Treatment of Adolescents
with Substance Use Disorders
Appendix B -- Medical Management of Drug Intoxication and Withdrawal
The following table was created by Dr. John Knight and reprinted with his permission. It will appear in the forthcoming publication, Knight, J.R. Substance use, abuse, and dependence. In: Levine, M.D.; Carey, W.B.; and Crocker, A.C., eds. Developmental-Behavioral Pediatrics, 3rd edition. Philadelphia: W.B.
Saunders, in press.
| A. Alcohol |
| Names/Preparations |
Intoxication |
Withdrawal |
| |
Signs and Symptoms |
Treatment |
Signs and Symptoms |
Treatment |
Beer
Wine
Hard Liquor |
Mild-Mod: lower level of consciousness, poor coordination, ataxia, nystagmus, conjunctival injection, slurred speech, stupor, GI bleed, orthostatic hypotension | Observation and supportive care, protect airway, position on side to avoid aspiration |
Mild-Mod: restlessness, agitation, coarse tremor, higher sensitivity to sensory input, nausea, vomiting, anorexia, autonomic hyperactivity (tachycardia, hypertension, hyperthermia), anxiety/depression, headache, insomnia |
Thiamine 100 mg.
IM,
Benzodiazepine taper (chlordiazepoxide 25-50 mg. q6h X 24 hrs., then 25 mg. q6h X 48 hrs.; or diazepam, clonazepam, oxazepam), Multivitamins |
| |
Severe: Respiratory depression, coma, death.
(Chronic: pancreatitis, cirrhosis, are rare in adolescents) |
Ventilatory support, intensive care |
Severe: seizures, hallucinations, delirium, death |
Seizures: benzodiazepines (diazepam 0.2-0.5 mg/kg/dose IV., Max. dose=10 mg., or 0.5 mg/kg/dose PR) Hallucinations: Haloperidol |
| |
Pathological: belligerent, excited, combative, psychotic state (even after small amount in susceptible person) |
Physical restraint,
low dose benzodiazepine (lorazepam 1-5 mg.
PO as needed), or
haloperidol 1-5 mg. q4-8 hrs.
IM or 1-15 mg/dose PO |
|
|
| Miscellaneous Information: Alcohol is highly addictive, and withdrawal from it is associated with serious, potentially lethal, side effects which begin 6-24 hours after the last drink. Alcohol dependency is rare in adolescents, however, but alcohol-related deaths are not. Adolescents tend to be binge drinkers and are at high risk for alcohol-related accidents and acute alcohol poisoning. |
| B. Cannabis |
| Names/Preparations |
Intoxication |
Withdrawal |
| |
Signs and Symptoms |
Treatment |
Signs and Symptoms |
Treatment |
Marijuana
Pot, herb, grass, weed, reefer, dope, Buds, sinsemilla, Thai sticks
THC capsules
Hashish
Hashish Oil |
Acute: Euphoria, sensory stimulation, pupillary constriction, conjunctival injection, photophobia, nystagmus, diplopia,
greater appetite, autonomic dysfunction (tachycardia, hypertension, orthostatic hypotension) temporary bronchodilatation |
Reassurance and observation | | |
| |
Chronic: gynecomastia, reactive airway disease,lower sperm count, weight gain, lethargy, amotivational syndrome |
Discontinuation of use, symptomatic treatment/care
(bronchodilators for wheezing) |
Chronic users: mild irritability, agitation, insomnia, EEG changes. |
Reassurance; symptoms disappear in 3-4 days |
| |
Pathological: panic, delirium, psychosis, flashbacks |
Psychosis: Neuroleptic medication |
|
|
| Miscellaneous Information: Cannabis derivatives have relatively low addictive potential. These drugs are commonly used by adolescents, however, and are associated with adverse psychological effects. The potency of marijuana has tripled over the past 25 years. |
| C. Hallucinogens |
| Names/Preparations |
Intoxication |
Withdrawal |
| |
Signs and Symptoms |
Treatment |
Signs and Symptoms |
Treatment |
Phencyclidine (PCP) angel dust, super grass, peace weed
Lysergic acid diethylamide (LSD) Acid, blotters, orange sunshine, blue heaven, microdot, sugar cubes
Mescaline
mesc
Peyote
buttons, cactus
Psilocybin
magic mushrooms, 'shrooms
Jimson weed
locoweed
Nightshade |
Acute: Perceptual (visual, auditory) distortion and hallucinations, nystagmus, feelings of depersonaliza-tion, mild nausea, tremors, tachycardia, hypertension, hyperreflexia
Chronic: flashbacks
Pathological: panic, paranoia, psychosis |
Reassurance and observation
(For anticholinergics, i.e., jimson weed, nightshade, symptoms are more severe and may require gastric lavage, benzodiazepine sedation, and hospitalization.)
Discontinuation of use
Psychosis: close observation in a quiet room.
benzodiazepines
(Lorazepam 1-5 mg.
PO). Use of neuroleptic medication is controversial. |
Psychological |
Reassurance |
| Miscellaneous Information: PCP may be sprinkled on marijuana and smoked. Exposure can thus occur without the user's knowledge. |
D. Inhalants
| D. Inhalants |
| Names/Preparations |
Intoxication |
Withdrawal |
| |
Signs and Symptoms |
Treatment |
Signs and Symptoms |
Treatment |
Nitrous Oxide, laughing gas, whippets
Amyl Nitrite,
poppers, snappers
Butyl Nitrate,
rush, bullet, climax
Chlorohydrocarbons aerosol spray cans
Hydrocarbons,
gasoline, glue, solvents, White-out (typewriter correction fluid)
Leaded Gasoline (not in US) |
Acute: euphoria, disorientation, sedation, conjunctival injection, acute toxicity to CNS, liver, kidneys
Nitrates: sudden hypoxemia, hypotension
Chronic: peripheral nerve, CNS, liver, and kidney damage
Pathological: cardiac arrhythmia and arrest |
Symptomatic medical treatments
Discontinuation of use, supportive therapies (dialysis, etc.)
Plumbism: Chelation therapy
Resuscitation, hospitalization |
Psychological
Physiological-unknown |
Reassurance, support |
| Miscellaneous Information: Nitrous oxide is sometimes sold at rock concerts inside balloons. Nitrate compounds have been most popular among gay men, allegedly to enhance sexual experiences. The volatile hydrocarbon compounds are favored by younger adolescents and popular in some Latin-American countries, on Native American reservations, and in Latino communities within the United States. |
E. Stimulants
| E. Stimulants |
| Names/Preparations |
Intoxication |
Withdrawal |
| |
Signs and Symptoms |
Treatment |
Signs and Symptoms |
Treatment |
Cocaine
Coke, Snow, Flake, Blow, Nose Candy
Crack
Freebase, Rocks
Amphetamines
Speed, Black Beauties
Methamphetamine
Crank, Crystal Meth, Ice
Methylphenidate
Ritalin
Pemoline
Cylert
Rx Diet Pills
Didrex, Tenuate, Ionamin, Sanorex, etc.
"Legal speed"
OTC diet or stay awake pills |
Acute: exhilaration, euphoria, restlessness, irritability, insomnia, pupillary dilatation, tachycardia, arrhythmia, chest pain, hypertension, anorexia, hyperpyrexia, hyperreflexia
Chronic: (if snorting: inflamed nasal mucosa, septal erosion or perforation) confusion, sensory hallucinations, paranoia, depression
Pathological: sudden cardiac arrest, hypertensive crisis, seizures |
Reassurance and observation
Symptomatic care
Agitation: high dose benzodiazepines (Diazepam 10-25 mg)
Tachycardia, HTN: (controversial, see below)
Hyperthermia: external cooling
Discontinuation of use, symptomatic treatment/care.
Psychosis: Neuroleptic medication
Resuscitation, hospitalization
HTN crisis: beta-blockers, Phentolamine, Nitroprusside
Seizures: IV Diazepam, (see alcohol section above), or Phenytoin 15-20 mg/kg slow IV push with cardiac monitor |
Chronic users: severe depression with suicidal/homicidal ideation, exhaustion, prolonged sleep, voracious appetite |
Close observation, reassurance; symptoms disappear in 3-4 days |
| Miscellaneous Information: While use of cocaine and crack has declined somewhat in recent years, amphetamines have become more popular. Methamphetamine is more commonly available in California, the West, and Southwest. With the increased public awareness of AD/HD and the popularity of stimulant medications to treat it, Ritalin has now become a drug of abuse among some adolescents. It can be ground up and "snorted," and has been implicated in several reports of sudden cardiac arrest and death. So-called "legal speed," OTC preparations which are available in pharmacies and through mail order houses, can cause toxicity similar to more potent stimulants when taken in high doses. |
F. Depressants
| F. Depressants |
| Names/Preparations |
Intoxication |
Withdrawal |
| |
Signs and Symptoms |
Treatment |
Signs and Symptoms |
Treatment |
Benzodiapines: Valium, "V's," Librium, Serax, Klonopin, Tranxene, Xanax, Halcion, Rohypnol, "Ruffies"
Barbiturates: Nembutal, Seconal, Amytal, Tuinal, downers, barbs, blue devils, red devils, yellows, yellow jackets
Methaqualone: Quaaludes, ludes, sopors |
Mild-Mod: CNS sedation, pupillary constriction, disorientation, slurred speech, staggering gait
Severe: Respiratory depression, hypothermia, coma, death
Pathological: paradoxical disinhibition, hyperexcitability |
Observation and supportive care, protect airway, position on side to avoid aspiration
Acute OD: Gastric lavage.
Supportive: ventilator, warming blanket, ICU care
Symptoms pass in a matter of hours; physical restraint, low dose benzodiazepine rarely needed |
Mild-Mod: restlessness, anxiety, agitation, tremor,
abdominal cramps, nausea, vomiting, hyperreflexia, hypertension, headache, insomnia
Severe: seizures, delirium, hyperpyrexia, hallucinations, death |
Gradual reduction of the drug of dependency, or Phenobarbital substitution (calculate phenobarbital equivalent of daily dose, or give 3-4 mg/kg/day divided by q8h) with gradual taper. Or change short-acting benzodiazepine to longer-acting benzodiazepine and then taper
Seizures: Diazepam
Hallucinations: Haloperidol
(see alcohol section above for doses) |
| Miscellaneous Information: These compounds are all similar to alcohol in effect and highly addictive. Withdrawal symptoms are severe and may begin 12-16 hours after last dose or may be delayed for up to a week. |
G. Narcotics
| G. Narcotics |
| Names/Preparations |
Intoxication |
Withdrawal |
| |
Signs and Symptoms |
Treatment |
Signs and Symptoms |
Treatment |
Heroin,
smack, horse, junk, brown sugar, Big H, mud
Opium
Rx Narcotics
Morphine, Meperidine
Fentanyl, Oxycodone, Hydrocodone, Codeine
Darvon, etc. |
Acute: Euphoria, pupillary constriction, depression of respirations and gag reflex, bradycardia, hypotension, constipation
Chronic: complications of IV use include Hepatitis B, HIV/AIDS, SBE, brain abscesses
Pathological: Acute OD may cause respiratory arrest and death |
Airway protection, judicious use of naloxone
Discontinuation of use, targeted medical care for infectious complications
Intubation and ventilation,
naloxone (IV, IM, SC, ETT): children < 20 kg:
0.1 mg/kg/dose q2-3 hrs.
children > 20 kg:
2-5 mg/dose |
Chronic users: restlessness, lacrimation, yawning, pupillary dilatation, rhinorrhea, sniffing, sneezing, sweating, flushing, tachycardia, hypertension, muscle cramps, abdominal cramps, nausea, vomiting, diarrhea |
Acute detoxification: Methadone (PO)
Children: 0.7 mg/kg/day divided by q4-6 hrs., or adult 30-40 mg./ day in 3-4 divided doses, with 5 mg/day taper.
Clonidine (PO)
Children: 5-7 mcg/kg/day divided by q6-12 hrs. (max = 0.9 mg/day)
Adult: 0.1 mg. test dose, check postural BPs. If stable, 0.1-0.2 mg PO q4-6 hrs.
Long-term treatment:
Long-term therapeutic support.
Methadone or LAAM maintenance (specialized clinics only) |
| Miscellaneous Information: Individuals who abuse narcotics seldom seek treatment for intoxication. They are more often found semi-comatose and brought to the hospital by friends or the EMS for treatment.
When treating an overdose, remember that naloxone has a shorter duration of action than most narcotic drugs, and doses therefore should be repeated at fairly frequent intervals. These patients require lengthy (12-24 hours) periods of observation in hospital. |
H. Designer Drugs
| H. Designer Drugs |
| Names/Preparations |
Intoxication |
Withdrawal |
| |
Signs and Symptoms |
Treatment |
Signs and Symptoms |
Treatment |
Fentanyl analogs Synthetic heroin, China White
Meperidine analogs
MPPP, MPTP |
Similar to narcotics (above) |
Similar to narcotics (above) |
Similar to narcotics (above) |
Similar to narcotics (above) |
Amphetamine analogs
MDMA, Ecstasy, Adam, EVE, STP, PMA, TMA, DOM, DOB, etc. |
Similar to amphetamines
(above) |
Similar to amphetamines
(above) |
Similar to amphetamines
(above) |
Similar to amphetamines
(above) |
PCP Analogs
PCPy, PCE |
Similar to PCP (above) |
Similar to PCP (above) |
Similar to PCP (above) |
Similar to PCP (above) |
| Miscellaneous Information: More popular on the West Coast, designer drugs can be both stronger and cheaper than the parent compound. Quality is not controlled during illicit manufacturing, posing great danger to users. For example: MPTP, a contaminant of the Meperidine analog MPPP, causes irreversible Parkinson's Disease. |
Source:
- Knight J.R.,
- Substance use, abuse, and dependence. In: Levine, M.D.; Carey, W.B.; Crocker, A.C. eds., Developmental-Behavioral Pediatrics, 3rd ed. Philadelphia: W.B. Saunders Co., in press.
References:
- Chang G., Kosten T.R.
- Emergency management of acute drug intoxication. In: Lowinson, J.H., Ruiz, P., Millman, R.B., eds., Substance Abuse: A Comprehensive Textbook. Baltimore: Williams Wilkins, 1992.
- Center for Substance Abuse Treatment.
- Guidelines for the Treatment of Alcohol- and Other Drug-Abusing Adolescents. Treatment Improvement Protocol (TIP) Series 4. DHHS Pub. No. 93-2010. Washington, DC: U.S. Government Printing Office, 1993.
- Center for Substance Abuse Treatment.
- Detoxification for Alcohol and Other Drugs. Treatment Improvement Protocol (TIP) Series 19. DHHS Pub. No. 93-2010. Washington, DC: U.S. Government Printing Office, 1995.
- Barone, M.A., ed.
- The Harriet Lane Handbook, 14th ed. St. Louis: Mosby, 1996.
Acknowledgment:
Michael Shannon, M.D., M.P.H. (Toxicology Program) and Brigid Vaughan, M.D. (Department of Psychiatry) at Children's Hospital, Boston, assisted with preparation of this table.
Source: The National Clearinghouse for Alcohol and Drug Information
DHHS Publication No. (SMA) 99-3283
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Additional Information
Teens
and Alcohol
Teen
Alcohol Use
Alcohol
and Families
Anabolic
Steroids
Effective
Parenting
Fostering
Responsibility
Fostering
Confidence
Problem
Solving
Adolescent
Substance Abuse
Successful
Dialogue
Fathers and
Discipline
Tobacco Use
FPN_6_17
Problem
Drinking
FPN_6_10
Anger and
Aggression
FPN_4_22
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