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Addict In The Family
by Dr. Andrew Byrne
Nicotine is one of the most addictive substances known. It can be consumed in the form of smoked tobacco, mouth wads or as snuff. Remarkably, it took over three hundred years for western doctors to recognise the disastrous health consequences of smoking. It is by far the most harmful drug, with almost 20,000 Australians dying annually as a result in the 1990s. It has been shown that over 50% of smokers will die prematurely as a direct result of tobacco induced illnesses.
Now that the duplicity of the tobacco companies has been exposed, a more logical approach is being taken by most western governments in protecting consumers and minimising the risks to smokers. This includes a choice of quality product availability, tax based on drug content, filters, truthful labelling, a ban on advertising, education campaigns and subsidised treatment for those needing it.
The principle of nicotine patch and gum treatment for smokers has close parallels with the use of replacement methadone for heroin addicts. The addictive component, nicotine, is given in a long acting and relatively harmless form, thus avoiding the injurious constituents of tobacco smoke such as carbon monoxide, tar, soot and other burnt by-products.
Nicotine patches have been widely studied in recent years including 'double blind' trials. There is no doubt that they are very safe and effective treatments for smokers. Their use at least doubles the number of quitters who remain abstinent from tobacco at six to twelve months. Many of the ex-smokers have also ceased the patches by this time.
About 90% of heroin addicts also smoke cigarettes. When in treatment, a proportion give up each year, some with the aid of patches or nicotine chewing gum, others by just going 'cold turkey'.
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Cannabis is a widely used drug with a relatively low potential for harm when compared with heroin, alcohol and tobacco. It is technically illegal throughout the world, but is tolerated in some jurisdictions such as Holland, Alaska, South Australia, Northern Territory and the Australian Capital Territory. It is usually smoked as dried leaf and flowering heads. It can also be used in the concentrated form called hashish. This can be smoked or incorporated into food such as biscuits or cake. It is a tar-like substance which can be broken up into a cigarette or 'bong'.
Cannabinol drugs are not addictive in the ordinary sense, but they can occasionally be associated with a psychological dependence. In such cases, the patient may spend inordinate amounts of time and money consuming the drug. Many such patients are gainfully employed although their finances and recreation time may be in disarray.
This drug was banned in the 1930s in America for reasons which are now known to have been related to commerce in hemp substitutes for the manufacture of paper. There was opposition to the bans by the medical profession. Indeed, many pharmaceutical preparations contained extract of cannabis as a major active ingredient. This was one of the few available drugs which had demonstrated beneficial actions with minimal side effects. It was useful in treating nausea, vomiting, anorexia, sleep disturbances and anxiety.
Cannabis use is not harmless. Like other burnt inhalations, it contains carcinogens, tar and carbon monoxide. Hence it causes respiratory inflammation and the risk of cancer. It has been estimated that these effects are more dangerous than tobacco smoke, but because a smaller quantity of cannabis is smoked on average, the degree of damage is probably less than that from tobacco.
There has been much publicity concerning the risk of cannabis causing motor accidents. This appears to have been based on anecdotal cases and personal concerns rather than scientific evidence. Most studies in this area point towards alcohol as being the major substance implicated in road accidents. There is even an indication that those who use cannabis drink less alcohol and therefore may be at reduced risk on the roads. This has yet to be examined definitively.
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The 'demon drink' is also a major problem in those with other addictions. Many heroin addicts do not drink at all. Some others only have drinking problems when they are off the heroin, while a small number drink excessively regardless of their intake of other drugs.
Breath tests can be used in the clinical setting to underline the obvious. Results should not, however be used in any way other than in the patient's interest. There are also blood tests (gGT and 'carbohydrate reduced transferrin') which give an accurate indication of the average alcohol consumption over previous weeks or months.
Alcohol is the commonest drug involved in overdose deaths. It causes depressed breathing which is worsened by narcotics and tranquillizers. It is not widely known that adults can also die from acute alcohol intoxication alone. This may result from the ingestion of large amounts of spirits in "I dare you" situations.
The commonest problems with alcohol, however, are behavioural. Family violence, drownings, motor accidents and crowd brawls are all closely associated with drinking. Medical consequences include acid dyspepsia, stomach ulcers, hepatitis, liver failure, heart disease, neuritis, brain damage, and dementia.
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These drugs were introduced as the successors to the barbiturates in the early 1960s. After thirty years of experience, they have been found to have many complications of their own including an addictive potential, respiratory depression, fits, amnesia and balance problems in the elderly. They are not ideal drugs for chronic anxiety and insomnia for which they were previously recommended.
The abuse potential is substantial and the only treatment is graduated reductions. Self help groups are also of assistance for some.
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Amphetamine, metamphetamine (speed), dex-amphetamine and methylphenydate (Ritalin) are all addictive stimulants. They prevent sleep and keep subjects active for hours or even days. At the end of the period of drug use, the subject becomes exhausted and depressed with extended periods of sleep.
Many truck drivers, motor cycle enthusiasts and rock band players use these drugs, some for extended periods without apparent problems. A number, however, come to the attention of the authorities due to serious complications such as road accidents, overdoses and addiction.
These drugs are used in the treatment of narcolepsy, a rare sleeping disorder. They have also been recommended as long-term treatment for children with attention deficit disorder and some cases of brain damage. Advocated by a number of paediatricians, this form of prescribing is difficult to study objectively. The management of these children as they reach adult life addicted to stimulants is also uncharted medical terrain.
Although no doctor would advocate recreational stimulants, the adage that 'speed kills' is not supported by the evidence. Deaths from stimulants are rare.
Another related stimulant, MDMA (3,4-methylene-dioxymethamphetamine or ecstasy) has increased in popularity as a party drug. Its use over many hours can cause problems with fluid balance. Deaths have been reported from water overload as well as some cases of the opposite, dehydration. The drug has also been associated with hyperthermia or overheating. This is very dangerous and can cause permanent brain damage or death. Effective treatment is available for these rare eventualities, but victims must reach treatment facilities in time.
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While these drugs are used less widely than in previous decades, they are more often used in a relatively controlled manner. They are generally less harmful than opiates, alcohol or tobacco. Deaths from these drugs alone are almost unknown in Australia. They are non-addictive psychedelic drugs, causing altered states of perception and hallucinations. Subjects often develop a syndrome like schizophrenia with paranoia, delusions and voices. This is usually short lived and reversible. It can sometimes be intensely unpleasant, leading to the term 'a bad trip'.
Some cases of massive LSD overdose have been reported to cause a permanent psychotic disorder. This is usually unintentional and may result from 'concentrate' being taken in place of the diluted form. The administration of large doses of anti-psychotic drugs to someone on LSD is also dangerous. This can happen if drug intoxication is mis-diagnosed as acute psychotic delirium.
Certain varieties of ground fungus have psychoactive properties. Some are deadly, so great care is taken by the users to identify them by shape, size, colour and seasonal appearance.
Peyote cactus tops contain an intoxicant which has been used by the traditional inhabitants of Mexico for hundreds of years. This practice has been adopted by some groups for recreation or as part of religious observance. The active ingredient, mescalin, produces hallucinations and mimicking schizophrenia.
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Refined from the South American coca leaf, this short acting stimulant can be injected, smoked ('free-based') or 'snorted'. In the USA cocaine is much cheaper than in Australia. This may be why cocaine deaths are still rare in Australia. Its clinical hallmark is multiple injections of the same age, often along the one vein. It is often considered a chic party drug.
In the form of leaf chewing or brewed tea, the drug is virtually harmless. Indeed, for some years it was one of the active constituents of Coca Cola and still forms part of the name. Being illegal in most countries, the bulky and safer leaf form is rarely made available outside South America, leaving only the more harmful concentrate for black market supplies.
It is certainly a 'more-ish' drug for which people beg, borrow and sometimes steal. It is considered to be non-addictive by many authorities as it has no reproducible abstinence syndrome.
It is said that Pope John-Paul II was revived by a cup of coca leaf tea when visiting high altitude areas in South America. This benign beverage may be a useful remedy for jet-lag as well as altitude sickness.
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On to the Chronology
|Dr. Andrew J. Byrne received the prestigious Marie Award at the 2006 national conference of the American Association for the Treatment of Opioid Dependence.|
|For more information about pain management and opiate pain medication, check out ManagingChronicPain.org.|