects such as dehydration and abdominal cramping, can also prove detrimental to the athlete. Studies have shown that the diuretic effect should not present any problems to athletes who consume moderate caffeine quantities before exercise. ( ) In a study to evaluate the amount of excessive sweating in long distance running, 9 athletes were given 450mg of caffeine either with 30 minutes of exercise or without. The running resulted in a decrease in the urine flow and also a decrease in the amount of caffeine that was excreted in the urine. This supports the belief that caffeine should not pose a threat of urinary problems to endurance athletes. (Barnard, 1992)   Tips for athletes using caffeine For the most part many doctors do not support the use of caffeine in athletics. For those athletes who believe that caffeine can enhance their performance, there are a few tips that may prove useful maximizing their full potential. It is important that the athlete refrains from caffeine use 3-4 days before their competition. This allows for the tolerance levels of caffeine to decrease, thus making the body susceptible to caffeine when consumed. Also it is important for athletes to understand their caffeine limits. If you have never used caffeine for sporting enhancement, then you are unfamiliar with caffeine’s affects on your body. Make sure that you have used caffeine in a variety of training conditions to understand your limitations. Also it is advantageous to ingest caffeine 2-3 hours before competition to ensure a peak of performance. Studies have shown that it takes several hours for caffeine to enter the body and exploit the use of fat, thus storing glycogen for endurance. All of these tips are essential in making the most of caffeine’s benefits in athletics. ( )   Conclusion In conclusion, caffeine’s use as an ergogenic aid has been proven to increase physical endurance but has many side effects and precautions. However, caffeine’s use for short-term endurance appears to have no affect on the athlete. Many sources seem to support these two statements, but it seems that the general consensus is for athletes to avoid the use of caffeine. The International Olympic Committee treats caffeine as any other illegal drug, which poses a serious question on how advantageous the substance is to athletes? Caffeine poses many potential side effects that can affect one’s lifestyle. It is important that the user understands their caffeine limitations before habitual use, especially athletes. There are many factors that shape caffeine’s effect on the individual. Factors such as metabolism, consumption, and frequency of use should all be taken into account before the use of caffeine in athletics. Sports Science Exchange Roundtable 50 VOLUME 13 (2002) NUMBER 4 HERBAL SUPPLEMENTS AND SPORT PERFORMANCE KEY POINTS Labels on dietary supplements can be misleading. Containers may include substantially more, but usually less, of the listed amounts of ingredients, and substances may be added?some of which can cause failed doping tests for athletes?that are not listed on the label. Many of the early studies claiming a positive effect of Chinese ginseng on exercise performance were of poor quality. Better research has failed to show any benefits of either Chinese or Siberian ginseng on athletic performance. Popular herbs consumed as "muscle building" anabolic agents include yohimbine, smilax, tribulus, wild yams, and gamma oryzanol. The plant steroids found in many of these herbs cannot be converted by the human body into testosterone or other anabolic steroids. Claims that these agents can increase muscle mass have little or no scientific basis. The herb Ephedra Sinica contains ephedrine, a stimulant to the nervous system and cardiovascular system, is used to accelerate fat loss and enhance feelings of "energy." There is no solid evidence that herbal ephedra can improve athletic performance, but the use of ephedrine-containing products can result in serious side effects, including death. INTRODUCTION Herbal dietary supplements are touted as "natural, safe, and effective" products that can decrease body fat, elevate blood levels of testosterone, increase muscle mass, enhance energy, improve strength and stamina, and generally improve health and athletic performance. However, these supplements and the advertising that promotes their use are essentially unregulated. Athletes and non-athletes alike must be alert to the potential risks of using herbal supplements and be realistic about the likelihood that they will enhance exercise performance. In this roundtable, four experts in sports nutrition have addressed some of the important issues related to the use of herbal supplements. Ellen Coleman, Ron Maughan, Suzanne Nelson-Steen, and Rob Skinner have all worked closely with elite and non-elite athletes, helping them with a wide variety of nutritional problems. Moreover, they have conducted extensive research and have published many books and articles on sports nutrition. When an athlete purchases an herbal supplement in a retail store or over the Internet, can the package label be trusted to accurately describe the contents of the container? COLEMAN: Not necessarily. For example, Gurley and colleagues (2000) analyzed the amount of ephedra in 20 herbal dietary supplements and found large discrepancies in the contents. Half the products varied by more than 20% from the amount listed on the label, and one product contained none of the active ingredient. Five products contained substantial quantities of nor-pseudoephedrine, a drug listed as a Schedule IV controlled substance by the U.S. Drug Enforcement Agency (DEA). The researchers also found extensive lot-to-lot variation from the same manufacturers, indicating poor quality control. They also reported that label claims for ephedra were not indicative of the quantity present, which ranged from 0 to over 150 percent of the amount listed on the label. Consumer Lab is a company that provides independent test results and information to help consumers and healthcare professionals evaluate and select dietary supplements. They found that only 14 out of 25 echinacea products passed review, nine of 17 valerian products, and 19 of 27 saw-palmetto products. As another example of how athletes cannot trust the labels on dietary supplements, the Medical Commission of the International Olympic Committee in 2002 found that of 634 non-hormonal nutritional supplements tested from 13 different countries, 94 (14.8%) contained substances that were not listed on any label and that could have led to a positive doping test. Out of these 94 samples, 23 contained compounds that could be metabolized to either nandrolone or testosterone, 64 contained substances that could have been metabolized to testosterone, and seven contained precursors of nandrolone alone. In another report, Green and associates (2001) bought 12 brands of over-the-counter steroid prohormones from stores that cater to athletes. Eleven out of 12 brands did not meet the minimal labeling requirements established by the 1994 Dietary Supplement and Health Education Act (DSHEA). One brand contained 10 mg of testosterone (a controlled steroid); another contained 77% more prohormone than the label stated, and 11 of 12 contained less than the label stated. MAUGHAN: Most people buying supplements trust the information on the label to be correct and have no way of checking this. However, as Ellen Coleman has described in some detail, several laboratories have found that certain supplements contain little or none of the expensive ingredients listed on the label and/or contain substances not listed on the label. In some cases, supplements have been found to contain small amounts of substances that can cause a positive drug test (nandrolone, testosterone, caffeine, ephedrine, and others). Even if you can find a laboratory to do the necessary analysis, there is no easy way to get your money back. NELSON-STEEN: While prescription and over-the-counter drugs and food additives must meet the Food and Drug Administration?s safety and effectiveness requirements, dietary supplements bypass these regulations. These products can go to market with no testing for efficacy, safety, or potency, and there is no guarantee that the product is what it says it is on the label since there is no legal standard for processing, harvesting, or packaging. Some studies with Chinese ginseng (Panax ginseng) claim a wide array of beneficial effects on exercise-related performance. What is your opinion of the relative quality of the published research on Chinese ginseng, and how likely do you think it is that an athlete would experience improved sport performance when using this herb? MAUGHAN: There are some studies that show beneficial effects of Chinese ginseng on a range of performance tests, but there are even more reports that show no effects on performance. It is important to recognize the differences in the quality of the evidence. Many of the studies showing positive effects were not well designed. Often there was no placebo group, and subjects were aware that they were being given something that might improve their performance. The subject numbers in these studies were often small, so the results may have been just due to chance. It is much harder in the world of science to get a negative finding published, so most studies that find no benefit are never made public. There is another problem in that the purity of the products used was usually not checked, and benefits claimed on mental concentration, reaction time, strength, power, endurance, and other tests may well have been due to the presence of caffeine or other added stimulants in commercial preparations, rather than to ginseng itself. COLEMAN: Ginseng plants contain varying levels of several different chemicals that appear to exert opposing pharmacological effects. This natural variation could conceivably explain the wide array of proposed beneficial effects on exercise performance, but it is more likely that a lack of standardization of ginseng?s biologically active compounds, variability in dosage and administration, and differences in the type of ginseng used influenced the research results. In my opinion, it is unlikely that ginseng will improve athletic performance in a research study that controls for the placebo effect. NELSON-STEEN: The highly advertised use of Panax ginseng to enhance physical performance in healthy individuals has not been substantiated in recent clinical trials. I doubt that ginseng has any reliable effect on performance. SKINNER: The earlier published studies on Panax ginseng would not stand up to today?s scientific standards. The likelihood of an athlete receiving performance-enhancing benefits from Panax ginseng is small, but you can never discount the placebo effect. What is the difference between Chinese ginseng and Siberian ginseng (Eleutherococcus senticosus or Acanthopanax senticosus: also known as Ciwujia)? Is Siberian ginseng of any value for athletes? SKINNER: The biggest differences between these herbs are the geographic locations in which the plants grow, the active ingredients, and the parts of the plants used for supplements. Chinese ginseng is native to Korea and China, whereas "Siberian ginseng" includes about 20 species of similar shrubs found in China, Russia, Korea, and Japan. Siberian ginseng extract was developed in the former Soviet Union as a substitute for Chinese ginseng, with claims of even greater health benefits. Unfortunately, there is little solid evidence that these products have any real health or performance benefits. COLEMAN: Siberian ginseng is not a true ginseng. It belongs to the same family but not the same genus as Chinese ginseng. Although both herbs have some similar properties, as Rob Skinner has indicated, there is essentially no research support for a positive effect of Siberian ginseng on exercise performance. MAUGHAN: To expand on what Rob and Ellen have said, it has been claimed that Siberian ginseng can improve endurance performance by increasing the use of fat as a fuel, thus sparing the body?s limited carbohydrate stores. A recent investigation tested this hypothesis in a randomized, double-blind study using a crossover design. There were no effects on fat and carbohydrate oxidation during 2 hours of moderate cycling exercise, and there was no effect on performance of a 10-km time trial that followed. Evidence for benefits usually comes from poorly controlled experiments. What are the most popular "anabolic" herbal supplements? Can steroids found in plants be converted to testosterone in humans? What is the evidence that any of these "musclebuilding" herbs actually helps build muscle and increases strength? Are there any potentially harmful side effects of using these supplements? COLEMAN: Popular purported anabolic herbs include yohimbine, smilax, tribulus, and gamma oryzanol. Yohimbine (extracted from yohimbe bark or from a South American herb, Quebracho) supposedly increases serum testosterone levels (presumably by increasing blood flow through the testes), thereby increasing muscle size and strength. There is no research basis for these claims. Because yohimbine can increase blood pressure, people who have diabetes or cardiovascular, liver or kidney disease should not take yohimbine. Moreover, red wine, liver, and cheese should be rigorously avoided when yohimbine is used to prevent a sudden and dangerous increase in blood pressure. (These foods contain the amino acid tyramine, which can cause blood vessel constriction and raise blood pressure. The liver normally inactivates tyramine, but yohimbine interferes with the inactivation process.) SKINNER: Yohimbine has also been documented to cause other adverse reactions, including nerve paralysis, fatigue, stomach and kidney disorders, seizures, and death. COLEMAN: Smilax (a genus of desert plants containing several species of sarsaparilla) allegedly increases serum testosterone levels and serves as legal alternative to anabolic steroids. Smilax does contain saponins (sarsapogenin and smilagenin) that serve as the building blocks for the laboratory production of certain steroids, but this conversion does not occur in the human body. There is no evidence that smilax is anabolic or functions as a "legal replacement" for anabolic steroids. The saponins in smilax stimulate urination, bowel evacuation, sweating, and coughing, any of which could be harmful to sport performance. Tribulus Terrestris (puncture vine) theoretically increases testosterone levels indirectly by increasing the release of luteinizing hormone from the pituitary, thereby resulting in greater production of testosterone by the testes. However, research on tribulus supplementation in weightlifters showed no effects on body weight, percentage fat, total muscle mass, or muscle strength. When taken in recommended doses, tribulis has not been associated with adverse side effects in humans. Gamma-Oryzanol (a plant sterol derived from rice bran oil) purportedly raises serum levels of both testosterone and growth hormone. As with other plant-derived steroids, the best research has failed to show any anabolic effect of supplementation with oryzanol. Due to poor absorption characteristics of oryzanol (less than 5% is typically absorbed from the gastrointestinal tract), there are no apparent adverse effects. NELSON-STEEN: Extracts of wild Mexican yams of the Dioscorea family are also popular "anabolic" supplements. These plants contain a steroidal substance called diosgenin, which can be converted by a series of chemical reactions in a test tube to dehydroepiandrosterone (DHEA), an anabolic hormone that can in turn be converted by the body to other steroids, including testosterone and estrogen. However, these reactions that convert diosgenin to DHEA in the laboratory do not occur in the human body! Products that claim that wild yams can lead to the formation of DHEA in the body or increase testosterone levels are a total scam. Because yam extracts are not converted to DHEA by the body, adverse side effects are unlikely. MAUGHAN: We have to recognize that the anabolic androgenic steroids are powerful pharmacological agents. They are subject to tight controls by the agencies that license the use of such drugs. Any product on sale that had a significant anabolic effect would be subject to these controls, and the fact that the "anabolic" herbal supplements are not controlled is a clear indication of their lack of effect. Mahuang or Chinese ephedra (Ephedra Sinica) contains ephedrine and related compounds that have stimulant effects similar to those of adrenaline (epinephrine). Does herbal ephedra have any effects on exercise performance? Is it harmful? MAUGHAN: Most reviews of the available evidence have concluded that neither ephedrine nor any of the compounds related to it will improve performance at the doses normally used. There is little information about the effects of much higher doses, but the adverse health risks of high doses far outweigh the limited possibility of performance enhancement. The evidence that pseudoephedrine?found in many supplements, decongestants and cold remedies?has no beneficial effect is so compelling that there has been a proposal for it to be removed from the list of banned substances for athletes. NELSON-STEEN: The International Olympic Committee and National Collegiate Athletic Association ban ephedrine, so athletes should not even consider using ephedra or other products that contain ephedrine. Because of its stimulating effect on the nervous system, ephedrine is found in some popular weight loss and "energy-enhancer" products. It is often combined with caffeine or ingredients such as koala nut or guarana that contain caffeine. Since they are stimulants, ephedra and caffeine may make athletes "feel" energized, but they do not provide athletes with energy. Adverse side effects of ephedrine use include increased blood pressure, heart rate irregularities, insomnia, nervousness, tremors, headaches, psychoses, seizures, heart attacks, strokes, and death. Athletes have described many negative effects of taking caffeine or ephedra, including dizziness, lack of focus, irritability, and heart palpitations, any of which could adversely affect performance. COLEMAN: Herbs that contain ephedrine (ephedra) and caffeine (guarana) have not been shown to improve exercise performance, but military research suggests that a combination of synthetic ephedrine and caffeine (0.8 to 1.0 mg of ephedrine per kg of body weight and 4 to 5 mg of caffeine per kg consumed 11/2 hours before exercise) can improve both anaerobic and high-intensity aerobic performance. In addition to the adverse effects outlined by Dr. Nelson-Steen, ephedrine also raises body temperature and increases the risk of developing a heat injury during exercise in warm weather. SKINNER: Most proponents of ephedra use stick to their guns and claim that adverse reactions only occur in people who have pre-existing medical conditions or who take more than the recommended amounts. The most interesting information to me is the accounts of autopsies conducted on individuals who have died, with ephedra use being a suspected cause of death. For example, in one case of the sudden death of a 32-year-old female with no cardiovascular of lung problems, ephedra was the only drug detected in her system. Are there other herbs used by athletes that have properties or problems that are especially intriguing to you? COLEMAN: Many athletes often incorrectly assume that herbal products are safe and without the side effects of medications because the products are marketed as "natural" and can be purchased without a prescription. This misconception is potentially dangerous because herbs, like medications, can have adverse effects. The risk of side effects is further increased when certain herbs are combined with prescription drugs or over-the-counter medications. Health care providers should encourage individuals to report what herbs they take. As many as seven out of ten herbal medicine users never tell their physicians about the herbal products they are taking. The ability of physicians to correctly diagnose and treat an illness or disease is limited when they are unaware of a patient?s use of herbs. In addition, people should be educated regarding the proper use of herbs and when to report a problem to their physicians. NELSON-STEEN: I?m concerned about the number of products being marketed as energy drinks that contain various herbs, caffeine, and ephedra. Not only can their consumption potentially cause a positive drug test in a collegiate or internationally competitive athlete, but there is also a risk for negative side effects and interactions among the compounds. MAUGHAN: I do believe that many of the traditional herbal remedies probably have some mild benefits for health and performance, but these effects are trivial in comparison with those achieved with modern drugs. Although I remain skeptical, there does seem to be some evidence that echinacea can stimulate the immune system and help in the treatment?but not the prevention ?of colds, flu, and upper respiratory tract infections. SUGGESTED ADDITIONAL RESOURCES: Antonio, J., J. Uelmen, R. Rodriguez, and C. Earnest (2000). The effects of Tribulus terrestris on body composition and exercise performance in resistance-trained males. Int. J. Sport Nutr. Exerc. Metab. 10:208-215. Bell, D.G., I. Jacobs, and K. Ellerington (2001). Effect of caffeine and ephedrine ingestion on anaerobic exercise performance. Med. Sci. Sports Exerc. 33:1399-1403. Bell, D.G., T.M. McLellan, and C.M. Sabiston (2002). Effect of ingesting caffeine and ephedrine on 10-km run performance. Med. Sci. Sports Exerc. 34:344-349. Dowling, E.A., D.R. Redondo, J.D. Branch, S. Jones, G. McNabb, and M.H. Williams (1996). Effect of Eleutherococcus senticosus on submaximal and maximal exercise performance. Med. Sci. Sports Exerc. 28:482-489. Engels, H.J., and J.C. Wirth (1997). No ergogenic effects of ginseng (Panax ginseng C.A. Meyer) during graded maximal aerobic exercise. J. Am. Diet. Assoc. 97:1110-1115. Eschbach, L.C., M.J. Webster, J.C. Boyd, P.D. McArthur, and T.K. Evetovich (2000). The effect of Siberian ginseng (Eleutherococcus Senticosus) on substrate utilization and performance during prolonged cycling. Int. J. Sports Nutr. Exerc. Metab. 10:444-451. Green, G.A., D.H. Catlin, and B. Starcevic (2001). Analysis of over-the-counter dietary supplements. Clin. J. Sport Med.11:254- 259. Gurley, B.J., S.F. Gardner, and M.A. Hubbard (2000). Content versus label claims in ephedra-containing dietary supplements. Am. J. Health Syst. Pharm. 57:963-969. Mahady, G., C. Gyllenhaal, H. Fong, and N.R. Farnswoth (2000). Ginsengs: a review of safety and efficacy. Nutr. Clin. Care. 3:90-101. Sarubin, A. (1999). The health professional?s guide to popular dietary supplements. Chicago, IL: American Dietetic Association. Steen, SN, and Coleman E. (1999). Selected ergogenic aids used by athletes. Nutr. Clin. Prac. 14:287-295. Wheeler, K.B., and K.A. Garleb (1991). Gamma oryzanol-plant sterol supplementation: metabolic, endocrine, and physiologic effects. Int. J. Sports Nutr. 1:178-191.   VOLUME 13 (2002) NUMBER 4 SUPPLEMENT Sports Science Exchange Roundtable 50 HERBAL SUPPLEMENTS: DO THEY WORK? ARE THEY SAFE? Are you using or thinking about using an herbal supplement to help improve your athletic performance? If so, here are some tips. Don?t assume that the ingredients listed on the supplement label, and only those ingredients, are present in the amounts stated. There is essentially no regulation of the supplement industry. Be aware that herbal supplements sometimes include anabolic steroids, ephedrine, caffeine, and other substances that may not be listed on the label and may cause you to fail a drug test in your sport. More important, they may damage your health. Some early research has claimed that ginseng supplements can improve exercise performance, but that research has many flaws. More recent, better-controlled experiments have failed to show any positive effect of either Chinese or Siberian ginseng on performance. So-called "muscle building" anabolic herbs, including yohimbine, smilax, tribulus, wild yams, and gamma or
  • Alcohol and drugs week 9

    1. 1. Copyright AllCEUs 2011-2020 Unlimited CEUs $99/year
    2. 2. <ul><li>To provide information about stimulants </li></ul><ul><li>To assist students in understanding consequences of stimulant use </li></ul><ul><li>To assist students in understanding drug interactions </li></ul><ul><li>To educate students about the symptoms of toxicity, overdose and withdrawal </li></ul><ul><li>To motivate students to make informed choices about stimulant use </li></ul>Copyright AllCEUs 2011-2020 Unlimited CEUs $99/year
    3. 3. <ul><li>Stimulants are drugs that act to “wake up” the fight or flight reaction from the sympathetic nervous system. </li></ul><ul><li>Stimulants can be found in everything from food and drink to over the counter medication to prescriptions and illicit drugs. </li></ul>Copyright AllCEUs 2011-2020 Unlimited CEUs $99/year
    4. 4. <ul><li>Amphetamines Stimulant Fact Sheet </li></ul><ul><li>Caffeine Caffeine Facts </li></ul><ul><li>Decongestants Overview of Decongestants (i.e. Sudafed) </li></ul><ul><li>Methamphetamines Methamphetamine Online Reading </li></ul>Copyright AllCEUs 2011-2020 Unlimited CEUs $99/year
    5. 5. <ul><li>Ritalin/Adderall </li></ul><ul><ul><li>Ritalin </li></ul></ul><ul><ul><li>Ritalin Part II </li></ul></ul><ul><ul><li>Adderall </li></ul></ul><ul><li>Cocaine: Cocaine Overview </li></ul>Copyright AllCEUs 2011-2020 Unlimited CEUs $99/year
    6. 6. <ul><li>Methamphetamine WebCast </li></ul><ul><li>Methamphetamine Quick Reference </li></ul><ul><li>Methamphetamine Technical Information </li></ul>Copyright AllCEUs 2011-2020 Unlimited CEUs $99/year
    7. 7. <ul><li>Cocaine Overview </li></ul><ul><li>Cocaine Technical Information </li></ul>Copyright AllCEUs 2011-2020 Unlimited CEUs $99/year
    8. 8. <ul><li>Based on your experiences, what is easier to get and what proportion of people are using the following: cocaine, Adderall, Ritalin, methamphetamines, Dexedrine, ephedrine </li></ul>Copyright AllCEUs 2011-2020 Unlimited CEUs $99/year
    9. 9. <ul><li>Regular use of amphetamines induces tolerance to some effects, </li></ul><ul><li>The most common symptoms of withdrawal among heavy amphetamine users are fatigue, long but troubled sleep, irritability, intense hunger, and moderate to severe depression, fits of violence </li></ul>Copyright AllCEUs 2011-2020 Unlimited CEUs $99/year
    10. 10. <ul><li>Increased heart rate, blood pressure, metabolism; feelings of exhilaration, energy, increased mental alertness /rapid or irregular heart beat; reduced appetite, weight loss, heart failure, nervousness, insomnia </li></ul><ul><li>Also, for amphetamine—rapid breathing/ tremor, loss of coordination; irritability, anxiousness, restlessness, delirium, panic, paranoia, impulsive behavior, aggressiveness, tolerance, addiction, psychosis </li></ul>Copyright AllCEUs 2011-2020 Unlimited CEUs $99/year
    11. 11. <ul><li>For cocaine—increased temperature/chest pain, respiratory failure, nausea, abdominal pain, strokes, seizures, headaches, malnutrition, panic attacks </li></ul><ul><li>For MDMA—mild hallucinogenic effects, increased tactile sensitivity, empathic feelings/impaired memory and learning, hyperthermia, cardiac toxicity, renal failure, liver toxicity </li></ul><ul><li>For methamphetamine—aggression, violence, psychotic behavior/memory loss, cardiac and neurological damage; impaired memory and learning, tolerance, addiction </li></ul>Copyright AllCEUs 2011-2020 Unlimited CEUs $99/year
    12. 12. <ul><li>Have you ever had a cold and been up studying late and taken Sudafed in addition to a BUNCH of coffee (especially on an empty stomach)? If so, what were the effects? How well did you learn? What made it harder to focus, the cold or the stimulants? </li></ul>Copyright AllCEUs 2011-2020 Unlimited CEUs $99/year
    13. 13. <ul><li>March of Dimes Report on Stimulants and Pregnancy </li></ul>Copyright AllCEUs 2011-2020 Unlimited CEUs $99/year
    14. 14. <ul><li>Caffeine in Athletics by Jack Hartley </li></ul><ul><li>ESPN Drugs and Sports </li></ul>Copyright AllCEUs 2011-2020 Unlimited CEUs $99/year
    15. 15. <ul><li>There are lots of reasons people give for why they use stimulants. What are some legal, non-drug ways to do each of the following: </li></ul><ul><ul><li>Increase endurance </li></ul></ul><ul><ul><li>Increase alertness </li></ul></ul><ul><ul><li>Decrease congestion (Hint: infants cannot take decongestants. What do you do for them) </li></ul></ul><ul><ul><li>Increase metabolism </li></ul></ul><ul><ul><li>Reduce body fat </li></ul></ul>Copyright AllCEUs 2011-2020 Unlimited CEUs $99/year
    16. 16. <ul><li>MYTH: Stimulants are safe for anyone to take because they are a prescription medication. </li></ul><ul><li>FACT: Stimulant medications are only to be taken by the person to whom it was prescribed as prescribed by qualified healthcare professionals. </li></ul><ul><li>MYTH: Stimulants are addictive. </li></ul><ul><li>FACT: There is no evidence to suggest that people taking stimulant medications as prescribed become addicted to the medications </li></ul>Copyright AllCEUs 2011-2020 Unlimited CEUs $99/year
    17. 17. <ul><li>Cocaine & the Concept of Addiction by S. Peele, Ph.D. & R. J. DeGrandpre ( Addiction Research in press) </li></ul><ul><li>Jamaican Chocolate by Dr. R. J. Lancashire </li></ul><ul><li>Researchers learn how Ritalin works to calm hyperactivity ( CNN 1/14/99) </li></ul><ul><li>Diagnosis and Evaluation of the Child With Attention-Deficit-Hyperactivity Disorder (American Academy of Pediatrics 5/2000) </li></ul><ul><li>Evidence and belief in ADHD by M. Zwi, P. Ramchandani, & C. Joughin (BMJ 2000;321:975-976) </li></ul>Copyright AllCEUs 2011-2020 Unlimited CEUs $99/year
    18. 18. <ul><li>FDA Clears Use of Adderall for Attention-Deficit-Hyperactivity Disorder (Doctors Guide 2/21/96) </li></ul><ul><li>Recreational Ritalin by N. Ziegler (AP 5/5/2000) </li></ul><ul><li>NICE issues new guidelines on Ritalin by R. Dobson (BMJ 2000;321:1100) </li></ul><ul><li>Study Suggests Tailoring ADHD Treatment (Science Daily Magazine 2/4/2000) </li></ul><ul><li>US parents sue psychiatrists for promoting Ritalin by F. Charatan (BMJ 2000;321:723) </li></ul>Copyright AllCEUs 2011-2020 Unlimited CEUs $99/year
    19. 19. <ul><li>What are 3 things you can do to make sure you are being “smart” when you take stimulants (i.e. decongestants, caffeine, diet pills etc.) </li></ul>Copyright AllCEUs 2011-2020 Unlimited CEUs $99/year
    20. 20. <ul><li>Overview: Online Methamphetamine Reading </li></ul><ul><li>Responsible use </li></ul><ul><ul><li>Do not mix decongestants with other stimulants including caffeine </li></ul></ul><ul><ul><li>Drink plenty of fluid to prevent dehydration from decongestants </li></ul></ul><ul><ul><li>Try non-drug alternatives first </li></ul></ul><ul><ul><li>Take prescriptions as prescribed </li></ul></ul>Copyright AllCEUs 2011-2020 Unlimited CEUs $99/year
    21. 21. <ul><li>Identify 5 concepts or pieces of information you gained from this lesson and why you believe they will be useful. </li></ul>Copyright AllCEUs 2011-2020 Unlimited CEUs $99/year