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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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