and diuretic intake. Binge-eating episodes and the loss of control over eating often occur in young women who are slightly overweight with a history of dieting.
Nutritional, educational, and self-monitoring techniques are used to increase awareness of the maladaptive behavior, following which efforts are made to change the eating behavior. Patients with bulimia nervosa may respond to antidepressant therapy because they often have personality disturbances, impulse control difficulties, and family histories of affective disorders. Patients feel embarrassed, guilty, and ashamed of their actions. Attempted suicide and completed suicide (5%) are an important concern.
The age at which street drugs are first used is decreasing (<12 years), and females are overtaking males in terms of substance use. Ninety percent of adult smokers begin their habit during their adolescent years. Marijuana and stimulant drug use is increasing. Inhalant use (glue solvents, aerosol products) is prevalent in younger adolescents and in Native Americans. The use of club drugs by adolescents from upper income groups at rave parties (3,4-methylenedioxymethamphetamine [Ecstasy]) and so-called date-rape drugs (gamma-hydroxybutyrate or flunitrazepam [Rohypnol]) has risen sharply. Anabolic steroid use has increased in adolescent boys seeking enhanced athletic performance.
A history of drug use should be taken in a nonjudgmentaland supportive manner and include the types of substances,frequency, timing, circumstances, and outcomes of substance use. Table 71-1 is a helpful screening tool. There are few physicalfindings even with chronic adolescent substance use. An adolescent may present in an overdose or intoxicated state, or ina psychosis triggered by a hallucinogen, such as phencyclidine(“angel dust”). Club drugs have direct (coma and seizures) andindirect (sexual assault and dehydration) adverse effects. Anabolic steroids also have direct (gynecomastia and testicular atrophy) and indirect (mood swings and violence) adverse effects.
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Many drugs (most commonly alcohol, amphetamines, opiates, and cocaine) can result in a toxicologic emergency, often with first time use (Table 71-2). Initial management should be directed at appropriate supportive medical treatment, with follow-up counseling after the toxic effects have diminished.
Alcohol (Meths) Disinhibition, ataxia, slurred Ingested (depends on amount Urine and blood speech, respiratory and CNS and tolerance) depression
Nicotine Relaxation, CNS dependence, Inhaled (minutes) ↑ blood pressure, ↑ heart rate, ↓
Snuffed, dipped, chewed temperature
Marijuana Euphoria, relaxation, ↑ appetite, ↓ Inhaled (minutes) Urine up to 1 mo (Cannabis, hashish, joints) reaction time Tablets (30 min +)
Stimulants Alertness, euphoria Inhaled and snorted Urine up to 48 h
Cocaine (crack) Insomnia, ↓ appetite (Quick high) Tablets (longer effect)
Hallucinogens Hallucination, anxiety Oral
Mescaline Psychosis, dilated pupils Injected, sniffed, ingested Immunoassay
LSD “Artistic high” 2–12 h “trip” “Lucy in the sky with diamonds”
Phencyclidine (PCP, angel dust) Microdots in many colors
Ecstasy not detected by urine combinations, i.e.,
Ecstasy (club drugs: screen of hallucinogens and amphetamines)
Opiates Euphoria, ataxia, miosis, slurred Oral, IV, smoked, snorted, and speech sniffed
OxyContin (cotton, hillbilly)—new
Sedatives (barbiturates, “downers”)