Adolescents who give at least two positive responses are increased risk of addiction and deserve further attention.
Dr. Leslie Gee
Many physicians received a screening tool in the mail last year from the National Institute on Alcohol Abuse and Alcoholism with specific questions for different age groups entitled "Alcohol Screening and Brief Intervention for Youth: A Practitioner’ Guide," but "I personally prefer the SBIRT," Dr. Ammerman said. "It’s validated and easy to use."
Dr. Gee described some of the common "legal highs" and designer drugs, and what to do besides taking a good history if you suspect adolescents are using them.
• Inhalants. The average U.S. household contains 30-50 products that can be used for inhalant abuse through sniffing, "bagging" (spraying or placing in a bag and then inhaling from the bag), or "huffing" (placing a rag soaked in chemicals on one’s face). Some contain hydrocarbons that depress the central nervous system. Others contain nitrite that cause vasodilation.
Inhalant abuse can cause asphyxia, suffocation, or "sudden sniffing death" from sensitization of the myocardium to catecholamines (especially Freon) and a catecholamine rush after exercise or masturbation, resulting in cardiovascular collapse, she said.
Clues to inhalant abuse include a "glue sniffer’s rash" on the face, cheeks, and nose. The family may notice empty containers around the house or a chemical smell on the teen’s breath, skin, or clothes.
Most inhalants won’t be detected by standard urine drug screens. Evaluate using pulse oximetry, an ECG, and cardiac monitoring for arrhythmias, complete blood count, complete metabolic panel, and urinalysis, she suggested. Depending on the substance being abused, consider checking methemoglobin and lead levels. Treat with supportive care.
• Prescription drugs. Prescribed narcotics, benzodiazepines, or medications for attention-deficit/hyperactivity disorder are found in many households. They may cause respiratory depression or organ failure. Evaluate with urine drug screening and manage with supportive care appropriate to the ingested substance.
• Dextromethorphan. It goes by at least 10 aliases: Robo; Skittles; Dex; and more. A typical dose for cold therapy is 15-30 mg four times a day. Higher doses produce side effects at different dose plateaus: mild inebriation or stimulation from 100-200 mg, and euphoria, mild hallucinations, slurred speech, and short-term memory loss after 200-400 mg. A dose of 300-600 mg can alter consciousness and impair vision and motor control. At 500-1,500 mg, the mind and body dissociate.
Abuse can produce life-threatening effects including serotonin syndrome, high fever, rhabdomyolysis, arrhythmias, loss of consciousness, and brain damage.
Treatment is supportive care. When you suspect dextromethorphan abuse, also screen and treat for coingestion of other substances, especially acetaminophen and selective serotonin reuptake inhibitors.
• Salvia. A perennial herb native to Mexico, salvia is not a controlled substance, but California prohibits its sale to minors. Effects kick in within 5-10 minutes of chewing or within 30 seconds of smoking 200-500 mcg, and include hallucinations, bright lights, vivid colors and shapes, body or object distortions, uncontrolled laughter, or a sense of body loss. Provide supportive care.
• Synthetic cannabinoids. Added to blends of herbs and sold legally in the United States as alternatives to marijuana from 2009 until the recent regulations, synthetic cannabinoids produce psychoactive and sedative effects similar to marijuana, although possibly less potent. They also may produce more adverse effects, including withdrawal symptoms, cardiac problems, or psychoses. "I’ve seen reports of acute MIs and arrhythmias" from these products, Dr. Gee said.
Standard urine drug screens won’t detect them, but newer screening tests are in development. Consider coingestion of other substances and contaminants and provide supportive care.
• Bath salts. These synthetic cathinones entered the United States from Europe around 2010. They contain methylenedioxypyrovalerone, methylone, 4-methylmethcathinone – all three of which became schedule I substances in 2011 – or an ever-new roster of similar drugs. "They’re just marketed as bath salts or plant food as a way to get around regulations," Dr. Gee said. "They’re not something you’d want to put in your bath or plants."
Snorting or consuming orally induce empathy, stimulation, alertness, and euphoria within 3-4 hours that last 6-8 hours – similar to the effects of cocaine, cathinone (khat), amphetamines, or 3,4-methylenedioxymethamphetamine (MDMA, or Ecstasy). But they also can cause intense, prolonged panic attacks, violent behavior, and psychosis. Some "dramatic, scary" news reports have linked bath salts with violent behavior, she said.
Standard drug screens won’t detect synthetic cathinones, but tests are being developed. Consider coingestion of other substances and contaminants if you suspect bath salts use, and provide supportive care for agitation and psychoses.
Some possible references to help with substance abuse screening follow: