Wikipedia - User contributions [en]

Heroin

2007-10-22T03:30:15Z

Quihn: /* External links */ corrected url to updated website ~~~~

:''Not to be confused with [[Hero]]ine (female hero).''
{{Otheruses|Heroin (disambiguation)}}

{{drugbox |
| IUPAC_name = (5α,6α)-7,8-didehydro-4,5-epoxy-<br>17-methylmorphinan-3,6-diol diacetate (ester)
| image = Heroin-2D-skeletal.svg
| image2 = Heroin-3D-balls.png
| CAS_number = 561-27-3
| ATC_prefix = N02
| ATC_suffix = AA09
| PubChem = 3592
| DrugBank =
| C=21 | H=23 | N=1 | O=5
| molecular_weight = 369.41
| bioavailability = <35%
| protein_bound = 0% ([[morphine]] metabolite 35%)
| metabolism = [[hepatic]]
| elimination_half-life = up to 30 minutes [http://www.emedicine.com/med/topic1003.htm]
| excretion = 90% [[renal]] as [[glucuronide]]s, rest [[biliary]]
| pregnancy_category =
| legal_AU = S9
| legal_CA = Schedule I
| legal_UK = Class A
| legal_US = Schedule I
| legal_status =
| dependency_liability =Extremely High
| routes_of_administration = Inhalation, Transmucosal, Intravenous, Oral, Intranasal, Rectal, Intramuscular}}
[[Image:20drugs.gif|thumb|right|Data from [[The Lancet]] shows Heroin to be the most dependent and most harmful of 20 drugs.]]
'''Heroin''' ([[International Nonproprietary Name|INN]]: '''diacetylmorphine''', [[British Approved Name|BAN]]: '''diamorphine''') is a [[opioid|semi-synthetic opioid]] synthesized from morphine, a derivative of the [[opium poppy]], ''Papaver somniferum''. It is the 3,6-[[acetate|diacetyl]] ester of [[morphine]] (hence ''diacetylmorphine'') and is processed by [[acetylation]], making it a [[prodrug]] for the systemic delivery of morphine. The white crystalline form is commonly the hydrochloride salt '''diacetylmorphine hydrochloride'''. Upon crossing the [[blood-brain barrier]], which occurs soon after introduction of the drug into the bloodstream, heroin is converted into morphine, which mimics the action of [[endorphin]]s, creating a sense of well-being; the characteristic euphoria has been described as an "orgasm" centered in the gut. One of the most common methods of heroin use is via [[Intravenous therapy#Needle and syringe|intravenous injection]].

Due to heroin's mimicry of opiates, it is used both as a [[pain-killer]] and a [[recreational drug]]. Frequent administration has a high potential for causing [[addiction]] and may quickly lead to tolerance; however, occasional use does not lead to symptoms of withdrawal. If a continuous, sustained use of heroin for as little as three days is stopped abruptly, withdrawal symptoms can appear. This is much shorter than the withdrawal effects experienced from other common painkillers such as [[oxycodone]] and [[hydrocodone]].<ref>{{cite journal|author=David Shewan, Phil Dalgarno|title=Evidence for controlled heroin use? high levels of negative health and social outcomes among non-treatment heroin users in Glasgow|url=http://www.gcal.ac.uk/news/downloads/BJHPpublished.pdf|journal=British Journal of Health Psychology|year=2005|doi=10.1348/135910704X14582|pages=33-48|volume= 10}}</ref><ref>{{cite news|author=Hamish Warburton, Paul J Turnbull, Mike Hough|title=Occasional and controlled heroin use: Not a problem?|url=http://www.jrf.org.uk/bookshop/details.asp?pubID=747|date=2005}}</ref>

Internationally, heroin is controlled under Schedules I and IV of the [[Single Convention on Narcotic Drugs]].<ref>{{cite web
| year = December 2004| url = http://www.incb.org/pdf/e/list/46thedition.pdf
| title = Yellow List: List of Narcotic Drugs Under International Control| format = PDF
| publisher = [[International Narcotics Control Board]]
| accessdate = May 5| accessyear = 2006
}} ''Referring URL = http://www.incb.org/incb/yellow_list.html''</ref> It is illegal to manufacture, possess, or sell heroin in the [[United States]] and the UK. However, under the name '''diamorphine''', heroin is a legal prescription drug in the [[United Kingdom]]. Popular street names for heroin include ''smack'', ''[[black tar heroin|black tar]]'', ''junk'', ''dope'', and others.


==History==
[[Image:BayerHeroin.png|thumb|left|Old advertisement for [[Bayer]] Heroin.]]
[[Image:Bayer Heroin bottle.jpg|thumb|left|Bayer Heroin bottle.]]

The [[opium poppy]] was cultivated in lower [[Mesopotamia]] as long ago as 3400 BC.<ref>{{cite web
|url=http://www.pbs.org/wgbh/pages/frontline/shows/heroin/etc/history.html
|title=Opium Throughout History
|publisher=PBS Frontline
|accessdate=2006-10-22
}}</ref> The chemical analysis of opium in the 19th century revealed that most of its activity could be ascribed to two ingredients, [[codeine]] and [[morphine]].

Heroin was first processed in 1874 by [[C.R. Alder Wright]], an English chemist working at [[St Mary's Hospital (London)|St. Mary's Hospital]] Medical School in London, England. He had been experimenting with combining morphine with various acids. He boiled anhydrous morphine alkaloid with acetic anhydride over a stove for several hours and produced a more potent, acetylated form of morphine, now called ''diacetylmorphine''. The compound was sent to F.M. Pierce of Owens College in Manchester for analysis, who reported the following to Wright:

:''Doses ... were [[Route of administration|subcutaneously injected]] into young dogs and rabbits ... with the following general results ... great prostration, fear, and sleepiness speedily following the administration, the eyes being sensitive, and pupils constrict, considerable [[salivation]] being produced in dogs, and slight tendency to [[vomit]]ing in some cases, but no actual emesis. [[Respiration (physiology)|Respiration]] was at first quickened, but subsequently reduced, and the heart's action was diminished, and rendered irregular. Marked want of coordinating power over the muscular movements, and loss of power in the pelvis and hind limbs, together with a diminution of temperature in the rectum of about 4° (rectal failure)''.<ref>{{cite web
|url=http://adhpage.dilaudid.net/heroin.html
|title=On the Action of Organic Acids and their Anhydrides on the Natural Alkaloids
|last = Wright
|first = C.R.A.
|date=[[2003-08-12]]
|archiveurl=http://web.archive.org/web/20040606103721/http://adhpage.dilaudid.net/heroin.html
|archivedate=2004-06-06
}} Note: this is an annotated excerpt of {{cite journal
| last = Wright
| first = C.R.A.
| year = 1874
| title = On the Action of Organic Acids and their Anhydrides on the Natural Alkaloids
| journal = [[Journal of the Chemical Society]]
| volume = 27
| pages = 1031-1043
}}</ref>

Wright's invention, however, did not lead to any further developments, and heroin only became popular after it was independently re-synthesized 23 years later by another chemist, [[Felix Hoffmann]]. Hoffmann, working at the [[Bayer]] pharmaceutical company in [[Elberfeld, Germany]], was instructed by his supervisor Heinrich Dreser to acetylate morphine with the objective of producing [[codeine]], a natural derivative of the opium poppy, similar to morphine but less potent and less addictive. But instead of producing codeine, the experiment produced an acetylated form of morphine that was actually 1.5-2 times more potent than morphine itself. Bayer would name the substance "heroin", probably from the word ''heroisch'', German for heroic, because in field studies people using the medicine felt "heroic".<ref>owden, Mary Ellen. Pharmaceutical Achievers. Philadelphia: Chemical Heritage Foundation, 2002.</ref>

From 1898 through to 1910 heroin was marketed as a non-addictive morphine substitute and cough medicine for children. Bayer marketed heroin as a cure for morphine addiction before it was discovered that heroin is converted to morphine when metabolized in the liver, and as such, "heroin" was basically only a quicker acting form of morphine. The company was somewhat embarrassed by this new finding and it became a historical blunder for Bayer.<ref>{{cite web
|year=1998
|month=September 13
|url=http://opioids.com/heroin/heroinhistory.html
|title= How aspirin turned hero
|publisher=Sunday Times
|accessdate=2006-10-22
}}</ref>

As with aspirin, Bayer lost some of its trademark rights to heroin following the German defeat in [[World War I]].
<ref>{{cite web
|url=http://history.sandiego.edu/gen/text/versaillestreaty/all440.html
|date=[[1919-06-28]]
|title=Treaty of Versailles
|accessdate=2007-05-05
|pages=Part X, Section IV, Annex, paragraph 5
}}</ref>

In the United States the [[Harrison Narcotics Tax Act]] was passed in 1914 to control the sale and distribution of heroin. The law did allow heroin to be prescribed and sold for medical purposes. In particular, recreational users could often still be legally supplied with heroin. In 1924, the United States Congress passed additional legislation banning the sale, importation or manufacture of heroin in the United States. It is now a Schedule I substance, and is thus illegal there.

<br>

==Usage and effects==
{{Expert-verify|date=April 2007}}
{| bgcolor="#ffffff" border="1" cellpadding="3" cellspacing="0" align="right" width="167px" style="border-collapse: collapse; clear: right; margin: 0 0 0 0.5em"
|-
|'''Indicated for:'''<br/>
*Relief of Extreme Pain

'''[[Recreational drug use|Recreational]] uses:'''<br/>
*[[Euphoria (emotion)|Euphoria]]
*[[Relaxation]]

'''Other uses:'''<br/>
*[[Pain and nociception|Pain]] relief
*[[Cough suppressant]]
*anti-[[diarrhea]]l
|-
|'''[[Contraindication]]s:'''<br/>
*[[Ethanol|Alcohol]]
*[[Barbiturate]]s and [[Benzodiazepines]]
*[[Stimulant]]s
*Other [[opioid]]s (depends heavily on tolerance)
|-
|'''[[Adverse drug reaction|Side effects]]'''{{Fact|date=July 2007}}
<div style="background: #ffcc99">
'''''{{red|Severe:}}'''''[http://www.drugs.com/enc/heroin-overdose.html]
*[[Respiratory arrest]], [[seizure]], [[coma]], [[death]]
*[[Spontaneous abortion]]

</div>

</div>
'''''[[Central nervous system]]:'''''
*[[Drowsiness]]
*[[Disorientation]]
*[[Delirium]]

'''''[[Cardiovascular]] & [[Respiration (physiology)|Respiratory]]:'''''
*Lowered [[heart rate]]
*[[Weak pulse]]
*[[Hypotension]]
*[[Hypoventilation]]
*[[Shallow breathing]]
*Respiratory depression

'''''[[Eyes]], [[Ears]], [[nose]], and [[mouth]]:'''''
*Dry mouth
*[[Pupil constriction]] ("pinpoint pupils")
*[[Miosis]]

'''''[[Gastrointestinal]]:'''''
*[[Nausea]]
*[[Vomiting]] (protracted)
*[[Constipation]]
*[[Dyspepsia]]

'''''[[Urinary System]]:'''''
*[[Urinary retention]]

'''''[[Muscle|Musculo]][[skeletal]]:'''''
*[[Analgesia]]
*[[Ataxia]]
*[[Muscle spasticity]]

'''''[[Neurological]]:'''''
*[[Analgesia]]
*[[Physical dependence]]

'''''[[Psychological]]:'''''
*[[Anxiolysis]]
*[[Confusion]]
*[[Euphoria (emotion)|Euphoria]]
*[[Psychological addiction#Psychological dependency|Psycological dependence]]
*[[Somnolence]]

'''''[[Skin]]:'''''
*Itching
*Flushing/Rash

[[Image:Diamorphine ampoules.JPG|thumb|left|Diamorphine ampoules for medicinal use]]
|}

Heroin is used as a recreational drug for its intense [[euphoria]], which often fades with increased [[Physiological tolerance|tolerance]]. It is believed that heroin's popularity with recreational users, compared to morphine or other opiates, comes from its somewhat different perceived effects.<ref>{{cite journal
| author = Tschacher W, Haemmig R, Jacobshagen N.
| year = 2003
| title = Time series modeling of heroin and morphine drug action.
| journal = [[Psychopharmacology]]
| PMID = 12404073
| url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12404073&query_hl=23&itool=pubmed_DocSum
}}</ref> This belief has not been supported by clinical research. In studies comparing the physiological and subjective effects of heroin and morphine administered intravenously in post-addicts, subjects showed no preference for one or the other of these drugs when administered on a single injection basis. Equipotent intravenous doses had comparable action courses. There was no difference found in their ability to produce feelings of "euphoria," ambition, nervousness, relaxation, drowsiness, or sleepiness.<ref>W. R. Martin 1 and H. F. Fraser 1</ref> Data acquired during short-term addiction studies did not support the statement that tolerance develops more rapidly to heroin than to morphine. These findings have been discussed in relation to the physicochemical properties of heroin and morphine and the metabolism of heroin. When compared to other opioids -- [[hydromorphone]], [[fentanyl]], [[oxycodone]], and [[meperidine]], post-addicts showed a strong preference to heroin and morphine over the others, suggesting that heroin and morphine are more liable to abuse and addiction. Morphine and heroin were also much more likely to produce feelings of "euphoria", and other subjective effects when compared to most other [[opioid]] analgesics.<ref>1 National Institute of Mental Health, Addiction Research Center, U. S. Public Health Service Hospital, Lexington, Kentucky</ref><ref>Journal of Pharmacology And Experimental Therapeutics, Vol. 133, Issue 3, 388-399, 1961</ref> Heroin can be [[route of administration|administered]] in a number of ways, including [[Insufflation#Medical uses|snort]]ing and [[injection (medicine)|injection]]. It may also be smoked by inhaling the vapors produced when heated (known as "[[chasing the dragon]]").

Some users mix heroin with [[cocaine]] in a so-called "speedball" or "snowball", which is usually injected intravenously although it can be smoked or dissolved in water and snorted. This causes a more intense rush than heroin alone but is more dangerous because the combination of the short-acting stimulant with the longer-acting depressant increases the risk of overdosing on one or both drugs.

Once in the brain, heroin is rapidly [[metabolism|metabolized]] into morphine by removal of the acetyl groups, therefore, it is known as a [[prodrug]]. It is the morphine [[molecule]] that then binds with opioid receptors and produces the subjective effects of the heroin high.

The onset of heroin's effects is dependent on the method of administration. Taken orally, heroin is totally metabolized [[in vivo]] into morphine before crossing the blood-brain barrier; so the effects are the same as oral morphine. Snorting heroin results in an onset within 3 to 5 minutes. Smoking heroin results in an almost immediate, though mild effect which strengthens the longer it is used 7 to 11 seconds. Intravenous injection results in rush and euphoria within 30 to 60 seconds; while intramuscular or subcutaneous injection takes longer, having an effect within 3 to 5 minutes.

Heroin is a μ-opioid ([[Mu opioid receptor|mu-opioid]]) [[agonist]]. It acts on [[endogenous]] [[Opioid receptor#The .CE.BC-opioid receptor|μ-opioid receptor]]s that are spread in discrete packets throughout the [[brain]], [[spinal cord]] and [[gut]] in almost all [[mammal]]s. Heroin, along with other [[opioids]], are [[agonists]] to four endogenous [[neurotransmitters]]. They are [[Beta-endorphin|β-endorphin]], [[dynorphin]], [[leu-enkephalin]], and [[met-enkephalin]]. The body responds to heroin in the brain by reducing (and sometimes stopping) production of the endogenous opioids when heroin is present. Endorphins are regularly released in the brain and nerves, attenuating pain. Their other functions are still obscure, but are probably related to the effects produced by heroin besides analgesia ([[antitussin]], [[anti-diarrheal]]). The reduced endorphin production in heroin users creates a dependence on the heroin, and the cessation of heroin results in extremely uncomfortable symptoms including pain (even in the absence of physical trauma). This set of symptoms is called [[withdrawal]] syndrome. It has an onset 6 to 8 hours after the last dose of heroin.

Large doses of heroin can be fatal. The drug can be used for suicide or, as in the case of [[Sigmund Freud]], physician-assisted suicide.  Heroin can also be used as a murder weapon. The serial killer Dr. [[Harold Shipman]] used it on his victims as did Dr. [[John Bodkin Adams]] ([[Edith Alice Morrell|see his victim, Edith Alice Morrell]]). Dealers can also supply unwanted customers with unusually pure heroin, or heroin cut with other dangerous drugs such as fentanyl, resulting in a fatal overdose. It can sometimes be difficult to determine whether a heroin death was an accident, suicide or murder. The deaths of [[Joseph Krecker]] and [[Janis Joplin]] were such cases. <ref>http://www.timesonline.co.uk/article/0,,11069-2329203,00.html</ref>

==Regulation==

In Canada heroin is a controlled substance under Schedule I of the [[Controlled Drugs and Substances Act]] (CDSA). Every person who seeks or obtains heroin without disclosing authorization 30 days prior to obtaining another prescription from a practitioner is guilty of an indictable offense and liable to imprisonment for a term not exceeding seven years. Possession for purpose of trafficking is guilty of an indictable offense and liable to imprisonment for life.

In Hong Kong, heroin is regulated under Schedule 1 of [[Hong Kong|Hong Kong's]] Chapter 134 ''Dangerous Drugs Ordinance''. It can only be used legally by health professionals and for university research purposes. It can be given by pharmacists under a prescription. Anyone who supplies heroin without prescription can be fined $10000(HKD). The penalty for trafficking or manufacturing heroin is a $5,000,000 ([[Hong Kong dollar|HKD]]) fine and life imprisonment. Possession of heroin for consumption without license from the Department of Health is illegal with a $1,000,000 (HKD) fine and/or 7 years of jail time.

In the [[United Kingdom]], heroin is available by prescription, though it is a restricted [[Class A drug]]. According to the [[British National Formulary]] (BNF) edition 50, diamorphine [[hydrochloride]] may be used in the treatment of acute pain, [[myocardial infarction]], acute [[pulmonary oedema]], and [[chronic pain]]. The treatment of chronic non-[[malignant]] pain must be supervised by a specialist. The BNF notes that all opioid analgesics cause dependence and tolerance but that this is "no deterrent in the control of pain in terminal illness". When used in the [[palliative care]] of cancer patients, heroin is often injected using a [[syringe driver]].

In [[Australia]] heroin is not available for therapeutic purposes.

==Production and trafficking==
[[Image:HeroinWorld.png|thumb|left|Primary worldwide producers of heroin.]]
===Manufacturing===
Heroin is produced for the black market through processes of opium refinement. The refinement of the first three grades of heroin from opium is a relatively simple process requiring only moderate technical expertise and common chemicals. The final grade of heroin favored in the [[Western world|West]] is more difficult to produce and involves a potentially dangerous chemical procedure.

First, morphine is isolated from crude opium by being dissolved in water, reacted with [[agricultural lime|lime]] fertilizer such that the morphine precipitates out, and then reacted again with [[ammonia]]. What remains is then mechanically filtered to yield a final product of morphine weighing about 90% less than the original quantity of opium. The morphine is reacted with [[acetic anhydride]] — a chemical also used in the production of aspirin — in a five-step process used by most refineries in the [[Golden Triangle (Southeast Asia)|Golden Triangle]]. The first step is to cook the morphine at 85 °C (185 °F) for six hours with an equivalent weight of acetic anhydride. In the second, a treatment of water and hydrochloric acid then purifies the product moderately. When the chemists add [[sodium carbonate]], the particulates settle. Step four involves heating the heroin in a mixture of [[alcohol]] and [[activated charcoal]] until the alcohol evaporates. The fifth step is optional, as it only changes the heroin into a finer white powder, more easily injectable; this so-called "no. 4 heroin" is principally exported to the Western markets. In this last, most dangerous step, the heroin (after being dissolved in alcohol), precipitates out in tiny white flakes when a mixture of [[ether]] and [[hydrochloric acid]] is injected; this step is dangerous because the ether may explode, leveling or severely damaging the refinery (as has happened to a number of such facilities).

The purity of the extracted morphine determines in large part the quality of the resulting heroin.

Heroin is also rarely made from [[codeine]] by first demethylating with [[pyridine]] followed by acetylation with acetic anhydride. The resulting product is an impure mixture of heroin and [[monoacetylmorphine]] known as [[Home Bake]].

===History of heroin traffic===

{{Original research|section|date=September 2007}}

The origins of the present international illegal heroin trade can be traced back to laws passed in many countries in the early 1900s that closely regulated the production and sale of opium and its derivatives including heroin. At first, heroin flowed from countries where it was still legal into countries where it was no longer legal. By the mid-1920s, heroin production had been made illegal in many parts of the world. An illegal trade developed at that time between heroin labs in China (mostly in Shanghai and Tianjin) and other nations. The weakness of government in China and conditions of civil war enabled heroin production to take root there. Chinese [[Triad society|triad]] gangs eventually came to play a major role in the heroin trade.

Heroin trafficking was virtually eliminated in the U.S. during [[World War II]] due to temporary trade disruptions caused by the war. Japan's war with China had cut the normal distribution routes for heroin and the war had generally disrupted the movement of opium. After the second world war, the Mafia took advantage of the weakness of the postwar Italian government and set up heroin labs in Sicily. The Mafia took advantage of Sicily's location along the historic route opium took from Iran{{Fact|date=July 2007}} westward into Europe and the United States. Large scale international heroin production effectively ended in China with the victory of the communists in the civil war in the late 1940s. The elimination of Chinese production happened at the same time that Sicily's role in the trade developed.

Although it remained legal in some countries until after World War II, health risks, addiction, and widespread abuse led most western countries to declare heroin a controlled substance by the latter half of the 20th century.

Between the end of World War II and the 1970s, much of the opium consumed in the west was grown in [[Iran]]{{Fact|date=July 2007}}, but in the late 1960s, under pressure from the U.S. and the [[United Nations]], Iran{{Fact|date=July 2007}} engaged in anti-opium policies. While opium production never ended in Iran{{Fact|date=July 2007}}, the decline in production in those countries led to the development of a major new cultivation base in the so-called "[[Golden Triangle (Southeast Asia)|Golden Triangle]]" region in South East Asia. In 1970-71, high-grade heroin laboratories opened in the Golden Triangle. This changed the dynamics of the heroin trade by expanding and decentralizing the trade. Opium production also increased in Afghanistan due to the efforts of Turkey and Iran{{Fact|date=July 2007}} to reduce production in their respective countries. Lebanon, a traditional opium supplier, also increased its role in the trade during years of civil war.{{Fact|date=July 2007}}

Soviet-Afghan war led to increased production in the Pakistani-Afghani border regions. It increased international production of heroin at lower prices in the 1980s. The trade shifted away from Sicily in the late 1970s as various criminal organizations violently fought with each other over the trade. The fighting also led to a stepped up government law enforcement presence in Sicily. All of this combined to greatly diminish the role of the country in the international heroin trade. {{Fact|date=July 2007}}

===Trafficking===
:''See also: [[Opium#Production Today|Opium production]]''

Traffic is heavy worldwide, with the biggest producer being Afghanistan.<ref>{{cite web
| last =Nazemroaya
| first =Mahdi Darius
| year =2006
| month =October 17
|url=http://www.globalresearch.ca/index.php?context=viewArticle&code=NAZ20061017&articleId=3516
|title=The War in Afghanistan: Drugs, Money Laundering and the Banking System
|publisher=GlobalResearch.ca
|accessdate=2006-10-22
}}</ref> According to U.N. sponsored survey,<ref>{{cite web
|url=http://www.unodc.org/pdf/afg/afghanistan_opium_survey_2004.pdf
|title=Afghanistan opium survey - 2004
|publisher=
|accessdate=2006-10-22
}}</ref> as of 2004, Afghanistan accounted for production of 87 percent of the world's heroin.<ref>{{cite web
| last =McGirk
| first =Tim
| year = 2004
| month =August 2
| url =http://www.time.com/time/asia/magazine/printout/0,13675,501040809-674806,00.html
| title =Terrorism's Harvest: How al-Qaeda is tapping into the opium trade to finance its operations and destabilize Afghanistan
| publisher =Time Magazine Asia
| accessdate =2006-10-22
}}</ref> Opium production in that country has increased rapidly since, reaching an all-time high in 2006. War once again appeared as a facilitator of the trade.<ref>{{cite web
| last =Gall
| first =Carolotta
| year =2006
| month =September 3
| url =http://www.nytimes.com/2006/09/03/world/asia/03afghan.html?ex=1314936000&en=77aca21e09c8576e&ei=5088&partner=rssnyt&emc=rss
| title =Opium Harvest at Record Level in Afghanistan
| publisher =New York Times - Asia Pacific
| accessdate =2006-10-22
}}</ref>

At present, opium poppies are mostly grown in [[Afghanistan]], and in [[Southeast Asia]], especially in the region known as the Golden Triangle straddling [[Myanmar]], [[Thailand]], [[Vietnam]], [[Laos]] and [[Yunnan]] province in the [[People's Republic of China]]. There is also cultivation of opium poppies in the [[Sinaloa]] region of [[Mexico]]{{Fact|date=September 2007}} and in [[Colombia]]. The majority of the heroin consumed in the United States comes from Mexico and Colombia{{Fact|date=February 2007}}. Up until 2004, Pakistan was considered one of the biggest opium-growing countries. However, the efforts of Pakistan's [[Anti-Narcotics Force]] have since reduced the opium growing area by 59% [[as of 2001]]{{Fact|date=February 2007}}. Some suggest that the decline in Pakistani production is inversely proportional to the rise of Afghani production, and that rather than anti-narcotics activity, the decline in Pakistan is due more to changed market forces.{{Fact|date=February 2007}}

Conviction for trafficking in heroin carries the death penalty in most [[South-east Asia]] and some [[East Asia]] and [[Middle Eastern]] countries (see [[Use of death penalty worldwide]] for details), among which [[Malaysia]], [[Singapore]] and [[Thailand]] are the most strict. The penalty applies even to citizens of countries where the penalty is not in place, sometimes causing controversy when foreign visitors are arrested for trafficking, for example the arrest of [[Bali Nine|nine Australians in Bali]] or the hanging of [[Australia]]n citizen [[Van Tuong Nguyen]] in Singapore, both in 2005.

[[Sandra Gregory]] has written an autobiography covering her experience of getting caught with Heroin at a Thai airport.

==Risks of non-medical use==
{{Refimprove|date=May 2007}}

[[Image:Heroincan.jpg|thumb|right|Heroin being cooked in an aluminum can]]
* For [[intravenous]] users of heroin (and any other substance), the use of non-sterile needles and syringes and other related equipment leads to the risk of contracting blood-borne [[pathogens]] such as [[HIV]] and [[hepatitis]], as well as the risk of contracting bacterial or fungal [[endocarditis]] and possibly venous sclerosis.
* Poisoning from [[contaminants]] added to "[[Cutting agent|cut]]" or dilute heroin
* Chronic [[constipation]]
* [[Addiction]] and constantly growing tolerance. Like all opiates and opioids, long term use can lead to addiction.
* [[Physical dependence]] can result from prolonged use of all opiate and opioids, resulting in withdrawal symptoms on cessation of use.
* Decreased kidney function. (although it is not currently known if this is due to adulterants used in the cut)<ref>http://cat.inist.fr/?aModele=afficheN&cpsidt=15612648</ref><ref>http://kidneyfoundation.ab.ca/Be_Active/preserving_function.htm</ref><ref>http://www.kidney.ab.ca/health/index.html</ref><ref>http://www.kidney.org/kidneydisease/howkidneyswrk.cfm</ref><ref>[http://www.catalog.niddk.nih.gov/resources/results.cfm?searchterms=kidney%20disease%20hypertension&databases=2&searchtype=basic&result=20]</ref>
Many countries and local governments have begun funding programs that supply [[sterilization (microbiology)|sterile]] needles to people who inject illegal drugs in an attempt to reduce these contingent risks and especially the contraction and spread of blood-borne diseases. The Drug Policy Alliance reports that up to 75% of new AIDS cases among women and children are directly or indirectly a consequence of drug use by injection. But despite the immediate [[public health]] benefit of [[needle-exchange programme|needle exchange]]s, some see such programs as tacit acceptance of illicit drug use. The United States federal government does not operate needle exchanges, although some state and local governments do support needle exchange programs. Needle exchanges have been instrumental in arresting the spread of HIV/AIDS in many communities with a significant heroin using population,{{Fact|date=February 2007}} Australia being a leader due to its early inception of needle exchanges. Needle exchange programs have also been attributed to saving the public significant amounts of tax money by preventing medical costs which would have been required otherwise for the treatment of diseases spread through the practice of sharing and reusing needles.

A heroin [[overdose]] is usually treated with an opioid [[Receptor antagonist|antagonist]], such as [[naloxone]] ([[Narcan]]), which has a high affinity for [[opioid receptors]] but does not activate them. This blocks heroin and other opioid antagonists and causes an immediate return of consciousness and the beginning of [[withdrawal]] symptoms when administered intravenously. The [[half-life]] of this antagonist is usually much shorter than that of the opiate drugs it is used to block, so the antagonist usually has to be re-administered multiple times until the opiate has been metabolized by the body.

Depending on drug interactions and numerous other factors, death from overdose can take anywhere from several minutes to several hours due to anoxia because the breathing reflex is suppressed by µ-opioids. An overdose is immediately reversible with an [[opioid antagonist]] injection. Heroin overdoses can occur due to an unexpected increase in the dose or purity or due to diminished opiate tolerance. However, most fatalities reported as overdoses are probably caused by interactions with other [[depressant]] drugs like alcohol or [[benzodiazepine]]s.<ref>{{cite journal | author=Shane Darke, Deborah Zador|title=Fatal Heroin 'Overdose': a Review|url=http://www.lindesmith.org/library/darke2.cfm|journal=Addiction|year=1996|volume = 91|issue =12|pages= 1765-1772 }}</ref>

The [[LD50|LD<sub>50</sub>]] for a physically addicted person is prohibitively high,{{Fact|date=June 2007}} to the point that there is no general medical consensus on where to place it. Several studies done in the 1920s gave users doses of 1,600–1,800 mg of heroin in one sitting, and no adverse effects were reported. This is approximately 16–18 times a normal recreational dose.{{Fact|date=June 2007}} Even for a non-user, the LD<sub>50</sub> can be placed above 350 mg{{Fact|date=June 2007}} though some sources give a figure of between 75 and 375 mg for a 75 kg person.<ref>personhttp://lincoln.pps.k12.or.us/lscheffler/ToxicSubstances%20in%20water.htm</ref>

Street heroin is of widely varying and unpredictable purity. This means that the user may prepare what they consider to be a moderate dose while actually taking far more than intended. Also, those who use the drug after a period of abstinence have tolerances below what they were during active addiction. If a dose comparable to their previous use is taken, an effect greater to what the user intended is caused, in extreme cases an overdose could result.

It has been speculated that an unknown portion of heroin related deaths are the result of an overdose or allergic reaction to [[quinine]], which may sometimes be used as a cutting agent.[http://www.druglibrary.org/schaffer/Library/studies/cu/cu12.htm]

A final source of overdose in users comes from [[conditioning|place conditioning]]. Heroin use, like other drug using behaviors, is highly ritualized. While the mechanism has yet to be clearly elucidated, it has been shown that longtime heroin users, immediately before injecting in a common area for heroin use, show an acute increase in metabolism and a surge in the concentration of [[opiate]]-metabolizing [[enzyme]]s. This acute increase, a reaction to a location where the user has repeatedly injected heroin, imbues him or her with a strong (but temporary) [[drug tolerance|tolerance]] to the toxic effects of the drug. When the user injects in a different location, this place-conditioned tolerance does not occur, giving the user a much lower-than-expected ability to metabolize the drug. The user's typical dose of the drug, in the face of decreased tolerance, becomes far too high and can be toxic, leading to overdose.[http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1196296]

A small percentage of heroin smokers may develop symptoms of [[toxic leukoencephalopathy]]. This is believed to be caused by an uncommon [[adulterant]] that is only active when heated. Symptoms include slurred speech and difficulty walking.

==Harm reduction approaches to heroin==
Proponents of the [[harm reduction]] philosophy seek to minimize the harms that arise from the recreational use of heroin. Safer means of taking the drug, such as smoking or nasal, oral and rectal insertion, are encouraged, due to injection having higher risks of overdose, infections and blood-borne viruses.
Where the strength of the drug is unknown, users are encouraged to try a small amount first to gauge the strength, to minimize the risks of overdose. For the same reason, poly drug use (the use of two or more drugs at the same time) is discouraged. Users are also encouraged to not use heroin on their own, as others can assist in the event of an overdose.
Heroin users who choose to inject should always use new needles, syringes, spoons/steri-cups and filters every time they inject and not share these with other users. Governments that support a harm reduction approach often supply new needles and syringes on a confidential basis, as well as education on proper filtering prior to injection, safer injection techniques, safe disposal of used injecting gear and other equipment used when preparing heroin for injection may also be supplied including citric acid sachets/vitamin C sachets, steri-cups, filters, alcohol pre-injection swabs, sterile water ampules and tourniquets (to stop use of shoe laces or belts).

==Withdrawal==
[[Image:Heroin black tar.jpg|thumb|left|[[Black tar heroin]]]]

The withdrawal syndrome from heroin may begin starting from within 6 to 24 hours of discontinuation of sustained use of the drug; however, this time frame can fluctuate with the degree of tolerance as well as the amount of the last consumed dose. Symptoms may include: [[sweating]], [[malaise]], [[anxiety]], [[clinical depression|depression]], persistent and intense penile erection in males ([[priapism]]), extra sensitivity of the genitals in females, general feeling of heaviness, cramp-like pains in the limbs, [[pandiculation]] and [[lacrimation]], sleep difficulties ([[insomnia]]), cold sweats, chills, severe muscle and bone aches not precipitated by any physical trauma; nausea and [[vomiting]], diarrhea, [[goose bumps]], [[cramps]], and [[fever]].<ref>http://www.drugaddictiontreatment.info/heroin.htm</ref><ref>http://www.med.umich.edu/1libr/aha/aha_subabu_bha.htm </ref> Many users also complain of a painful condition, the so-called "itchy blood", which often results in compulsive scratching that causes bruises and sometimes ruptures the skin, leaving scabs. Abrupt termination of heroin use causes muscle spasms in the legs of the user ([[restless leg syndrome]]). Users taking the "[[cold turkey]]" approach (withdrawal without using symptom-reducing or counteractive drugs), or induced withdrawal with opiate antagonist drugs, are more likely to experience the negative effects of withdrawal in a more pronounced manner.

Two general approaches are available to ease the physical part of opioid withdrawal. The first is to substitute a longer-acting opioid such as [[methadone]] or [[buprenorphine]] for heroin or another short-acting opioid and then slowly taper the dose.

In the second approach, [[benzodiazepine]]s such as [[diazepam]] (Valium) may temporarily ease the often extreme anxiety of opioid withdrawal. The most common benzodiazepine employed as part of the detox protocol in these situations is [[oxazepam]] (Serax). Benzodiazepine use must be prescribed with care because benzodiazepines have an addiction potential, and many opioid users also use other central nervous system [[depressants]], especially alcohol. Also, though unpleasant, opioid withdrawal seldom has the potential to be fatal, whereas complications related to withdrawal from benzodiazepines, [[barbiturates]] and alcohol (such as epileptic [[seizures]], [[cardiac arrest]], and [[delirium tremens]]) can prove hazardous and are potentially fatal.

Many symptoms of opioid withdrawal are due to rebound hyperactivity of the [[sympathetic nervous system]], which can be suppressed with [[clonidine]] (Catapres), a centrally-acting alpha-2 agonist primarily used to treat [[hypertension]]. Another drug sometimes used to relieve the "restless legs" symptom of withdrawal is [[baclofen]], a [[muscle relaxant]]. Diarrhea can likewise be treated symptomatically with the peripherally active opioid drug [[loperamide]].

[[Buprenorphine]] is one of the substances most recently licensed for the substitution of opioids in the treatment of users. Being a partial opioid agonist/antagonist, it develops a lower grade of tolerance than heroin or methadone due to the so-called ceiling effect. It also has less severe withdrawal symptoms than heroin when discontinued abruptly, which should never be done without proper medical supervision. It is usually administered every 24-48 hrs. Buprenorphine is a kappa-opioid receptor antagonist. This gives the drug an anti-depressant effect, increasing physical and intellectual activity. {{Fact|date=February 2007}} Buprenorphine also acts as a partial agonist at the same μ-receptor where opioids like heroin exhibit their action. Due to its effects on this receptor, all patients whose tolerance is above a certain level are unable to obtain any "high" from other opioids during buprenorphine treatment except for very high doses.

Researchers at [[Johns Hopkins University]] have been testing a sustained-release "depot" form of buprenorphine that can relieve cravings and withdrawal symptoms for up to six weeks.<ref>{{cite web
| last = Thomas| first = Josephine| year = May 2001
| url = http://www.nida.nih.gov/PDF/NNCollections/NNHeroin.pdf
| title = Buprenorphine Proves Effective, Expands Options For Treatment of Heroin Addiction
| format = PDF| work = NIDA Notes: Articles that address research on Heroin| pages = 23
| publisher = [[National Institute on Drug Abuse]]
| accessdate = May 5| accessyear = 2006
}}</ref> A sustained-release formulation would allow for easier administration and adherence to treatment, and reduce the risk of diversion or misuse.

Methadone is another μ-opioid agonist most often used to substitute for heroin in treatment for heroin addiction. Compared to heroin, methadone is well (but slowly) absorbed by the gastrointestinal tract and has a much longer duration of action of approximately 24 hours. Thus [[methadone maintenance]] avoids the rapid cycling between [[intoxication]] and withdrawal associated with heroin addiction. In this way, methadone has shown some success as a "less harmful substitute"; despite bearing about the same addiction potential as heroin, it is recommended for those who have repeatedly failed to complete withdrawal or have recently relapsed. As of 2005, the μ-[[opioid]] [[agonist]] [[buprenorphine]] is also being used to manage heroin addiction, being a superior, though still imperfect and not yet widely known alternative to methadone. Methadone, since it is longer-acting, produces withdrawal symptoms that appear later than with heroin, but usually last considerably longer and can in some cases be more intense. Methadone withdrawal symptoms can potentially persist for over a month, compared to heroin where significant physical symptoms would subside in 4 days.

Three opioid [[antagonists]] are known: [[naloxone]] and the longer-acting [[naltrexone]] and [[nalmefene]]. These medications block the effects of heroin, as well as the other opioids at the receptor site. Recent studies have suggested that the addition of naltrexone may improve the success rate in treatment programs when combined with the traditional therapy. {{Fact|date=February 2007}}

The [[University of Chicago]] undertook preliminary development of a heroin vaccine in [[monkeys]] during the 1970s, but it was abandoned. There were two main reasons for this. Firstly, when immunized monkeys had an increase in dose of x16, their [[antibodies]] became [[saturation (chemistry)|saturated]] and the monkey had the same effect from heroin as non-immunized monkeys. Secondly, until they reached the x16 point immunized monkeys would substitute other drugs to get a heroin-like effect. These factors suggested that immunized human users would simply either take massive quantities of heroin, or switch to other drugs, which is known as [[cross-tolerance]].

There is also a controversial treatment for heroin addiction based on a [[Iboga]]-derived African drug, [[ibogaine]]. Many people travel abroad for ibogaine treatments that generally interrupt substance use disorders for 3-6 months or more in up to 80% of patients.<ref> H.S. Lotsof. Ibogaine in the Treatment of Chemical Dependence Disorders: Clinical Perspectives. MAPS Bulletin 1995 V(3):19-26 </ref> Relapse may occur when the person returns home to their normal environment however, where drug seeking behavior may return in response to social and environmental cues.{{Fact|date=February 2007}} Ibogaine treatments are carried out in several countries including Mexico and Canada as well as, in South and Central America and Europe. Opioid withdrawal therapy is the most common use of ibogaine. Some patients find ibogaine therapy more effective when it is given several times over the course of a few months or years. A synthetic derivative of ibogaine, [[18-methoxycoronaridine]] was specifically designed to overcome cardiac and neurotoxic effects seen in some ibogaine research but, the drug has not yet found its way into clinical research..

== Heroin prescription ==
The UK Department of Health's Rolleston Committee report in 1926 established the British approach to [[heroin prescription]] to users, which was maintained for the next forty years: dealers were prosecuted, but doctors could prescribe heroin to users when withdrawing from it would cause harm or severe distress to the patient. This "policing and prescribing" policy effectively controlled the perceived heroin problem in the UK until the 1960s. Attitudes eventually began to change, however: in 1964 only specialized clinics and selected approved doctors were allowed to prescribe heroin to users. Eventually, from the 1970s, the emphasis shifted to abstinence and the prescription of methadone, until now only a small number of users in the UK are prescribed heroin.<ref>{{cite web
| last =Goldacre
| first =Ben
| year =1998
| url =http://www.badscience.net/?p=327
| title =Methadone and Heroin: An Exercise in Medical Scepticism
| accessdate =2006-12-18
}}</ref>

In 1994 Switzerland began a trial program featuring a heroin prescription for users not well suited for withdrawal programs—e.g. those that had failed multiple withdrawal programs. The aim is maintaining the health of the user in order to avoid medical problems stemming from low-quality street heroin. Reducing [[drug-related crime]] was another goal. Users can more easily get or maintain a paid job through the program as well. The first trial in 1994 began with 340 users and it was later expanded to 1000 after medical and social studies suggested its continuation. Participants are prescribed to inject heroin in specially designed pharmacies for about US $13 per dose.<ref>{{cite web
| last =Nadelmann
| first =Ethan
| year =1995
| month =July 10
| url =http://www.drugpolicy.org/library%5Ctlcnr.cfm
| title =Switzerland's Heroin Experiment
| publisher =Drug Policy Alliance
| accessdate =2006-10-22
}}</ref>

The success of the Swiss trials led German, Dutch,<ref>{{cite web
| year = 2005
| month =June 5
| url =http://news.bbc.co.uk/2/hi/health/4607233.stm
| title =Heroin prescription 'cuts costs'
| publisher =BBC News
| accessdate =2006-10-22
}}</ref> and Canadian<ref>{{cite web
| url =http://www.naomistudy.ca/
| title =About the study
| publisher =North American Opiate Medication Initiative
| accessdate =2006-10-22
}}</ref> cities to try out their own heroin prescription programs.<ref>{{cite web
| last =
| first =
| coauthors = Carlos Nordt, Rudolf Stabler
| year = 2006
| month ='''367''', 1830-4,
| url =http://www.cesda.net/downloads/lancet1.pdf
| title =Incidence of heroin use in Zurich, Switzerland: a treatment case register analysis
| format =PDF
| publisher =The Lancet
| language =
| accessdate =2006-10-22
}}</ref> Some Australian cities (such as Sydney) have trialed legal heroin [[Safe injection site|supervised injecting centers]], in line with other wider [[harm minimization]] programs. Heroin is unavailable on prescription however, and remains illegal outside the injecting room, and effectively decriminalized inside of the injecting room. {{Fact|date=February 2007}}

==Drug interactions==
Opioids are strong [[central nervous system]] depressants, but regular users develop [[physiological tolerance]] allowing gradually increased dosages. In combination with other central nervous system depressants, heroin may still kill even experienced users, particularly if their tolerance to the drug has reduced or the strength of their usual dose has increased.

[[Toxicology]] studies of heroin-related deaths reveal frequent involvement of other central nervous system depressants, including alcohol, benzodiazepines such as diazepam ([[Valium]]), and, to a rising degree, methadone. Ironically, benzodiazepines are often used in the treatment of heroin addiction while they cause much more severe withdrawal symptoms.

[[Cocaine]] sometimes proves to be fatal when used in combination with heroin. Though "[[speedballs]]" (when injected) or "moonrocks" (when smoked) are a popular mix of the two drugs among users, combinations of [[stimulants]] and depressants can have unpredictable and sometimes fatal results. In the United States in early 2006, a rash of deaths was attributed to either a combination of [[fentanyl]] and heroin, or pure fentanyl [[Wiktionary:masquerading|masquerading]] as heroin particularly in the Detroit Metro Area; one news report refers to the combination as 'laced heroin', though this is likely a generic rather than a specific term.<ref>{{cite news
|first=Robin
|last=Brown
|title=Heroin's Hell
|publisher=[[The News Journal]]
|pages=A1,A12
|date=[[2006-05-04]]
}}</ref>

==Culture==
Heroin has inspired countless writers, musicians and other artists over the past century of use. However, its influence is often misunderstood or unfairly assumed; many creative people have used or been addicted to heroin, but the extent to which the drug affected their creativity is debatable. Relatively few artists with great talent have credited heroin use with major epiphanies. The 1996 [[Danny Boyle]] film ''[[Trainspotting (film)|Trainspotting]]'', based on the book by [[Irvine Welsh]], depicts heroin users in the areas around [[Edinburgh]] in [[Scotland]]. Other movies that deal with heroin users include the 1955 [[Frank Sinatra]] film ''[[The Man with the Golden Arm]]''; the 1969 film ''[[More (film)|More]]''; the 1971 [[Al Pacino]] film, ''[[Panic in Needle Park]]''; the 1981 true story ''[[Christiane F. - Wir Kinder vom Bahnhof Zoo (film)|Christiane F. - Wir Kinder vom Bahnhof Zoo]]''; ''[[The Basketball Diaries (film)|The Basketball Diaries]]'', based on the diary of author, poet, and musician [[Jim Carroll]] during his heroin addiction; the 1998 television movie ''[[Gia]]'' starring [[Angelina Jolie]] about drug-addicted supermodel [[Gia Carangi]]; and the 2000 film ''[[Requiem for a Dream]]''.

==See also==
{{wiktionary}}
{{wikinewspar| 2005 Afghan opium harvest begins}}
*[[Morphine]]
*[[Opioids]]
*[[Black Tar Heroin]]
*[[Cheese (recreational drug)|Cheese]] (recreational drug)
*[[Alphamethylfentanyl|China White]]
*[[HIV in Yunnan]]
*[[Drugs and prostitution]]
*[[Ibogaine]]
*[[Monoacetylmorphine]]
*[[Dipropanoylmorphine]]
*[[Diacetyldihydromorphine]]
*[[Recreational drug use]]
*[[Psychoactive drug]]
*[[The Great Binge]]
*[[Opium]]
*[[Polish heroin]]
*[[Opium poppy|Poppy]]
*[[Drug injection]]
*[[Illegal drug trade]]

==References==
{{reflist|2}}

^ Bowden, Mary Ellen. Pharmaceutical Achievers. Philadelphia: Chemical Heritage Foundation, 2002.

==Literature==

*''Heroin'' (1998) ISBN 1-56838-153-0
*''Heroin Century'' (2002) ISBN 0-415-27899-6
*''This is Heroin'' (2002) ISBN 1-86074-424-9
*''The Heroin User's Handbook'' by [[Francis Moraes]] (paperback 2004) ISBN 1-55950-216-9
*''The Little Book of Heroin'' by Francis Moraes (paperback 2000) ISBN 0-914171-98-4
*''Heroin: A True Story of Addiction, Hope and Triumph'' by Julie O'Toole (paperback 2005) ISBN 1-905379-01-3

==External links==
{{Commons|Heroin}}

*[http://www.emcdda.europa.eu/index.cfm?fuseaction=public.Content&nnodeid=25483&sLanguageiso=EN EMCDDA drugs profiles: heroin (2007)]
*[http://www.geopium.org Geopium: Geopolitics of Illicit Drugs in Asia, especially opium and heroin production and trafficking in and around Afghanistan and Burma (Articles and maps and French and English)]
*[http://www.watton.org/drugsinfo/aboutheroin.shtml Drugs Factfile what you really need to know]
*[http://wired-vig.wired.com/wired/archive/13.04/bupe.html?pg=1&topic=bupe&topic_set= The mismanagement of methadone]
*[http://www.NAABT.org/ National Alliance of Advocates for Buprenorphine Treatment - non-profit education website for treatment of Heroin addiction]
*[http://www.nida.nih.gov/Infofacts/heroin.html NIDA InfoFacts on Heroin]
*[http://www.whitehousedrugpolicy.gov/drugfact/heroin/ ONDCP Drug Facts]
*[http://usinfo.state.gov/is/Archive_Index/Pakistans_Cultivation_of_Opium_Drops.html United States Department of State fact sheet: anti-narcotics efforts in Pakistan] - dated [[June 7]], [[2002]]
*[http://news.bbc.co.uk/1/hi/magazine/4647018.stm BBC Article entitled 'When Heroin Was Legal'. References to the United Kingdom and the United States]
*[http://www.heroin.org Heroin Facts]
*[http://www.saferinjecting.net/ Harm reduction strategies in relation to heroin and other illicit drugs]
*[http://historyofalcoholanddrugs.typepad.com/alcohol_and_drugs_history/heroin/index.html Heroin news page] - [[Alcohol and Drugs History Society]]

{{Analgesics}}

[[Category:Heroin| ]]
[[Category:Drug culture]]
[[Category:Addiction]]
[[Category:Mental health]]
[[Category:Diseases]]
[[Category:Medical terms]]
[[Category:Prodrugs]]
[[Category:Harm reduction]]
[[Category:Substance-related disorders]]



[[bg:Хероин]]
[[ca:Heroïna]]
[[cs:Heroin]]
[[da:Heroin]]
[[de:Heroin]]
[[es:Heroína]]
[[eo:Heroino]]
[[eu:Heroina]]
[[fa:هروئین]]
[[fr:Héroïne]]
[[gl:Heroína (droga)]]
[[hr:Heroin]]
[[id:Heroin]]
[[is:Heróín]]
[[it:Eroina]]
[[he:הרואין]]
[[lt:Heroinas]]
[[hu:Heroin]]
[[ms:Heroin]]
[[nl:Heroïne]]
[[ja:ヘロイン]]
[[no:Heroin]]
[[nn:Heroin]]
[[pl:Heroina]]
[[pt:Heroína]]
[[ru:Героин]]
[[simple:Heroin]]
[[sk:Heroín]]
[[sr:Хероин]]
[[fi:Heroiini]]
[[sv:Heroin]]
[[th:เฮโรอีน]]
[[vi:Bạch phiến]]
[[tr:Eroin]]
[[uk:Героїн]]
[[zh:海洛因]]

Harm reduction

2007-10-22T03:27:31Z

Quihn: /* See also */ corrected url to our updated website ~~~~

'''Harm reduction''' is a [[philosophy]] of [[public health]], intended to be a [[progressivism|progressive]] alternative to the prohibition of certain potentially dangerous [[lifestyle]] choices.

The central idea of harm reduction is the recognition that some people always have and always will engage in behaviours which carry risks, such as [[casual sex]], [[prostitution]], and drug use. The main objective of harm reduction is to mitigate the potential dangers and health risks associated with the risky behaviours themselves. Another objective of harm reduction is to reduce harm associated with, or caused by, the legal circumstances under which the behaviours are carried out (for example, prohibition of certain acts or substances can help create a [[black market]] where illicit trade flourishes).

Harm reduction initiatives range from widely accepted ideas, such as [[designated driver]] campaigns, to more controversial initiatives, like the provision of [[condom]]s in public schools, needle exchange programs or [[Harm reduction#Safer injection sites|safer injection sites]] for intravenous drug users, drug legalization, and [[heroin]] maintenance programs.

Harm reductionists contend that no one should be denied services, such as [[health care]] or [[social security]], merely because they take certain risks or exhibit certain behaviours that are illegal or are generally disapproved of by society as a whole. Further, harm reduction seeks to take a social justice stance in response to behaviours such as the use of illicit drugs or prostitution, as opposed to criminalising and prosecuting these behaviours. Often, harm reduction advocates the view that prohibition of [[drugs]] is discriminatory, ineffective and counter-productive. Among other arguments, they point out that the burden placed on the public health system and society as a whole from cannabis use and other illegal drugs are relatively low. They also contend that the substances are still widely used, despite extremely expensive attempts to enforce laws criminalizing them, and that the prohibition has the effect of criminalizing and marginalizing otherwise law-abiding drug users.

Critics of harm reduction contend that it appears to condone and even facilitate behaviours that are dangerous, socially destabilizing or considered immoral. For these reasons, harm reduction has been very controversial in the [[United States]], where it has met more resistance than in [[Europe]], [[Canada]], [[Australia]] and [[New Zealand]]. In the United States, debate about harm reduction is very polarized. Advocates are often characterized as "pro-drug". Opponents of harm reduction are often criticised for ignoring the realities and circumstances of addictions, disregarding scientific evidence, marginalizing the basic human rights of affected persons, and responding from a position of "[[moral panic]]".

There is a third group that advocates an approach which is sometimes referred to as gradualism. Gradualism advocates are of the opinion that harm reduction programs are sometimes rooted in pessimism about the ability of addicts to stop their illegal addictive behaviors and represent the "soft bigotry of low expectations."{{Fact|date=February 2007}} They are unlikely to categorize interventions as "good" or "bad". Rather, they tend to be more concerned that programs should urge clients toward [[abstinence]] when windows of opportunity open.{{Fact|date=February 2007}}

== Drugs ==
=== Cannabis ===
Some harm reductionists favor outright [[drug legalization|legalization]] of [[cannabis (drug)|cannabis]], allowing its sale e.g. through [[Netherlands|Dutch]]-style "[[Coffee shop#Cannabis coffee shops|coffee shop]]s". Others think the best option would be some degree of [[decriminalization]], such as allowing the possession of small amounts of cannabis and possibly its cultivation for personal use, while concentrating law-enforcement resources on more serious crimes, e.g. crimes that have victims instead of an individual breaking a law of prohibition.

Cannabis decriminalization has been a hotly debated issue in many parts of the world, especially in many Western European countries such as [[Belgium]], [[Germany]], [[United Kingdom]], [[Portugal]], and [[Spain]], where some measures have been taken towards lifting the ban on cannabis. [[Mexico]]'s recent legalization of possession of small amounts of marijuana for recreational use has also prompted increased concern about the drug becoming more available in the United States.

''Related articles'': [[Legal issues of cannabis]], [[Health issues and the effects of cannabis]], [[Cannabis rescheduling in the United States]]

=== Methadone ===
{{POV-section}}

Some harm reductionists advocate the availability of the synthetic drug [[methadone]] (or, more recently, of [[buprenorphine]]) for users who are dependent on [[opioids]] (e.g. [[heroin]], [[codeine]]). Methadone does not cause a strong euphoria in the user but reduces or eliminates cravings and the symptoms of opioid [[withdrawal]]. Therefore, harm reductionists maintain, methadone should be made widely available to people, temporarily or permanently, to promote the transition to a fulfilling and healthy lifestyle. Critics of methadone treatment claim that this is merely a substitution of one addiction for another, or that methadone treatment does not work.
There is an international literature to show that methadone programmes can help opioid users stabilise their lifestyles by obtaining a legal, regulated substitute drug. This could potentially help them look after themselves, their families, and re-enter the work force or pursue further education. These are the building blocks for regaining dignity and self esteem and are imperative for those who want to become contributing members of society. Harm reduction is a flexible philosophy that stresses understanding of the needs of the drug user, and responding to these needs in a way as flexible and realistic as the local laws allow, working at the pace - and to achieve the goals - that the person wants. However, for those drug users who want to change their life, substitute medication should be complemented by psychological and practical support, enabling the person to reach their stated goals. In the UK prescribing methadone is seen as a way of reducing drug related-crime — the provision of substitute medication removes the need to buy drugs through the underground street market.

====Benefits of methadone treatment====

These are benefits as stated by a [[Belgium|Belgian]] [[Consensus Conference]] on Methadone Treatment, conducted by the Belgian Minister of Health. The following conclusions were sent to every Belgian doctor: [http://www.habitsmart.com/meth2.htm 1].
*Methadone is an effective medication for the treatment of opioid addiction.
*Methadone (and any other suitable opioid medically prescribed for an addicted person) reduces illegal heroin consumption, especially injection, reduces mortality related to heroin addiction, reduces the risk of infection with HIV as well as hepatitis B and C, improves therapeutic compliance of HIV-positive drug addicts, facilitates detection of illness and health education strategies and is associated with an improvement in socio-professional aptitude along with a reduction in delinquency.
*Prolonged treatment with proper doses of methadone is medically safe. At present, methadone has not been shown to be toxic for any organ.
*There is no scientific reason to limit the overall number of heroin addicts admitted for methadone treatment.
*Methadone treatment availability should be increased in order to respond to the need for such treatment, including by private practitioners.
*Psycho-social support is not compulsory and should be adapted to the individual needs of patients.

=== Syringe exchange and related programs ===
[[Image:800px-Caernarfon womens toilets.jpg|thumb|300px|right|A [[bin]] allowing for safe disposal of [[syringe|needle]]s in a [[washroom|public toilet]] in [[Caernarfon]], [[Wales]].]]
The use of heroin and certain other illicit drugs can involve hypodermic syringes (mainly because of high prices, limited quality and thus limited availability as a saving measure). In some areas (notably in many parts of the US), these are available solely by prescription. Where availability is limited, users of heroin and other drugs frequently share the syringes and use them more than once. As a result, one user's infection (such as [[HIV]] or Hepatitis C) can spread to other users through the reuse of syringes contaminated with infected blood, and the repeated use of a non-sterilised syringe by a single user also bears a significant infection risk.

The principles of harm reduction propose that syringes should be easily available (i.e. without a prescription). Where syringes are provided in sufficient quantities, rates of HIV are much lower than in places where supply is restricted. Harm reductionists also argue that users should be supplied free of charge at clinics set up for this purpose: so-called [[needle exchange program]]s. Critics claim that these measures will encourage immoral behavior, the use of illegalized drugs, by making it easier to inject them without endangering oneself, although it has been shown in the many evaluations of needle exchange programs that in areas where clean syringes are more available illegal drug use is not higher than in areas where this is not the case.
A closely related harm reduction based initiative is the "safe injection" site (see below).

=== DanceSafe and related programs ===

[[DanceSafe]] is a not-for-profit organization in the [[United States]], wherein volunteers situated at [[rave party|raves]] and similar events perform free-of-charge tests on pills that participants bought on the assumption they were [[ecstasy (drug)|Ecstasy]]. These tests are viewed by proponents as a viable means of Harm Reduction because Ecstasy sold on the black market is commonly impure, containing unknown chemicals which can occasionally be harmful to the user. DanceSafe does not sell Ecstasy or other drugs; rather, they perform chemical tests after being provided with a sample of a pill by its owner. Harm reductionists support these programs as a means of information for drug users of the purity of their drugs, thus decreasing the possibility of accidental overdoses and adverse drug reactions. Similar programs have been proposed and, in some cases, implemented to test the purity of other drugs. Critics of these services claim that such programs encourage immoral drug use by making it safer.

In [[Australia]] the first program targeting those attending [[raves]] was '''Ravesafe''', conducted in [[Sydney]] in 1993 by the NSW USers & AIDS Association as a part of the TRIBES project. In [[Melbourne]] ravers self-organised '''Ravesafe Melbourne''' in 1995. This project received government funding in 1997.

A service hosted in [[Russia]] called [[Bluelight]] was formed initially as an MDMA-focused harms reduction resource, and has since matured into a multi-substance harms reduction community. [http://www.bluelight.ru]

=== Drunk driving and alcohol-related programs ===

A high amount of media coverage exists informing users of the dangers of [[drunk driving|driving drunk]]. Most alcohol users are now aware of these dangers and safe ride techniques like '[[designated driver]]s' and free taxicab programs are reducing the number of drunk-driving accidents. Many cities have free-ride-home programs during holidays involving high alcohol abuse, and some bars and clubs will provide a visibly drunk patron with a free cab ride.

In New South Wales [Australia] groups of licensees have formed local liquor accords and collectively developed, implemented and promoted a range of harm minimisation programs including the aforementioned 'designated driver' and 'late night patron transport' schemes. Many of the transport schemes are free of charge to patrons, to encourage them to avoid drink-driving and at the same time reduce the impact of noisy patrons loitering around late night venues.

[[Moderation Management]] is a program which helps drinkers to cut back on their consumption of alcohol by encouraging safe drinking behavior.

The [[HAMS Harm Reduction Network]] is a program which encourages any positive change with regard to the use of alcohol or other mood altering substances. HAMS encourages goals of safer drinking, reduced drinking, moderate drinking, or abstinence. The choice of the goal is up to the individual.

== Sex ==
=== Safer sex programs ===

Many schools now provide [[safer sex]] education to teen and pre-teen students, some of whom engage in sexual activity. Given the premise that some, if not most, adolescents are going to have sex, a harm-reductionist approach supports a sexual education which emphasizes the use of protective devices like [[condoms]] and [[dental dam]]s to protect against unwanted pregnancy and the transmission of [[sexually transmitted disease|STD]]s. This runs contrary to the ideology of [[sexual abstinence|abstinence]]-only sex education, which holds that telling kids about sex can encourage them to engage in it.

Supporters of this approach cite statistics which they claim demonstrate that this approach is significantly more effective at preventing teenage pregnancy and STDs than abstinence-only programs; social conservatives disagree with these claims -- see the [[sex education]] article for more details on this controversy.

=== Legalized prostitution ===

There are many advocates of the legalization of [[prostitution]] in jurisdictions where it is illegal. Proponents state that there are several benefits:
* legalization allows prostitutes to escape the influence of [[pimp]]s and [[organized crime]]
* legalization allows more effective [[public health]] measures against [[sexually transmitted disease]]s
* legalization removes a [[victimless crime]]

== Self-harm ==

Harm reduction programs work with people who are at risk of harming themselves (e.g. cutting, burning themselves with cigarettes, etc.). Such programs aim at education and the provision of medical services for wounds and other negative consequences. The hope is that the harmful behaviour will be moderated and the people helped to keep safe as they learn to take more responsibility for their behaviour.

== Other forms of harm reduction initiative ==
Other harm reduction programs to be expanded on:
*Encouragement of the use of safer smoking alternatives such as [[vaporizer]]s, as opposed to water pipes, cigarettes and straight pipes
* Encouragement of the the use of smokeless systems of nicotine delivery, known as [[Tobacco harm reduction]], as opposed to the much riskier method of burning and inhaling tobacco.
* Promote the use of safer modes of use such as safer crack pipes (as opposed to use of a pipe which may burn or cut the users mouth, increasing risk of transmittable diseases) Use of screens which are safer than the use of a brillo pad which may embed metal particles into the lungs.
*Promote various safer use strategies such as having a chronic alcoholic have a chaser of water between drinks.
* Advocate the use of a Substitute Decision Maker or Power of Attorney so a person's rent is paid before the drug of choice, ensuring the person always has housing.
* Provide vitamins to ensure a person's physical needs are somewhat met
* Lessen the use of mouthwash, gravol, cough syrup etc as a substance to use, substitute with something less destructive to the human body.
* Harm reduction also reduces harm to community, thus teaching a user to dispose of a dirty needle properly, lessening chance of accidental needle prick.
* Allowing young people decision making power and access to [[birth control|contraceptives]]
* Allowing young people decision making power and access to abortions
*State regulated production and distribution of formerly illegal drugs (legalization)

== Safer injection sites ==
{{main|Safe injection site}}
"Safe injection rooms" are legally sanctioned, supervised facilities designed to reduce the health and public order problems associated with illegal injection drug use.

Safe injection rooms provide sterile injection equipment, information about drugs and health care, treatment referrals, and access to medical staff. Some offer counseling, hygienic and other services of use to itinerant and impoverished individuals. Most programs prohibit the sale or purchase of illegal drugs. Many require identification cards. Some restrict access to local residents and apply other admission criteria.

Evaluations of safe injection rooms generally find them successful in reducing injection-related risks and harms, including vein damage, overdose and transmission of disease. They also appear to be successful in reducing public order problems associated with illicit drug use, including improper syringe disposal and publicly visible illegal drug use.

The first and only [[safe injection site]] in North America, [[Insite]], opened in [[Vancouver]], [[British Columbia|BC]] [[Canada]], in September 2003.

There are some 47 safer injection sites in cities in Europe. Generally in Europe they are referred to as "safer consumption rooms".

Some facts about safer injection sites can be found at [http://www.drugwarfacts.org/scfsif.htm Drug War Facts].

Since opening in [[2001]], [[Sydney]]’s [[Medically Supervised Injecting Centre]] has treated thousands of potentially fatal [[Drug overdose|Drug overdoses]] without a single fatality. [http://www.news.com.au/dailytelegraph//story/0,,19794856-5001035,00.html]

== Heroin maintenance programs ==

Providing a medical prescription for pharmaceutical heroin (diamorphine) to heroin addicts has been seen in some countries as a way of solving the ‘heroin problem’ with potential benefits to the individual addict and to society.

In Switzerland '''Heroin Assisted Treatment''' is fully a part of the national health program. There are some 38 centers throughout the country at which dependent persons can receive heroin maintenance. The Swiss heroin maintenance [http://www.parl.gc.ca/37/1/parlbus/commbus/senate/com-e/ille-e/presentation-e/ucht1-e.htm program] is generally regarded as a success and a valuable component of that country's overall approach to managing drug use in a harm decreasing manner. See the [http://www.druglibrary.org/schaffer/Library/studies/OVERALLS.htm Report]on the Evaluation of the Swiss Scientific Studies of Medically Prescribed Narcotics to Drug Addicts.

The British have had system of heroin maintenance since the 1920s. It was de-emphasized somewhat during the 1960s-1980s as a result of the U.S. led "war on drugs". However, in recent years the British are again moving toward heroin maintenance as a legitimate component of their National Health Service. This is because evidence is clear that methadone maintenance is not the answer for all opioid addicts and that heroin is a viable maintenance drug which has shown equal or better rates of success in terms of assisting long-term users establish stable, crime-free lives. Access a British report on heroin maintenance entitled [http://www.jrf.org.uk/knowledge/findings/socialpolicy/943.asp Prescribing Heroin: what is the evidence?]

The Netherlands is another country which has had several successful studies of medically supervised heroin maintenance. Results of two major clinical studies involving 547 heroin treatment patients are available from the [http://www.ccbh.nl/ENG/index.htm CCBH] (Central Committee on the Treatment of Heroin Addicts) website.

The first, and only, North American [[heroin maintenance]] project is being run in [[Vancouver]], [[British Columbia|B.C.]] and [[Montreal]], [[Quebec]]. Currently some 80+ long-term [[heroin]] addicts who have not been helped by available treatment options are taking part in the [http://www.naomistudy.ca/ NAOMI] [[(North American Opiate Medication Initiative)]] trials.

==Criticism of harm reduction==
Critics maintain that a risk posed by Harm Reduction is by creating the perception that certain behaviours can be partaken safely, such as illicit drug use, that it may lead to an increase in that behavior by people who would otherwise be deterred.

==See also==
[[Brief intervention]]

≠== External links ==

*[http://evidence.no/en/marlatt Evidence Knowledge Exchange] Workshops, resources and links to harm reduction and addictive behaviors
*[http://www.harmreduction.org Harm Reduction Coalition]The Harm Reduction Coalition is a national advocacy and capacity-building organization that promotes the health and dignity of individuals and communities impacted by drug use.
*[http://www.anypositivechange.org The Chicago Recovery Alliance]
*[http://www.harmreductiontherapy.org The Harm Reduction Therapy Center]
*[http://www.canadianharmreduction.com The Canadian Harm Reduction Network](includes content from the Toronto Harm Reduction Task Force)
*[http://www.harmredux.org Harm Reduction Project]Provides support and resources to both the marginalized and their providers.
*[http://www.ukhra.org UK Harm Reduction Alliance]
*[http://www2.potsdam.edu/hansondj/YouthIssues/1046349581.html Harm Reduction Works]
*[http://www.tripproject.ca/ TRIP! Project] A Toronto-based, harm reduction-focused nightlife awareness project.
*[http://www.himynameistina.com/ Hi! My Name Is Tina.] A crystal meth website with a focus on Toronto's gay community.
*[http://www.saferinjecting.net/ Harm reduction strategies for injecting drug use]
*[http://www.tni.org/drugsreform-docs/unharmred.htm The United Nations and Harm Reduction] website of the Transnational Institute (TNI)
*[http://www.ihra.net International Harm Reduction Association (IHRA)]
*[http://www.ahrn.net Asian Harm Reduction Network (AHRN)]
*[http://www.TobaccoHarmReduction.org Tobacco Harm Reduction site from the University of Alberta School of Public Health]
*[http://gripmontreal.org/eng/home.html GRIP Montréal]is a non profit organization established in Montreal since 1997. GRIP’s first goal is to dispense information and education about psychotropic substances to help individuals (particularly youth) to be more capable in making enlightened decisions regarding the use of drugs.
*[http://www.drugpolicy.org DrugPolicy.org] Policy initiatives promoting public health, public safety, and human rights.
*[http://www.salon.com/news/feature/2006/09/22/harm_reduction/print.html The Needle and the Damage Undone] discusses ''Insite'' a safe-injecting room initiative in Vancouver, Canada.
*[http://www.eudoxascience.com The harm reduction Bulletin Board] The [[Eudoxa]] think tank's Bulletin Board for harm reduction discussions
*[http://www.drugblog.net The Australian Drug Blog] Health professionals debate harm minimisation strategies
*[http://www.hamshrn.org The HAMS Harm Reduction Network]
*[http://www.aidsportal.org/overlay_details.aspx?nex=55 AIDSPortal page on injecting drug use] Research, case studies and news stories
* [http://www.drugs-forum.co.uk/forum/showthread.php?t=29845 Drug Policy Debate: Helpful Links / Sources of Information]
*[http://www.positivehealthproject.org/ Positive Health Project] New York, NY - Harm reduction resources and education
*[http://www.preventionpointphilly.org/ Prevention Point Philly] A Harm Reduction oriented, multi-service public health organization Philadelphia, PA.
*[http://www.bluelight.ru Bluelight], Bluelight is an international message board that educates the public about responsible drug use by promoting free discussion.
*[http://www.erowid.org Erowid], Erowid is a member-supported organization providing access to reliable, non-judgmental information about psychoactive plants and chemicals and related issues.
*[http://www.harmreduction.org/idu/idu_manual.pdf Harm Reduction Coalition], Getting Off Right: A Safety Manual for Injection Drug Users: A how-to survival guide for injection drug users.
*[http://www.drugpolicy.org/docUploads/aboutmethadone.pdf Drug Policy Alliance], About Methadone
*[http://www.housing.gov.bc.ca/ptf/hrcommunityguide.pdf Harm Reduction: A British Columbia Community Guide]
[[Category:Alcohol abuse]]
[[Category:Medical ethics]]
[[Category:Addiction]]
[[Category:Sex trade]]
[[Category:Harm reduction|*]]
[[Category:Mental health]]
[[Category:Diseases]]
[[Category:Medical terms]]
[[Category:Alternate reality]]
[[Category:Belief]]
[[Category:Drug culture]]

[[fr:Réduction des risques]]
[[it:Riduzione del danno]]
[[no:Skadereduksjon]]
[[pl:Redukcja szkód]]

Talk:Autism therapies

2007-03-26T07:21:56Z

Quihn: /* Merge with biomedical intervention for autism */

==Gold Salts==
It seems to me this is quite lengthy for a treatment that has only rarely been used.. perhaps we could cut down the details and quotes a little and move them to their own article (then add a "for more details see...")? I didn't want to do this without discussing it first, given that this section has obviously been written with a lot of care. Opinions? [[User:Sparkleyone|Sparkleyone]] 04:29, 16 February 2006 (UTC)

:Not a bad idea, but the content has repeatedly been removed from the new [[gold salts]] article itself, with similar justifications. Given that gold salts have been a backwater of medical treatment for decades, apparently replaced for the most part by allopathic drugs such as [[methotrexate]], it seems rather ridiculous that strident efforts are being made to downplay the current intrigue by removing content from the article where it belongs, despite the fact that the heyday for the use of gold salts for other purposes may have reached its zenith nearly a century ago. Trimming the reference in this article makes far more sense, given that a great deal of emphasis, upon a wide range of desperately needed interventions, have generated more interest, thus far, than gold salts. [[User:Ombudsman|Ombudsman]] 04:56, 16 February 2006 (UTC)
::The content is much more consise presented at [[gold salts]], and I think at the moment is somewhat to short. That is different from being removed. --[[User:KimvdLinde|KimvdLinde]] 05:05, 16 February 2006 (UTC)
At first, the entire section was being removed, now there is an overly truncated 'effects on autism' section that has replaced the brief aside elsewhere in the article that previously was offered as a substitute. The current lead for the abbreviated section, where the name of a journalist, [[Dan Olmsted]], comes first, needs a rewrite that addresses the science first. It is good to see additional editors involved, in order to keep the focus on reaching a compromise on content, rather than constant distractions caused by wholesale deletions. [[User:Ombudsman|Ombudsman]] 08:05, 16 February 2006 (UTC)
:Could we please limit our discussions to the current version, and leave the history for what it it. The curent version at gold salts is somewhat truncated in my opinion, but the focus is diffeent there than here. --[[User:KimvdLinde|KimvdLinde]] 12:21, 16 February 2006 (UTC)
:::First off, let me apologise for commenting on something that has obviously been widely discussed elsewhere. It's a tricky one this, because while I can see this section's place over at [[Gold salts]] I can also see it here, just not at the level of detail currently described. Please do not read too much into this, but I think it should be cut down here because whilst it may have potential as a treatment it is not currently being used on a regular basis as the others are, therefore should not be discussed as extensively. My other concern is that the section is dominated by quotes that the reader can clearly see for themselves if they go to the linked article. Anyway, this is my suggestion for the gold salt section in this article, obviously linked, properly edited and so forth.

:::''Gold salts have been suggested as a treatment for individuals afflicted by autistic spectrum disorders, because mercury and gold interact in a way that could de-activate ongoing toxic effects of heavy metal poisoning, thought by some to be a major factor in the increase in autism rates in recent decades. Boyd Haley, a University of Kentucky professor and leading proponent of the mercury-autism theory, has suggested that it may reverse conditions attributed to mercury administration, as the gold molecules bond with the mercury molecules and in turn may detach the mercury from the enzyme it is attached to.

:::''The salts are administered by way of injection. The treatment was given to the first child diagnosed with autism at the Campbell Clinic in Memphis, Tennessee, in 1947, and reports suggest that the child’s symptoms improved significantly. The treatment is not in widespread use, but research continues into the effects of gold salts in animals bred to be susceptible to thimerosol, a mercury-based compound that was used in many vaccinations until recently.''

::: [[User:Sparkleyone|Sparkleyone]] 07:27, 16 February 2006 (UTC)
::::(I have made you suggestion italic as to distingish it from ordinary comments.) The major problem with the piece as it is now (at the article), is that there is to much speculation, hypothesis etc, based on some anecdotal (yet important) information. So, I think it needs to reflect what we do know, and limits on the speculation. And the reporting should be factual. So, start with the anecdotal story, then move to the general idea (there is no need to discuss the whole mercury-vaccination-controversy), then current research and finally caution (Crucial to mention, you do not want tons of people demanding gold salt treatment because they have read something about it here!)....
::::''[[Gold salts]] have come recently in focus as a potential treatment for authism when [[Dan Olmsted]][http://www.upi.com/ConsumerHealthDaily/view.php?StoryID=20051230-104250-2870r] reported on an autistic patient who was treated for [[arthritis]] using gold salts. Together with the clearing up of the arthritis, the "extreme nervousness" and excitability that had afflicted him cleared up as well, according to his brother.
::::''[[Boyd Haley]], a [[University of Kentucky]] professor and leading proponent of the [[Autism_epidemic#Thimerosal_containing_vaccines|mercury-autism hypothesis]], has suggested that gold salts may reverse conditions attributed to mercury administration in the form of thimerosal that was used as a preservative in vaccinations untill recently. Currently, Dr. [[Mady Hornig]] of [[Columbia University]] is testing gold salts on mice specially bred to be susceptible to thimerosal. However, Haley cautions "<nowiki>[p]</nowiki>lease note that I am not recommending using gold salts to treat autistics, but it would certainly be worth a project if carefully monitored by a physician in a good clinic".
::::Just my 0.02 euro cents --[[User:KimvdLinde|KimvdLinde]] 12:21, 16 February 2006 (UTC)

==Methotrexate==
Methotrexate: allopathic; Gold salts not?

Methotrexate has been used for some time by conventional doctors to reduce immune activity in Rheumatoid arthritis

Gold salts have been used for some time by conventional doctors to reduce immune activity in Rheumatoid arthritis

Perhaps I'm missing something obvious, but the only differences here seem to be that nobody at all has yet suggested that Methotrexate might improve autism (has any autistic person had methotrexate I wonder?) whereas one case report suggests improvement in one patient after one gold salt. I think the definition of allopathic in regard of drugs may need a bit more work there. [[User:Midgley|Midgley]] 13:00, 22 March 2006 (UTC)

: Well by the reasoning suggested by some of the contributors, of course [[methotrexate]] should be effective in improving autism given the undoubted efficacy of gold salts. The only reason why it hasn't been used is that, of course, there's a medical-political conspiracy to suppress its benefits! [[User:Andrew73|Andrew73]] 13:04, 22 March 2006 (UTC)
:I am sorry, do you suggest to include [[methotrexate]] also as a potential treatment of authism? [[User:KimvdLinde|KimvdLinde]]
:: No, I was just being sarcastic! [[User:Andrew73|Andrew73]] 13:54, 22 March 2006 (UTC)

Never mind the fact that Wakefield treats his autistic enterocolitis patients with mercaptopurine. [[User:Jfdwolff|JFW]] | [[User_talk:Jfdwolff|<small>T@lk</small>]] 22:19, 22 March 2006 (UTC)

==Removal of information==
Ombudsman removed well-sourced information (URL to an article by James R. Laidler) in favour of his unsourced POV. [[User:Jfdwolff|JFW]] | [[User_talk:Jfdwolff|<small>T@lk</small>]] 14:42, 21 March 2006 (UTC)

:And again. [[User:Jfdwolff|JFW]] | [[User_talk:Jfdwolff|<small>T@lk</small>]] 21:50, 22 March 2006 (UTC)

==ABA==
"Some claim Lovaas' ABA methods were the first scientifically validated therapy for autism"

WP:Weasel. Was there a claim of a previous sc. val. Rx? Are there claims beyond the rest of that para that ABA is sc. val.? Who claims it? Needs recasting. [[User:Midgley|Midgley]] 13:02, 22 March 2006 (UTC)

:Does anyone else think that a couple anecdotal "ABA horror stories" from parents are not appropriate sources for this article? [[User:Rhobite|Rhobite]] 14:34, 19 May 2006 (UTC)

ABA horror stories are inappropriate. Incidences of malpractioners shouldn't be used to indict a scientifically validated therapy. [[User:Bbrazy|Bbrazy]]

==Merge with biomedical intervention for autism==
A recent Australian study categorized early interventions as behavioral, developmental, combined, and a few other categories I can't remember now. Biomedical interventions seem to be only a small part of what is available so to merge these doesn't seem warranted. One example of these categories is at:http://www.autism-help.org/early-intervention-aspergers-autism.htm [[User:Quihn|Quihn]] 07:21, 26 March 2007 (UTC)

I discovered [[Biomedical intervention for autism]]. That article basically has the same information as the Biomedical intervention section in this article. A merge would be to prefer.

The question then arrises if the biomedical section of this article should be moved to the other article, or if the additional information in the other article should be brought here and the other article then would be changed to a redirect?

Thoughts? --[[User:Rdos|Rdos]] 06:52, 12 April 2006 (UTC)

: Latter I would say - if this article is to cover 'autism therapies' it needs to have the biomedical stuff here. [[User:Sparkleyone|Sparkleyone]] 08:04, 12 April 2006 (UTC)

:: What I actually meant was that if you make [[Biomedical intervention for autism]] the main article on this subject, this article should be renamed to [[Behavioral intervention for autism]] or something similar. --[[User:Rdos|Rdos]] 11:37, 12 April 2006 (UTC)

I agree with the merge...there is much overlap between the two articles. Perhaps biomedical and behavioral intervention could both be incorporated into the same article. [[User:Andrew73|Andrew73]] 12:57, 12 April 2006 (UTC)

The merge is critical there is too much redundency and on the other article there is too little information on drug therapy which this article has. I third the motion of merger.

Well i too i'm in favor of a merge--[[User:Pixel ;-)|Pixel ;-)]] 19:57, 20 September 2006 (UTC)

== == No therapy ,not a disorder view == ==
I reverted the above section because it is written very badly. There are no sources - who holds this view? - and it describes therapy as "racism". People with Autism are not a race. Please clean up the section before you put it back in. <font color="DarkGray">...</font> [[User:discospinster|<font color="DarkOrange">'''disco'''</font><font color="DarkOliveGreen">'''spinster'''</font>]] <sub>[[User talk:discospinster|'''<font color="DarkGray">talk</font>''']]</sub> 14:43, 2 July 2006 (UTC)

==NPOV dispute==
I am marking the "Non-coercive approaches" section of this article as having questionable neutrality. The section tries to shoot down each of the non-coercive approaches by saying that they "have been criticized", that it "gives false hope to parents", or both. This section sounds critical of each non-coercive approach mentioned within it.

Personally, I am appalled by the first sentence of the "Non-coercive approaches" section:
:"The autism rights movement has been criticized for promoting 'doing nothing' about autism."
What does this sentence have to do with non-coercive approaches?! Also, the sentence assumes that the reader knows the values of the autistic rights movement.

The "Non-coercive approaches" section should simply list and describe non-coercive approaches, and then state their pros and cons--without opinion or bias. Just [[Wikipedia:Neutral point of view#Let_the_facts_speak_for_themselves|let the facts speak for themselves]], and this section will be much more encyclopedic. --[[User:Voidxor|Voidxor]] 07:51, 13 October 2006 (UTC)

== Biomed section suggestions ==

I think the biomed section should be more clear on the fact that no double-blind studies exist on any of the treatments currently listed. This is important with something like autism, because it's a developmental delay, not a developmental halt. Perhaps it should list Secretin, with a discussion of existing double-blind studies, and claims about recovery rates prior to those studies. The section is also missing the Ketogenic diet, L-carnosine, and Omega-3 supplementation (the latter 2 do have one unreplicated double-blind study each). [[User:Neurodivergent|Neurodivergent]] 23:00, 19 October 2006 (UTC)

===Merging===
I think that the Biomed section could be reduced to a synopsis of the biomed article and any additional information here transferred there. As for merging the entire article, clearly this article on therapies covers much more material in different areas and the merge would mean placing a lot of peripheral material in the biomed article. So no, not a wholly constructive idea. [[User:Malangthon|Malangthon]] 02:28, 16 March 2007 (UTC)

== Let me hear your voice ==

I removed a big chunk of a paragraph from the page, that basically came across as a plug for [[Bridget Taylor]] to my eyes. I left in the ''Let me hear your voice'' 'cause I'm happy to include it (surprised there's not an article already), it was a good book and I believe one of the first discussing autism. Incidentally, the editor who added the paragraph wholesale really seems like a [[WP:sockpuppet|sockpuppet] for [[User:Squeaky2]], apologies if I'm wrong. Anyway, I took out most of the rest of the paragraph, here's the gist and here's why:
Previously, the research documenting the effectiveness of this approach had been little disseminated outside of academia and a handful of center based school programs.
:needs a citation
The lead therapist of the children was [[Bridget Taylor]], one of the country's most renowned ABA professionals.
:This addition is questionable, and appears to be a way of avoiding the orphan tag on that page. I'd never heard of her before, and when I worked in ABA I'd never heard of her during my training. The whole page seems like a vanity addition to me too.
Both children are considered to be ''indistinguishable from their peers.''
:I'd like to see a citation for this, at least a reference to a page number in LMHYV.
Thoughts? Am I over-reacting? [[User:WLU|WLU]] 01:55, 17 January 2007 (UTC)

== Newest EL ==

What do people think of this EL:
:[http://rsaffran.tripod.com/aba.html ABA Resources for Recovery from Autism/PDD/Hyperlexia] - Information on behavioral intervention (ABA)
Though it does look like it has a ton of possible references, it's not a professional site. Looking at [[WP:EL]], in the "Links normally to be avoided" section, #11 says no personal webpages, and though this is a fairly comprehensive site, it is still one guy's. [[User:WLU|WLU]] 16:49, 16 March 2007 (UTC)

Applied behavior analysis

2007-03-26T07:13:46Z

Quihn: /* External links */ Fixed broken link ~~~~

{{POV}}

'''Applied Behavior Analysis''' (ABA) is a systematic process of studying and modifying observable behavior through a manipulation of the environment. Its principles can be applied to virtually anything capable of learning, but generally is applied in humans to individuals with [[autism]] and other developmental disorders. It uses an experimental approach of manipulating the environment and tracking alterations in behavior to understand and manipulate functional relationships between behavior and environments

==Definition==
Definitions of ABA vary considerably. In one example, ABA is:

"...the design, implementation, and evaluation of environmental modifications to produce socially significant improvement in human behavior. ABA includes the use of direct observation, measurement, and functional analysis of the relations between environment and behavior. ABA uses antecedent stimuli and consequences, based on the findings of descriptive and functional analysis, to produce practical change.<ref name="shapingbhv">[http://www.shapingbehavior.com/whatisaba.html Definition of ABA according to shapingbehavior.com]</ref>" This definition places emphasis on socially significant changes, but ABA can be used to alter virtually any behavior irrespective of its social relevance.

Frequently, the [[Assessment of Basic Language and Learning Skills]] (ABLLS) is used to create a baseline of the student's functional skill set. The ABLLS breaks down the student's strengths and weaknesses so that the ABA curriculum can be more effectively designed for the student. By focusing on the exact skills that need help, the teacher does not waste time teaching a skill the student knows. This can also prevent student frustration at attempting a skill for which he or she is not ready. By focusing on the exact skills lacking, the student can better be set for success, and progress onward more quickly.

The components of any behavior are as follows: <br />
<li>'''Antecedent''': a verbal or physical stimulus such as a command or request. This may come from the environment or from another person, or even internal to the subject.
<li>'''Behavior''': the student's response
<li>'''Consequence''': What happens conditional to the behavior. In controlled situations the consequence is that the student receives something motivational to him/her: commonly food, rewards, praise, a toy, etc. Consequence could also include correction (or punishment, but this is rarely used).
<p>

The key aspects of ABA are:<ref name="behaviororg">[http://www.behavior.org/autism/index.cfm?page=http%3A//www.behavior.org/autism/autism_ABA_FAQ.cfm Key points taken from www.behavior.org]</ref>

*Observation of current behavior for topography (what the movement looks like), frequency, antecedents and consequences
*Breaking down desired skills into steps
*Teaching the steps through repeated presentation of discrete trials
*Data on performance is tracked to show changes over time

==ABA and Autism==

ABA is one of the most common, and the only proven method used to treat autism (c.f.<ref>Smith, T, Groen, A.D & Wynn, J.W. (2000). Randomized Trial of Intensive Early Intervention for Children with Pervasive Developmental Disorder. ''American Journal on Mental Retardation, 105 (4)'', 269-285.</ref><ref>McConachie, H. & Diggl, T. (2006). Parent implemented early intervention for young children with autism spectrum disorder: a systematic review. ''Journal of Evaluation in Clinical Practice'' (early release)</ref><ref>Sallows, G. O. & Graupner, T. D. (2005). Intensive Behavioral Treatment for Children with Autism: Four-Year Outcome and Predictors. ''American Journal on Mental Retardation, 110 (2),'' 417-438.</ref><ref> Eikeseth, S., Smith, T., Jahr, E. & Eldevik, E. (2002). Intensive Behavioral Treatment at School for 4- to 7-Year-Old Children with Autism: A 1-Year Comparison Controlled Study. ''Behavior Modification, 26 (1),'' 49-68.</ref>) '''Applied Behavior Analysis''' has been shown to be an effective means of intervention for adults and children with pervasive developmental disorder and is one of the most widely used with this population. The ABA approach teaches social, motor, and verbal behaviors as well as reasoning skills (Harris, 2002). ABA therapy is especially useful in teaching behaviors to children with autism who do not otherwise "pick up" on these behaviors on their own as other children would. ABA teaches these skills through use of careful behavioral observation and positive reinforcement or prompting to teach each step of a behavior (Simpson 2001). Generally ABA involves intensive training of the therapists, extensive time spent in ABA therapy (20-40 hours per week) and weekly supervision by experienced clinical supervisors known as a certified behavior analyst.<ref>Shook, G.L. & Neisworth, J.T. (2005). Ensuring Appropriate Qualifications for Applied Behavior Analyst Professionals: The Behavior Analyst Certification Board. ''Exceptionality, 13(1),'', 3-10</ref>

An increasing amount of research in the field of ABA is concerned with [[autism]]; and it is a common misconception that Behavior Analysts work almost exclusively with individuals with autism and that ABA is synonymous with Discrete Trials teaching. ABA principles can also be used with ''typical'' individuals demonstrating developmental delays or significant behavioral problems.

ABA is often confused as a ''table-only'' therapy. Properly performed, ABA should be done in the table and natural environments, depending on the student's progress and needs. Once a student has mastered a skill at the table, the ABA team should move the student into a natural environment for further training and generalization of the skills just learned.

===Discrete Trials===
Discrete Trials were originally used by [[B.F. Skinner]] in his experimental studies with rats and pigeons to demonstrate how learning was influenced by rates of [[reinforcement]]. The discrete trials method was adapted as a therapy for [[developmental disability|developmentally delayed]] children and children with autism. For example, [[Ivar Lovaas]] pioneered the use of discrete trials for autistic children to help them learn skills ranging from making eye contact and following simple instructions to advanced language and social skills. Discrete trials involve breaking a behavior into its most basic functional unit and presenting the units in a series.

A discrete trial usually consists of the following: The antecedant, possibly combined with a prompt (a non-essential element used to assist learning or correct responding), the behavior of the student, and a consequence. If the student's behavior is what is desired, the consequence is something positive: food, candy, a game, praise, etc. If the behavior was not correct, the teacher offers the correct answer, then repeats the trial, possibly with more prompting if needed.

There is usually an inter-trial interval that allows for a few seconds to separate each trial, to allow the student to process the information, teaches the student to wait, and makes the onset of the next trial more discrete. Discrete trials can be used to develop most skills, which includes cognitive, verbal communication, play, social and self-help skills.

==Techniques used in Applied Behavior Analysis==
===Chaining===
{{main|Chaining}}
The skill to be learned is broken down into the smallest units for easy learning. For example, a child learning to brush teeth independently may start with learning to unscrew the toothpaste cap. Once the child has learned this, the next step may be squeezing the tube, and so on.

===Prompting===
The parent or therapist provides assistance to encourage the desired response from the child. The aim is to use the least intrusive prompt possible that will still lead to the desired response. Prompts can include:
• Verbal cues ie. "Take the toothpaste cap off, Bobby"
• Visual cues ie. pointing at the toothpaste
• Physical guidance ie. moving the child's hands to unscrew the lid
• Demonstration ie. taking the cap off to show the child how it is done.

===Fading===
The overall goal is for a child to eventually not need prompts. This is why the least intrusive prompts are used, so the child does not become overly dependent on them when learning a new behavior or skill. Prompts are gradually faded out as then new behavior is learned. Learning to unscrew the toothpaste lid may start with physically guiding the child's hands, to pointing at the toothpaste, then just a verbal request.

===Generalization===
Once a skill is learned in a controlled environment (usually table-time), the skill is taught in more general settings. Perhaps the skill will be taught in the natural environment. If the student has successfully mastered learning colors at the table, the teacher may take the student around the house or his school and then re-teach the skill in these more natural environments.

===Shaping===
{{main|Reinforcing successive approximations}}
Shaping involves gradually modifying the existing behavior of a child into the desired behavior. An example here is a young boy who only engages with the pet dog by hitting it. Although time consuming, the parents intervene every time he interacts with the dog, grab his hand and turn the hit into a stroking motion. This is paired with positive reinforcement "It's great when you are gentle with Pooch!" and doing a favorite activity immediately afterwards as a reward.

===Differential reinforcement===
[[Reinforcement]] provides a response to a child’s behavior that will most likely increase that behavior. It is “differential” because the level of reinforcement varies depending on the child’s response. Difficult tasks may be reinforced heavily whereas easy tasks may be reinforced less heavily. We must systematically change our reinforcement so that the child eventually will respond appropriately under natural schedules of reinforcement (occasional) with natural types of reinforcers (social).

==Other teaching techniques==
===Video Modeling===
One teaching technique found to be effective with some children is the use of video modeling (the use of taped sequences as exemplars of behavior). It can be used by therapists to assist in the acquisition of both verbal and [[Voluntary action|motor]] resoponses, in some cases for long [[chaining|chains]] of behavior.<ref>D'Ateno, P., Mangiapanello, K. & Taylor, B. (2003). "Using video modeling to teach complex play sequences to a preschooler with autism". ''Journal of Positive Behavior Interventions'' '''5''', 5-11.</ref>

==Maintaining parental and professional relationships in the ABA approach==
An adequate communication and a supportive relationship between educational systems and families allow children to receive a beneficial education. This pertains to typical learners as well as to children who need additional services. It was not until the 1960s that researchers began exploring Applied Behavior Analysis as a method to educate those children who fall somewhere on the autism spectrum. Behavioral analysts agree that consistency in and out of the school classroom is key in order for autistic children to maintain proper standing in school and continue to develop to their greatest potential.

Applied behavior analysis involves an entire team working together to address a child's needs. This team includes professionals such as speech therapists as well as the children's primary caregivers, who are treated as key to the implementation of successful therapy in the ABA model. The ABA method relies on behavior principles and a recommended curriculum that reflects an individual child's needs and abilities. As such, regular meetings with professionals to discuss programming are one way to establish a successful working relationship between a child's family and their school. When a caregiver can be the outlet source for the generalization of skills outside of school, it helps the child's therapy process by catering to the child's individual needs. In the ABA framework, developing and maintaining a structured working relationship between parents and professionals is essential to ensure consistency of thought and practice of behavioral methods.

==Criticisms of ABA==
Applied behavioral analysis has been criticized for several perceived failings. For one thing, it can be very expensive - generally therapists are required for 20-40 hours of therapy per week, and a reputable ABA program should involve regular supervision from expensive and experienced clinicians. It is also criticized for producing 'robot-like' behavior in children, as well as its use of punishment to reduce or eliminate problem behavior. These criticisms are frequently seen as addressed by more recent practices, which emphasize rewards or 'reinforcers' for desired behavior, the absence of reinforcement for undesired behavior and the use of punishment for only extreme dangerous or disruptive behavior.<ref name="behaviororg"/> It is also suggested that ABA and discrete trials are less effective for improving language than 'naturalized' teaching. Naturalized teaching mimics the use of language in the natural environment, focusing on manding (requesting) tacting (labeling) receptive language (physical manipulation based on commands or requests) and the other functions of language.<ref>Delprato, D.J. (2001). Comparisons of Discrete-Trial and Normalized Behavioral Language Intervention for Young Children with Autism. ''Journal of Autism and Developmental Disorders'' '''31'''(3), 315-325.</ref>

==Notes==

<references/>

==Further reading==
* Department of Health and Rehabilitative Services, Developmental Services Program. (1996). Chapter 10F-4, service delivery practice and procedure. Tallahassee, FL: Author.
* Harris, S.L.P., and L.P. Delmolino (2002). "Applied Behavior Analysis: Its Application in the Treatment of Autism and Related Disorders in Young Children". ''Infants and Young Children'', '''14'''(3):11-17.
* Moran, D.J., & Malott, R.W. (2004). ''Evidence-Based Educational Methods''. San Diego, CA: Elsevier Academic Press.
* Lovaas, O. I. (1987). "Behavioral treatment and normal education and intellectual functioning in young autistic children". ''Journal of Consulting and Clinical Psychology'', '''55''', 3-9
* McEachin, J.J., Smith, T, & Lovaas, O. I (1993). "Long-term outcome for children with autism who received early intensive behavioral treatment". ''American Journal of Mental Retardation'' '''97''', 359-372
* Howard, Sparkman, Cohen, Green, & Stanislaw, (2005). "A comparison of intensive behavior analytic and eclectic treatments for young children with autism". ''Research in Developmental Disabilities'', '''26''', (2005), pp. 359-383
* Schoneberger, T. (2006). "EIBT research after Lovaas (1987): A tale of two studies". ''The Journal of Speech-Language Pathology and Applied Behavior Analysis'' '''1''', 207-217. Available: http://www.slp-aba.com/SLP-ABA-1-3.pdf
* Simpson, R.L. (2001). "ABA and Students with Autism Spectrum Disorders: Issues and Considerations for Effective Practice". ''Focus on Autism and Other Developmental Disabilities'', '''16'''(2):68-71.

==See also==
*[[Conditioning]]
*[[Behaviorism]]
*[[Educational psychology]]
*[[Ethical challenges to autism treatment]]
*[[Autism therapies]]
*[[Verbal Behavior (book)]]

== External links==

* [http://www.healingthresholds.com/ HealingThresholds] - Provides lay summaries of current research in the field of Applied Behavioral Analysis and other autism therapies
* [http://www.ascribe.org/cgi-bin/behold.pl?ascribeid=20050805.160552&time=16 Ascribe.org] - '[[California State University, Stanislaus|Cal State University Stanislaus]] Professors Publish Revealing Report on Methods for Treating Autism' (August 5, 2005)
* [http://www.bacb.com/pages/aboutBAs.html BACB.com] - 'Defining the Field of Behavior Analysis', Behavior Analyst Certification Board
* [http://www.behavior.org/ Behavior.org] - Cambridge Center for Behavioral Studies
* [http://www.sentex.net/~nexus23/naa_aba.html Sentex.net] - 'The Misbehaviour of [[Behaviorism|Behaviourists]]: [[Ethics|Ethical]] Challenges to the Autism-ABA Industry', [[Michelle Dawson]] (2004)
* [http://www.centerforautism.com/aba/whatisaba.asp centerforautism.com] - Understanding ABA, [[Center for Autism and Related Disorders]]
* [http://www.autism-help.org/early-intervention-aspergers-autism.htm ABA as an Autism intervention]
* [http://www.autismtreatment.info/concepts+of+aba.aspx Concepts of ABA] - Concepts of ABA and Autism Treatment.

[[Category:Autism]]
[[Category:Educational psychology]]

[[de:Applied Behavior Analysis]]
[[nl:ABA]]

Talk:Syringe filter

2007-02-13T04:42:59Z

Quihn: /* Wheel filters as a harm reduction strategy */

==Not NPOV==

This article seems almost to advocate the use of drugs. Not very neutral at all. -- [[User:Where|<b><font color="blue">Where</font></b>]] 00:47, 20 June 2006 (UTC)

== Split ==
Perhaps this article should be split into two, one called [[syringe end filter]], and the other called [[illegal drug filtration]]? And possibly another needs to be written, on [[drug adulteration]]. -- [[User:The Anome|The Anome]] 10:53, 15 August 2006 (UTC)

==Wheel filters as a harm reduction strategy==
I cleaned up some in this section and removed some of the <nowiki>{{fact}}</nowiki> tags from the paragraph because there were too many of them.

:''While wheel filters are the most effective filter available for injecting drug users,''

I don't think anyone doubts this. Filtration is a standard method for purifying liquids.

:''other more common types of filters used include cotton wool, tampons, and cigarette filters.''

I don't have any druggie friends to ask, but this also doesn't seem controversial.

:''While these can serve as basic filters, they have a greater risk of bacterial infection or contamination from pieces of the filter itself. The condition known as [[cotton fever]] is caused by bacteria present in cotton used as a filter.''

The wepbage on [[cotton fever]] has some references (or will when I finish editing that page).

:''Wheel filters are available in sizes that will filter out bacteria from a mix, but viruses are too small to be effectively filtered out.''

This is true. According to the [[virus]] page, most viruses are 10-300 nm, whereas the most common small-pore filter is 0.2 micron (200 nm). As an example, the [[HIV]] virus particle is 120 nm. [[Bacteria]] are typically 0.5-5 microns in size and can be filtered out. [[User:Tocharianne|Tocharianne]] 04:36, 20 December 2006 (UTC)

Thanks for your help. As the original author of this article, I tried to find research backing many of the statements in this article. Unfortunately harm reduction among injecting drug users does not attract researchers so many of these findings are from the 'coal face' - harm reduction agencies trying to find practical strategies as new issues emerge among injecting drug users.
[[User:Quihn|Quihn]] 04:42, 13 February 2007 (UTC)

Drug injection

2007-02-13T04:34:05Z

Quihn:

[[Wikipedia:Medical disclaimer]]

Injection of [[recreational drugs]] is a method of the drug into the body with a hollow needle and a [[syringe]] which is pierced through the skin into the body.
Although there are various methods of taking drugs, injection is favoured by some users as the full effects of the drug are experienced very quickly, typically in five to ten seconds. This shorter, more intense high can lead to a dependency, both physical and psychological, developing more quickly than with other methods of taking drugs.

While a wide variety of drugs are injected, among the most popular in many countries are [[heroin]], [[cocaine]], [[amphetamine]], [[methamphetamine]] and [[cocaine]]. Other drugs that are injected less often include [[MDMA]] and certain prescription medications such as [[benzodiazepines]] and [[MS Contin]].

Of all the ways to get drugs into your system, injection has the most risks by far as it bypasses the body's natural filtering mechanisms against viruses, bacteria and foreign objects. There will always be much less risk of overdose, infections and health problems with alternatives to injecting, such as smoking, snorting (nasal ingestion), shafting (rectal ingestion) or swallowing.

Viruses such as [[HIV]] and [[hepatitis C]] are prevalent among injecting drug users in many countries. Other health problems arise from poor hygiene and injection technique, such as [[phlebitis]], [[abscesses]], [[Collapsed vein|vein collapse]], [[ulcers]], [[thrombosis]] and local infections.

==Harm reduction==
[[Harm reduction]] is a philosophy of public health intended to be a progressive alternative to the prohibition of certain lifestyle choices such as the taking of illicit drugs. While it does not condone the taking of illicit drugs, it does seek to reduce the harms arising from their use, both for the person taking illicit drugs and the wider community.

==Safer injection of illicit drugs==
A [[philosophy]] of [[harm reduction]] promotes information and resources for injecting drug users. General guidelines on safer injecting are typically based on the following steps.

The preparation area for drug preparation should be cleaned with warm soapy water to minimize the risk of bacterial infection.

The equipment required involves new syringes and needles, swabs, sterile water, filter, tourniquet and a clean spoon. The person should soap their hands with warm water and use a swab to wipe down the spoon. The swab should be wiped once, in one direction only, over the injection site and another swab used on the spoon.

A person should not inject alone due to the dangers of overdosing. They also should not share any of their injecting equipment, even tourniquets, due to the dangers of bacterial and viral transmission.

Sterile water should be drawn into the syringe then into the spoon to prepare the mix. Where sterile water is not obtainable, the next option is tap water boiled for five minutes.

Some drugs need heat applied to mix with the water completely. The mix should be allowed to cool before injecting. Some alkaline forms of heroin require an acid to render the mix pH neutral. While some people use lemon juice to do this, this can lead to serious bacterial infections. Citric acid is the best option and is usually available in supermarkets in granular form. The next best option is vinegar which will have less chance of bacteria than lemon juice.

The mix should be drawn up into the syringe through a filter. The ideal here is a wheel filter, particularly if prescription medication pills have been ground up for injection. These contain many fillers that can lead to very serious health problems if injected. Although not as efficient, alternative filters include cotton wool, tampons or cigarette filters (if they do not have a fibreglass base).

Once the mix is drawn into the syringe, remove any air bubbles by flicking the barrel with the needle pointed upwards. At the same time, gently push the plunger to expel any air.

Place a tourniquet above the injection site (injection sites should be rotated to allow veins to heal). The tourniquet should not be on too tight, or left on for too long. The needle’s 'hole' should be facing upward then it should be eased into the vein at a 45 degree angle. Make sure the needle is going in the same direction as the blood flow.

The plunger should be pulled back a little (‘jacked back’) to see if the needle is in the vein. Blood should appear in the barrel of the syringe if this is the case.

Take the tourniquet off and gently press the plunger. If it hurts or there is pressure against the plunger, stop immediately as the vein has probably been missed. After injection, remove the syringe and keep a clean tissue or cotton wool against the injection site to prevent bleeding. Don’t use a swab to do this as the alcohol base prevents the blood from clotting.

Dispose of injecting gear using your a 'sharps bin' if supplied. Otherwise place the used equipment in a rigid-walled container and dispose of safely.

==Alternatives to injection==
The safest alternative is, of course, not to take illicit drugs. The majority of legal systems around the world encourage this option. Harm reduction acknowledges that some people in a society will not choose this option and will at least provide information to safer means of taking illicit drugs to minimise the individual health risks, and also the spread of viruses such as HIV and hepatitis C to the wider community.

Snorting, or nasal ingestion of drugs, is usually safer than injection in terms of the relative danger of transmission of blood-borne viruses. However, the membranes in the nose are very delicate and can rupture when snorting so users should have their own snorting equipment that you don’t share with anyone else, to prevent viral transmission. As with injection, a clean preparation surface is required to prepare a drug for snorting. Nasal membranes can be seriously damaged from regular snorting.

Smoking, often called 'chasing the dragon', has negligible risk of bacterial or viral transmission and the risk of overdose is lessened compared to injecting. It still retains much of the 'rush' of injecting as the effects of the drug occur very rapidly. It is a far safer way to use heroin, with the best option being to use new aluminium foil, first passing a cigarette lighter flame over both sides to get rid of any contaminants.

Swallowing tends to the safest and slowest method of ingesting drugs. It is safer as the body has a much greater chance to filter out impurities. As the drug comes on slower, the effect tends to last longer as well, making it a favourite technique on the dance scene for speed and ecstasy. People rarely take heroin orally, as it is converted to morphine in the stomach and its strength is halved in the process. Pills like benzodiazepines are best swallowed as they have chalk or wax fillers in them. These fillers won’t irritate the stomach, but pose serious health risk for veins or nasal membranes.

Shafting, or rectal ingestion, relies on the many veins in the anal passage passing the drug into the blood stream quite rapidly. Some users find that trading off some of the 'rush' for much less health risks is a good compromise. Shafting usually involves about 1.5ml of fluid mixed with the drug. While squatting, gently insert the syringe (without the needle) until it is just inside the anus then ease the plunger down. A bit of Vaseline or lubricant will help if there is any pain. The sphincter muscles should be strong enough to hold the mix inside while it is absorbed. It can pay to do a trial run with water first.

Women have the added advantage of shelving, where drugs can be inserted in the vagina. This is similar to the rectum, in that you have plenty of blood vessels behind a very thin wall of cells, so the drug passes into the blood stream very quickly. Care should be taken with drugs such as amphetamine that may irritate the sensitive lining of the rectum and vagina.

==External links==
* [http://www.quihn.org.au Fact sheets on illicit drugs] including harm reduction strategies, detox and information for people affected by another's illicit drug use
[[Category:Drug paraphernalia]]

* [http://www.anypositivechange.org/bvcsi.html Safer injection and vein care] Chicago Recovery Alliance's extremely comprehensive and well designed informational series

Hepatitis C

2007-02-05T06:35:13Z

Quihn: /* Methods of transmission */

{{dablink|This page is for the disease. For the virus, see [[Hepatitis C virus]].}}

{{Infobox_Disease |
Name = Hepatitis C |
Image = |
Caption = |
DiseasesDB = 5783 |
ICD10 = {{ICD10|B|17|1|b|15}}, {{ICD10|B|18|2|b|15}} |
ICD9 = {{ICD9|070.4}}, {{ICD9|070.5}} |
ICDO = |
OMIM = 609532 |
MedlinePlus = 000284 |
eMedicineSubj = med |
eMedicineTopic = 993 |
}}
'''Hepatitis C''' is a [[Blood-borne disease|blood-borne]], infectious, [[virus|viral]] disease that is caused by a hepatotropic virus called ''[[Hepatitis C virus]]'' ('''HCV''').<ref name=Sherris>{{cite book | author = Ryan KJ; Ray CG (editors) | title = Sherris Medical Microbiology | edition = 4th ed. | publisher = McGraw Hill | year = 2004 | pages=pp. 551–2 | id = ISBN 0838585299 }}</ref> The infection can cause [[hepatitis|liver inflammation]] that is often asymptomatic, but ensuing chronic hepatitis can result later in [[cirrhosis]] ([[Fibrosis|fibrotic scarring]] of the liver) and [[hepatocellular carcinoma|liver cancer]].

The hepatitis C virus (HCV) is spread by blood-to-blood contact with an infected person's [[blood]]. While the symptoms can be medically managed, there are no curative treatements. Although modification of diet and early medical intervention are helpful, people with HCV infection often experience mild symptoms, and subesquently do not seek treatment.<ref name=Sherris /> An estimated 150-200 million people worldwide are infected with hepatitis C. In the U.S., those with a history of intravenous drug use, [[tattoo]]s, or who have been exposed to blood via unsafe sex or social practices are high risk for this disease. Hepatitis C is the leading cause of [[liver transplant]] in the United States.

The hepatitis C virus is one of six known hepatitis viruses: [[hepatitis A|A]], [[hepatitis B|B]], C, [[hepatitis D|D]], [[hepatitis E|E]], [[hepatitis G|G]].
[[Image:Liver 1.jpg|thumbnail|right|400px|[[cirrhosis|Cirrhosis of the liver]] and [[hepatocellular carcinoma|liver cancer]] may ensue from Hepatitis C.]]

==History==
In the mid 1970s, [[Harvey J. Alter]], Chief of the Infectious Disease Section in the Department of Transfusion Medicine at the [[National Institutes of Health]] (NIH), and his research team demonstrated that most post-transfusion hepatitis cases were not due to [[hepatitis A]] and [[Hepatitis B|B]] viruses. Despite this discovery, international research effort to identify the virus, initially called ''non-A, non-B hepatitis'' (NANBH), failed for the next decade. In [[1987]], Michael Houghton, Qui-Lim Choo, and George Kuo at Chiron Corporation utilized [[molecular cloning]] to identify the unknown organism. In [[1988]], the virus was confirmed by Alter by verifying its presence in a panel of NANBH specimens. In April of [[1989]], the discovery of the virus, re-named hepatitis C virus (HCV), was published in two articles in the journal ''Science''.<ref name="chiron">[http://www.chiron.com Chiron Corporation] ''Chiron Hepatitis C Research Honored with 2000 Lasker Award for Clinical Medical Research'' Press release, [[18 September]] [[2000]].</ref><ref name="choo">{{cite journal | author = Choo Q, Kuo G, Weiner A, Overby L, Bradley D, Houghton M | title = Isolation of a cDNA clone derived from a blood-borne non-A, non-B viral hepatitis genome. | journal = Science | volume = 244 | issue = 4902 | pages = 359-62 | year = 1989 | id = PMID 2523562}}</ref><ref name="kuo">{{cite journal | author = Kuo G, Choo Q, Alter H, Gitnick G, Redeker A, Purcell R, Miyamura T, Dienstag J, Alter M, Stevens C | title = An assay for circulating antibodies to a major etiologic virus of human non-A, non-B hepatitis. | journal = Science | volume = 244 | issue = 4902 | pages = 362-4 | year = 1989 | id = PMID 2496467}}</ref><ref name="houghton">Houghton, M., Q.-L. Choo, and G. Kuo. ''NANBV Diagnostics and Vaccines.'' European Patent No. EP-0-3 18-216-A1. European Patent Office (filed [[18 November]] [[1988]], published [[31 May]] [[1989]]).</ref>

==Signs and symptoms==
===Acute Hepatitis C===
Acute hepatitis C refers to the first 6 months after infection with HCV. Between 60% to 70% of people infected develop no symptoms during the acute phase. In the minority of patients who experience acute phase symptoms, they are generally mild and nonspecific, and rarely lead to a specific diagnosis of hepatitis C. Symptoms of acute hepatitis C infection include decreased appetite, fatigue, [[abdominal pain]], [[jaundice]], [[itching]], and flu-like symptoms.

The hepatitis C virus is usually detectable in the blood within one to three weeks after infection, and antibodies to the virus are generally detectable within 3 to 12 weeks. Approximately 20-30% of persons infected with HCV clear the virus from their bodies during the acute phase as shown by normalization in [[liver function tests]] (LFTs) such as [[alanine transaminase]] (ALT) & [[aspartate transaminase]] (AST) normalization, as well as plasma HCV-RNA clearance (this is known as ''spontaneous viral clearance''). The remaining 70-80% of patients infected with HCV develop [[chronic (medicine)|chronic]] hepatitis C, i.e., infection lasting more than 6 months.

Previous practice was to not treat acute infections to see if the person would spontaneously clear; recent studies have shown that treatment during the acute phase of genotype 1 infections has a greater than 90% success rate with half the treatment time required for chronic infections, but that the majority of acute hepatitis C is cleared. <ref name=Jaeckel>{{cite journal | author = Jaeckel E, Cornberg M, Wedemeyer H, Santantonio T, Mayer J, Zankel M, Pastore G, Dietrich M, Trautwein C, Manns MP | title = Treatment of acute hepatitis C with interferon alfa-2b | journal = New England Journal of Medicine | year = 2001 | month = Nov | volume = 345 | issue = 20 | pages = 1452-1457 | id = PMID 11794193 }}</ref>

===Chronic Hepatitis C===
Chronic hepatitis C is defined as infection with the hepatitis C virus persisting for more than six months. Clinically, it is often asymptomatic (without jaundice) and it is mostly discovered accidentally.

The natural course of chronic hepatitis C varies considerably from one person to another. Virtually all people infected with HCV have evidence of inflammation on liver biopsy, however, the rate of progression of liver scarring (fibrosis) shows significant variability among individuals. Recent data suggests that among untreated patients, roughly one-third progress to liver cirrhosis in less than 20 years. Another third progress to cirrhosis within 30 years. The remainder of patients appear to progress so slowly that they are unlikely to develop cirrhosis within their lifetimes. Factors that have been reported to influence the rate of HCV disease progression include age (increasing age associated with more rapid progression), gender (males have more rapid disease progression than females), alcohol consumption (associated with an increased rate of disease progression), HIV coinfection (associated with a markedly increased rate of disease progression), and fatty liver (the presence of fat in liver cells has been associated with an increased rate of disease progression).

Symptoms specifically suggestive of liver disease are typically absent until substantial scarring of the liver has occurred. However, hepatitis C is a systemic disease and patients may experience a wide spectrum of clinical manifestations ranging from an absence of symptoms to debilitating illness prior to the development of advanced liver disease. Generalized signs and symptoms associated with chronic hepatitis C include fatigue, marked weight loss, flu-like symptoms, muscle pain, joint pain, intermittent low-grade fevers, itching, sleep disturbances, abdominal pain (especially in the right upper quadrant), appetite changes, nausea, diarrhea, dyspepsia, cognitive changes, depression, headaches, and mood swings.

Once chronic hepatitis C has progressed to cirrhosis, signs and symptoms may appear that are generally caused by either decreased liver function or increased pressure in the liver circulation, a condition known as portal hypertension. Possible signs and symptoms of liver cirrhosis include [[ascites]] (accumulation of fluid in the abdomen), bruising and bleeding tendency, bone pain, [[varices]] (enlarged veins, especially in the stomach and esophagus), fatty stools ([[steatorrhea]]), [[jaundice]], and a syndrome of cognitive impairment known as [[hepatic encephalopathy]].

Liver function tests show variable elevation of [[ALAT]], [[AST]] and [[GGTP]] and periodically they might show normal results. Usually [[prothrombin]] and [[serum albumin|albumin]] results are normal.

Chronic hepatitis C, more than other forms of hepatitis, is diagnosed because of extrahepatic manifestations associated with the presence of HCV such as [[thyroiditis]] (inflammation of the thyroid) with hyperthyreosis or hypothyreosis, [[porphyria cutanea tarda]], [[cryoglobulinemia]] (a form of [[vasculitis]])<ref name="pascual">{{cite journal | author = Pascual M, Perrin L, Giostra E, Schifferli J | title = Hepatitis C virus in patients with cryoglobulinemia type II. | journal = J Infect Dis | volume = 162 | issue = 2 | pages = 569-70 | year = 1990 | id = PMID 2115556}}</ref> and [[glomerulonephritis]] (inflammation of the kidney), specifically [[membranoproliferative glomerulonephritis]] (MPGN)<ref name="johnson">{{cite journal | author = Johnson R, Gretch D, Yamabe H, Hart J, Bacchi C, Hartwell P, Couser W, Corey L, Wener M, Alpers C | title = Membranoproliferative glomerulonephritis associated with hepatitis C virus infection. | journal = N Engl J Med | volume = 328 | issue = 7 | pages = 465-70 | year = 1993 | id = PMID 7678440}}</ref>. Hepatitis C is also associated with [[sicca]] syndrome, [[thrombocytopenia]], [[lichen planus]], [[diabetes mellitus]] and with B-cell [[lymphoproliferative disorder]]s.<ref name=Extrahepatic>{{cite journal | author = Zignego AL, Ferri C, Pileri SA, Caini P, Bianchi FB; for the Italian Association of the Study of Liver (A.I.S.F.) Commission on Extrahepatic Manifestations of HCV infection | title = Extrahepatic manifestations of Hepatitis C Virus infection: A general overview and guidelines for a clinical approach | journal = Dig Liver Dis. | volume = | issue = | pages = E-publication | year = 2006 | id = PMID 16884964}}</ref>

==Diagnosis==
The diagnosis of hepatitis C is rarely made during the acute phase of the disease because the majority of people infected experience no symptoms during this phase of the disease. Those who ''do'' experience acute phase symptoms are rarely ill enough to seek medical attention. The diagnosis of chronic phase hepatitis C is also challenging due to the absence or lack of specificity of symptoms until advanced liver disease develops, which may not occur until decades into the disease.

Chronic hepatitis C may be suspected on the basis of the [[medical history]], a history of piercings or [[tattoo]]s, unexplained symptoms, or abnormal liver enzymes or liver function tests found during routine blood testing. Occasionally, hepatitis C is diagnosed as a result of targeted screening such as [[blood donation]] (blood donors are screened for numerous blood-borne diseases including hepatitis C) or [[contact tracing]].

Hepatitis C testing begins with [[serology|serological]] blood tests used to detect antibodies to HCV. Anti-HCV antibodies can be detected in 80% of patients within 15 weeks after exposure, in >90% within 5 months after exposure, and in >97% by 6 months after exposure. Overall, HCV antibody tests have a strong [[positive predictive value]] for exposure to the hepatitis C virus, but may miss patients who have not yet developed antibodies ([[seroconversion]]), or have an insufficient level of antibodies to detect. While uncommon, a small minority of people infected with HCV never develop antibodies to the virus and therefore, never test positive using HCV antibody screening.

Anti-HCV antibodies indicate exposure to the virus, but ''cannot'' determine if ongoing infection is present. All persons with positive anti-HCV antibody tests must undergo additional testing for the presence of the hepatitis C virus itself to determine whether current infection is present. The presence of the virus is tested for using molecular nucleic acid testing methods such as polymerase chain reaction (PCR), transcription mediated amplification (TMA), or branched DNA (b-DNA). All HCV nucleic acid molecular tests have the capacity to detect not only whether the virus is present, but also to measure the amount of virus present in the blood (the HCV viral load). The HCV viral load is an important factor in determining the probability of response to interferon-base therapy, but does ''not'' indicate disease severity nor the likelihood of disease progression.

In people with confirmed HCV infection, genotype testing is generally recommended. There are six major genotypes of the hepatitis C virus, which are indicated numerically (e.g., genotype 1, genotype 2, etc.). HCV genotype testing is used to determine the required length and potential response to interferon-based therapy.

==Virology==
{{main|Hepatitis C virus}}
The '''''Hepatitis C virus''''' ('''HCV''') is a small (50 [[metre#SI prefixes|nm]] in size), enveloped, single-stranded, positive sense [[RNA]] virus in the families ''[[Flaviviridae]]''.

==Transmission==
[[Image:Sources of Infection for Persons with Hepatitis C (CDC) US.png|thumb|350px|right|CDC figures for sources of infection in the US. [http://www.cdc.gov/ncidod/diseases/hepatitis/c/plan/HCV_infection.htm Source]]]
The hepatitis C virus (HCV) is transmitted by blood-to-blood contact. In developed countries, it is estimated that 90% of persons with chronic HCV infection were infected through transfusion of unscreened blood or blood products or via injecting drug use. In developing countries, the primary sources of HCV infection are unsterilized injection equipment and infusion of inadequately screened blood and blood products.

Although injection drug use and receipt of infected blood/blood products are the most common routes of HCV infection, ''any'' practice, activity, or situation that involves blood-to-blood exposure can potentially be a source of HCV infection.

===Methods of transmission===
Several activities and practices have been identified as potential sources of exposure to the hepatitis C virus. Anyone who may have been exposed to HCV through one or more of these routes should be screened for hepatitis C.

;Injection drug use
Those who currently, or have used [[drug injection]] as their delivery route for illicit drugs, are at increased risk for getting hepatitis C because they may be sharing needles or other [[drug paraphernalia]] (includes cookers, cotton, spoons, water, etc.), which may be contaminated with HCV-infected blood. An estimated 60% to 80% of all IV drug users in the United States have been infected with HCV. HCV is also transmitted by inhalational drugs, such as intranasal cocaine usage. [[Harm reduction]] strategies are encouraged in many countries to reduce the spread of hepatitis C, through education, provision of clean needles and syringes, and safer injecting techniques.

;Insuffulated drug use (Drugs which are "snorted")
Researchers have suggested that the transmission of HCV may be possible through the insuffulation of illegal drugs such as cocaine and crank when straws ( containing even trace elements of mucous and blood) are shared among users.<ref name=Thompson_1996>{{cite journal |author=Thompson S, Hernberger F, Wale E, Crofts N |title=Hepatitis C transmission through tattooing: a case report |journal=Aust N Z J Public Health |volume=20 |issue=3 |pages=317-8 |year=1996 |id=PMID 8768424}}</ref>

;Blood products
[[Blood transfusion]], blood products, or [[organ transplantation]] prior to implementation of HCV screening (in the U.S., this would refer to procedures prior to 1992) is a decreasing risk factor for hepatitis C.

The virus was first isolated in 1989 and reliable tests to screen for the virus were not available until 1992. Therefore, those who received blood or blood products prior to the implementation of screening the blood supply for HCV may have been exposed to the virus. Blood products include clotting factors (taken by [[hemophilia]]cs), immuneglobulin, Rhogam, platelets, and plasma. As of 2001, the Centers for Disease Control and Prevention reports that the risk of HCV infection from a unit of transfused blood in the United States is less than one per million transfused units.

;Iatrogenic medical or dental exposure
People can be exposed to HCV via inadequately or improperly sterilized medical or dental equipment. Examples include equipment that may harbor contaminated blood if improperly sterilized include reused needles or syringes, hemodialysis equipment, oral hygiene instruments, and jet air guns, etc. Scrupulous use of appropriate sterilization techniques and proper disposal of used equipment can bring the risk of iatrogenic exposure to HCV to virtually zero.

;Occupational exposure to blood
Medical and dental personnel, first responders (e.g., firefighters, paramedics, emergency medical technicians, law enforcement officers), and military combat personnel can be exposed to HCV through accidental exposure to blood through accidental needlesticks or blood spatter to the eyes. Universal precautions to protect against such accidental exposures significantly reduce the risk of exposure to HCV.

;Recreational exposure to blood
Contact sports and other activities, such as "slam dancing" that may result in accidental blood-to-blood exposure are potential sources of exposure to HCV.

;Sexual exposure to blood
Although HCV is not a [[sexually transmitted disease]] (STD), transmission can occur during unprotected sexual contact if the sexual activity involves blood-to-blood contact. The sexual spread of HCV is due to blood-blood contact rather than the presence of the [[virus]] in [[vaginal fluid]] or [[semen]].

;Body piercings and tattoos
Tattooing dyes, ink pots, stylets and piercing implements can transmit HCV-infected blood from one person to another if proper sterilization techniques are not followed. Tattoos or piercings performed before the mid 1980's, "underground," or non-professionally are of particularly concern since sterile techniques in such settings may have been or be insufficient to prevent disease.

;Shared personal care items
Personal care items such as razors, toothbrushes, cuticle scissors, and other manicuring or pedicuring equipment can easily be contaminated with blood. Sharing such items can potentially lead to exposure to HCV.

HCV is ''not'' spread through casual contact such as hugging, kissing, or sharing eating or cooking utensils.

===Vertical transmission===
[[Vertical transmission]] refers to the transmission of a communicable disease from an infected mother to her child during the birth process. Mother-to-child transmission of hepatitis C has been well described, but occurs relatively infrequently. Transmission occurs only among women who are HCV RNA positive at the time of delivery; the risk of transmission in this setting is approximately 6 out of 100. Among women who are both HCV and HIV positive at the time of delivery, the risk of HCV is increased to approximately 25 out of 100.

The risk of vertical transmission of HCV does ''not'' appear to be associated with method of delivery or breast feeding.

==Epidemiology==
Hepatitis C infects an estimated 170 million people worldwide and 4 million in the United States. There are about 35,000 to 185,000 new cases a year in the United States. Co-infection with [[HIV]] is common and rates among HIV positive populations are higher. 10,000-20,000 deaths a year in the United States are from HCV; expectations are that this mortality rate will increase, as those who were infected by transfusion before HCV testing become apparent. A survey conducted in California showed prevalence of up to 34% among prison inmates;<ref>{{cite journal | author = Ruiz J, Molitor F, Plagenhoef J | title = Trends in hepatitis C and HIV infection among inmates entering prisons in California, 1994 versus 1999. | journal = AIDS | volume = 16 | issue = 16 | pages = 2236-8 | year = 2002 | id = PMID 12409752}}</ref>
82% of subjects diagnosed with hepatitis C have previously been in jail,<ref>{{cite journal | author = Campbell J, Hagan H, Latka M, Garfein R, Golub E, Coady M, Thomas D, Strathdee S | title = High prevalence of alcohol use among hepatitis C virus antibody positive injection drug users in three US cities. | journal = Drug Alcohol Depend | volume = 81 | issue = 3 | pages = 259-65 | year = 2006 | id = PMID 16129567}}</ref>
and transmission while in prison is well described.<ref>{{cite journal | author = McGovern B, Wurcel A, Kim A, Schulze zur Wiesch J, Bica I, Zaman M, Timm J, Walker B, Lauer G | title = Acute hepatitis C virus infection in incarcerated injection drug users. | journal = Clin Infect Dis | volume = 42 | issue = 12 | pages = 1663-70 | year = 2006 | id = PMID 16705568}}</ref>

[[Egypt]] has the highest seroprevalence for HCV, up to 20% in some areas. There is a hypothesis that the high prevalence was linked, in 2000, to a mass-treatment campaign for [[schistosomiasis]], which is endemic in that country.<ref name="frank">{{cite journal | author = Frank C, Mohamed M, Strickland G, Lavanchy D, Arthur R, Magder L, El Khoby T, Abdel-Wahab Y, Aly Ohn E, Anwar W, Sallam I | title = The role of parenteral antischistosomal therapy in the spread of hepatitis C virus in Egypt. | journal = Lancet | volume = 355 | issue = 9207 | pages = 887-91 | year = 2000 | id = PMID 10752705}}</ref>

===Co-infection with HIV===
Approximately 350,000, or 35% of patients in the USA infected with HIV are also infected with the hepatitis C virus, mainly because both viruses are blood-borne and present in similar populations. In other countries, co-infection is less common, this is possibly related to differing drug policies. HCV is the leading cause of chronic liver disease in the USA. It has been demonstrated in clinical studies that HIV infection causes a more rapid progression of chronic hepatitis C to cirrhosis and liver failure. This is not to say treatment is not an option for those living with co-infection.

==Treatment and prognosis==
There is a very small chance of clearing the virus spontaneously (0.5 to 0.74% per year),<ref name=Watanabe_2003>{{cite journal |author=Watanabe H, Saito T, Shinzawa H, Okumoto K, Hattori E, Adachi T, Takeda T, Sugahara K, Ito J, Saito K, Togashi H, Suzuki R, Hayashi M, Miyamura T, Matsuura Y, Kawata S |title=Spontaneous elimination of serum hepatitis C virus (HCV) RNA in chronic HCV carriers: a population-based cohort study |journal=J Med Virol |volume=71 |issue=1 |pages=56-61 |year=2003 |id=PMID 12858409}}</ref><ref name=Scott_2006>{{cite journal |author=Scott J, McMahon B, Bruden D, Sullivan D, Homan C, Christensen C, Gretch D |title=High rate of spontaneous negativity for hepatitis C virus RNA after establishment of chronic infection in Alaska Natives |journal=Clin Infect Dis |volume=42 |issue=7 |pages=945-52 |year=2006 |id=PMID 16511757}}</ref> and the majority of patients with chronic hepatitis C will not clear it without treatment.

Current treatment is a combination of [[pegylated interferon alpha]] (brand names Pegasys and PEG-Intron) and the antiviral drug [[ribavirin]] for a period of 24 or 48 weeks, depending on genotype. Indications for treatment include patients with proven hepatitis C virus infection and persistent abnormal liver function tests. Sustained cure rates (sustained viral response) of 75% or better occur in people with genotypes HCV 2 and 3 in 24 weeks of treatment, about 50% in those with genotype 1 with 48 weeks of treatment and 65% for those with genotype 4 in 48 weeks of treatment. About 80% of hepatitis C patients in the United States have genotype 1. Genotype 4 is more common in the [[Middle East]] and Africa. Should treatment with pegylated ribivirin-interferon not return a 2-log viral reduction or complete clearance of RNA (termed ''early virological response'') after 12 weeks for genotype 1, the chance of treatment success is less than 1%. Early virological response is typically not tested for in non-genotype 1 patients, as the chances of attaining it are greater than 90%.

Treatment during the acute infection phase has much higher success rates (greater than 90%) with a shorter duration of treatment (but balance this against the 80% chance of spontaneous clearance without treatment).

Those with low initial viral loads respond much better to treatment than those with higher viral loads (greater than 2 million virons/ml). Current combination therapy is usually supervised by physicians in the fields of [[gastroenterology]], [[hepatology]] or [[infectious disease]].

The treatment may be physically demanding, particularly those with a prior history of drug or alcohol abuse. It can qualify for temporary [[disability]] in some cases. A substantial proportion of patients will experience a panoply of side effects ranging from a 'flu-like' syndrome (the most common, experienced for a few days after the weekly injection of interferon) to severe adverse events including [[anemia]], [[cardiovascular disease|cardiovascular events]] and psychiatric problems such as [[suicide]] or suicidal ideation. The latter are exacerbated by the general physiological stress experienced by the patient.

In addition to the standard treatment with interferon and ribavirin, several studies have shown higher success rates when the antiviral drug [[amantadine]] (Symmetrel) is added to the regimen. Sometimes called "triple therapy", it involves the addition of 100mg of amantadine twice a day. Studies indicate that this may be especially helpful for "nonresponders" - patients who have not been successful in previous treatments using interferon and ribavirin only.<ref name="Maynard">{{cite journal | author = Maynard M, Pradat P, Bailly F, Rozier F, Nemoz C, Si Ahmed S, Adeleine P, Trépo C | title = Amantadine triple therapy for non-responder hepatitis C patients. Clues for controversies (ANRS HC 03 BITRI). | journal = J Hepatol | volume = 44 | issue = 3 | pages = 484-90 | year = 2006 | id = PMID 16426697}}</ref>
Currently, amantadine is not approved for treatment of Hepatitis C, and studies are ongoing to determine when it is most likely to benefit the patient.

Current guidelines strongly recommend that hepatitis C patients be vaccinated for hepatitis A and B if they have not yet been exposed to these viruses, as this would radically worsen their liver disease.

[[Alcoholic beverage]] consumption accelerates HCV associated fibrosis and cirrhosis, and makes liver cancer more likely; [[insulin resistance]] and [[metabolic syndrome]] may similarly worsen the hepatic prognosis.

===During pregnancy and breastfeeding===
If a [[pregnant]] woman has risk factors for hepatitis C, she should be tested for antibodies against HCV. About four out of every hundred infants born to HCV infected women become infected. The virus is spread to the baby at the time of birth. There is no treatment that can prevent this from happening.

In a mother that also has HIV, the rate of transmission can be as high as 19%. There is currently no data to determine whether antiviral therapy reduces [[perinatal transmission]]. [[Ribavirin]] and [[interferon]]s are contraindicated during pregnancy. However, avoiding [[fetal scalp monitoring]] and prolonged labor after [[rupture of membranes]] may reduce the risk of transmission to the infant.

HCV antibodies from the mother may persist in infants until 15 months of age. If an early [[diagnosis]] is desired, testing for [[HCV RNA]] can be performed between the ages of 2 and 6 months, with a repeat test done independent of the first test result. If a later diagnosis is preferred, an anti-HCV test can performed after 15 months of age. Most infants infected with HCV at the time of birth have no [[symptoms]] and do well during childhood. There is no evidence that [[breast-feeding]] spreads HCV. To be cautious, an infected mother could avoid breastfeeding if her nipples are cracked and bleeding.<ref>{{cite journal | author = Mast E | title = Mother-to-infant hepatitis C virus transmission and breastfeeding. | journal = Adv Exp Med Biol | volume = 554 | issue = | pages = 211-6 | year = | id = PMID 15384578}}</ref>

===Alternative therapies===
Several "[[alternative medicine|alternative therapies]]" purport to reduce the liver's duties, rather than treat the virus itself, thereby slowing the course of the disease or keeping the quality of life of the person. As an example, extract of ''[[Silybum marianum]]'' and [[licorice]] are sold for their HCV related effects; the first is said to provide some generic help to hepatic functions, and the second to have a mild antiviral effect and to raise blood pressure. The current standard of treatment with pegylated-interferon and ribavirin is unsurpassed in its ability to control HCV replication<sup class="noprint">[[[Wikipedia:Citing sources|''<span title="The material in the vicinity of this tag needs references to reliable sources." style="white-space: nowrap;">citation needed</span>'']]]</sup>{{#if: {{NAMESPACE}} || }}.

===Experimental treatments===
The drug [[viramidine]], which is a prodrug of [[ribavirin]] which has better targeting for the liver, and therefore may be more effective against hepatitis C for a given tolerated dose, is in phase III experimental trials against hepatitis C. It will be used in conjunction with interferon, in the same manner as ribavirin. However, this drug is not expected to be active against ribavirin-resistant strains, and the use of the drug against infections which have already failed ribavirin/interferon treatment, is unproven.<p> There are new drugs under development like the [[protease inhibitor (pharmacology)|protease inhibitors]] (including ''VX 950'') and polymerase inhibitors (such as ''NM 283''), but development of these is still in the early phase.<ref name="hinrichsen">{{cite journal | author = Hinrichsen H, Benhamou Y, Wedemeyer H, Reiser M, Sentjens R, Calleja J, Forns X, Erhardt A, Crönlein J, Chaves R, Yong C, Nehmiz G, Steinmann G | title = Short-term antiviral efficacy of BILN 2061, a hepatitis C virus serine protease inhibitor, in hepatitis C genotype 1 patients. | journal = Gastroenterology | volume = 127 | issue = 5 | pages = 1347-55 | year = 2004 | id = PMID 15521004}}</ref><ref name="lamarre">{{cite journal | author = Lamarre D, Anderson P, Bailey M, Beaulieu P, Bolger G, Bonneau P, Bös M, Cameron D, Cartier M, Cordingley M, Faucher A, Goudreau N, Kawai S, Kukolj G, Lagacé L, LaPlante S, Narjes H, Poupart M, Rancourt J, Sentjens R, St George R, Simoneau B, Steinmann G, Thibeault D, Tsantrizos Y, Weldon S, Yong C, Llinàs-Brunet M | title = An NS3 protease inhibitor with antiviral effects in humans infected with hepatitis C virus. | journal = Nature | volume = 426 | issue = 6963 | pages = 186-9 | year = 2003 | id = PMID 14578911 doi:10.1038/nature02099}}</ref>
One protease inhibitor, ''BILN 2061'', had to be discontinued due to safety problems early in the clinical testing. Some more modern new drugs that provide some support in treating HCV are ''Albuferon'', ''Zadaxin'', and ''DAPY''. Antisense phosphorothioate oligos have been targeted to hepatitis C<ref name="zhang">{{cite journal | author = Zhang H, Hanecak R, Brown-Driver V, Azad R, Conklin B, Fox M, Anderson K | title = Antisense oligonucleotide inhibition of hepatitis C virus (HCV) gene expression in livers of mice infected with an HCV-vaccinia virus recombinant. | journal = Antimicrob Agents Chemother | volume = 43 | issue = 2 | pages = 347-53 | year = 1999 | id = PMID 9925530 | url=http://aac.asm.org/cgi/content/full/43/2/347?view=long&pmid=9925530}}</ref>. Antisense [[Morpholino]] oligos have shown promise in preclinical studies and began human clinical trials in 2005 at Veterans Affairs Palo Alto Health Care System, Palo Alto, California and Alpine Clinical Research Center, Inc., Boulder, Colorado.<ref name="mccaffrey">{{cite journal | author = McCaffrey A, Meuse L, Karimi M, Contag C, Kay M | title = A potent and specific morpholino antisense inhibitor of hepatitis C translation in mice. | journal = Hepatology | volume = 38 | issue = 2 | pages = 503-8 | year = 2003 | id = PMID 12883495}}</ref>

All of these are not approved remedies and have not yet demonstrated their efficacy in clinical trials.

[[Immunoglobulin]]s against the hepatitis C virus exist and newer types are under development. Thus far, their roles have been unclear as they have not been shown to help in clearing chronic infection or in the prevention of infection with acute exposures (e.g. needlesticks). They do have a limited role in transplant patients.

== Prevention ==
The following guidelines will prevent infection with the hepatitis C virus, which is spread by blood:

* Avoid sharing drug needles or any other drug paraphernalia including works for injection or bills or straws
* Avoid unsanitary tattoo methods
* Avoid unsanitary body piercing methods and acupuncture
* Avoid needlestick injury
* Avoid sharing grooming utensils
* Avoid sharing personal items such as toothbrushes, razors, and nail clippers.

Proponents of [[harm reduction]] believe that strategies such as the provision of new needles and syringes, and education about [[safer drug injection]] procedures, greatly decreases the risk of hepatitis C spreading between injecting drug users.

==See also==
*[[List of people with hepatitis C]]

==References==

<div class="references-small">
<references />
</div>

==External links==
*[http://www.cdc.gov/ncidod/diseases/hepatitis/c/fact.htm CDC's Hepatitis C Fact Sheet]
*[http://www.cdc.gov/ncidod/diseases/hepatitis/c/faq.htm CDC's Hepatitis C Frequently Asked Questions]
*[http://www.hepcuk.info Hepatitis C resource for the UK]
*[http://www.hepcaustralia.com.au Australian Hepatitis C Support (AHCS)]
*[http://www.quihn.org.au Fact sheets on harm reduction strategies for injecting drug users and hepatitis C issues]

{{gastroenterology}}

[[Category:Articles with unsourced statements]]
[[Category:Hepatitis|C]]

[[ca:Hepatitis C]]
[[de:Hepatitis C]]
[[et:HCV]]
[[es:Hepatitis C]]
[[fr:Hépatite C]]
[[hr:Hepatitis C]]
[[it:Epatite virale C]]
[[mk:Хепатит Ц]]
[[nl:Hepatitis C]]
[[pl:Wirus zapalenia wątroby typu C]]
[[pt:Hepatite C]]
[[ru:Гепатит C]]
[[sr:Хепатитис Ц]]
[[zh:丙型肝炎]]

Amphetamine

2007-02-05T06:30:11Z

Quihn: /* Addiction */

{{Drugbox|
|IUPAC_name = ''1-phenylpropan-2-amine''
| image=Amphetamine-2D-skeletal.png
| CAS_number=300-62-9
| ATC_prefix=N06
| ATC_suffix=BA01
| ATC_supplemental=
| PubChem=3007
| DrugBank=APRD00480
| C=9 | H=13 | N=1 |
| molecular_weight = 135.2084
| bioavailability= 4L/kg; low binding to plasma proteins (20%)
| metabolism = [[Hepatic]]
| elimination_half-life= 10–13 hours
| excretion = [[Renal]]; significant portion unaltered
| pregnancy_US = C
| legal_AU = Schedule 8
| legal_CA = Schedule III
| legal_UK = Class B
| legal_US = Schedule II
| legal_status =
| routes_of_administration= Oral, [[Intravenous infusion|Intravenous]], [[Vaporize]]d, [[Insufflate]]d, [[Suppository]]
}} '''Amphetamine''' ([[Alpha|'''a'''lpha-]][[methyl group|'''m'''ethyl]]-[[phenethylamine|'''ph'''en'''et'''hyl'''amine''']]), is a [[stimulant]] that is now primarily used to treat [[narcolepsy]] and [[attention-deficit hyperactivity disorder]]. It is also used recreationally as a [[club drug]] and as a performance enhancer (these uses are illegal in some countries). In the past it was more popularly used to [[anorectic|diminish the appetite]] and to control weight. Illicit production and use of amphetamines occurs on a widespread basis in several European nations, typically in the form of amphetamine sulfate synthesized from [[phenylpropanolamine]]. {{fact}} In addition, because of the widespread use of amphetamines as a treatment for [[narcolepsy]] and [[attention-deficit hyperactivity disorder|ADD/ADHD]], prescription amphetamines are subject to diversion and are one of the most frequently- abused drugs in high schools and colleges.

==History==
Amphetamine was synthesized in 1887 by [[Lazar Edeleanu]] at the University of Berlin. It was one of a series of compounds related to the plant derivative [[Ephedrine]], which had been purified two years previously by [[Nagayoshi Nagai]]. No medical use was found for Amphetamine until the 1900s, when it was introduced in most of the world in the form of the pharmaceutical [[Benzedrine]]. This drug was used by the militaries of several nations, especially the air forces, to fight fatigue and increase alertness among servicemen. After decades of reports of abuse, the [[United States Food and Drug Administration|FDA]] banned Benzedrine inhalers, and limited amphetamines to prescription use in 1959, but illegal use became common.

The related compound [[methamphetamine]] was first synthesized from ephedrine in Japan in 1893 by chemist [[Nagayoshi Nagai]]. In 1919, crystallized methamphetamine was synthesized by [[Akira Ogata]] via reduction of ephedrine using red phosphorus and iodine. The German military was notorious for their use of methamphetamine in World War Two. Many historians believe that [[Adolf Hitler]] abused the stimulant and that it influenced his powerful speeches. Nazi chemists are held responsible for a longer lasting form of amphetamines.

==Chemistry==
Amphetamine was first synthesized in 1887 by the [[Romania]]n [[chemist]] [[Lazăr Edeleanu]] at the [[University of Berlin]], who called it "'''phenylisopropylamine'''". Amphetamine is a [[chirality (chemistry)|chiral]] compound. The [[racemic]] mixture can be divided into its optical antipodes: levo- and [[dextroamphetamine|dextro-amphetamine]]. Amphetamine is the parent compound of its own structural class, comprising a broad range of psychoactive [[derivative (chemistry)|derivative]]s, e.g., [[MDMA]] (Ecstasy) and the ''N''-methylated form, [[methamphetamine]]. Amphetamine is a [[homologous series|homologue]] of [[phenethylamine]].

Traditionally the medical drug came in the racemic salt d, l-amphetamine sulfate (racemic amphetamine contains ''levo''- and ''dextro''-form in equal amounts). Today, dextroamphetamine sulphate is the predominant form of the drug used; it consists entirely of the ''d''-[[isomer]]. Attention disorders are often treated using [[Adderall]] or generic-equivalent formulations of mixed amphetamine salts that contain both ''d/l''-amphetamine and ''d''-amphetamine in the sulfate and saccharate forms mixed to a final ratio of 3 parts ''d''-amphetamine to 1 part ''l''-amphetamine.

== Pharmacology ==

Amphetamine, both as d-amphetamine ([[dextroamphetamine]]) and l-amphetamine (or a racemic mixture of the two isomers), is believed to exert its effects by binding to the monoamine transporters and increasing extracellular levels of the biogenic amines [[dopamine]], [[norepinephrine]] and [[serotonin]]. It is hypothesized that d-amphetamine acts primarily on the dopaminergic systems, while l-amphetamine is comparatively norepinephrinergic. The primary reinforcing and behavioral-stimulant effects of amphetamine, however, are linked to enhanced dopaminergic activity, primarily in the mesolimbic DA system. Amphetamine binds to the dopamine transporter (DAT) and blocks the transporters ability to clear DA from the synaptic space. In addition, amphetamine is transported into the cell which leads to dopamine efflux (DA is transported out of the cell and into the synaptic space via reverse transport of the DAT).

==Medicinal use==
{| bgcolor="#ffffff" border="1" cellpadding="3" cellspacing="0" align="right" width="167px" style="border-collapse: collapse; clear: right; margin: 0 0 0 0.5em"
|-
|'''Indicated for:'''<br/>
*[[Diet suppressant]]
*[[Attention deficit disorder|ADD]]
*[[Attention deficit hyperactivity disorder|ADHD]]
*[[Narcolepsy]]
*Treatment-resistant [[clinical depression|depression]]

'''[[Recreational drug use|Recreational]] uses:'''<br/>
*[[Stimulant]]

'''Other uses:'''<br/>
*Used by the U.S. military to combat fatigue and increase wakefulness
|-
|'''[[Contraindication]]s:'''<br/>
*CNS Stimulants
*[[MAOI]] use
|-
|'''[[Adverse drug reaction|Side effects]]:'''
*[[Dizziness]]
*[[Tachycardia]]
*[[Sweating]]
*Decrease in appetite/weight loss
*Euphoria followed by depression
*[[Insomnia]]
*Anger
*Aggressiveness
*Hostility

'''''[[Cardiovascular]]:'''''
*[[Bronchodilator]]

'''''[[Ear]], [[nose]], and [[throat]]:'''''
*[[Decongestant]]

'''''[[Eye]]:'''''
*[[Mydriasis]] (Pupil dilation)

'''''[[Gastrointestinal]]:'''''
*[[Diarrhea]]

'''''[[Muscle|Musculo]][[skeletal]]:'''''
*Muscle aches/cramps

'''''[[Neurological]]:'''''
*[[Dopamine]] [[Agonist]]
*[[Norepinephrine]] [[Agonist]]

'''''[[Respiration (physiology)|Respiratory]]:'''''
*[[Bronchodilator]]
|}
Along with [[methylphenidate]] ([[Ritalin]], [[Concerta]], etc.), amphetamine is one of the standard treatments for [[ADHD]]. Beneficial effects for ADHD can include improved impulse control, improved concentration, decreased sensory overstimulation, and decreased irritability. These effects can be dramatic, particularly in young children. The ADHD medication [[Adderall]] is composed of four different amphetamine [[salt]]s, and [[Adderall XR]] is a timed release formulation of these same salt forms.

When used within the recommended doses, side-effects like loss of appetite tend to decrease over time. However, amphetamines last longer in the body than [[methylphenidate]] ([[Ritalin]], [[Concerta]], etc.), and tend to have stronger side-effects on appetite and sleep.

Amphetamines are also a standard treatment for [[narcolepsy]] as well as other sleeping disorders. They are generally effective over long periods of time without producing addiction or physical dependence.

Amphetamines are sometimes used to augment anti-depressant therapy in treatment-resistant depression.

Medical use for weight loss is still approved in some countries, but is regarded as obsolete and dangerous in, for example, the United States.

==Effects of use==
Amphetamines release stores of [[norepinephrine]] and [[dopamine]] from nerve endings by converting the respective molecular transporters into open channels. Amphetamine also releases stores of [[serotonin]] from [[synaptic vesicle]]s. Like [[methylphenidate]] ([[Ritalin]]), amphetamines also prevent the [[monoamine transporter]]s for [[dopamine]] and [[norepinephrine]] from recycling them (called [[reuptake]] inhibition), which leads to increased amounts of dopamine and norepinephrine in [[synaptic cleft]]s.

These combined effects rapidly increase the concentrations of the respective [[neurotransmitter]]s in the [[synaptic cleft]], which promotes nerve impulse transmission in neurons that have those receptors.

==='''Physical effects'''===
* Short-term [[physiology|physiological]] effects vary greatly, depending on dosage used and the method in which the drug is taken. These effects could include [[decreased appetite]], increased [[endurance|stamina]] and physical energy, increased [[sexual drive]]/response, involuntary bodily movements, [[hyperhidrosis]], [[hyperactivity]], jitteriness, [[nausea]], itchy, blotchy or greasy skin, [[tachycardia]], irregular heart rate, [[hypertension]], and [[headache]]s. [[Fatigue (physical)|Fatigue]] can often follow the dose's period of effectiveness. Overdose can be treated with [[chlorpromazine]]. [http://www.rxlist.com/cgi/generic/amphsulf_od.htm]

* Long-term abuse or overdose effects can include [[tremor]], restlessness, changed sleep patterns, [[anxiety]] and increase in pre-existing anxiety, poor skin condition, [[hyperreflexia]], [[tachypnea]], gastrointestinal narrowing, and weakened [[immune system]]. Fatigue and [[Depression (mood)|depression]] can follow the excitement stage. [[Erectile dysfunction]], heart problems, stroke, and liver, kidney and lung damage can result from prolonged use. When insufflated, amphetamine can lead to a deterioration of the lining of the nostrils.

==='''Psychological effects'''===
* Short-term psychological effects can include alertness, euphoria, increased concentration, rapid talking, increased confidence, increased social responsiveness, [[nystagmus]] (eye wiggles), hallucinations, and loss of [[Rapid eye movement|REM]] sleep the night after use.

* Long-term psychological effects can include insomnia, mental states resembling [[schizophrenia]], aggressiveness (not associated with schizophrenia), addiction or dependence with accompanying withdrawal symptoms, irritability, confusion, and panic. Chronic and/or extensively-continuous use can lead to [[amphetamine psychosis]], which causes delusions and paranoia, but this is uncommon when taken as prescribed. Amphetamine is highly-psychologically addictive, and, with chronic use, tolerance develops very quickly. Withdrawal is, although not physiologically threatening, an unpleasant experience (including [[paranoia]], depression, difficult breathing, [[dysphoria]], gastric fluctuations and/or pain, and [[lethargia]]). This commonly leads chronic users to re-dose amphetamine frequently, explaining tolerance and increasing the possibility of addiction.

==Addiction==
[[Drug tolerance|Tolerance]] is developed rapidly in amphetamine abuse, therefore increasing the amount of the drug that is needed to satisfy the addiction. {{fact}} Many abusers will repeat the amphetamine cycle by taking more of the drug during the [[withdrawal]]. This leads to a very dangerous cycle and may involve the use of other drugs to get over the withdrawal process.
Chronic abusers of amphetamines typically snort or resort to [[drug injection]] to experience the full effect of the drug in a faster and more intense way, with the added risks of bacterial and viral transmission, vein damage and higher risk of overdose.

==Harm reduction approach to amphetamine use==
Proponents of the [[harm reduction]] philosophy seek to minimize the harms that arise from the recreational use of amphetamines. Safer means of taking the drug—smoking or nasal, oral and rectal insertion—are encouraged due to the higher risks of overdose, infections and blood-borne viruses associated with [[drug injection]].

Where the strength of the drug is unknown, users are encouraged to try a small amount first to guage the strength, to minimize the risks of overdose. For the same reason, poly drug use (the use of two or more drugs at the one time) is discouraged. Users are also encouraged to not use amphetamines alone, as others can assist in the event of an overdose or [[amphetamine psychosis]].

Amphetamine users who choose to inject should always use new needles and syringes where possible, and not share these with other users. Governments that support a harm reduction approach often supply new needles and syringes on a confidential basis, as well as education on proper filtering prior to injection, safer injection techniques, and safe disposal of used injecting gear.

==Legal issues==
*In the United Kingdom, amphetamines are regarded as [[Misuse of Drugs Act 1971#Class B drugs|Class B]] drugs. The maximum penalty for unauthorised possession is three months' imprisonment and a £2,500 fine.{{cn}} Methamphetamine has recently been reclassified to Class A, penalties for possession of which are more severe.
*In the United States, amphetamine and [[methamphetamine]] are [[Controlled Substances Act#Schedule II drugs|Schedule II]] controlled drugs, classified as a CNS (Central Nervous System) Stimulant.{{cn}} A Schedule II drug is classified as one that: has a high potential for abuse, has a currently-accepted medical use and is used under severe restrictions, and has a high possibility of severe psychological and physiological dependence.

Internationally, amphetamine is a Schedule II drug under the [[Convention on Psychotropic Substances]].<ref>{{cite web
| title=List of psychotropic substances under international control
| publisher = International Narcotics Control Board
| url=http://www.incb.org/pdf/e/list/green.pdf
| format = PDF
| accessmonthday=November 19
| accessyear=2005
}}</ref>

==Popular culture==
*[[Rock (music)|Rock]] band [[Everclear (band)|Everclear]] wrote the song "Amphetamine", about a young girl's journey into amphetamine use for the album [[So Much for the Afterglow]].
*[[Hardcore Punk]] band [[Hüsker Dü]] wrote the song "Crystal", about crystal methamphetamine for the album [[Candy Apple Grey]].
*[[Indie Rock]] band [[Pure (band)|Pure]] has a song called "Anna" about an amphetamine addict on the album "[[Generation Six Pack]]".
*[[Avant-garde]] [[rock and roll]] band [[The Velvet Underground]] wrote the song [[White Light/White Heat (song)|White Light/White Heat]], about the effects of the drug.
*[[Blues-Rock]] band [[Canned Heat]] wrote a song, on the album [[Boogie With Canned Heat]] called Amphetamine Annie, about a girl who takes speed regularly.
*[[Rock and roll]] band [[Eve 6]] wrote a song called ''Amphetamines and Jellybeans'', on their album [[Horrorscope (Eve 6 album)|Horrorscope]].
*[[Space-rock]] band [[Hawkwind]] performed a song entitled "[[Motörhead (song)|Motörhead]]", written by [[Lemmy Kilmister]] shortly before forming his own band of the same name. Kilmister is known for being a longtime user of speed.
*[[Alternative Rock]] band [[The Smashing Pumpkins]] mention Amphetamine in a song titled "Annie Dog" from the album "[[Adore]]".
*[[Rock and Roll]] band [[The Sisters of Mercy]] were (in)famous for the constant references to amphetamine throughout their career.
*[[Industrial Rock]] band [[Marilyn Manson]] mention Amphetamines in a song titled "Rock is Dead".
*[[Punk rock]] band [[Toys That Kill]] have a song entitled Amphetamine St. off their album The Citizen Abortion.
*[[Alternative Metal]] band [[Seether]] mention Amphetamine in a song titled "I'm The One" from the album "[[Karma And Effect]]".
*[[Indie Rock]] singer-songwriter [[Elliott Smith]] mentions Amphetamine use in a song titled "St. Ides Heaven" from his self titled album.
*[[Indie Rock]] band [[Elle Milano]] has a song named "Amphetamine Skyrocket" from the Elle Milano EP called "[[Swearing's For Art Students]]".
*[[UK]] [[indie rock]] band [[Bromheads Jacket]] have a song called "Rosey Lee" which is about a young girl who is addicted to amphetamines.
*[[Bob Dylan]] references amphetamines in the song "Just Like A Woman", in the line "With her fog, her amphetamine, and her pearls"
*[[Jack Kerouac]] novel "[[On The Road]]" frequently references amphetamines in the form of [[benzedrine]], or bennies.
*Amphetamine was the drug of choice at [[The Factory]], famed [[New York City]] studio of [[Andy Warhol]] and hangout for artists and scenesters. Use of the drug was reflected in much of the Factory aesthetic, as well as being explicitly portrayed in works such as the [[1966]] movie [[Chelsea Girls]].
*During the 2006 [[Major League Baseball]] season controversial [[San Francisco Giants]] slugger [[Barry Bonds]] failed an Amphetamine test.
*Amphetamines are the drugs most often used by the characters of Katsuhiro Otomo's [[Akira (manga)|Akira]], and an image of a capsule that represents the drug is, aruguably, the series' iconic logo.

==Books==
*{{cite book
| last = Seabrook | first = Jeremy
| title=In the Cities of the South: scenes from a developing world
| location = London; New York
| publisher = Verso
| year=1996
| id=ISBN 1-85984-986-5
}}

==Related pages==
* [[Adderall]]
* [[Attention Deficit Hyperactivity Disorder]]
* [[Clandestine chemistry]]
* [[Dextroamphetamine]] (Dexedrine)
* [[Methamphetamine]] ([[Desoxyn]])
* [[Methylphenidate]] (Ritalin, Concerta)
* [[Phenethylamine]]s
* [[Stimulants]]
* [[Eugeroic]]
** [[Adrafinil]]
** [[Modafinil]]

==External links==
*{{PubChemLink|5826}} ([[D-form]] — dextroamphetamine)
*{{PubChemLink|3007}} ([[L-form]] and D, L-forms)
*{{PubChemLink|32893}} ([[L-form]] — Levamphetamine or L-amphetamine)
*[http://www.erowid.org/chemicals/amphetamines/amphetamines.shtml Erowid - Amphetamines]
*[http://www.thegooddrugsguide.com/amphetamines/index.htm The Good Drugs Guide - Amphetamines]
*[http://leda.lycaeum.org/?ID=364 Lycaeum - Amphetamines]
*[http://www.speedsmart.org SpeedSmart.org: Support for Safe and Successful Stimulant Use]
*[http://www.drugs.com/Amphetamine Drugs.com - Amphetamine]
*[http://www.apaic.org Asia & Pacific Amphetamine-Type Stimulants Information Centre]

{{ChemicalSources}}

==References and Notes==

<references />

{{Phenethylamines}}
{{Stimulants}}

[[Category:Sympathomimetic amines]]
[[Category:Stimulants]]
[[Category:Amphetamines]]
[[Category:Criminology topics]]

[[da:Amfetamin]]
[[de:Amphetamin]]
[[es:Anfetamina]]
[[fr:Amphétamine]]
[[hr:Amfetamin]]
[[it:Anfetamina]]
[[he:אמפטמין]]
[[lt:Amfetaminas]]
[[hu:Amfetamin]]
[[ms:Amfetamina]]
[[nl:Amfetamine]]
[[ja:アンフェタミン]]
[[no:Amfetamin]]
[[nn:Amfetamin]]
[[pl:Amfetamina]]
[[pt:Anfetamina]]
[[ru:Амфетамин]]
[[sr:Амфетамин]]
[[fi:Amfetamiini]]
[[sv:Amfetamin]]
[[tr:Amfetamin]]
[[uk:Амфетамін]]
[[zh:苯丙胺]]

Heroin

2007-02-05T06:25:49Z

Quihn: Addition of a harm reduction section. Scrutiny and further additions/editing welcomed!

{{otheruses}}
{{drugbox |
| IUPAC_name = (5α,6α)-7,8-didehydro-4,5-epoxy-<br>17-methylmorphinan-3,6-diol diacetate (ester)
| British Approved Name = Diamorphine
| International Nonproprietary Name = Diacetylmorphine
| image = Heroin-2D-skeletal.png
| image2 = Heroin-3D-balls.png
| CAS_number = 561-27-3
| ATC_prefix = N02
| ATC_suffix = AA09
| PubChem = 3592
| DrugBank =
| C=21 | H=23 | N=1 | O=5
| molecular_weight = 369.41
| bioavailability = <35%
| protein_bound = 0% ([[morphine]] metabolite 35%)
| metabolism = [[hepatic]]
| elimination_half-life = 2-3 minutes
| excretion = 90% [[renal]] as [[glucuronide]]s, rest [[biliary]]
| pregnancy_category =
| legal_AU =
| legal_CA = Schedule I
| legal_UK = Class A
| legal_US = Schedule I
| legal_status =
| dependency_liability =Extremely High
| routes_of_administration = Inhalation, Transmucosal, Intravenous, Oral, Intranasal, Rectal, Intramuscular}}

'''Heroin''', also known as '''diamorphine''' ([[British Approved Name|BAN]]) or '''diacetylmorphine''' ([[International Nonproprietary Name|INN]]), is a semi-synthetic [[opioid]]. It is the 3,6-[[acetate|diacetyl]] derivative of [[morphine]] (hence ''diacetylmorphine'') and is synthesised from it by [[acetylation]]. The white crystalline form is commonly the hydrochloride salt, '''diacetylmorphine hydrochloride'''. It mimics [[endorphin]]s and thus causes a high sense of well-being when entered into the bloodstream (usually through injection). For this reason it can be used both as a [[pain-killer]] and a [[recreational drug]]. It has a high [[addiction]] potential, and frequent administration may cause a rapid development of tolerance by the user, especially when compared to other substances, though occasional use may not lead to symptoms of withdrawal.<ref>{{cite journal|author=David Shewan, Phil Dalgarno|title=Evidence for controlled heroin use? Low levels of negative health and social outcomes among non-treatment heroin users in Glasgow|url=http://www.gcal.ac.uk/news/downloads/heroin_use.pdf|journal=British Journal of Health Psychology|year=2005|doi=10.1348/135910704X14582|pages=33-48|volume= 10}}</ref><ref>{{cite news|author=Hamish Warburton, Paul J Turnbull, Mike Hough|title=Occasional and controlled heroin use: Not a problem?|url=http://www.jrf.org.uk/bookshop/details.asp?pubID=747|date=2005}}</ref> Internationally, heroin is controlled under Schedules I and IV of the [[Single Convention on Narcotic Drugs]].<ref>{{cite web
| year = December 2004| url = http://www.incb.org/pdf/e/list/46thedition.pdf
| title = Yellow List: List of Narcotic Drugs Under International Control| format = PDF
| publisher = [[International Narcotics Control Board]]
| accessdate = May 5| accessyear = 2006
}} ''Referring URL = http://www.incb.org/incb/yellow_list.html''</ref> It is illegal to manufacture, possess, or sell heroin in the [[United States]]; however, under the name '''diamorphine''', heroin is a legal prescription drug in the [[United Kingdom]]. Popular street names for heroin include ''gear'', ''diesel'', ''smack'', ''B'', ''skag'', ''Bobby'', ''[[black tar heroin|black tar]]'', ''horse'', ''junk'', ''jenny'', ''brown'', ''brown sugar'', ''dark'', ''dope'', ''dragon'', ''bitch'', ''gak'' and ''H''.


==History==
[[image:BayerHeroin.png|thumb|175px|left|[[Bayer]] Heroin (TM)]]
[[Image:Bayer Heroin bottle.jpg|thumb|175px|left|Bayer Heroin bottle.]]

The [[opium poppy]] was cultivated in lower [[Mesopotamia]] as long ago as [[3400 BC]].<ref>{{cite web
|url=http://www.pbs.org/wgbh/pages/frontline/shows/heroin/etc/history.html
|title=Opium Throughout History
|publisher=PBS Frontline
|accessdate=2006-10-22
}}</ref> The chemical analysis of opium in the 19th century revealed that most of its activity could be ascribed to two ingredients, [[codeine]] and [[morphine]].

Heroin was first [[Chemical synthesis|synthesized]] in 1874 by [[C.R. Alder Wright]], an English chemist working at [[St Mary's Hospital (London)|St. Mary's Hospital]] Medical School in London, England. He had been experimenting with combining morphine with various acids. He boiled anhydrous morphine alkaloid with acetic anhydride over a stove for several hours and produced a more potent, acetylated form of morphine, now called ''diacetylmorphine''. The compound was sent to F.M. Pierce of Owens College in Manchester for analysis, who reported the following to Wright:

:''Doses … were [[Route of administration|subcutaneously injected]] into young dogs and rabbits … with the following general results … great prostration, fear, and sleepiness speedily following the administration, the eyes being sensitive, and pupils constrict, considerable [[salivation]] being produced in dogs, and slight tendency to [[vomit]]ing in some cases, but no actual emesis. [[Respiration]] was at first quickened, but subsequently reduced, and the heart's action was diminished, and rendered irregular. Marked want of coordinating power over the muscular movements, and loss of power in the pelvis and hind limbs, together with a diminution of temperature in the rectum of about 4°(rectal failure)''.<ref>{{cite web
|url=http://adhpage.dilaudid.net/heroin.html
|title=On the Action of Organic Acids and their Anhydrides on the Natural Alkaloids
|last = Wright
|first = C.R.A.
|date=[[2003-08-12]]
|archiveurl=http://web.archive.org/web/20040606103721/http://adhpage.dilaudid.net/heroin.html
|archivedate=2004-06-06
}} Note: this is an annotated excerpt of {{cite journal
| last = Wright
| first = C.R.A.
| year = 1874
| title = On the Action of Organic Acids and their Anhydrides on the Natural Alkaloids
| journal = [[Journal of the Chemical Society]]
| volume = 27
| pages = 1031–1043
}}</ref>

However, as is often the case with scientific discovery, Wright's invention did not lead to any further developments, and heroin's fame would only begin to grow after it was independently re-synthesized 23 years later by another chemist, [[Felix Hoffmann]]. Hoffman was working at the [[Bayer]] pharmaceutical company in [[Elberfeld, Germany]], where the head of his laboratory was Heinrich Dreser. Dreser instructed Hoffmann to acetylate morphine, with the objective of producing [[codeine]], a natural derivative of the opium poppy, similar to morphine but less potent and held to be less addictive. But instead of producing codeine, the experiment produced a substance that was actually three times more potent than morphine. Bayer would name the substance "heroin", probably from the word ''heroisch'', German for heroic, because in field studies people using the medicine felt "heroic".<ref>owden, Mary Ellen. Pharmaceutical Achievers. Philadelphia: Chemical Heritage Foundation, 2002.</ref>

From 1898 through to 1910 heroin was marketed as a non-addictive morphine substitute and cough medicine for children. Bayer marketed heroin as a cure for morphine addiction before it was discovered that heroin is converted to morphine when metabolized in the liver. The company was somewhat embarrassed by this new finding and it became a historical blunder for Bayer.<ref>{{cite web
|year=1998
|month=September 13
|url=http://opioids.com/heroin/heroinhistory.html
|title= How aspirin turned hero
|publisher=Sunday Times
|accessdate=2006-10-22
}}</ref>

As with aspirin, Bayer lost some of its trademark rights to heroin following the German defeat in [[World War I]].

In the United States the [[Harrison Narcotics Tax Act]] was passed in 1914 to control the sale and distribution of heroin. The law did allow heroin to be prescribed and sold for medical purposes. In particular, addicts could often still be legally supplied with heroin. In 1924, the United States Congress passed additional legislation banning the sale, importation or manufacture of heroin in the United States.

==Usage and effects==
{| bgcolor="#ffffff" border="1" cellpadding="3" cellspacing="0" align="right" width="167px" style="border-collapse: collapse; clear: right; margin: 0 0 0 0.5em"
|-
|'''Indicated for:'''<br/>
*Relief of extreme pain

'''[[Recreational drug use|Recreational]] uses:'''<br/>
*[[Euphoria]]
*[[Relaxation]]

'''Other uses:'''<br/>
*[[Pain and nociception|Pain]] relief
*[[Cough suppressant]]
*anti-[[diarrhea]]l
|-
|'''[[Contraindication]]s:'''<br/>
*[[Ethanol|Alcohol]]
*[[Barbiturate]]s and [[Benzodiazepines]]
*[[Stimulant]]s
*Other [[opioid]]s (depends heavily on tolerance)
|-
|'''[[Adverse drug reaction|Side effects]]:'''
<div style="background: #ffcc99">
'''''{{red|Severe:}}'''''
*[[Respiratory arrest]], [[seizure]], [[coma]], death
*[[Spontaneous abortion]]

</div>

</div>

'''''[[Cardiovascular]] & [[Respiration (physiology)|Respiratory]]:'''''
*Lowered [[heart rate]]
*Slowed, shallow or ineffective [[respiration]]

'''''[[Eyes]], [[Ears]], [[nose]], and [[mouth]]:'''''
*Dry mouth
*[[Pupil constriction]]

'''''[[Gastrointestinal]]:'''''
*[[Nausea]]
*[[Vomiting]] (protracted)
*[[Constipation]]

'''''[[Urinary System]]:'''''
*[[Urinary retention]]

'''''[[Muscle|Musculo]][[skeletal]]:'''''
*[[Analgesia]]
*[[Ataxia]]

'''''[[Neurological]]:'''''
*[[Analgesia]]
*[[Physical dependence]]

'''''[[Psychological]]:'''''
*[[Anxiolytic]]
*[[Confusion]]
*[[Euphoria]]
*[[Somnolence]]
*[[Addiction]]

'''''[[Skin]]:'''''
*Itching
*Flushing/Rash

[[Image:Diamorphine_ampoules.JPG|thumb|left|Diamorphine ampoules for medicinal use]]
|}

In Canada, heroin is a controlled substance under Schedule I of the [[Controlled Drugs and Substances Act]] (CDSA). Every person who seeks or obtains the substance without disclosing authorization to obtain such substances 30 days prior to obtaining another prescription from a practitioner is guilty of an indictable offence and liable to imprisonment for a term not exceeding seven years. Possession for purpose of trafficking is guilty of an indictable offence and liable to imprisonment for life.

In [[Hong Kong]], heroin is regulated under Schedule 1 of [[Hong Kong|Hong Kong's]] Chapter 134 ''Dangerous Drugs Ordinance''. It can only be used legally by health professionals and for university research purposes. The substance can be be given by pharmacists under a prescription. Anyone who supplies the substance without prescription can be fined $10000(HKD). The penalty for trafficking or manufacturing the substance is a $5,000,000 ([[Hong Kong dollar|HKD]]) fine and life imprisonment. Possession of the substance for consumption without license from the Department of Health is illegal with a $1,000,000 (HKD) fine and/or 7 years of jail time.

In the [[United Kingdom]], heroin is available on prescription, though it is a restricted [[Class A drug]]. According to the [[British National Formulary]] (BNF) edition 50, diamorphine [[hydrochloride]] may be used in the treatment of acute pain, [[myocardial infarction]], acute [[pulmonary edema]], and [[chronic pain]]. The treatment of chronic non-[[malignant]] pain must be supervised by a specialist. The BNF notes that all opioid analgesics cause dependence and tolerance but that this is "no deterrent in the control of pain in terminal illness". When used in the [[palliative care]] of cancer patients, heroin is often injected using a [[syringe driver]]. In comparison to morphine, it may cause less [[nausea]], [[hypotension]], but more [[sedation]] and [[euphoria]] and can be dissolved in a smaller quantity of liquid.

Heroin is also widely (and usually illegally) used as a powerful and addictive drug that produces intense euphoria, which often disappears with increasing [[Physiological tolerance|tolerance]]. It is thought that heroin's popularity with recreational users, compared to morphine or other opiates, comes from its somewhat different perceived effects.<ref>{{cite journal
| author = Tschacher W, Haemmig R, Jacobshagen N.
| year = 2003
| title = Time series modeling of heroin and morphine drug action.
| journal = [[Psychopharmacology]]
| PMID = 12404073
| url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12404073&query_hl=23&itool=pubmed_DocSum
}}</ref> This in turn comes from its high lipid [[solubility]] provided by the two [[acetyl]] groups, resulting in a very rapid penetration of the [[blood-brain barrier]] after use. Heroin can be taken or [[route of administration|administered]] in a number of ways, including [[snort]]ing and [[injection (medicine)|injection]]. It may also be smoked by inhaling the vapors produced when heated from below (known as "[[chasing the dragon]]").

Many users dissolve the drug together with [[ cocaine]] in a so-called "speedball" or "snowball", which is injected intravenously. This causes an even more intense rush but is more dangerous than heroin alone because the mixture of short-acting stimulant with longer-acting depressant increases the risk of overdosing on one or both drugs. Cocaine is an irritant to all bodily tissues causing eventual [[necrosis]] at any site with which it is in frequent contact.{{fact}}

Once in the brain, heroin is rapidly [[metabolism|metabolized]] into morphine by removal of the acetyl groups. It is the morphine [[molecule]] that then binds with opioid receptors and produces the subjective effects of the heroin high. Heroin is therefore a [[prodrug]].

The onset of heroin's effects is dependent on the method of administration. Orally, the heroin is totally metabolized [[in vivo]] into morphine before crossing the blood-brain barrier, so the effects are the same as morphine when taken by mouth. Snorting heroin results in onset within 10 to 15 minutes. Smoking heroin results in an almost immediate, though mild effect which strengthens the longer it is used in that particular session. Intravenous injection results in rush and euphoria within 7 to 8 seconds, while intramuscular injection takes longer, having an effect within 5 to 8 minutes.

Heroin is a μ-opioid ([[mu-opioid]]) [[agonist]]. It acts on [[endogenous]] [[Opioid receptor#The .CE.BC-opioid receptor|μ-opioid receptor]]s that are spread in discrete packets throughout the [[brain]], [[spinal cord]] and [[gut]] in almost all [[mammal]]s. Heroin, along with other opioids, are [[agonists]] to four endogenous [[neurotransmitters]]. They are [[Beta-endorphin|β-endorphin]], [[dynorphin]], [[leu-enkephalin]], and [[met-enkephalin]]. The body responds to heroin in the brain by reducing (and sometimes stopping) production of the endogenous opioids when heroin is present. Endorphins are regularly released in the brain and nerves and attenuate pain. Their other functions are still obscure, but are probably related to the effects produced by heroin besides analgesia ([[antitussin]], [[anti-diarrheal]]). The reduced endorphin production in heroin users creates a dependence on the heroin, and the cessation of heroin results in extremely uncomfortable symptoms including pain (even in the absence of physical trauma). This set of symptoms is called [[withdrawal]] syndrome. It has an onset 6 to 8 hours after the last dose of heroin.

Large doses of heroin can be fatal. The drug can be used for suicide or, as in the case of [[Sigmund Freud]], physician-assisted suicide.  Heroin can be used as a murder weapon. The serial killer Dr. [[Harold Shipman]] used it on his victims. Dealers can supply unwanted customers with unusually pure heroin, or heroin cut with other dangerous drugs such as [[fentanyl]], resulting in a fatal overdose. It can sometimes be difficult to determine whether a heroin death was an accident, suicide or murder. The death of [[Joseph Krecker]]<ref>http://www.timesonline.co.uk/article/0,,11069-2329203,00.html</ref> is an example.

==Production and trafficking==
[[Image:HeroinWorld.png|thumb|250px|left|Primary worldwide producers of heroin.]]
===Manufacturing===
Heroin is produced for the black market through [[opium]] refinement processes. Unlike drugs such as [[LSD]], the production of which requires considerable expertise in [[chemistry]] and access to constituents which are now tightly controlled, the refinement of the first three grades of heroin from opium is a relatively simple process requiring only moderate technical expertise and common chemicals. The final grade of heroin favored in the west is more difficult to produce and involves a potentially dangerous chemical procedure.

First, morphine is isolated from crude opium by being dissolved in water, reacted with [[agricultural lime|lime]] fertilizer such that the morphine precipitates out, and then reacted again with [[ammonia]]. What remains is then mechanically filtered to yield a final product of morphine weighing about 90% less than the original quantity of opium. The morphine is reacted with [[acetic anhydride]] — a chemical also used in the production of aspirin — in the complicated five-step process used by most refineries in the [[Golden Triangle (Southeast Asia)|Golden Triangle]]. The first step is to cook the morphine at 85°C (185°F) for six hours with an equivalent weight of acetic anhydride. In the second, a treatment of water and hydrochloric acid then purifies the product moderately. When the chemists add [[sodium carbonate]], the particulates settle. Step four involves heating the heroin in a mixture of [[alcohol]] and [[activated charcoal]] until the alcohol evaporates. The fifth step is optional, as it only changes the heroin into a finer white powder, more easily injectable; this so-called "no. 4 heroin" is principally exported to the Western markets. In this last, most dangerous step, the heroin (after being dissolved in alcohol), precipitates out in tiny white flakes when a mixture of [[ether]] and [[hydrochloric acid]] is injected; this step is dangerous due to the fact that the ether may explode, leveling or severely damaging the refinery (as has happened to a number of such facilities).

The purity of the extracted morphine determines in large part the quality of the resulting heroin. Most [[black market]] heroin is highly impure due to contaminants left after refinement of opium into morphine which then remain in the final product; even if the final product is in the upper range of purity (80–99% pure), once it reaches the consumer, it has typically been [[cutting agent|cut]] multiple times.

===History of heroin traffic===

The origins of the present international illegal heroin trade can be traced back to laws passed in many countries in the early 1900s that closely regulated the production and sale of opium and its derivatives including heroin. At first, heroin flowed from countries where it was still legal into countries where it was no longer legal. By the mid-1920s, heroin production had been made illegal in many parts of the world. An illegal trade developed at that time between heroin labs in China (mostly in Shanghai and Tientsin) and other nations. The weakness of government in China and conditions of civil war enabled heroin production to take root there. Chinese [[triad]] gangs eventually came to play a major role in the heroin trade.

Heroin trafficking was virtually eliminated in the U.S. during [[World War II]] due to temporary trade disruptions caused by the war. Japan's war with China had cut the normal distribution routes for heroin and the war had generally disrupted the movement of opium. After the second world war, the Mafia took advantage of the weakness of the postwar Italian government and set up heroin labs in Sicily. The Mafia took advantage of Sicily's location along the historic route opium took from Iran westward into Europe and the United States. Large scale international heroin production effectively ended in China with the victory of the communists in the civil war in the late 1940s. The elimination of Chinese production happened at the same time that Sicily's role in the trade developed.

Although it remained legal in some countries until after World War II, health risks, addiction, and widespread abuse led most western countries to declare heroin a controlled substance by the latter half of the 20th century.

Between the end of World War II and the 1970s, much of the opium consumed in the west was grown in [[Iran]], but in the late 1960s, under pressure from the U.S. and the [[United Nations]], Iran engaged in anti-opium policies. While opium production never ended in Iran, the decline in production in those countries led to the development of a major new cultivation base in the so-called "[[Golden Triangle (Southeast Asia)|Golden Triangle]]" region in South East Asia. In 1970-71, high-grade heroin laboratories opened in the Golden Triangle. This changed the dynamics of the heroin trade by expanding and decentralizing the trade. Opium production also increased in Afghanistan due to the efforts of Turkey and Iran to reduce production in their respective countries. Lebanon, a traditional opium supplier, also increased its role in the trade during years of civil war.

After the overthrow of the Shah of Iran, the new Iranian regime was much more tolerant of opium production. At the same time, the Soviet-Afghan war led to increased production in the Pakistani-Afghani border regions. Both events led to increased international production of heroin at lower prices in the 1980s. The trade shifted away from Sicily in the late 1970s as various criminal organizations violently fought with each other over the trade. The fighting also led to a stepped up government law enforcement presence in Sicily. All of this combined to greatly diminish the role of the country in the international heroin trade.

===Dr. Alfred W. McCoy's account of the history of the heroin trade===

Although it was beginning to become more prevalent by the 1930s, Asian historian and drug traffic expert Dr. Alfred W. McCoy reports that heroin trafficking was virtually eliminated in the U.S. during World War II due to temporary trade disruptions caused by the war. McCoy contends the Mafia was able to gain control of the heroin trade thanks in large measure due to the [[unintended consequences]] of a covert deal between top Mafia leader [[Lucky Luciano]] and American military intelligence. The deal resulted in a large increase in Mafia influence in Sicily after the 1943 American invasion. {{fact}}

In southeast Asia, the governments of most countries and many colonial officials had been involved in the opium trade for a very long time. Thanks to Corsican Mafia connections in the former French colony of Vietnam, Luciano was able to begin to develop Southeast Asia as a new source of Opium even as Iranian production declined. The [[Vietnam War]] and [[CIA]] operations in Laos had the unintended consequence of first opening up many areas of Southeast Asia to modern transportation and then presenting a ready-made market for the drug among the U.S. military personnel stationed in the region. {{fact}}

The turning point came in 1970-71 when the first high-grade heroin laboratories opened in the Golden Triangle. Prior to this, the chemical skills for refinement had existed only in Europe. This gave the opium producers control over the creation of the final product. The hundreds of thousands of American servicemen in Vietnam provided a perfect market for the heroin producers, and heroin use among soldiers rapidly increased. In 1971 the first large consignments of South East Asian heroin were intercepted in Europe and America, and by the mid-1970s heroin addiction fulfilled its promise as a serious social problem in the United States, Australia, the United Kingdom, and many other nations.{{fact}}

===Trafficking===
:''See also: [[Opium#Production Today|Opium production]]''
[[Image:Heroin asian.jpg|thumb|right|Asian heroin]]
[[Illegal drug trade|Traffic]] is heavy worldwide, with the biggest producer being [[Afghanistan]].<ref>{{cite web
| last =Nazemroaya
| first =Mahdi Darius
| year =2006
| month =October 17
|url=http://www.globalresearch.ca/index.php?context=viewArticle&code=NAZ20061017&articleId=3516
|title=The War in Afghanistan: Drugs, Money Laundering and the Banking System
|publisher=GlobalResearch.ca
|accessdate=2006-10-22
}}</ref> According to U.N. sponsored survey,<ref>{{cite web
|url=http://www.unodc.org/pdf/afg/afghanistan_opium_survey_2004.pdf
|title=Afghanistan opium survey - 2004
|publisher=
|accessdate=2006-10-22
}}</ref> as of 2004, Afghanistan accounted for production of 87 percent of the world's heroin.<ref>{{cite web
| last =McGirk
| first =Tim
| year = 2004
| month =August 2
| url =http://www.time.com/time/asia/magazine/printout/0,13675,501040809-674806,00.html
| title =Terrorism's Harvest: How al-Qaeda is tapping into the opium trade to finance its operations and destabilize Afghanistan
| publisher =Time Magazine Asia
| accessdate =2006-10-22
}}</ref> Opium production in that country has increased rapidly since, reaching an all-time high in 2006. War once again appeared as a facilitator of the trade.<ref>{{cite web
| last =Gall
| first =Carolotta
| year =2006
| month =September 3
| url =http://www.nytimes.com/2006/09/03/world/asia/03afghan.html?ex=1314936000&en=77aca21e09c8576e&ei=5088&partner=rssnyt&emc=rss
| title =Opium Harvest at Record Level in Afghanistan
| publisher =New York Times - Asia Pacific
| accessdate =2006-10-22
}}</ref>
[[Image:Balininelawrenceevidence.jpg|thumb|left|Heroin concealed under the clothes of a drug smuggler.]]

Dr. [[Alfred W. McCoy]] has claimed that the C.I.A. secretly collaborated with Asian drug syndicates and was complicit in the expansion of the global heroin trade from 1970 to 1973 in order to prosecute the Cold War. While the Vietnam War brought modern transportation to remote opium areas, McCoy himself does not claim that the CIA set up the drug labs in Southeast Asia or created the trade. {{fact}}

At present, opium poppies are mostly grown in the [[Middle East]], [[Pakistan]], and [[Afghanistan]], and in [[Asia]], especially in the region known as the Golden Triangle straddling [[Myanmar]], [[Thailand]], [[Vietnam]], [[Laos]] and [[Yunnan]] province in the [[People's Republic of China]]. There is also cultivation of opium poppies in the [[Sinaloa]] region of [[Mexico]] and in [[Colombia]]. The majority of the heroin consumed in the United States comes from Mexico and Colombia{{fact}}. Up until 2004, Pakistan was considered one of the biggest opium-growing countries. However, the efforts of Pakistan's [[Anti-Narcotics Force]] have since reduced the opium growing area by 59% [[as of 2001]]{{fact}}. Some suggest that the decline in Pakistani production is inversely proportional to the rise of Afghani production, and that rather than anti-narcotics activity, the decline in Pakistan is due more to changed market forces.{{fact}}

Conviction for trafficking in heroin carries the death penalty in most [[Southeast Asia]] and some [[East Asia]], [[southern Asia]] and Middle East countries (see [[Use of death penalty worldwide]] for details), among which [[Malaysia]], [[Singapore]] and Thailand are the most strict. The penalty applies even to citizens of countries where the penalty is not in place, sometimes causing controversy when foreign visitors are arrested for trafficking, for example the arrest of [[Bali Nine|nine Australians in Bali]] or the hanging of [[Australia]]n citizen [[Van Tuong Nguyen]] in Singapore, both in 2005.

==Risks of non-medical use==
* [[Overdose]], heroin rarely causes death alone, most overdoses are due to multi-drug use (particularly alcohol and/or benzodiazepines)
* For [[intravenous]] users of heroin (and any other substance), the use of non-sterile needles and syringes and other related equipment leads to the risk of contracting blood-borne [[pathogens]] such as [[HIV]] and [[hepatitis]], as well as the risk of contracting bacterial or fungal [[endocarditis]] and possibly Venous sclerosis
* Poisoning from [[contaminants]] added to "[[Cutting agent|cut]]" or [[dilute]] heroin
* Chronic [[constipation]]
* Heroin-induced [[toxic leukoencephalopathy]] (very rare, smokers only, probably due to a toxic byproduct of a cutting substance)
* [[Addiction]] and constantly growing tolerance. Like all opioids, heroin quickly cause physical addiction. Because endorphin receptors increase in number under continuous stimulation, tolerance also increases quickly.

Many countries and local governments have begun funding programs that supply [[sterilization (microbiology)|sterile]] needles to people who inject illegal drugs in an attempt to reduce these contingent risks and especially the contraction and spread of blood-borne diseases. The Drug Policy Alliance reports that up to 75% of new AIDS cases among women and children are directly or indirectly a consequence of drug use by injection. But despite the immediate [[public health]] benefit of [[needle-exchange programme|needle exchange]]s, some see such programs as tacit acceptance of illicit drug use. The United States does not support needle exchanges federally by law, and although some state and local governments do support needle exchange programs, they continue to face harassment by police in most areas. Needle exchanges have been instrumental in arresting the spread of HIV/AIDS in many communities with a significant heroin using population{{fact}}, Australia being a leader due to its early inception of needle exchanges. Needle exchange programs have also been attributed to saving the public significant amounts of tax dollars by preventing medical costs which would have been required otherwise for the treatment of diseases spread through the practice of sharing and reusing needles.

A heroin [[overdose]] is usually treated with an opioid [[Receptor antagonist|antagonist]], such as [[naloxone]] ([[Narcan]]) or [[naltrexone]], which have a high affinity for [[opioid receptors]] but do not activate them. This blocks heroin and other opioid agonists and causes an immediate return of consciousness and the beginning of [[withdrawal]] symptoms when administered intravenously. The [[half-life]] of these antagonists is usually much shorter than that of the opiate drugs they are used to block, so the antagonist usually has to be re-administered multiple times until the opiate has been metabolized by the body.

Depending on drug interactions and numerous other factors, death from overdose can take anywhere from several minutes to several hours due to anoxia because the breathing reflex is suppressed by µ-opioids. An overdose is immediately reversible with an [[opioid antagonist]] injection. Heroin overdoses can occur due to an unexpected increase in the dose or purity or due to diminished opiate tolerance. However, most fatalities reported as overdoses are probably caused by interactions with other [[depressant]] drugs like [[alcohol]] or [[benzodiazepine]]s.<ref>{{cite journal | author=Shane Darke, Deborah Zador|title=Fatal Heroin 'Overdose': a Review|url=http://www.lindesmith.org/library/darke2.cfm|journal=Addiction|year=1996|volume = 91|issue =12|pages= 1765-1772 }}</ref>

The [[LD50|LD<sub>50</sub>]] for a person already addicted is prohibitively high, to the point that there is no general medical consensus on where to place it. Several studies done in the 1920s gave addicts doses of 1,600–1,800 mg of heroin in one sitting, and no adverse effects were reported. This is approximately 160–180 times a normal recreational dose. Even for a non-addict, the LD<sub>50</sub> can be credibly placed above 350 mg.

Street heroin is of widely varying and unpredictable purity. This means that an addict may prepare what they consider to be a moderate dose while actually taking far more than intended. Also, relapsing addicts after a period of abstinence have tolerances below what they were during active addiction. If a dose comparable to their previous use is taken, a effect greater to what the user intended is caused, in extreme cases a overdose could result.

A final source of overdose in addicts comes from [[conditioning|place conditioning]]. Heroin use, like other drug abuse behaviors, is highly ritualized. While the mechanism has yet to be clearly elucidated, it has been shown that longtime heroin users, immediately before injecting in a common area for heroin use, show an acute increase in metabolism and a surge in the concentration of [[opiate]]-metabolizing [[enzyme]]s. This acute increase, a reaction to a location where the addict has repeatedly injected heroin, imbues the addict with a strong (but temporary) [[drug tolerance|tolerance]] to the toxic effects of the drug. When the addict injects in a different location, this place-conditioned tolerance does not occur, giving the addict a much lower-than-expected ability to metabolize the drug. The user's typical dose of the drug, in the face of decreased tolerance, becomes far too high and can be toxic, leading to overdose.[http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1196296]

A small percentage of heroin smokers may develop symptoms of [[toxic leukoencephalopathy]]. This is believed to be caused by an uncommon [[adulterant]] that is only active when heated. Symptoms include slurred speech and difficulty walking.

==Harm reduction approaches to heroin==
Proponents of the [[harm reduction]] philosophy seek to minimize the harms that arise from the recreational use of heroin. Safer means of taking the drug, such as smoking or nasal, oral and rectal insertion, are encouraged, due to the higher risks of overdose, infections and blood-borne viruses associated with [[drug injection]].
Where the strength of the drug is unknown, users are encouraged to try a small amount first to guage the strength, to minimize the risks of overdose. For the same reason, poly drug use (the use of two or more drugs at the one time) is discouraged. Users are also encouraged to not use heroin alone, as others can assist in the event of an overdose.
Heroin users who choose to inject should always use new needles and syringes where possible, and not share these with other users. Governments that support a harm reduction approach often supply new needles and syringes on a confidential basis, as well as education on proper filtering prior to injection, safer injection techniques and safe disposal of used injecting gear.

==Withdrawal==
[[Image:Heroin black tar.jpg|thumb|left|[[Black tar heroin]]]]

The withdrawal syndrome from heroin may begin starting from within 6 to 24 hours of discontinuation of sustained use of the drug; however, this time frame can fluctuate with the degree of tolerance as well as the amount of the last consumed dose. Symptoms may include: [[sweating]], [[malaise]], [[anxiety]], [[clinical depression|depression]], persistent and intense penile erection in males ([[priapism]]), extra sensitivity of the genitals in females, general feeling of heaviness, cramp-like pains in the limbs, yawning and [[lacrimation]], sleep difficulties, cold sweats, chills, severe muscle and bone aches not precipitated by any physical trauma, nausea and [[vomiting]], [[diarrhea]], [[goose bumps]], [[cramps]], and [[fever]]. In an addict with a high tolerance, heroin withdrawal may even lead to death <ref>http://www.drugaddictiontreatment.info/heroin.htm</ref>.

Many addicts also complain of a painful condition, the so-called "[[itchy blood]]", which often results in compulsive scratching that causes bruises and sometimes ruptures the skin, leaving scabs. Abrupt termination of heroin use causes muscle spasms in the legs of the user ([[restless leg syndrome]]). Users taking the "cold turkey" approach (withdrawal without using symptom-reducing or counteractive drugs) are more likely to experience the negative effects of withdrawal in a more pronounced manner.

Two general approaches are available to ease the physical part of opioid withdrawal. The first is to substitute a longer-acting opioid such as [[methadone]] or [[buprenorphine]] for heroin or another short-acting opioid and then slowly taper the dose.

[[image:Heroincan.jpg|thumb|300px|Heroin being cooked in an aluminium can]]
In the second approach, [[benzodiazepine]]s such as [[diazepam]] (Valium) may temporarily ease the often extreme anxiety of opioid withdrawal. The most common benzodiazepine employed as part of the detox protocol in these situations is [[oxazepam]] ([[Serax]]). Benzodiazepine use must be prescribed with care because benzodiazepines have a great addiction potential, and many opioid addicts also use other central nervous system [[depressants]] including [[barbiturates]]. Also, though unpleasant, opioid withdrawal seldom has the potential to be fatal, whereas complications related to withdrawal from benzodiazepines, [[barbiturates]] and alcohol (such as epileptic [[seizures]], [[cardiac arrest]], and [[delirium tremens]]) can prove hazardous and are potentially fatal. Many symptoms of opioid withdrawal are due to rebound hyperactivity of the [[sympathetic nervous system]], which can be suppressed with [[clonidine]] (Catapres), a centrally-acting alpha-2 agonist primarily used to treat [[hypertension]].

[[Buprenorphine]] is one of the substances most recently licensed for the substitution of illegal opioids. Being a partial opioid agonist/antagonist, it develops a lower grade of tolerance than heroin or methadone due to the so-called ceiling effect. It also has less severe withdrawal symptoms than heroin when discontinued abruptly, which should never be done without proper medical supervision. It is usually administered every 24-48 hrs. Buprenorphine is a kappa-opioid receptor antagonist. This gives the drug an anti-depressant effect, increasing physical and intellectual activity. {{fact}} Buprenorphine also acts as a partial agonist at the same μ-receptor where illicit opioids like heroin exhibit their action. Due to its effects on this receptor, all patients whose tolerance is above a certain level are unable to obtain any "high" from other opioids during buprenorphine treatment except for very high doses.

Researchers at [[Johns Hopkins University]] have been testing a sustained-release "depot" form of buprenorphine that can relieve cravings and withdrawal symptoms for up to six weeks.<ref>{{cite web
| last = Thomas| first = Josephine| year = May 2001
| url = http://www.nida.nih.gov/PDF/NNCollections/NNHeroin.pdf
| title = Buprenorphine Proves Effective, Expands Options For Treatment of Heroin Addiction
| format = PDF| work = NIDA Notes: Articles that address research on Heroin| pages = 23
| publisher = [[National Institute on Drug Abuse]]
| accessdate = May 5| accessyear = 2006
}}</ref> A sustained-release formulation would allow for easier administration and adherence to treatment, and reduce the risk of diversion or misuse.

Methadone is another μ-opioid agonist most often used to substitute for heroin in treatment for heroin addiction. Compared to heroin, methadone is well (but slowly) absorbed by the gastrointestinal tract and has a much longer duration of action of approximately 24 hours. Thus [[methadone maintenance]] avoids the rapid cycling between [[intoxication]] and withdrawal associated with heroin addiction. In this way, methadone has shown some success as a "less harmful substitute"; despite bearing about the same addiction potential as heroin, it is recommended for those who have repeatedly failed to complete withdrawal or have recently relapsed. As of 2005, the μ-[[opioid]] [[agonist]] [[buprenorphine]] is also being used to manage heroin addiction, being a superior, though still imperfect and not yet widely known alternative to methadone. Methadone, since it is longer-acting, produces withdrawal symptoms that appear later than with heroin, but usually last considerably longer and can in some cases be more intense. Methadone withdrawal symptoms can potentially persist for over a month, compared to heroin where significant physical symptoms would subside by 4 days.

Two opioid [[antagonists]] are known: [[naloxone]] and the longer-acting [[naltrexone]]. These two medications block the effects of heroin, as well as the other opioids at the receptor site. Recent studies have suggested that the addition of naloxone and naltrexone may improve the success rate in treatment programs when combined with the traditional therapy. {{fact}}

The [[University of Chicago]] undertook preliminary development of a heroin vaccine in [[monkeys]] during the 1970s, but it was abandoned. There were two main reasons for this. Firstly, when immunised monkeys had an increase in dose of x16, their [[antibodies]] became [[saturation (chemistry)|saturated]] and the monkey had the same effect from heroin as non-immunised monkeys. Secondly, until they reached the x16 point immunised monkeys would substitute other drugs to get a heroin-like effect. These factors suggested that immunised human addicts would simply either take massive quantities of heroin, or switch to other hard drugs, which is known as [[cross-tolerance]].

There is also a controversial treatment for heroin addiction based on a plant-derived African psychedelic drug, [[ibogaine]]. Many people travel abroad for ibogaine treatments that generally interrupt the addiction for 3 - 6 months or more in up to 80% of patients.{{fact}} Relapse often occurs when the person returns home to their normal environment however, where drug seeking behaviour may return in response to social and environmental cues.{{fact}} Ibogaine treatments are carried out in several countries in South America and in Europe but can be dangerous. Some addicts find the ibogaine therapy most effective when it is given several times over the course of a few months or years, but this can be very expensive. A synthetic derivative of ibogaine, [[18-methoxycoronaridine]] is in phase 2 trials in humans as an anti-addictive drug.

== Heroin prescription ==
The UK Department of Health's Rolleston Committee report in 1926 established the British approach to [[heroin prescription]] to addicts, which was maintained for the next forty years: dealers were prosecuted, but doctors could prescribe heroin to addicts when withdrawing it would cause harm or severe distress to the patient. This "policing and prescribing" policy effectively controlled the heroin problem in the UK until the 1960s. Attitudes eventually began to change, however: in 1964 only specialised clinics and selected approved doctors were allowed to prescribe heroin to addicts. Eventually, from the 1970s, the emphasis shifted to abstinence and the prescription of methadone, until now only a small number of addicts in the UK are prescribed heroin.<ref>{{cite web
| last =Goldacre
| first =Ben
| year =1998
| url =http://www.badscience.net/?p=327
| title =Methadone and Heroin: An Exercise in Medical Scepticism
| accessdate =2006-12-18
}}</ref>

In 1994 Switzerland began a trial program featuring a heroin prescription for addicts not well suited for withdrawal programs—e.g. those that had failed multiple withdrawal programs. The aim is maintaining the health of the addict in order to avoid medical problems stemming from low-quality street heroin. Reducing [[drug-related crime]] was another goal. Addicts can more easily get or maintain a paid job through the program as well. The first trial in [[1994]] began with 340 addicts and it was later expanded to 1000 after medical and social studies suggested its continuation. Participants are prescribed to inject heroin in specially designed pharmacies for about US $13 per dose.<ref>{{cite web
| last =Nadelmann
| first =Ethan
| year =1995
| month =July 10
| url =http://www.drugpolicy.org/library%5Ctlcnr.cfm
| title =Switzerland's Heroin Experiment
| publisher =Drug Policy Alliance
| accessdate =2006-10-22
}}</ref>

The success of the Swiss trials led German, Dutch,<ref>{{cite web
| year = 2005
| month =June 5
| url =http://news.bbc.co.uk/2/hi/health/4607233.stm
| title =Heroin prescription 'cuts costs'
| publisher =BBC News
| accessdate =2006-10-22
}}</ref> and Canadian<ref>{{cite web
| url =http://www.naomistudy.ca/
| title =About the study
| publisher =North American Opiate Medication Initiative
| accessdate =2006-10-22
}}</ref> cities to trial their own heroin prescription programs.<ref>{{cite web
| last =
| first =
| coauthors = Carlos Nordt, Rudolf Stabler
| year = 2006
| month ='''367''', 1830-4,
| url =http://www.cesda.net/downloads/lancet1.pdf
| title =Incidence of heroin use in Zurich, Switzerland: a treatment case register analysis
| format =PDF
| publisher =The Lancet
| language =
| accessdate =2006-10-22
}}</ref> Some Australian cities (such as Sydney) have trialed legal heroin injecting rooms, in line with other wider [[harm minimisation]] programs. Heroin is unavailable on prescription however, and remains illegal outside the injecting room, and effectively decriminalised inside of the injecting room. {{fact}}

==Drug interactions==
Opioids are strong [[central nervous system]] depressants, but regular users develop [[physiological tolerance]] allowing gradually increased dosages. In combination with other central nervous system depressants, heroin may still kill even experienced users, particularly if their tolerance to the drug has reduced or the strength of their usual dose has increased.

[[Toxicology]] studies of heroin-related deaths reveal frequent involvement of other central nervous system depressants, including alcohol, benzodiazepines such as diazepam ([[valium]]), and, to a rising degree, methadone. Ironically, benzodiazepines are often used in the treatment of heroin addiction while they cause much more severe withdrawal symptoms.

[[Cocaine]] also proves to be often fatal when used in combination with heroin. Though "[[speedballs]]" (when injected) or "[[moonrocks]]" (when smoked) are a popular mix of the two drugs among users, combinations of [[stimulants]] and depressants can have unpredictable and sometimes fatal results. In the United States in early 2006, a rash of deaths was attributed to either a combination of [[fentanyl]] and heroin, or pure fentanyl [[Wiktionary:masquerading|masquerading]] as heroin particularly in the Detroit Metro Area; one news report refers to the combination as 'laced heroin', though this is likely a generic rather than a specific term.<ref>{{cite news
|first=Robin
|last=Brown
|title=Heroin's Hell
|publisher=[[The News Journal]]
|pages=A1,A12
|date=[[2006-05-04]]
}}</ref>

==Culture==
{{main|Heroin in popular culture}}
Heroin has inspired countless writers, musicians and other artists over the past century of use. However, its influence is often misunderstood or unfairly assumed; many creative people have used or been addicted to heroin, but the extent to which the drug affected their creativity is debatable. Relatively few artists with great talent have credited heroin use with major epiphanies. The 1996 [[Danny Boyle]] film [[Trainspotting (film)|Trainspotting]], based on the book by [[Irvine Welsh]], depicts heroin addicts in the areas around Edinburgh in Scotland. A notable song by [[The Velvet Underground]] is titled "[[Heroin (song)|Heroin]]", as is the [[System of a Down]] song; "[[She's like Heroin]]".

==See also==
{{wikinewspar| 2005 Afghan opium harvest begins}}
*[[Black Tar Heroin]]
*[[Cheese (recreational drug)|Cheese]] (recreational drug)
*[[Oxycodone#Abuse|Hillbilly heroin]]
*[[China white|China White]]
*[[Drugs and prostitution]]
*[[Morphine]]
*[[Monoacetylmorphine]]
*[[Dipropanoylmorphine]]
*[[Diacetyldihydromorphine]]
*[[Recreational drug use]]
*[[Psychoactive drug]]
*[[List of people known to be addicted to opiates]]
*[[List of famous drug smugglers]]
*[[Opium]]
*[[Poppy]]
*[[Drug injection]]

==References==
<div class="references-small"><references/></div>

==Literature==

*''Heroin'' (1998) ISBN 1-56838-153-0
*''Heroin Century'' (2002) ISBN 0-415-27899-6
*''This is Heroin'' (2002) ISBN 1-86074-424-9
*''The Heroin User's Handbook'' by [[Francis Moraes]] (paperback 2004) ISBN 1-55950-216-9
*''The Little Book of Heroin'' by Francis Moraes (paperback 2000) ISBN 0-914171-98-4
*''Heroin: A True Story of Addiction, Hope and Triumph'' by Julie O'Toole (paperback 2005) ISBN 1-905379-01-3

==External links==
{{Commons|Heroin}}
*[http://www.geopium.org Geopium: Geopolitics of Illicit Drugs in Asia, especially opium and heroin production and trafficking in and around Afghanistan and Burma (Articles and maps and French and English)]
*[http://www.watton.org/drugsinfo/aboutheroin.shtml Drugs Factfile what you really need to know]
*[http://www.heroinhelper.com/ Heroin Helper]
*[https://www.cia.gov/cia/publications/heroin/flowers_to_heroin.htm From Flowers to Heroin], CIA publication.
*[http://wired-vig.wired.com/wired/archive/13.04/bupe.html?pg=1&topic=bupe&topic_set= The mismanagement of methadone]
*[http://navisite.collegeclub.com/servlet/channels.ChannelArticleServlet?articleid=4461&areaid=8&grid-messageboard-page=1 Harrowing Heroin by Geoff Morton]
*[http://www.NAABT.org/ National Alliance of Advocates for Buprenorphine Treatment - non-profit education website for treatment of Heroin addiction]
*[http://www.nida.nih.gov/Infofacts/heroin.html NIDA InfoFacts on Heroin]
*[http://www.whitehousedrugpolicy.gov/drugfact/heroin/ ONDCP Drug Facts]
*[http://www.paksearch.com/globe/2001/june/narcotics.html Role of Government of Pakistan in Narcotics Control]
*[http://usinfo.state.gov/is/Archive_Index/Pakistans_Cultivation_of_Opium_Drops.html United States Department of State fact sheet: anti-narcotics efforts in Pakistan] - dated [[June 7]], [[2002]]
*[http://news.bbc.co.uk/1/hi/magazine/4647018.stm BBC Article entitled 'When Heroin Was Legal'. References to the United Kingdom and the United States]
*[http://www.heroin.org Heroin Facts]
* [http://www.quihn.org.au/illicit_drug_use_information.htm Information on heroin and other illicit drugs]
*[http://www.reallymadmonkey.com/index2.php?c=poppy_seeds Can poppy seeds make you test positive for heroin?]
*[http://historyofalcoholanddrugs.typepad.com/alcohol_and_drugs_history/heroin/index.html Heroin news page] - [[Alcohol and Drugs History Society]]
*[http://www.heroin-detox.com Discussion forum about heroin and other opiates]

{{ChemicalSources}}

{{Analgesics}}

[[Category:Heroin| ]]


[[bg:Хероин]]
[[ca:Heroïna]]
[[cs:Heroin]]
[[da:Heroin]]
[[de:Heroin]]
[[es:Heroína]]
[[eo:Heroino]]
[[eu:Heroina]]
[[fa:هروئین]]
[[fr:Diacétylmorphine]]
[[gl:Heroína]]
[[hr:Heroin]]
[[id:Heroin]]
[[is:Heróín]]
[[it:Eroina]]
[[he:הרואין]]
[[lt:Heroinas]]
[[hu:Heroin]]
[[ms:Heroin]]
[[nl:Heroïne]]
[[ja:ヘロイン]]
[[no:Heroin]]
[[nn:Heroin]]
[[pl:Heroina]]
[[pt:Heroína]]
[[ru:Героин]]
[[sr:Хероин]]
[[fi:Heroiini]]
[[sv:Heroin]]
[[th:เฮโรอีน]]
[[vi:Bạch phiến]]
[[uk:Героїн]]
[[zh:海洛因]]

Hepatitis C

2007-02-05T06:09:10Z

Quihn:

{{dablink|This page is for the disease. For the virus, see [[Hepatitis C virus]].}}

{{Infobox_Disease |
Name = Hepatitis C |
Image = |
Caption = |
DiseasesDB = 5783 |
ICD10 = {{ICD10|B|17|1|b|15}}, {{ICD10|B|18|2|b|15}} |
ICD9 = {{ICD9|070.4}}, {{ICD9|070.5}} |
ICDO = |
OMIM = 609532 |
MedlinePlus = 000284 |
eMedicineSubj = med |
eMedicineTopic = 993 |
}}
'''Hepatitis C''' is a [[Blood-borne disease|blood-borne]], infectious, [[virus|viral]] disease that is caused by a hepatotropic virus called ''[[Hepatitis C virus]]'' ('''HCV''').<ref name=Sherris>{{cite book | author = Ryan KJ; Ray CG (editors) | title = Sherris Medical Microbiology | edition = 4th ed. | publisher = McGraw Hill | year = 2004 | pages=pp. 551–2 | id = ISBN 0838585299 }}</ref> The infection can cause [[hepatitis|liver inflammation]] that is often asymptomatic, but ensuing chronic hepatitis can result later in [[cirrhosis]] ([[Fibrosis|fibrotic scarring]] of the liver) and [[hepatocellular carcinoma|liver cancer]].

The hepatitis C virus (HCV) is spread by blood-to-blood contact with an infected person's [[blood]]. While the symptoms can be medically managed, there are no curative treatements. Although modification of diet and early medical intervention are helpful, people with HCV infection often experience mild symptoms, and subesquently do not seek treatment.<ref name=Sherris /> An estimated 150-200 million people worldwide are infected with hepatitis C. In the U.S., those with a history of intravenous drug use, [[tattoo]]s, or who have been exposed to blood via unsafe sex or social practices are high risk for this disease. Hepatitis C is the leading cause of [[liver transplant]] in the United States.

The hepatitis C virus is one of six known hepatitis viruses: [[hepatitis A|A]], [[hepatitis B|B]], C, [[hepatitis D|D]], [[hepatitis E|E]], [[hepatitis G|G]].
[[Image:Liver 1.jpg|thumbnail|right|400px|[[cirrhosis|Cirrhosis of the liver]] and [[hepatocellular carcinoma|liver cancer]] may ensue from Hepatitis C.]]

==History==
In the mid 1970s, [[Harvey J. Alter]], Chief of the Infectious Disease Section in the Department of Transfusion Medicine at the [[National Institutes of Health]] (NIH), and his research team demonstrated that most post-transfusion hepatitis cases were not due to [[hepatitis A]] and [[Hepatitis B|B]] viruses. Despite this discovery, international research effort to identify the virus, initially called ''non-A, non-B hepatitis'' (NANBH), failed for the next decade. In [[1987]], Michael Houghton, Qui-Lim Choo, and George Kuo at Chiron Corporation utilized [[molecular cloning]] to identify the unknown organism. In [[1988]], the virus was confirmed by Alter by verifying its presence in a panel of NANBH specimens. In April of [[1989]], the discovery of the virus, re-named hepatitis C virus (HCV), was published in two articles in the journal ''Science''.<ref name="chiron">[http://www.chiron.com Chiron Corporation] ''Chiron Hepatitis C Research Honored with 2000 Lasker Award for Clinical Medical Research'' Press release, [[18 September]] [[2000]].</ref><ref name="choo">{{cite journal | author = Choo Q, Kuo G, Weiner A, Overby L, Bradley D, Houghton M | title = Isolation of a cDNA clone derived from a blood-borne non-A, non-B viral hepatitis genome. | journal = Science | volume = 244 | issue = 4902 | pages = 359-62 | year = 1989 | id = PMID 2523562}}</ref><ref name="kuo">{{cite journal | author = Kuo G, Choo Q, Alter H, Gitnick G, Redeker A, Purcell R, Miyamura T, Dienstag J, Alter M, Stevens C | title = An assay for circulating antibodies to a major etiologic virus of human non-A, non-B hepatitis. | journal = Science | volume = 244 | issue = 4902 | pages = 362-4 | year = 1989 | id = PMID 2496467}}</ref><ref name="houghton">Houghton, M., Q.-L. Choo, and G. Kuo. ''NANBV Diagnostics and Vaccines.'' European Patent No. EP-0-3 18-216-A1. European Patent Office (filed [[18 November]] [[1988]], published [[31 May]] [[1989]]).</ref>

==Signs and symptoms==
===Acute Hepatitis C===
Acute hepatitis C refers to the first 6 months after infection with HCV. Between 60% to 70% of people infected develop no symptoms during the acute phase. In the minority of patients who experience acute phase symptoms, they are generally mild and nonspecific, and rarely lead to a specific diagnosis of hepatitis C. Symptoms of acute hepatitis C infection include decreased appetite, fatigue, [[abdominal pain]], [[jaundice]], [[itching]], and flu-like symptoms.

The hepatitis C virus is usually detectable in the blood within one to three weeks after infection, and antibodies to the virus are generally detectable within 3 to 12 weeks. Approximately 20-30% of persons infected with HCV clear the virus from their bodies during the acute phase as shown by normalization in [[liver function tests]] (LFTs) such as [[alanine transaminase]] (ALT) & [[aspartate transaminase]] (AST) normalization, as well as plasma HCV-RNA clearance (this is known as ''spontaneous viral clearance''). The remaining 70-80% of patients infected with HCV develop [[chronic (medicine)|chronic]] hepatitis C, i.e., infection lasting more than 6 months.

Previous practice was to not treat acute infections to see if the person would spontaneously clear; recent studies have shown that treatment during the acute phase of genotype 1 infections has a greater than 90% success rate with half the treatment time required for chronic infections, but that the majority of acute hepatitis C is cleared. <ref name=Jaeckel>{{cite journal | author = Jaeckel E, Cornberg M, Wedemeyer H, Santantonio T, Mayer J, Zankel M, Pastore G, Dietrich M, Trautwein C, Manns MP | title = Treatment of acute hepatitis C with interferon alfa-2b | journal = New England Journal of Medicine | year = 2001 | month = Nov | volume = 345 | issue = 20 | pages = 1452-1457 | id = PMID 11794193 }}</ref>

===Chronic Hepatitis C===
Chronic hepatitis C is defined as infection with the hepatitis C virus persisting for more than six months. Clinically, it is often asymptomatic (without jaundice) and it is mostly discovered accidentally.

The natural course of chronic hepatitis C varies considerably from one person to another. Virtually all people infected with HCV have evidence of inflammation on liver biopsy, however, the rate of progression of liver scarring (fibrosis) shows significant variability among individuals. Recent data suggests that among untreated patients, roughly one-third progress to liver cirrhosis in less than 20 years. Another third progress to cirrhosis within 30 years. The remainder of patients appear to progress so slowly that they are unlikely to develop cirrhosis within their lifetimes. Factors that have been reported to influence the rate of HCV disease progression include age (increasing age associated with more rapid progression), gender (males have more rapid disease progression than females), alcohol consumption (associated with an increased rate of disease progression), HIV coinfection (associated with a markedly increased rate of disease progression), and fatty liver (the presence of fat in liver cells has been associated with an increased rate of disease progression).

Symptoms specifically suggestive of liver disease are typically absent until substantial scarring of the liver has occurred. However, hepatitis C is a systemic disease and patients may experience a wide spectrum of clinical manifestations ranging from an absence of symptoms to debilitating illness prior to the development of advanced liver disease. Generalized signs and symptoms associated with chronic hepatitis C include fatigue, marked weight loss, flu-like symptoms, muscle pain, joint pain, intermittent low-grade fevers, itching, sleep disturbances, abdominal pain (especially in the right upper quadrant), appetite changes, nausea, diarrhea, dyspepsia, cognitive changes, depression, headaches, and mood swings.

Once chronic hepatitis C has progressed to cirrhosis, signs and symptoms may appear that are generally caused by either decreased liver function or increased pressure in the liver circulation, a condition known as portal hypertension. Possible signs and symptoms of liver cirrhosis include [[ascites]] (accumulation of fluid in the abdomen), bruising and bleeding tendency, bone pain, [[varices]] (enlarged veins, especially in the stomach and esophagus), fatty stools ([[steatorrhea]]), [[jaundice]], and a syndrome of cognitive impairment known as [[hepatic encephalopathy]].

Liver function tests show variable elevation of [[ALAT]], [[AST]] and [[GGTP]] and periodically they might show normal results. Usually [[prothrombin]] and [[serum albumin|albumin]] results are normal.

Chronic hepatitis C, more than other forms of hepatitis, is diagnosed because of extrahepatic manifestations associated with the presence of HCV such as [[thyroiditis]] (inflammation of the thyroid) with hyperthyreosis or hypothyreosis, [[porphyria cutanea tarda]], [[cryoglobulinemia]] (a form of [[vasculitis]])<ref name="pascual">{{cite journal | author = Pascual M, Perrin L, Giostra E, Schifferli J | title = Hepatitis C virus in patients with cryoglobulinemia type II. | journal = J Infect Dis | volume = 162 | issue = 2 | pages = 569-70 | year = 1990 | id = PMID 2115556}}</ref> and [[glomerulonephritis]] (inflammation of the kidney), specifically [[membranoproliferative glomerulonephritis]] (MPGN)<ref name="johnson">{{cite journal | author = Johnson R, Gretch D, Yamabe H, Hart J, Bacchi C, Hartwell P, Couser W, Corey L, Wener M, Alpers C | title = Membranoproliferative glomerulonephritis associated with hepatitis C virus infection. | journal = N Engl J Med | volume = 328 | issue = 7 | pages = 465-70 | year = 1993 | id = PMID 7678440}}</ref>. Hepatitis C is also associated with [[sicca]] syndrome, [[thrombocytopenia]], [[lichen planus]], [[diabetes mellitus]] and with B-cell [[lymphoproliferative disorder]]s.<ref name=Extrahepatic>{{cite journal | author = Zignego AL, Ferri C, Pileri SA, Caini P, Bianchi FB; for the Italian Association of the Study of Liver (A.I.S.F.) Commission on Extrahepatic Manifestations of HCV infection | title = Extrahepatic manifestations of Hepatitis C Virus infection: A general overview and guidelines for a clinical approach | journal = Dig Liver Dis. | volume = | issue = | pages = E-publication | year = 2006 | id = PMID 16884964}}</ref>

==Diagnosis==
The diagnosis of hepatitis C is rarely made during the acute phase of the disease because the majority of people infected experience no symptoms during this phase of the disease. Those who ''do'' experience acute phase symptoms are rarely ill enough to seek medical attention. The diagnosis of chronic phase hepatitis C is also challenging due to the absence or lack of specificity of symptoms until advanced liver disease develops, which may not occur until decades into the disease.

Chronic hepatitis C may be suspected on the basis of the [[medical history]], a history of piercings or [[tattoo]]s, unexplained symptoms, or abnormal liver enzymes or liver function tests found during routine blood testing. Occasionally, hepatitis C is diagnosed as a result of targeted screening such as [[blood donation]] (blood donors are screened for numerous blood-borne diseases including hepatitis C) or [[contact tracing]].

Hepatitis C testing begins with [[serology|serological]] blood tests used to detect antibodies to HCV. Anti-HCV antibodies can be detected in 80% of patients within 15 weeks after exposure, in >90% within 5 months after exposure, and in >97% by 6 months after exposure. Overall, HCV antibody tests have a strong [[positive predictive value]] for exposure to the hepatitis C virus, but may miss patients who have not yet developed antibodies ([[seroconversion]]), or have an insufficient level of antibodies to detect. While uncommon, a small minority of people infected with HCV never develop antibodies to the virus and therefore, never test positive using HCV antibody screening.

Anti-HCV antibodies indicate exposure to the virus, but ''cannot'' determine if ongoing infection is present. All persons with positive anti-HCV antibody tests must undergo additional testing for the presence of the hepatitis C virus itself to determine whether current infection is present. The presence of the virus is tested for using molecular nucleic acid testing methods such as polymerase chain reaction (PCR), transcription mediated amplification (TMA), or branched DNA (b-DNA). All HCV nucleic acid molecular tests have the capacity to detect not only whether the virus is present, but also to measure the amount of virus present in the blood (the HCV viral load). The HCV viral load is an important factor in determining the probability of response to interferon-base therapy, but does ''not'' indicate disease severity nor the likelihood of disease progression.

In people with confirmed HCV infection, genotype testing is generally recommended. There are six major genotypes of the hepatitis C virus, which are indicated numerically (e.g., genotype 1, genotype 2, etc.). HCV genotype testing is used to determine the required length and potential response to interferon-based therapy.

==Virology==
{{main|Hepatitis C virus}}
The '''''Hepatitis C virus''''' ('''HCV''') is a small (50 [[metre#SI prefixes|nm]] in size), enveloped, single-stranded, positive sense [[RNA]] virus in the families ''[[Flaviviridae]]''.

==Transmission==
[[Image:Sources of Infection for Persons with Hepatitis C (CDC) US.png|thumb|350px|right|CDC figures for sources of infection in the US. [http://www.cdc.gov/ncidod/diseases/hepatitis/c/plan/HCV_infection.htm Source]]]
The hepatitis C virus (HCV) is transmitted by blood-to-blood contact. In developed countries, it is estimated that 90% of persons with chronic HCV infection were infected through transfusion of unscreened blood or blood products or via injecting drug use. In developing countries, the primary sources of HCV infection are unsterilized injection equipment and infusion of inadequately screened blood and blood products.

Although injection drug use and receipt of infected blood/blood products are the most common routes of HCV infection, ''any'' practice, activity, or situation that involves blood-to-blood exposure can potentially be a source of HCV infection.

===Methods of transmission===
Several activities and practices have been identified as potential sources of exposure to the hepatitis C virus. Anyone who may have been exposed to HCV through one or more of these routes should be screened for hepatitis C.

;Injection drug use
Those who currently or have previously injected drugs are at increased risk for getting hepatitis C because they may be sharing needles or other [[drug paraphernalia]] (includes cookers, cotton, spoons, water, etc.), which may be contaminated with HCV-infected blood. An estimated 60% to 80% of all IV drug users in the United States have been infected with HCV. HCV is also transmitted by inhalational drugs, such as intranasal cocaine usage. [[Harm reduction]] strategies are encouraged in many countries to reduce the spread of hepatitis C, through education, provision of clean needles and syringes, and safer injecting techniques.

;Insuffulated drug use (Drugs which are "snorted")
Researchers have suggested that the transmission of HCV may be possible through the insuffulation of illegal drugs such as cocaine and crank when straws ( containing even trace elements of mucous and blood) are shared among users.<ref name=Thompson_1996>{{cite journal |author=Thompson S, Hernberger F, Wale E, Crofts N |title=Hepatitis C transmission through tattooing: a case report |journal=Aust N Z J Public Health |volume=20 |issue=3 |pages=317-8 |year=1996 |id=PMID 8768424}}</ref>

;Blood products
[[Blood transfusion]], blood products, or [[organ transplantation]] prior to implementation of HCV screening (in the U.S., this would refer to procedures prior to 1992) is a decreasing risk factor for hepatitis C.

The virus was first isolated in 1989 and reliable tests to screen for the virus were not available until 1992. Therefore, those who received blood or blood products prior to the implementation of screening the blood supply for HCV may have been exposed to the virus. Blood products include clotting factors (taken by [[hemophilia]]cs), immuneglobulin, Rhogam, platelets, and plasma. As of 2001, the Centers for Disease Control and Prevention reports that the risk of HCV infection from a unit of transfused blood in the United States is less than one per million transfused units.

;Iatrogenic medical or dental exposure
People can be exposed to HCV via inadequately or improperly sterilized medical or dental equipment. Examples include equipment that may harbor contaminated blood if improperly sterilized include reused needles or syringes, hemodialysis equipment, oral hygiene instruments, and jet air guns, etc. Scrupulous use of appropriate sterilization techniques and proper disposal of used equipment can bring the risk of iatrogenic exposure to HCV to virtually zero.

;Occupational exposure to blood
Medical and dental personnel, first responders (e.g., firefighters, paramedics, emergency medical technicians, law enforcement officers), and military combat personnel can be exposed to HCV through accidental exposure to blood through accidental needlesticks or blood spatter to the eyes. Universal precautions to protect against such accidental exposures significantly reduce the risk of exposure to HCV.

;Recreational exposure to blood
Contact sports and other activities, such as "slam dancing" that may result in accidental blood-to-blood exposure are potential sources of exposure to HCV.

;Sexual exposure to blood
Although HCV is not a [[sexually transmitted disease]] (STD), transmission can occur during unprotected sexual contact if the sexual activity involves blood-to-blood contact. The sexual spread of HCV is due to blood-blood contact rather than the presence of the [[virus]] in [[vaginal fluid]] or [[semen]].

;Body piercings and tattoos
Tattooing dyes, ink pots, stylets and piercing implements can transmit HCV-infected blood from one person to another if proper sterilization techniques are not followed. Tattoos or piercings performed before the mid 1980's, "underground," or non-professionally are of particularly concern since sterile techniques in such settings may have been or be insufficient to prevent disease.

;Shared personal care items
Personal care items such as razors, toothbrushes, cuticle scissors, and other manicuring or pedicuring equipment can easily be contaminated with blood. Sharing such items can potentially lead to exposure to HCV.

HCV is ''not'' spread through casual contact such as hugging, kissing, or sharing eating or cooking utensils.

===Vertical transmission===
[[Vertical transmission]] refers to the transmission of a communicable disease from an infected mother to her child during the birth process. Mother-to-child transmission of hepatitis C has been well described, but occurs relatively infrequently. Transmission occurs only among women who are HCV RNA positive at the time of delivery; the risk of transmission in this setting is approximately 6 out of 100. Among women who are both HCV and HIV positive at the time of delivery, the risk of HCV is increased to approximately 25 out of 100.

The risk of vertical transmission of HCV does ''not'' appear to be associated with method of delivery or breast feeding.

==Epidemiology==
Hepatitis C infects an estimated 170 million people worldwide and 4 million in the United States. There are about 35,000 to 185,000 new cases a year in the United States. Co-infection with [[HIV]] is common and rates among HIV positive populations are higher. 10,000-20,000 deaths a year in the United States are from HCV; expectations are that this mortality rate will increase, as those who were infected by transfusion before HCV testing become apparent. A survey conducted in California showed prevalence of up to 34% among prison inmates;<ref>{{cite journal | author = Ruiz J, Molitor F, Plagenhoef J | title = Trends in hepatitis C and HIV infection among inmates entering prisons in California, 1994 versus 1999. | journal = AIDS | volume = 16 | issue = 16 | pages = 2236-8 | year = 2002 | id = PMID 12409752}}</ref>
82% of subjects diagnosed with hepatitis C have previously been in jail,<ref>{{cite journal | author = Campbell J, Hagan H, Latka M, Garfein R, Golub E, Coady M, Thomas D, Strathdee S | title = High prevalence of alcohol use among hepatitis C virus antibody positive injection drug users in three US cities. | journal = Drug Alcohol Depend | volume = 81 | issue = 3 | pages = 259-65 | year = 2006 | id = PMID 16129567}}</ref>
and transmission while in prison is well described.<ref>{{cite journal | author = McGovern B, Wurcel A, Kim A, Schulze zur Wiesch J, Bica I, Zaman M, Timm J, Walker B, Lauer G | title = Acute hepatitis C virus infection in incarcerated injection drug users. | journal = Clin Infect Dis | volume = 42 | issue = 12 | pages = 1663-70 | year = 2006 | id = PMID 16705568}}</ref>

[[Egypt]] has the highest seroprevalence for HCV, up to 20% in some areas. There is a hypothesis that the high prevalence was linked, in 2000, to a mass-treatment campaign for [[schistosomiasis]], which is endemic in that country.<ref name="frank">{{cite journal | author = Frank C, Mohamed M, Strickland G, Lavanchy D, Arthur R, Magder L, El Khoby T, Abdel-Wahab Y, Aly Ohn E, Anwar W, Sallam I | title = The role of parenteral antischistosomal therapy in the spread of hepatitis C virus in Egypt. | journal = Lancet | volume = 355 | issue = 9207 | pages = 887-91 | year = 2000 | id = PMID 10752705}}</ref>

===Co-infection with HIV===
Approximately 350,000, or 35% of patients in the USA infected with HIV are also infected with the hepatitis C virus, mainly because both viruses are blood-borne and present in similar populations. In other countries, co-infection is less common, this is possibly related to differing drug policies. HCV is the leading cause of chronic liver disease in the USA. It has been demonstrated in clinical studies that HIV infection causes a more rapid progression of chronic hepatitis C to cirrhosis and liver failure. This is not to say treatment is not an option for those living with co-infection.

==Treatment and prognosis==
There is a very small chance of clearing the virus spontaneously (0.5 to 0.74% per year),<ref name=Watanabe_2003>{{cite journal |author=Watanabe H, Saito T, Shinzawa H, Okumoto K, Hattori E, Adachi T, Takeda T, Sugahara K, Ito J, Saito K, Togashi H, Suzuki R, Hayashi M, Miyamura T, Matsuura Y, Kawata S |title=Spontaneous elimination of serum hepatitis C virus (HCV) RNA in chronic HCV carriers: a population-based cohort study |journal=J Med Virol |volume=71 |issue=1 |pages=56-61 |year=2003 |id=PMID 12858409}}</ref><ref name=Scott_2006>{{cite journal |author=Scott J, McMahon B, Bruden D, Sullivan D, Homan C, Christensen C, Gretch D |title=High rate of spontaneous negativity for hepatitis C virus RNA after establishment of chronic infection in Alaska Natives |journal=Clin Infect Dis |volume=42 |issue=7 |pages=945-52 |year=2006 |id=PMID 16511757}}</ref> and the majority of patients with chronic hepatitis C will not clear it without treatment.

Current treatment is a combination of [[pegylated interferon alpha]] (brand names Pegasys and PEG-Intron) and the antiviral drug [[ribavirin]] for a period of 24 or 48 weeks, depending on genotype. Indications for treatment include patients with proven hepatitis C virus infection and persistent abnormal liver function tests. Sustained cure rates (sustained viral response) of 75% or better occur in people with genotypes HCV 2 and 3 in 24 weeks of treatment, about 50% in those with genotype 1 with 48 weeks of treatment and 65% for those with genotype 4 in 48 weeks of treatment. About 80% of hepatitis C patients in the United States have genotype 1. Genotype 4 is more common in the [[Middle East]] and Africa. Should treatment with pegylated ribivirin-interferon not return a 2-log viral reduction or complete clearance of RNA (termed ''early virological response'') after 12 weeks for genotype 1, the chance of treatment success is less than 1%. Early virological response is typically not tested for in non-genotype 1 patients, as the chances of attaining it are greater than 90%.

Treatment during the acute infection phase has much higher success rates (greater than 90%) with a shorter duration of treatment (but balance this against the 80% chance of spontaneous clearance without treatment).

Those with low initial viral loads respond much better to treatment than those with higher viral loads (greater than 2 million virons/ml). Current combination therapy is usually supervised by physicians in the fields of [[gastroenterology]], [[hepatology]] or [[infectious disease]].

The treatment may be physically demanding, particularly those with a prior history of drug or alcohol abuse. It can qualify for temporary [[disability]] in some cases. A substantial proportion of patients will experience a panoply of side effects ranging from a 'flu-like' syndrome (the most common, experienced for a few days after the weekly injection of interferon) to severe adverse events including [[anemia]], [[cardiovascular disease|cardiovascular events]] and psychiatric problems such as [[suicide]] or suicidal ideation. The latter are exacerbated by the general physiological stress experienced by the patient.

In addition to the standard treatment with interferon and ribavirin, several studies have shown higher success rates when the antiviral drug [[amantadine]] (Symmetrel) is added to the regimen. Sometimes called "triple therapy", it involves the addition of 100mg of amantadine twice a day. Studies indicate that this may be especially helpful for "nonresponders" - patients who have not been successful in previous treatments using interferon and ribavirin only.<ref name="Maynard">{{cite journal | author = Maynard M, Pradat P, Bailly F, Rozier F, Nemoz C, Si Ahmed S, Adeleine P, Trépo C | title = Amantadine triple therapy for non-responder hepatitis C patients. Clues for controversies (ANRS HC 03 BITRI). | journal = J Hepatol | volume = 44 | issue = 3 | pages = 484-90 | year = 2006 | id = PMID 16426697}}</ref>
Currently, amantadine is not approved for treatment of Hepatitis C, and studies are ongoing to determine when it is most likely to benefit the patient.

Current guidelines strongly recommend that hepatitis C patients be vaccinated for hepatitis A and B if they have not yet been exposed to these viruses, as this would radically worsen their liver disease.

[[Alcoholic beverage]] consumption accelerates HCV associated fibrosis and cirrhosis, and makes liver cancer more likely; [[insulin resistance]] and [[metabolic syndrome]] may similarly worsen the hepatic prognosis.

===During pregnancy and breastfeeding===
If a [[pregnant]] woman has risk factors for hepatitis C, she should be tested for antibodies against HCV. About four out of every hundred infants born to HCV infected women become infected. The virus is spread to the baby at the time of birth. There is no treatment that can prevent this from happening.

In a mother that also has HIV, the rate of transmission can be as high as 19%. There is currently no data to determine whether antiviral therapy reduces [[perinatal transmission]]. [[Ribavirin]] and [[interferon]]s are contraindicated during pregnancy. However, avoiding [[fetal scalp monitoring]] and prolonged labor after [[rupture of membranes]] may reduce the risk of transmission to the infant.

HCV antibodies from the mother may persist in infants until 15 months of age. If an early [[diagnosis]] is desired, testing for [[HCV RNA]] can be performed between the ages of 2 and 6 months, with a repeat test done independent of the first test result. If a later diagnosis is preferred, an anti-HCV test can performed after 15 months of age. Most infants infected with HCV at the time of birth have no [[symptoms]] and do well during childhood. There is no evidence that [[breast-feeding]] spreads HCV. To be cautious, an infected mother could avoid breastfeeding if her nipples are cracked and bleeding.<ref>{{cite journal | author = Mast E | title = Mother-to-infant hepatitis C virus transmission and breastfeeding. | journal = Adv Exp Med Biol | volume = 554 | issue = | pages = 211-6 | year = | id = PMID 15384578}}</ref>

===Alternative therapies===
Several "[[alternative medicine|alternative therapies]]" purport to reduce the liver's duties, rather than treat the virus itself, thereby slowing the course of the disease or keeping the quality of life of the person. As an example, extract of ''[[Silybum marianum]]'' and [[licorice]] are sold for their HCV related effects; the first is said to provide some generic help to hepatic functions, and the second to have a mild antiviral effect and to raise blood pressure. The current standard of treatment with pegylated-interferon and ribavirin is unsurpassed in its ability to control HCV replication<sup class="noprint">[[[Wikipedia:Citing sources|''<span title="The material in the vicinity of this tag needs references to reliable sources." style="white-space: nowrap;">citation needed</span>'']]]</sup>{{#if: {{NAMESPACE}} || }}.

===Experimental treatments===
The drug [[viramidine]], which is a prodrug of [[ribavirin]] which has better targeting for the liver, and therefore may be more effective against hepatitis C for a given tolerated dose, is in phase III experimental trials against hepatitis C. It will be used in conjunction with interferon, in the same manner as ribavirin. However, this drug is not expected to be active against ribavirin-resistant strains, and the use of the drug against infections which have already failed ribavirin/interferon treatment, is unproven.<p> There are new drugs under development like the [[protease inhibitor (pharmacology)|protease inhibitors]] (including ''VX 950'') and polymerase inhibitors (such as ''NM 283''), but development of these is still in the early phase.<ref name="hinrichsen">{{cite journal | author = Hinrichsen H, Benhamou Y, Wedemeyer H, Reiser M, Sentjens R, Calleja J, Forns X, Erhardt A, Crönlein J, Chaves R, Yong C, Nehmiz G, Steinmann G | title = Short-term antiviral efficacy of BILN 2061, a hepatitis C virus serine protease inhibitor, in hepatitis C genotype 1 patients. | journal = Gastroenterology | volume = 127 | issue = 5 | pages = 1347-55 | year = 2004 | id = PMID 15521004}}</ref><ref name="lamarre">{{cite journal | author = Lamarre D, Anderson P, Bailey M, Beaulieu P, Bolger G, Bonneau P, Bös M, Cameron D, Cartier M, Cordingley M, Faucher A, Goudreau N, Kawai S, Kukolj G, Lagacé L, LaPlante S, Narjes H, Poupart M, Rancourt J, Sentjens R, St George R, Simoneau B, Steinmann G, Thibeault D, Tsantrizos Y, Weldon S, Yong C, Llinàs-Brunet M | title = An NS3 protease inhibitor with antiviral effects in humans infected with hepatitis C virus. | journal = Nature | volume = 426 | issue = 6963 | pages = 186-9 | year = 2003 | id = PMID 14578911 doi:10.1038/nature02099}}</ref>
One protease inhibitor, ''BILN 2061'', had to be discontinued due to safety problems early in the clinical testing. Some more modern new drugs that provide some support in treating HCV are ''Albuferon'', ''Zadaxin'', and ''DAPY''. Antisense phosphorothioate oligos have been targeted to hepatitis C<ref name="zhang">{{cite journal | author = Zhang H, Hanecak R, Brown-Driver V, Azad R, Conklin B, Fox M, Anderson K | title = Antisense oligonucleotide inhibition of hepatitis C virus (HCV) gene expression in livers of mice infected with an HCV-vaccinia virus recombinant. | journal = Antimicrob Agents Chemother | volume = 43 | issue = 2 | pages = 347-53 | year = 1999 | id = PMID 9925530 | url=http://aac.asm.org/cgi/content/full/43/2/347?view=long&pmid=9925530}}</ref>. Antisense [[Morpholino]] oligos have shown promise in preclinical studies and began human clinical trials in 2005 at Veterans Affairs Palo Alto Health Care System, Palo Alto, California and Alpine Clinical Research Center, Inc., Boulder, Colorado.<ref name="mccaffrey">{{cite journal | author = McCaffrey A, Meuse L, Karimi M, Contag C, Kay M | title = A potent and specific morpholino antisense inhibitor of hepatitis C translation in mice. | journal = Hepatology | volume = 38 | issue = 2 | pages = 503-8 | year = 2003 | id = PMID 12883495}}</ref>

All of these are not approved remedies and have not yet demonstrated their efficacy in clinical trials.

[[Immunoglobulin]]s against the hepatitis C virus exist and newer types are under development. Thus far, their roles have been unclear as they have not been shown to help in clearing chronic infection or in the prevention of infection with acute exposures (e.g. needlesticks). They do have a limited role in transplant patients.

== Prevention ==
The following guidelines will prevent infection with the hepatitis C virus, which is spread by blood:

* Avoid sharing drug needles or any other drug paraphernalia including works for injection or bills or straws
* Avoid unsanitary tattoo methods
* Avoid unsanitary body piercing methods and acupuncture
* Avoid needlestick injury
* Avoid sharing grooming utensils
* Avoid sharing personal items such as toothbrushes, razors, and nail clippers.

Proponents of [[harm reduction]] believe that strategies such as the provision of new needles and syringes, and education about [[safer drug injection]] procedures, greatly decreases the risk of hepatitis C spreading between injecting drug users.

==See also==
*[[List of people with hepatitis C]]

==References==

<div class="references-small">
<references />
</div>

==External links==
*[http://www.cdc.gov/ncidod/diseases/hepatitis/c/fact.htm CDC's Hepatitis C Fact Sheet]
*[http://www.cdc.gov/ncidod/diseases/hepatitis/c/faq.htm CDC's Hepatitis C Frequently Asked Questions]
*[http://www.hepcuk.info Hepatitis C resource for the UK]
*[http://www.hepcaustralia.com.au Australian Hepatitis C Support (AHCS)]
*[http://www.quihn.org.au Fact sheets on harm reduction strategies for injecting drug users and hepatitis C issues]

{{gastroenterology}}

[[Category:Articles with unsourced statements]]
[[Category:Hepatitis|C]]

[[ca:Hepatitis C]]
[[de:Hepatitis C]]
[[et:HCV]]
[[es:Hepatitis C]]
[[fr:Hépatite C]]
[[hr:Hepatitis C]]
[[it:Epatite virale C]]
[[mk:Хепатит Ц]]
[[nl:Hepatitis C]]
[[pl:Wirus zapalenia wątroby typu C]]
[[pt:Hepatite C]]
[[ru:Гепатит C]]
[[sr:Хепатитис Ц]]
[[zh:丙型肝炎]]

Pervasive developmental disorder

2006-12-18T23:40:32Z

Quihn: /* External links */

{{Mergefrom|Neurodevelopmental Disorders|date=September 2006}}
{{DiseaseDisorder infobox |
Name = Pervasive developmental disorders |
ICD10 = F84 |
ICD9 = {{ICD9|299}} |
}}
The diagnostic category '''pervasive developmental disorders''' (PDD), as opposed to [[specific developmental disorder]]s (SDD), refers to a group of [[mental illness|disorder]]s characterized by delays in the development of multiple basic functions including [[socialization]] and [[communication]]. The most commonly known PDD is [[autism]]. Parents may note symptoms of PDD as early as infancy and typically onset is prior to 3 years of age. PDD itself generally does not affect life expectancy. However, PDDs are correlated with [[poverty]], [[suicide]]s, [[crime]]s, and a [[Conditions comorbid to autism spectrum disorders|variety of medical problems]].

==Symptoms==
Symptoms of PDD may include communication problems such as:
* Difficulty using and understanding language
* Difficulty relating to people, objects, and events
* Unusual play with toys and other objects
* Difficulty with changes in routine or familiar surroundings
* Repetitive body movements or behavior patterns

==Types and degrees==
[[Autism]], a developmental brain disorder characterized by impaired social interaction and [[communication skill]]s, and limited range of activities and interests, is the most characteristic and best studied PDD. Other types of PDD include [[Asperger's syndrome]], [[childhood disintegrative disorder]], [[Rett syndrome]], and [[PDD not otherwise specified]] (PDD-NOS).

Children with PDD vary widely in abilities, intelligence, and behaviors. Some children do not speak at all, others speak in limited phrases or conversations, and some have relatively normal language development. Repetitive play skills and limited social skills are generally evident as well. Unusual responses to sensory information – loud noises, lights – are also common.

==Diagnosis in early childhood==
Some clinicians use PDD-NOS as a "temporary" diagnosis for children under the age of 5, when for whatever reason there is a reluctance to diagnose autism. There are several justifications for this: very young children have limited social interaction and communication skills to begin with, therefore it can be tricky to diagnose milder cases of autism in toddlerhood. The unspoken assumption is that by the age of 5, unusual behaviors will either resolve or develop into diagnosable autism. However, some parents view the PDD label as no more than a euphemism for [[autistic spectrum]] disorders, problematic because this label makes it more difficult to receive aid for [[early intervention]].

==Cure and care==
There is no known cure for PDD. Medications are used to address certain behavioral problems; therapy for children with PDD should be specialized according to the child's specific needs.

Some children with PDD benefit from specialized classrooms in which the class size is small and instruction is given on a one-to-one basis. Others function well in standard special education classes or regular classes with support. Early intervention including appropriate and specialized educational programs and support services plays a critical role in improving the outcome of individuals with PDD.

==See also==
* [[Autism]]
* [[Autistic spectrum]]
* [[Asperger syndrome]]
* [[Atypical autism|Atypical Autism]]
* [[Conditions comorbid to autism spectrum disorders]]
* [[Developmental disability]]
* [[Rett syndrome|Rett Syndrome]]
* [[Childhood disintegrative disorder|Childhood Disintegrative Disorder]]
* [[Overactive disorder associated with mental retardation and stereotyped movements|Overactive Disorder Associated with Mental Retardation and Stereotyped Movements]]
* [[PDD not otherwise specified]]
* [[Specific developmental disorder]]
* [[Multiple-complex Developmental Disorder]]
* [[Multisystem Developmental Disorder]]

==Reference==
* ''The ADHD-Autism Connection: A Step toward more accurate diagnosis and effective treatment''. By Diane M. Kennedy. ISBN 1-57856-498-0 – The aim of this book is to explore the similarities that [[attention-deficit hyperactivity disorder]] (ADHD) shares with pervasive developmental disorders.

==External links==
*[http://www.cdc.gov/ncbddd/autism/actearly/autism.html CDC's "Learn the Signs. Act Early.” campaign] - Information for parents on early childhood development and developmental disabilities
*[http://www.autism-help.org Fact sheets] - Information on Pervasive Developmental Disorders, early interventions, behavioral issues and family concerns
* [http://www.ninds.nih.gov/health_and_medical/disorders/pdd.htm NINDS Pervasive Developmental Disorders Information Page]
* [http://www.autism.org/pdd.html Dr. Bernard Rimland: Plain talk about PDD and the Diagnosis of Autism]
* [http://www.autismandcomputing.org.uk Autism and Computing] They argue that the central feature of Autism is attention-tunnelling, [[monotropism]].
* [http://www.nichcy.org/pubs/factshe/fs20txt.htm NICHCY fact sheet on Pervasive Developmental Disorder] (note: ''not'' in the public domain)
* [http://info.med.yale.edu/chldstdy/autism/pddinfo.html Information about Pervasive Developmental Disorders] ''Yale Developmental Disabilities Clinic''
* [http://www.staff.ncl.ac.uk/daniel.nettle/jrp.pdf Nettle, D. ''Schizotypy and mental health amongst poets, visual artists and mathematicians'' Comparison of cognitive skills in persons with schizotypal or autistic traits]

----

''Note: An earlier version of this article included text from the public domain source "NINDS Pervasive Developmental Disorders Information Page" at [http://www.ninds.nih.gov/health_and_medical/disorders/pdd.htm]''

{{Pervasive developmental disorders}}

[[Category:Childhood psychiatric disorders]]
[[Category:Autism]]
[[Category:Disability]]
[[Category:Special education]]

[[de:Tiefgreifende Entwicklungsstörung]]
[[fr:Trouble envahissant du développement]]
[[he:הפרעה התפתחותית נרחבת]]
[[nl:Pervasieve ontwikkelingsstoornis]]
[[sv:Autismspektrumstörning]]

Heroin

2006-06-20T06:29:00Z

Quihn: /* Drug interactions */

{{cleanup}}
{{otheruses}}
{{drugbox |
| IUPAC_name = (5α,6α)-7,8-didehydro-4,5-epoxy-<br>17-methylmorphinan-3,6-diol diacetate (ester)
| image = Heroin5.png
| CAS_number = 561-27-3
| ATC_prefix = N02
| ATC_suffix = AA09
| PubChem = 3592
| DrugBank =
| chemical_formula = [[Carbon|C]]<sub>21</sub>[[Hydrogen|H]]<sub>23</sub>[[Nitrogen|N]][[Oxygen|O]]<sub>5</sub>
| molecular_weight = 369.42
| bioavailability = <35%
| protein_bound = 0% ([[morphine]] metabolite 35%)
| metabolism = liver
| elimination_half-life = 2-3 minutes
| excretion = 90% renal as [[glucuronide]]s, rest [[biliary]]
| pregnancy_category =
| legal_status = Schedule I ([[United States|U.S.]])<br>[[Class A drug|Class A]]/CD Sch 2([[United Kingdom|UK]])<br>Schedule I ([[Controlled Drugs and Substances Act|Canada]])
| dependency_liability =Extremely High
| routes_of_administration = [[smoking|smoked]]/[[inhale]]d, [[insufflate]]d, [[injection (medicine)|injected]], [[ingest]]ed
}}
'''Heroin''' or '''diacetylmorphine''' ([[International Nonproprietary Name|INN]]) is a semi-synthetic [[opioid]]. It is the 3,6-[[acetate|diacetyl]] derivative of [[morphine]] (hence ''diacetylmorphine'') and is synthesised from it by [[acetylation]]. The white crystalline form is commonly the hydrochloride salt, '''diacetylmorphine hydrochloride'''. It is highly [[Addiction|addictive]], and chronic ingestion causes a relatively large tolerance to it when compared to other substances, although occasional use without symptoms of withdrawal has been noted.<ref>{{cite journal | author=David Shewan, Phil Dalgarno|title=Evidence for controlled heroin use? Low levels of negative health and social outcomes among non-treatment heroin users in Glasgow|url=http://www.gcal.ac.uk/news/downloads/heroin_use.pdf|journal=British Journal of Health Psychology|year=2005}}</ref><ref>{{cite news|author=Hamish Warburton, Paul J Turnbull, Mike Hough|title=Occasional and controlled heroin use: Not a problem?|url=http://www.jrf.org.uk/bookshop/details.asp?pubID=747|date=2005}}</ref> Internationally, Heroin is controlled under Schedules I and IV of the [[Single Convention on Narcotic Drugs]].<ref>{{cite web
| year = December 2004| url = http://www.incb.org/pdf/e/list/46thedition.pdf
| title = Yellow List: List of Narcotic Drugs Under International Control| format = PDF
| publisher = [[International Narcotics Control Board]]
| accessdate = May 5| accessyear = 2006
}} ''Referring URL = http://www.incb.org/incb/yellow_list.html''</ref> It is illegal to manufacture, possess, or sell heroin in the [[United States]] but, under the name '''diamorphine''', heroin is a legal prescription drug in the [[United Kingdom]]. Popular [[List of street names of drugs#Heroin|street names for heroin]] include ''[[diesel]]'', ''[[smack]]'', ''[[scag]]'', ''heron'', ''black tar'', ''horse'', ''junk'', ''brown'', ''dark'' and ''H''.


==History==
<div style="float:left;width:200px;">
[[image:BayerHeroin.png|thumb|175px|left|[[Bayer]] Heroin (TM)]]
[[Image:Bayer Heroin bottle.jpg|thumb|175px|left|Bayer Heroin bottle.]]
</div>
Heroin was first [[Chemical synthesis|synthesized]] in 1874 by [[C.R. Alder Wright]], a [[United Kingdom|British]] [[chemist]] working at [[St Mary's Hospital (London)|St. Mary's Hospital]] Medical School, [[London]]. He had been experimenting with combining morphine with various acids. He boiled anhydrous morphine alkaloid with acetic anhydride over a stove for several hours and produced a more potent, acetylated form of morphine. We now call it ''diacetylmorphine''. The compound was sent to F.M. Pierce of Owens College, [[Manchester]], for analysis. He reported the following to Wright:

:''Doses … were [[Route of administration|subcutaneously injected]] into young dogs and rabbits … with the following general results … great prostration, fear, and sleepiness speedily following the administration, the eyes being sensitive, and pupils dilated, considerable [[salivation]] being produced in dogs, and slight tendency to [[vomit]]ing in some cases, but no actual emesis. [[Respiration]] was at first quickened, but subsequently reduced, and the heart's action was diminished, and rendered irregular. Marked want of coordinating power over the muscular movements, and loss of power in the pelvis and hind limbs, together with a diminution of temperature in the rectum of about 4°(rectal failure)''.<ref>{{Waybackref
|url=http://web.archive.org/web/20040606103721/http://adhpage.dilaudid.net/heroin.html
|title=On the Action of Organic Acids and their Anhydrides on the Natural Alkaloids
|work = |date=2003-08-12
}} Note: this is an annotated excerpt of {{cite journal
| last = Wright
| first = C.R.A.
| year = 1874
| title = On the Action of Organic Acids and their Anhydrides on the Natural Alkaloids
| journal = [[Journal of The Chemical Society]]
| volume = 27
| pages = 1031–1043
}}</ref>

[[Felix Hoffmann]], of [[Bayer]] in [[Elberfeld, Germany]] created heroin as a medicine 11 days after inventing [[aspirin]]. Afraid of the possible side effects of aspirin, Bayer registered ''heroin'' (probably from ''heroisch'', German for heroic, chosen because in field studies people using the medicine felt "heroic") as a [[trademark]].

From 1898 through to 1910 it was marketed as a non-addictive morphine substitute and cough medicine for children. Bayer marketed heroin as a "cure" for morphine addiction before it was discovered that heroin is converted to morphine in the liver. All opiates are converted by the human liver into the identical molecule with varying degrees of concentration in the blood stream. The company felt somewhat embarrassed by this new finding and it became a historical blunder for Bayer [http://opioids.com/heroin/heroinhistory.html]. As with aspirin, Bayer lost some of its trademark rights to heroin following [[World War I]].

In 1914 the [[Harrison Narcotics Tax Act]] made it illegal to manufacture or possess heroin in the [[United States]].

==Usage and effects==
{| bgcolor="#ffffff" border="1" cellpadding="3" cellspacing="0" align="right" width="167px" style="border-collapse: collapse; clear: right; margin: 0 0 0 0.5em"
|-
|'''Indicated for:'''<br />
*Relief of extreme pain

'''[[Recreational drug use|Recreational]] uses:'''<br />
*[[Euphoria]]
*[[Relaxation]]

'''Other uses:'''<br />
*[[Pain]] relief
*[[Cough suppressant]]
*anti-[[diarrhea]]l
|-
|'''[[Contraindication]]s:'''<br />
*[[Ethanol|Alcohol]]
*[[Barbiturate]]s
*[[Stimulant]]s
*Other [[opioid]]s
|-
|'''[[Adverse drug reaction|Side effects]]:'''
<div style="background: #ffcc99">
'''''{{red|Severe:}}'''''
*[[Respiratory arrest]]
*[[Spontaneous abortion]]

</div>

'''''Atypical [[sensation]]s:'''''
*?

'''''[[Cardiovascular]]:'''''
*Lowered [[heart rate]]
*Infection of [[heart]] lining and [[Heart valve|valve]]s (chronic use)

'''''[[Ear]], [[nose]], and [[throat]]:'''''
*Dry mouth

'''''[[Endocrinal]]:'''''
*?

'''''[[Eye]]:'''''
*[[Pupil constriction]]

'''''[[Gastrointestinal]]:'''''
*[[Nausea]]
*[[Constipation]]

'''''[[Hepatological]]:'''''
*[[Liver disease]] (chronic use)

'''''[[Hematological]]:'''''
*?

'''''[[Muscle|Musculo]][[skeletal]]:'''''
*?

'''''[[Neurological]]:'''''
*[[Analgesia]]

'''''[[Psychological]]:'''''
*[[Confusion]]
*[[Euphoria]]
*[[Sedation]]

'''''[[Respiration (physiology)|Respiratory]]:'''''
*Slow respiration
*Shallow respiration
*[[Pneumonia]] (chronic use)

'''''[[Skin]]:'''''
*Itchiness
*Flushing
*[[Abscess]]es

'''''Miscellaneous:'''''
*Heavy extremities
|}

In the [[United Kingdom]] heroin is available on prescription, though it is a restricted [[Class A drug]]. According to the [[British National Formulary]] edition 50, diamorphine [[hydrochloride]] may be used in the treatment of acute pain, [[myocardial infarction]], acute [[Pulmonary edema|pulmonary edema]], and [[chronic pain]]. The treatment of chronic non-[[malignant]] pain must be supervised by a specialist. The [[British National Formulary]] (BNF) notes that all opioid analgesics cause dependence and tolerance but that this is "no deterrent in the control of pain in terminal illness". When used in the [[palliative care]] of cancer patients, heroin is often injected using a [[syringe driver]]. In comparison to morphine, it may cause less [[nausea]], [[hypotension]], [[sedation]], [[euphoria]] and can be dissolved in a smaller quantity of liquid.

Heroin is also widely and illegally used as a powerful and [[addictive]] drug that produces intense [[euphoria]], which often disappears with increasing [[Physiological tolerance|tolerance]]. It is thought that heroin's popularity with recreational users, compared to morphine or other opiates, comes from its somewhat different perceived effects<ref>{{cite journal
| author = Tschacher W, Haemmig R, Jacobshagen N.
| year = 2003
| title = Time series modeling of heroin and morphine drug action.
| journal = [[Psychopharmacology]]
| PMID = 12404073
| url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12404073&query_hl=23&itool=pubmed_DocSum
}}</ref>. This in turn comes from its high lipid [[solubility]] provided by the two [[acetyl]] groups, resulting in a very rapid penetration of the [[blood-brain barrier]] after use. Heroin can be taken or [[route of administration|administered]] in a number of ways, including [[snort]]ing it and [[injection (medicine)|injecting]] it. It may also be smoked by inhaling the vapors produced when heated from below (known as "[[chasing the dragon]]").

Once in the brain, heroin is rapidly [[metabolism|metabolized]] into morphine by removal of the acetyl groups. It is the morphine [[molecule]] that then binds with opioid receptors and produces the subjective effects of the heroin high. Heroin is therefore a [[prodrug]].

The onset of heroin's effects is dependent on the method of administration. Orally the heroin is totally metabolized [[in vivo]] into [[morphine]] before crossing the blood-brain barrier, so the effects are the same as [[morphine]] when taken by mouth. Snorting heroin results in onset within 10 to 15 minutes. Smoking heroin results in an [[adrenaline]] rush within 2-5 minutes. Intravenous injection results in rush and euphoria within 7 to 8 seconds, while intramuscular injection takes longer, having an effect within 5 to 8 minutes.

Heroin is a μ-opioid ([[mu-opioid]]) [[agonist]]. It acts on [[endogenous]] μ-[[opioid receptor]]s that are spread in discrete packets throughout the [[brain]], [[spinal cord]] and [[gut]] in almost all [[mammal]]s. Heroin, along with other opioids, are [[agonists]] to four endogenous [[neurotransmitters]]. They are [[Beta-endorphin|β-endorphin]], [[dynorphin]], [[leu-enkephalin]], and [[met-enkephalin]]. The body responds to heroin in the brain by reducing (and sometimes stopping) production of the endogenous opioids when heroin is present. Endorphins are regularly released in the brain and nerves and attenuate pain. Their other functions are still obscure, but are probably related to the effects produced by heroin besides analgesia ([[antitussin]], [[anti-diarrheal]]). The reduced endorphin production in heroin users creates a dependence on the heroin, and the cessation of heroin results in extreme symptoms including pain (even in the absence of physical trauma). This set of symptoms is called [[withdrawal]] syndrome. It has an onset 6 to 8 hours after the last dose of heroin.

The [[serial killer]] and [[general practitioner]] [[Harold Shipman]] obtained large quantities of diamorphine by writing prescriptions for his cancer patients and keeping the drugs. Shipman was convicted of killing 15 patients with diamorphine, though an enquiry later estimated that between 220 and 240 were murdered[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12960657&dopt=Abstract].

==Production and trafficking==
[[Image:HeroinWorld.png|thumb|250px|left|Primary worldwide producers of heroin.]]

===Manufacturing===
Heroin is produced for the black market through [[opium]] refinement processes. Unlike drugs such as [[LSD]], the production of which requires considerable expertise in [[chemistry]] and access to constituents which are now tightly controlled, the refinement of the first three grades of heroin from opium is a relatively simple process requiring only moderate technical expertise and common chemicals. The final grade of heroin favored in the west is more difficult to produce and involves a potentially dangerous chemical procedure. Usually a pound of heroin powder can cost from $US5,000 to $US7,000, depending on the quality and purity of the drug.{{fact}}

First [[morphine]] is isolated from the crude opium (through being dissolved in water, reacted with [[agricultural lime|lime]] fertilizer such that it precipitates out, and then reacted again with [[ammonia]]; what is left is then mechanically filtered to yield a final product of morphine weighing about 90% less than the original quantity of opium). The morphine is reacted with [[acetic anhydride]] — a chemical also used in the production of [[aspirin]] — in the complicated five-step process used by most refineries in the Golden Triangle. The first step is to cook the morphine at 85°C (185°F) for six hours with an equivalent weight of acetic anhydride. In the second, a treatment of water and hydrochloric acid then purifies the product moderately. When the chemists add [[sodium carbonate]], the particulates settle. Step four involves heating the heroin in a mixture of [[alcohol]] and [[activated charcoal]] until the alcohol evaporates. The fifth step is optional, as it only changes the heroin into a finer white powder, more easily injectable; this so-called "no. 4 heroin" is principally exported to the Western markets. In this last, most dangerous step, the heroin (after being dissolved in alchohol), precipates out in tiny white flakes when a mixture of [[ether]] and [[hydrochloric acid]] is injected; this step is dangerous due to the fact that the ether may explode, leveling or severely damaging the refinery (as has happened to a number of such facilities).

The purity of the extracted morphine determines in large part the quality of the resulting heroin. Most [[black market]] heroin is highly impure due to contaminants left after refinement of opium into morphine which then remain in the final product; even if the final product is in the upper range of purity (80 - 99% pure), once it reaches the consumer, it typically has been cut multiple times, and often its purity is down to less than 5-10%, which is amplified by the judgment of the addicts when they go to buy from their [[pusher]] because the addict has no way of telling how pure the substance is when buying it illegally on the street, so they usually only look for the bulk. It has even been anecdotally reported that many if not most addicts preferred a 5-10% heroin to almost pure heroin when given the choice if the foremost was quantitatively more bulky. On the illegal market, most times relatively pure heroin has substantial sales difficulties because if it is not cut (as much) it also costs a lot more per weight.
When given the choice between declared 0,4 grams of approx. 10% pure heroin and 0,15 grams of very clean (purity between 80-98%) heroin, even if they were informed about the contents of the prospective sales objects, most users chose the more bulky but impure variant.{{fact}}

===History===
The origins of the present international illegal heroin trade can be traced back to the forcible imposition of the [[opium]] trade on [[China]] by the [[United Kingdom]] in the late 1700s. The opium trade sparked the two [[Opium Wars]] that resulted in a series of [[Unequal Treaties]] that ceded [[Hong Kong]] to the United Kingdom in mid 19th century. Later in the 20th century, Chinese [[triad]] gangs, most of which are based in Hong Kong and Southern China, would eventually come to play a major role in the heroin trade.

Although it remained legal in some countries until after World War II, health risks, addiction, and widespread abuse led most western countries to declare heroin a controlled substance by the latter half of the 20th century.

Prior to the 1970s, much of the opium consumed in the west was grown in [[Turkey]], but in the late 1960s, under pressure from the U.S. and the [[United Nations]], Turkey agreed to eliminate its opium production, leading to the development of a major new cultivation and refining base in the so-called "[[Golden Triangle (Southeast Asia)|Golden Triangle]]" region in South East Asia in the late 1960s.

Although it was beginning to become more prevalent by the 1930s, Asian historian and drug traffic expert [[Dr Alfred W. McCoy]] reports that heroin trafficking was virtually eliminated in the U.S. during [[World War II]] due to temporary trade disruptions caused by the war. McCoy contends the Mafia was able to gain control of the heroin trade thanks in large measure due to the unintended consquences of a covert deal between top Mafia leader [[Lucky Luciano]] and American military intelligence.

McCoy claims that Luciano was asked to provide Mafia assistance in rooting out communist and/or Nazi influence on the waterfronts. Other historians have suggested that the US gave in to Mafia extortion and that the Mafia itself was the threat to the waterfront.{{fact}} Later, the US Army wanted Luciano to provide their forces with local Mafia assistance during America's planned invasion of Sicily. The end result was the US Army ended up unintentionally handing control over Sicily to the Mafia. Luciano was eventually released from prison and deported to Sicily where he was able to construct a series of large-scale heroin factories. The Network eventually spread out into other areas of southern Europe. Luciano arranged, for example, a deal with the Corsican Mafia operating out of [[Marseilles]] in France. He allegedly masterminded the creation of the network that was known as the "[[French Connection]]". The Corsican Mafia in Marseilles were used by the US and French governments as a force to counter-balance the strong communist movement in the South of France after the war.

In southeast Asia, the governments of most countries and many colonial officials had been involved in the opium trade for a very long time. Thanks to Corsican Mafia connections in the former French colony of Vietnam, Luciano was able to begin to develop Southeast Asia as a new source of Opium even as Turkish and Iranian production declined. The [[Vietnam War]] had the unintended consquence of first opening up many areas of Southeast Asia to modern transportation and then presenting a ready-made market for the drug among the U.S. military personnel stationed in the region.

McCoy's most controversial assertion is that the [[C.I.A.]] pursued a policy, which he describes as "radical pragmatism", and that in the name of the fight against Communism, the Agency was covertly making expedient alliances with local warlords, Mafiosi and corrupt South Vietnamese officials. His critics are not convinced that the actions were those of the agency rather than the actions of individuals.{{fact}} They also point out that North Vietnamese and Viet Cong officials were equally complicit in the trade.{{fact}}

The real turning point came in 1970-71 when the first high-grade heroin laboratories opened in the Golden Triangle. Prior to this, the chemical skills for refinement had existed only in Europe. This gave the opium producers control over the creation of the final product. The hundreds of thousands of American servicemen in Vietnam provided a perfect market for the heroin producers, and heroin use among soldiers rapidly reached near-epidemic proportions in 1970-71, with some unit medical officers reporting that as many as 15% percent of G.I.s in some units were regular users.{{fact}} The money from this huge American market for Heroin flooded into the hands of warlords in the region and allowed them to self-finance ever-larger activities.{{fact}}

In 1971 the first large consignments of South East Asian heroin were intercepted in Europe and America, and by the mid-1970s heroin addiction fulfilled its promise as a serious social problem in the United States (where it had already been growing in street traffic throughout the late 1950s and 1960s), Australia, the United Kingdom, and many other nations, notably among youth and particularly in the African-American population in the U.S.{{fact}} Based on the success of this network, organised crime groups began to establish illegal trades in other illegal drugs, notably [[cocaine]].

===Trafficking===
:''See also: [[Opium#Production Today|Opium production]]''
[[Image:Heroin asian.jpg|thumb|right|Asian heroin]]
[[Illegal drug trade|Traffic]] is heavy worldwide, with the biggest producer being [[Afghanistan]]. According to U.N. sponsored survey [http://www.unodc.org/pdf/afg/afghanistan_opium_survey_2004.pdf], as of 2004, Afghanistan accounted for production of 87 percent of the world's heroin. It is thought that such organizations as [[Al-Qaeda]] and [[Taliban]] are largely funded by heroin trafficking. [http://www.foxnews.com/story/0,2933,111131,00.html] [http://www.time.com/time/asia/magazine/printout/0,13675,501040809-674806,00.html]
[[Image:Balininelawrenceevidence.jpg|thumb|left|Heroin concealed under the clothes of a drug smuggler.]]

Some observers, particularly political [[conservative]]s in the [[United States]], have accused [[People's Republic of China|China]] of being a leading producer of heroin.{{fact}} Dr. [[Alfred W. McCoy]] has claimed that the [[C.I.A.]] secretly collaborated with Asian drug syndicates and was complicit in the expansion of the global heroin trade from 1970 to 1973 in order to prosecute the Cold War. While the Vietnam War brought modern transportation to remote opium areas, even McCoy does not claim that the CIA set up the drug labs in Southeast Asia or created the trade. {{fact}}

Heroin is one of the most profitable illicit drugs since it is compact and easily concealed. At present, opium poppies are mostly grown in the [[Middle East]], [[Pakistan]], and [[Afghanistan]], and in [[Asia]], especially in the region known as the [[Golden Triangle (Southeast Asia)|Golden Triangle]] straddling [[Myanmar]], [[Thailand]], [[Vietnam]], [[Laos]] and [[Yunnan]] province in [[China]]. There is also cultivation of opium poppies in the [[Sinaloa]] region of [[Mexico]] and in [[Colombia]]. The majority of the heroin consumed in the United States comes from Mexico and Colombia. Up until 2004, [[Pakistan]] was considered as one of the biggest opium-growing countries. However, the efforts of Pakistan's [[Anti-Narcotics Force]] have since reduced the opium growing area by 59% [[as of 2001]]. Some suggest that the decline in Pakistani production is inversely proportional to the rise of Afghani production.{{fact}} And that rather than anti-narcotics activity, the decline in Pakistan is due more to changed market forces.

Conviction for trafficking in heroin carries the [[Use of death penalty worldwide|death penalty]] in many countries, including [[Malaysia]], [[Indonesia]], [[Taiwan]], [[Thailand]] and [[Singapore]]. The penalty applies even to citizens of countries where the penalty is not in place, sometimes causing controversy when foreign visitors are arrested for trafficking, for example the arrest of [[Bali Nine|nine Australians in Bali]] or the hanging of [[Australia]]n citizen [[Van Tuong Nguyen]] in [[Singapore]], both in [[2005]].

==Risks of non-medical use==
* [[Overdose]], possibly causing death
* For [[intravenous]] users of heroin, the use of non-sterile needles and syringes and other materials leads to the risk of contracting blood-borne [[pathogens]] such as [[HIV]] and/or [[hepatitis]] infections as well as the risk of contracting bacterial or fungal [[endocarditis]]
* Poisoning from [[contaminants]] added to "[[Cutting agent|cut]]" or [[dilute]] heroin
* Chronic constipation
* Venous sclerosis
* Tolerance leading to larger doses to achieve the same effect

Many countries and local governments have begun funding programs to supply [[sterile]] needles to people who inject illegal drugs in order to reduce some of these contingent risks including the contraction and spread of blood-bourne diseases. The Drug Policy Alliance reports that up to 75% of new AIDS cases among women and children are directly or indirectly a consequence of injection drug use. But despite the immediate [[public health]] benefit of [[needle-exchange programme|needle exchange]]s, some see such programs as tacit acceptance of illicit drug use (however, studies on areas where needle exchange programs have been instituted have shown no link between the availability of clean needles and an increase in illicit drug use). The [[United States]] does not support needle exchanges federally by law, and although some state and local governments do support needle exchange programs, they continue to face harassment by police in most areas. Needle exchanges have been instrumental in arresting the spread of HIV/AIDS in many communities with a significant heroin using population, Australia being a leader due to its early inception of needle exchanges. Needle exchange programs have also been attributed for saving the public significant amounts of tax dollars by preventing medical costs which would have been required otherwise for the treatment of diseases spread through the practice of sharing/re-using needles.

A heroin [[overdose]] is usually treated with an opioid [[Receptor antagonist|antagonist]], such as [[naloxone]] ([[Narcan]]) or [[naltrexone]], which have a high affinity for [[opioid receptors]] but do not activate them. This blocks heroin and other opioid agonists and causes an immediate return of consciousness and start of withdrawal symptoms when administered intraveneously. The [[half-life]] of these antagonists is usually much shorter than that of the opiate drugs they are used to block, so the antagonist usually has to be re-administered multiple times until the opiate has been metabolized by the body.

A heroin overdose is not fast-acting. Stories about people who "OD with the needle still in their arm" and the like are not attributable to heroin overdoses, but rather they are very often the result of a fatal reaction with the adulterant. [[Quinine]] is notorious for causing such deaths. In the case of an actual heroin overdose, it very often takes many hours to die.

An overdose is immediately reversible with an [[opioid antagonist]] injection. The overwhelmingly vast majority of reported heroin overdoses are actually adulterant poisonings or fatal interactions with alcohol, cocaine ("speedballing") or methadone. True overdoses are rare {{fact}} because the [[LD50|LD<sub>50</sub>]] for a person already addicted is prohibitively high, to the point that there is no general medical consensus on where to place it. Several studies done in the 1920s gave addicts doses of 1,600–1,800 mg of heroin in one sitting, and no adverse effects were reported. This is approximately 160–180 times a normal recreational dose. Even for a non-addict, the LD<sub>50</sub> can be credibly placed above 350 mg.

Street heroin is of widely varying and unpredictable purity. This means that an addict may prepare what they consider to be a moderate dose while actually taking far more than intended. Also, relapsing addicts after a period of abstinence have tolerances below what they were during active addiction. If a dose comparable to their previous use is taken an overdose often results.{{fact}}

A final source of overdose in addicts comes from [[conditioning|place conditioning]]. Heroin use, like other drug abuse behaviors is highly ritualized. While the mechanism has yet to be clearly elucidated, it has been shown that longtime heroin users, immediately before injecting in a common area for heroin use, show an acute increase in [[metabolism]] and a surge in the concentration of [[opiate]]-metabolizing [[enzyme]]s. This acute increase, a reaction to a location where the addict has repeatedly injected heroin, imbues the addict with a strong (but temporary) [[drug tolerance|tolerance]] to the toxic effects of the drug. When the addict injects in a different location, this place-conditioned tolerance does not occur, giving the addict a much lower-than-expected ability to metabolize the drug. The user's typical dose of the drug, in the face of decreased tolerance, becomes far too high and can be toxic, leading to overdose.{{fact}}

==Withdrawal==
[[Image:Heroin black tar.jpg|thumb|left|[[Black tar heroin]]]]

The withdrawal syndrome from heroin (or any other short-acting opioid) can begin within 6 hours of discontinuation of sustained use of the drug: [[sweating]], [[malaise]], [[anxiety]], [[clinical depression|depression]], persistent and intense penile erection in males ([[priapism]]), general feeling of heaviness, cramp-like pains in the limbs, yawning and [[lacrimation]], sleep difficulties, cold sweats, chills, severe muscle and bone aches not precipitated by any physical trauma, [[nausea]] and [[vomiting]], [[diarrhea]], gooseflesh (hence, the term "[[cold turkey]]"), [[cramps]], and [[fever]] occur. Many addicts also complain of a painful condition, the so-called "[[itchy blood]]", which often results in compulsive scratching that causes bruises and sometimes ruptures the skin leaving scabs. Abrupt termination of heroin use causes muscle spasms in the legs of the user ([[restless leg syndrome]]), hence the term "[[kicking the habit]]". Users seeking to take the "[[cold turkey]]" (without any preparation or accompaniments) approach are generally more likely to experience the negative effects of withdrawal in a more pronounced manner.

Two general approaches are available to ease opioid withdrawal. The first is to substitute a longer-acting opioid such as [[methadone]] or [[buprenorphine]] for heroin or another short-acting opioid and then slowly taper the dose. The other approach, which can be used alone or in combination, is to relieve withdrawal symptoms with non-opioid medications.

In the second approach, [[benzodiazepine]]s such as [[diazepam]] (Valium) ease the often extreme anxiety of opioid withdrawal. The most common [[benzodiazepine]] employed as part of the detox protocol in these situations is [[oxazepam]] ([[Serax]]). Benzodiazepine use can also lead to a dependence, and many opiate addicts also abuse other central nervous system [[depressants]] including [[benzodiazepines]] and [[barbituates]]. Also, though unpleasant, opiate withdrawal seldom has the potential to be fatal, whereas complications related to withdrawal from [[benzodiazepines]], [[barbiturates]] and [[ethanol|alcohol]] (such as [[seizures]], [[cardiac arrest]], and [[delirium tremens]]) can prove hazardous and potentially fatal. Many symptoms of opioid withdrawal are due to rebound hyperactivity of the [[sympathetic nervous system]], and this can be suppressed with [[clonidine]] (Catapres), a centrally-acting alpha-2 [[agonist]] primarily used to treat [[hypertension]].

[[Buprenorphine]] is one of the most recent opioid agonist/antagonist used for treating addiction. It develops tolerance much more slowly than heroin or methadone. It also has a withdrawal many times softer than heroin and other opioids. It can be admnistered up to every 24-48 hrs. By itself buprenorphine has low overdose dangers. Buprenorphine is a kappa-opioid receptor antagonist. This gives the drug an anti-depressant effect, increasing physical and intellectual activity. Buprenorphine also acts as a partial agonist at the same μ-receptor illicit opiates such as Heroin initiate from. Due to its effects on this receptor, patients are unable to obtain any "high" from other opiates during buprenorphine treatment.

Researchers at [[Johns Hopkins University]] have been testing a sustained-release "[[depot]]" form of [[buprenorphine]] that can relieve cravings and withdrawal symptoms for up to six weeks.<ref>{{cite web
| last = Thomas| first = Josephine| year = May 2001
| url = http://www.nida.nih.gov/PDF/NNCollections/NNHeroin.pdf
| title = Buprenorphine Proves Effective, Expands Options For Treatment of Heroin Addiction
| format = PDF| work = NIDA Notes: Articles that address research on Heroin| pages = 23
| publisher = [[National Institute on Drug Abuse]]
| accessdate = May 5| accessyear = 2006
}}</ref> A sustained-release formulation would allow for easier administration and adherance to treatment, and reduce the risk of diversion or misuse.

[[Methadone]] is another μ-opioid agonist often used to substitute for heroin in treatment for heroin addiction. Compared to heroin, methadone is well (but slowly) absorbed orally and has a much longer duration of action. Thus [[methadone maintenance]] avoids the rapid cycling between [[intoxication]] and [[withdrawal]] associated with heroin addiction. In this way, methadone has shown some success as a "less harmful substitute"; despite being much more addictive than heroin, and is recommended for those who have repeatedly failed to complete detoxification. As of [[2005]], the μ-opioid agonist [[buprenorphine]] is also being used to manage heroin addiction, being a superior, though still imperfect and not yet widely known alternative to methadone. Methadone, since it is longer-acting, produces withdrawal symptoms that are usually less severe and that appear later than with heroin, but may last longer.

Researchers have discovered two other opioid [[antagonists]]: [[naloxone]] and the longer-acting [[naltrexone]]. These two medications block the effects of heroin, as well as the other opioids at the receptor site. Recent studies have suggested that the addition of naloxone and naltrixone may improve the success rate in treatment programs when combined with the traditional therapy. {{fact}}

The [[University of Chicago]] undertook preliminary development of a heroin vaccine in [[monkeys]] during the [[1970s]], but it was abandoned. There were two main reasons for this. Firstly, when immunised monkeys had an increase in dose of x16, their [[antibodies]] became [[saturation (chemistry)|saturated]] and the monkey had the same effect from heroin as non-immunised monkeys. Secondly, until they reached the x16 point immunised monkeys would substitute other drugs to get a heroin-like effect. These factors suggested that immunised human addicts would simply either take massive quantities of heroin, or switch to other hard drugs, which is known as [[cross-tolerance]].

There is also a controversial treatment for heroin addiction based on a plant-derived African
psychedelic drug, [[ibogaine]]. Many people travel abroad for ibogaine treatments that
generally interrupt the addiction for 3 - 6 months or more in up to 80% of patients.{{fact}} Relapse often occurs when the person returns home to their normal environment however, where drug seeking behaviour may return in response to social and environmental cues.{{fact}} Ibogaine treatments are carried out in several countries in South America and in Europe but can be dangerous. Some addicts find the ibogaine therapy most effective when it is given several times over the course of a few months or years, but this can be very expensive if a high price is charged for the treatment.{{fact}} A synthetic derivative of ibogaine, [[18-methoxycoronaridine]] is in phase 2 trials in humans as an anti-addictive drug.

== Heroin prescription ==
In 1994 Switzerland began trailing a program for [[heroin prescription]] for addicts which are not suited for withdrawal programs - for example because several withdrawal attempts have failed. The aim is maintaining the health of the addict in order to avoid medical harms stemming from low-quality street heroin; and reducing [[drug-related crime]] is another goal; and furthermore addicts can more easily get or maintain a paid job. The first trial in [[1994]] began with 340 addicts and it was later expanded to 1000 users after medical and social studies suggested its continuation. The people are prescribed to inject the heroin where they bought it (specially designed rooms, pharmacies) for about US$13 per dose.

The success of the Swiss trials led German, Dutch and Australian cities to trial their own heroin prescription programs.[http://www.drugpolicy.org/library%5Ctlcnr.cfm Drugpolicy.org on Swiss trials], [http://news.bbc.co.uk/1/hi/health/4607233.stm BBC online on Dutch trials]

==Drug interactions==
Opiates are strong [[central nervous system]] [[depressants]], but regular users develop [[physiological tolerance]] allowing gradually increased dosages. In combination with other central nervous system depressants, heroin may still kill experienced users, particularly if their tolerance to the drug has reduced or the strength of their usual dose has increased.

[[Toxicology]] studies of heroin-related deaths reveal frequent involvement of other central nervous system depressants, including [[alcohol]], [[benzodiazepines]] such as [[diazepam]] ([[valium]]), and occasionally [[methadone]]. Ironically, benzodiazepines and methadone are often used in the treatment of heroin addiction.

[[Cocaine]] also proves to be often fatal when used in combination with heroin. Though "[[speedballs]]" (when injected) or "[[moonrocks]]" (when smoked) are a popular mix of the two drugs among users, combinations of [[stimulants]] and [[depressants]] can have unpredictable and sometimes fatal results. In the United States in early 2006, a rash of deaths have been attributed to either a combination of [[fentanyl]] and heroin, or pure fentanyl [[Wiktionary:masquerading|masquerading]] as heroin particularly in the Detroit Metro Area; one news report refers to the combination as 'laced heroin', though this is likely a generic rather than a specific term.<ref>{{cite news
|first=Robin
|last=Brown
|title=Heroin's Hell
|publisher=[[The News Journal]]
|pages=A1,A12
|date=[[2006-05-04]]
}}</ref>

==Culture==
{{main|Heroin in popular culture}}
Heroin has inspired countless writers, musicians and other artists over the past century of use.

==See also==
{{wikinewspar| 2005 Afghan opium harvest begins}}

*[[Black Tar Heroin]]
*[[Cheese (recreational drug)|Cheese]] (recreational drug)
*[[Oxycodone#Abuse|Hillbilly heroin]]
*[[China white|China White]]
*[[Drugs and prostitution]]
*[[Methadone]]
*[[Recreational drug use]]
*[[Psychoactive drug]]
*[[Scag]]
*[[List of people known to be addicted to opiates]]
*[[List of famous drug smugglers]]
*[[Opium]]
*[[Poppy]]

==References==
*''Heroin'' (1998) ISBN 1-568-38153-0
*''Heroin Century'' (2002) ISBN 0-415-27899-6
*''This is Heroin'' (2002) ISBN 1-860-74424-9
*''The Heroin User's Handbook'' by [[Francis Moraes]] (paperback 2004) ISBN 1-559-50216-9
*''The Little Book of Heroin'' by [[Francis Moraes]] (paperback 2000) ISBN 0-914-17198-4
*''Heroin: A True Story of Addiction, Hope and Truimph'' by Julie O'Toole (paperback 2005) ISBN 1-905-37901-3

===Notes===
<references/>

==External links==
{{Commons|Heroin}}

*[http://www.geopium.org Geopium: Geopolitics of Illicit Drugs in Asia, especially opium and heroin production and trafficking in and around Afghanistan and Burma (Articles and maps and French and English)]
*[http://www.heroinhelper.com/ Heroin Helper]
*[http://www.cia.gov/cia/publications/heroin/flowers_to_heroin.htm From Flowers to Heroin], CIA publication.
*[http://wired-vig.wired.com/wired/archive/13.04/bupe.html?pg=1&topic=bupe&topic_set= The mismanagement of methadone]
*[http://navisite.collegeclub.com/servlet/channels.ChannelArticleServlet?articleid=4461&areaid=8&grid-messageboard-page=1 Harrowing Heroin by Geoff Morton]
*[http://www.NAABT.org/ National Alliance of Advocates for Buprenorphine Treatment - non-profit education website for treatment of Heroin addiction]
*[http://www.nida.nih.gov/Infofacts/heroin.html NIDA InfoFacts on Heroin]
*[http://www.whitehousedrugpolicy.gov/drugfact/heroin/ ONDCP Drug Facts]
*[http://www.paksearch.com/globe/2001/june/narcotics.html Role of Government of Pakistan in Narcotics Control]
*[http://usinfo.state.gov/is/Archive_Index/Pakistans_Cultivation_of_Opium_Drops.html United States Department of State fact sheet: anti-narcotics efforts in Pakistan] - dated [[June 7]], [[2002]]
*[http://news.bbc.co.uk/1/hi/magazine/4647018.stm BBC Article entitled 'When Heroin Was Legal'. References to the United Kingdom and the United States]
*[http://www.heroin.org Heroin Facts]
* [http://www.quihn.org.au/illicit_drug_use_information.htm Information on heroin and other illicit drugs]

{{Analgesics}}

[[Category:Acetates]]
[[Category:Alkaloids]]
[[Category:Analgesics]]
[[Category:Class A drugs]]
[[Category:Ethers]]
[[Category:Mu-opioid agonists]]
[[Category:Schedule I controlled substances]]
[[Category:Semisynthetic opioids]]



[[bg:Хероин]]
[[ca:Heroïna]]
[[da:Heroin]]
[[de:Heroin]]
[[es:Heroína]]
[[eo:Heroino]]
[[eu:Heroina]]
[[fa:هروئین]]
[[fr:Diacétylmorphine]]
[[gl:Heroína]]
[[hr:Heroin]]
[[id:Heroin]]
[[is:Heróín]]
[[it:Eroina]]
[[he:הרואין]]
[[lt:Heroinas]]
[[hu:Heroin]]
[[ms:Heroin]]
[[nl:Heroïne]]
[[ja:ヘロイン]]
[[no:Heroin]]
[[nn:Heroin]]
[[pl:Heroina]]
[[pt:Heroína]]
[[ru:Героин]]
[[fi:Heroiini]]
[[sv:Heroin]]
[[th:เฮโรอีน]]
[[uk:Героїн]]
[[zh:海洛因]]

Methamphetamine

2006-06-20T06:20:58Z

Quihn: /* External links */

{{mergefrom|Desoxyn}}
{{mergefrom|Tik}}
{{redirect|Meth}}
{{limitedgeographicscope}}

{{Drugbox|
|IUPAC_name = ''(S)-N-methyl-1-phenyl-propan-2-amine''
| image=Methamphetamine_molecular_structure.jpg
| width=200
| CAS_number=537-46-2
| ATC_prefix=N06
| ATC_suffix=BA03
| ATC_supplemental=
| PubChem=1206
| DrugBank=
| chemical_formula = {{carbon}}<sub>10</sub>{{hydrogen}}<sub>15</sub>{{nitrogen}}
| molecular_weight = 149.2
| bioavailability= Depends on route of administration
| metabolism = [[Hepatic]]
| elimination_half-life= 4-12 hours, 8 hours on average
| excretion = [[Renal]]
| pregnancy_category = C ([[USA]])
| legal_status = Schedule II ([[USA]])<br>Class B (oral) ([[United Kingdom|UK]])<br>Class A (injectable) ([[United Kingdom|UK]])<br>Schedule I ([[Canada]])<br>Schedule 5 ([[South Africa]])
| routes_of_administration= Medical: Oral, 5 mg and 10 mg tablets<br>Recreational: Oral, I.V, I.M., Insufflation, Inhalation, Suppository
}}
'''Methamphetamine ''' (or methylamphetamine or desoxyephedrine) is a synthetic [[stimulant]] [[psychoactive drug|drug]] used for both [[medication|medicinal]] and [[recreational drug use|recreational]] purposes (the latter use is illegal in most countries — see [[Methamphetamine#Legal issues|Legal issues]]). Like most stimulants, methamphetamine can cause a strong feeling of [[happiness|euphoria]], thus creating the potential for [[drug addiction|addiction]].

==Availability and names==
Pure methamphetamine in tablet form is prescribed by physicians, and is available under the brand name '''[[Desoxyn]]'''®.

Illicit methamphetamine comes in a variety of forms. Most commonly it is found as a colourless [[crystalline]] solid, sold on the street under a variety of names, such as: '''crystal meth or crystal'''. Crystal methamphetamine may also be referred to as '''shards, rock, P, pony, crystal, glass, ice, devil's dandruff, chimichanga,''' '''Tina''', or '''tik'''.

It is also sold as a less-pure crystalline powder called '''crank''' or '''speed''', or in crystalline rock form called '''dope''', '''shit''', or '''tweak'''; both "[[dope]]" and "[[speed (disambiguation)|speed]]" are also sometimes used to refer to other drugs. Colourful flavored pills containing methamphetamine and [[caffeine]] are known as [[yaba (drug)|yaba]] ([[Thai language|Thai]] for "crazy medicine"). At its most impure, it is sold as a crumbly brown or off-white rock commonly referred to as peanut butter meth. See the [[List of street names of drugs#Methamphetamine|list of street names]] for a more comprehensive list of common street names for methamphetamine.

Methamphetamine found on the street may be pure, or adulterated with chemicals that were used to synthesize it. In some instances, it may be diluted or ''[[cutting agent|cut]]'' with non-psychoactive substances like [[inositol]]. In other instances, it may be mixed with other psychoactive drugs.

==History==
Methamphetamine was first synthesized in [[1919]] in [[Japan]] by the chemist [[A. Ogata]]. The method of synthesis was reduction of [[ephedrine]] using red [[phosphorus]] and [[iodine]].

Methamphetamine is closely related to [[amphetamine]], which was first synthesized in [[1887]] by [[Lazar Edeleanu]], a [[Romania|Romanian]] chemist. Over time, the chemical's use, distribution, and place in society has changed from insignificant, to controversially beneficial, to infamous.

Methamphetamine was later distributed during [[World War II]] by the [[Allies]] and the [[Axis Powers|Axis]] to troops, under the name '''Pervitin'''.<ref name=Pervitin>[http://pubchem.ncbi.nlm.nih.gov/summary/summary.cgi?sid=271075 SID 271075 PubChem Substance Page on Methamphetamine]</ref> The [[Nazis]] widely distributed methamphetamine to their soldiers for use as a stimulant, particularly to [[SS]] personnel and [[Wehrmacht]] forces in the [[Eastern Front (World War II)|Eastern Front]]. [[Adolf Hitler]] received shots of methamphetamine from his personal physician, [[Theodore Morell]].

After World War II, a massive supply of methamphetamine, formerly stockpiled by the Japanese military, became available in Japan under the street name [[shabu]]{{citation needed}}. The Japanese banned the drug soon after World War II, which is thought to have added to the growing [[yakuza]] activities related to illicit drug production. Today, the Japanese underworld is still associated with the drug, although its use is discouraged by strong social taboos.

With the [[1950s]] came a rise in the legal prescription of methamphetamine to the American public. According to the [[1951 in literature|1951 edition]] of ''Pharmacology and Therapeutics'' (by [[Arthur Grollman]]), it was to be prescribed for "[[narcolepsy]], post-[[Encephalitis|encephalitic]] [[parkinsonism]], [[alcoholism]], ... in certain [[Clinical depression|depressive states]]...and in the treatment of [[obesity]]."

[[Image:Methlab.jpg|thumb|166px|left|Meth lab.]]
The [[1960s]] saw the start of the significant use of clandestine manufacture to supply methamphetamine. Prior to [[1983]], U.S. laws prohibiting the possession of precursors and equipment for methamphetamine production were not yet in place. The recreational use of methamphetamine sky-rocketed in the [[1980s]]. The [[December 2]], [[1989]] edition of ''[[The Economist]]'' described [[San Diego, California]] as the "methamphetamine capital of North America."

In [[1986]], the U.S. government passed the [[Federal Controlled Substance Analogue Enforcement Act]] in an attempt to combat the growing usage of [[designer drugs]]. In spite of this, its use expanded throughout the rural [[United States]], especially in the [[Midwestern United States|Midwest]] and [[Southern United States|South]]. Growth of methamphetamine use continues into the [[21st century]], and many states are considering tougher [[legislation]].

On [[August 8]], [[2005]], an issue of ''[[Newsweek]]'' devoted a cover story to methamphetamine and its abuse[http://www.msnbc.msn.com/id/8770112/site/newsweek/], including criticism of the [[George W. Bush|Bush]] administration's policies regarding methamphetamine. ''Newsweek'' blamed the administration for not devoting enough resources to education about and prevention of the drug's use. The Bush administration has countered with the position that [[cannabis]] is a dangerous '[[gateway drug]]', so prevention of cannabis use will prevent potential abusers from trying and becoming hooked on "hard" drugs such as methamphetamine. This is known as the "stepping stone theory".

Meanwhile, the online magazine ''[[Slate (magazine)|Slate]]'' posted an article in reaction to the ''Newsweek'' article [http://slate.msn.com/id/2123838/], attacking ''Newsweek'' for failing to appropriately cite sources and data to back up the claim that this is a "new" problem.

The topic remains controversial. The most recent figures released by the Federal government indicate that contrary to public perception, methamphetamine use has actually declined nationally in recent years.

==Production==
Methamphetamine is structurally similar to [[methcathinone]], [[amphetamine]], and other [[stimulant]]s, and it may be produced from [[ephedrine]] or [[pseudoephedrine]] by chemical reduction. Most of the necessary chemicals are readily available in household products or [[over-the-counter substance|over-the counter medicine]]s. This makes methamphetamine appear unusually easy to make.

Many different syntheses for conversion can be found on the internet, although most sources are usually not considered trustworthy. Almost every method of synthesis involves highly dangerous chemicals and processes.

Most production methods involve [[hydrogenation]] of the [[hydroxyl]] group on the ephedrine/pseudoephedrine molecule. The most common method in the United States involves red [[phosphorus]] and [[iodine]] which forms [[hydroiodic acid]]. This is a fairly dangerous process; in fact, on the [[Darwin Awards]] [http://www.darwinawards.com/ site], there is a story of a man who burned himself trying to conceal these chemicals.[http://www.darwinawards.com/stupid/index_stupid2004.html (See the '''Hot Pants''' story.)] An increasingly common method utilizes a [[Birch reduction]] process, where metallic [[lithium]] is substituted for metallic [[sodium]] (due to the difficulty in obtaining metallic sodium). The Birch reduction is extremely dangerous since the alkali metal and liquid anhydrous ammonia are both extremely reactive, and because the temperature of liquid ammonia makes it susceptible to explosive boiling when reactants are added. Other less-common methods use other means of hydrogenation, such as hydrogen gas in the presence of a catalyst.

A completely different synthesis procedure involves creating methamphetamine by the [[reductive amination]] of [[phenylacetone]] with [[methylamine]], both of which are currently [[Drug Enforcement Administration|DEA]] [[DEA list I chemicals|list I]] chemicals (as are pseudoephedrine and ephedrine). This was once the preferred method of production by [[Hell's Angels|motorcycle gangs]] in [[California]], but DEA restrictions on the chemicals have made this an uncommon way to produce the drug today.

The chemicals used in methamphetamine manufacturing are safely used in and around the household for a variety of different purposes, but despite this, their use in the production of methamphetamine is generally quite dangerous. Because of the dangers, specially trained and certified professionals wearing full [[hazardous material]]s protection suits must be called in to dismantle and dispose of illegal methamphetamine lab equipment and materials. It is estimated that, for every pound of methamphetamine produced, 5 pounds of hazardous waste are also produced.[http://www.usdoj.gov/dea/pubs/cngrtest/ct020604.htm] The highly [[toxic]] [[by-product]]s of methamphetamine synthesis are often dumped in unsafe places.

Some of the more obvious signs of a production lab of metamphetamine in operation is the smell of a cat-[[urine]]-like odor and witnessing [[brass]] fittings on pipes, such as [[propane]] bottles, turn a blue colour. This is caused by hydrochloric acid vapours and in some cases from anhydrous HCl gas. It also makes [[stainless steel]] go a blackish colour and become [[rust]]ed; anything made of regular steel ends up quickly coated in rust.{{citation needed}}

When performed by individuals who are not trained [[chemist]]s, methamphetamine manufacture can lead to extremely dangerous situations. For example, in certain syntheses, if a particular reaction is allowed to overheat, [[phosphine]] gas can be produced. When produced in large quantities, it usually explodes, due to autoignition from [[diphosphine]] formation caused by overheating phosphorus, injuring or killing any individuals who are present. Since the late 1990s, the number of burn victims in the United States whose injuries were sustained from meth labs has skyrocketed{{citation needed}}.

Until the early 1990s, methamphetamine was made mostly in clandestine labs run by drug traffickers in [[Mexico]] and [[California]]. These areas are still the largest producers for the U.S. market. Since then, however, authorities have discovered increasing numbers of small-scale methamphetamine labs all over the United States, mostly located in rural, suburban, or low-income areas. The [[Indiana]] [[state police]] found 1,260 labs in 2003, compared to just 6 in 1995, although this may only be a result of increased police activity[http://www.in.gov/cji/methfreeindiana/enforce.html].

Recently, mobile and motel-based methamphetamine labs have caught the attention of both the news media and [[law enforcement]] agencies. The labs can cause explosions and fires, as well as expose the public to hazardous chemicals. In addition to these issues, individuals who manufacture methamphetamine are often armed and dangerous. Many police forces have responded by creating a specialized task force educated in responding to persons involved in methamphetamine production.

The amount of methamphetamine actually contributed to the market by small-scale labs is disputed. Large-scale labs maintained by criminal organizations continue to exist, and rely more on diverted or stolen shipments of laboratory-grade precursors than over-the-counter prescriptions. [[War on Drugs|Drug policy critics]] suggest that restriction of over-the-counter medication is more politically than socially motivated, and may in fact shift the balance of supply more in favor of large criminal organizations.

==Distribution==
A wide variety of groups are involved in the distribution of methamphetamine, from the aforementioned prison gangs and motorcycle gangs to street gangs, traditional organized crime operations, and impromptu small networks made up of users. The government of [[North Korea]] is said to promote the manufacture of crystal meth, and allegedly plays a role in distribution networks throughout Asia as well as those in [[Australia]] and even in [[North America]] {{citation needed}}. Regardless, meth trafficking is not exclusively dominated by [[cartel]]s along the lines of [[Colombia]]'s cocaine cartels or [[Pakistan]]'s heroin cartels.

==Medical use==
Methamphetamine is used medically to treat the following conditions:
*[[attention deficit hyperactivity disorder]]
*[[narcolepsy]]
*[[obesity]]

==Pharmacology==
Methamphetamine is a potent [[central nervous system]] [[stimulant]], that affects neurochemical mechanisms responsible for regulating heart rate, body temperature, blood pressure, appetite, attention, mood and responses associated with alertness or alarm conditions. Methamphetamine causes the [[norepinephrine transporter|norepinephrine-]] and [[dopamine transporter]] to reverse its direction of flow, in the same manner as amphetamine. This inversion leads to a release of these both [[transmitter]]s from the [[Vesicle (biology)|vesicle]]s to the [[cytoplasm]] and from the cytoplasm to the synapse and it also prevents the re-uptake of these neurotransmitters, causing them to remain in the [[synaptic cleft]] longer. In medicine it is used as an appetite suppressant in treating obesity, anesthetic overdose, and [[narcolepsy]].

The acute effects of the drug closely resemble the physiological and psychological effects of the [[fight-or-flight response]], including increased heart rate and blood pressure, vasoconstriction (constriction of the arterial walls), pupil dilation, bronchodilation, and hyperglycemia (increased blood sugar). The person who ingests meth will experience an increased focus and mental alertness and the elimination of the subjective effects of fatigue, as well as a decrease in appetite. Many of these effects are broadly interpreted as euphoria or a sense of well-being, intelligence, and power.

The 17th edition of "The [[Merck Manual]]" (1999) describes the effects of heavy methamphetamine use in these terms: "Continued high doses of methamphetamine produce [[anxiety]] reactions during which the person is fearful, tremulous, and concerned about his physical well-being; an amphetamine [[psychosis]] in which the person misinterprets others' actions, [[hallucination|hallucinates]], and becomes unrealistically suspicious; an exhaustion syndrome, involving intense [[fatigue]] and need for [[sleep]], after the stimulation phase; and a prolonged [[clinical depression|depression]], during which [[suicide]] is possible".<ref>[http://www.merck.com/mrkshared/mmanual/section15/chapter195/195g.jsp Merck Manual, chapter 195, p. 1593]</ref> Depending on delivery method and dosage, a dose of methamphetamine will potentially keep the user awake with a feeling of euphoria for periods lasting 2–24 hours.

=== Tolerance ===
The acute central effects decline as the natural transmitter resources (within the vesicles) depletes and as the body gradually metabolizes the chemical, leading to a rapid loss of the initial effect and a significant [[rebound effect]] as the previously-saturated synaptic cleft becomes depleted of the same neurotransmitters that had previously been elevated ([[tachyphylaxis]]). Many users then compensate by administering more of the drug to maintain their current state of euphoria and alertness. This process can be repeated many times, often leading to the user remaining awake for days, after which secondary [[sleep deprivation]] effects manifest in the user. Classic sleep deprivation effects include irritability, blurred vision, memory lapses, confusion, paranoia, hallucinations, nausea, and (in extreme cases) death. After prolonged use, the meth user will begin to become irritable, most likely due to lack of sleep.


=== Side effects ===
Methamphetamine is reported to attack the immune system, resulting in increased susceptibility to a variety of opportunistic infections (including [[MRSA]], streptococcus, pseudomonads, and other bacterias and yeasts). This, too, may simply be a result of long-term sleep deprivation and/or chronic malnutrition.

It is a common belief that methamphetamine gives people super-human strength. This is not really true, although methamphetamine inhibits pain and increases [[metabolism]], which allows a person to push muscles to points of failure that would otherwise be harder or impossible to reach. (See the article entitled [[Exercise and Stimulants]] for a better description of the factors involved.)

Other side effects include twitching, "jitteriness", repetitive behavior (known as "tweaking"), and jaw clenching or teeth grinding. It has been noted anecdotally that methamphetamine addicts lose their teeth abnormally fast, a condition known as "methmouth"; this may be due to the jaw clenching, although heavy meth users also tend to neglect personal hygiene, such as brushing teeth. It is often claimed that smoking methamphetamine speeds this process by leaving a crystalline residue on the teeth, but no studies have been done to support that claim. In fact, it is largely believed by most dentists that the cause of tooth rot in methamphetamine users is dry mouth. Methamphetamine causes the user to have a loss of saliva and increased thirst, which is quenched usually by soda{{citation needed}}. The combination of high sugar content and loss of acid fighting saliva create an increased risk for tooth decay.
Some users exhibit [[sexual compulsion|sexually compulsive]] behavior and may engage in extended sexual encounters with one or more individuals, often strangers. As it is symptomatic to continue taking the drug to combat fatigue, an encounter or series of encounters can last for several days. This compulsive behavior has created a link between meth use and [[sexually transmitted disease]] (STD) transmission, especially [[HIV]] and [[syphilis]]. This caused great concern among larger gay communities, particularly those in [[Atlanta]], [[Miami]], [[Chicago]], [[New York City]], and [[San Francisco]], leading to outreach programs and rapid growth in [[12-step program|12-step]] organizations such as [[Crystal Meth Anonymous]].

==Effects==
Methamphetamine is used both medically and recreationally for one or more of the following effects:
* Increased alertness, motivation, and brain activity (short-term)
* Euphoria in high doses
* Weight loss (may also be an adverse effect, depending upon circumstances)
* Heightened sexual stimulation

The undesirable effects of methamphetamine use include:
* Compulsive fascination with useless repetitive tasks (see [[Punding]])
* Severe [[psychological addiction]]
* [[Acne]]
* [[clinical depression|Depression]]
* [[Formication]] (false sensation of flesh crawling with bugs, with possible associated compulsive picking and infected sores)
* [[Amphetamine psychosis]]
* [[Erectile dysfunction]] ("[[Crystal dick|Crystal cock]]")
* Long-term cognitive impairment due to [[neurotoxicity]]
* [[Dental cavities|Tooth decay]] ("[[meth mouth]]")
* Damage to [[immune system]]
* Persistent [[anhedonia]] with chronic use
* [[Death]]
* [[Staphylococcus]] infection

The drug can stay in your system between three to four days

==Side effects==
Common side effects of methamphetamine include:
* '''[[Cardiovascular]]''' - [[Hypertension]]

* '''[[Endocrinal]]''' - Elevated [[body temperature]]

* '''[[Eye]]''' - Dilated [[pupil]]s

* '''[[Gastrointestinal]]''' - [[Diarrhea]], [[nausea]]

* '''Neuro-psychological''' - [[Paranoia]], especially when mixed with [[Cannabis (drug)|cannabis]].

* '''Neuro-psychological''' - [[Euphoria]], followed by [[depression]]

* '''[[Skin]]''' - [[Rash]]

* '''Miscellaneous''' - [[Anorexia]], [[insomnia]], restlessness, [[weight loss]]

* '''Decrease in Appetite'''

Severe side effects (with [[chronic (medicine)|chronic]] use) include:
* [[Amphetamine psychosis]]
* [[Clinical depression]]
* [[Kidney]] damage
* [[Liver]] damage

==Contraindications==
The use of methamphetamine should be avoided in persons with the following:
* [[Glaucoma]]
* [[Hypertension]]
* [[Cardiovascular disease]]
* Methamphetamine should not be taken within 14 days of taking a non-reversible [[MAOI]]. (If in good health, it can be safely combined with reversible [[MAOI]]'s such as [[moclobemide]].)

==Addiction==
Methamphetamine is a highly psychologically [[addiction|addictive]] drug. The mental and social consequences of quitting can be severe and extremely difficult for the addict. As with all addictions, [[relapse]] is common. To combat [[relapse]], many recovering addicts attend [[Twelve-step program|12 Step]] meetings, such as [[Crystal Meth Anonymous]].

In an article about his son's addiction to methamphetamine, a California writer who has also experimented with the drug put it this way:
:''[T]his drug has a unique, horrific quality. In an interview, [[Stephan Jenkins]], the singer in the band [[Third Eye Blind]], said that methamphetamine makes you feel 'bright and shiny.' It also makes you paranoid, incoherent and both destructive and pathetically and relentlessly ''self''-destructive. Then you will do unconscionable things in order to feel bright and shiny again'' (David Sheff, "My Addicted Son," ''New York Times Magazine'', February 6, 2005, p. 44).

Former users have noted that they feel stupid or dull when they quit using methamphetamine. This is because the brain is [[Adaptation (biology)|adapting]] a need for methamphetamine to think faster, or at what seems to be a higher level. Individuals with [[ADHD]] are often at especially higher risk for addiction to methamphetamine, because the drug often increases the user's ability to focus and reduces impulsivity, creating a mechanism by which one is better able to cope. For this reason, drugs like this should be used only under the supervision of a [[physician]]. The individual with ADHD is susceptible to meth's adverse effects (see ''[[Methamphetamine#Adverse effects|below]]''), so prescription stimulants such as [[methylphenidate]] (Ritalin®), [[dextroamphetamine]] (Dexadrine®) and [[amphetamine|amphetamine salt]] (Adderall®) are overwhelmingly indicated.

Chronic use may result in a tolerance of the drug.

With long-term methamphetamine use, enough [[dopamine]] will have flooded the brain to cause chemical cell damage. This often leads to slow thinking (which in turn requires that the addict use meth to 'fix' it), and depression. This is known colloquially as "The Vampire Life." In one particular case, researchers were able to reverse many of the addict's symptoms by treatment with fish oil[http://www.fishoilblog.com/benefits/fish-oil-reverses-brain-damage-from-crystal-meth-addiction.php]

Very serious long-term meth abuse correlates highly with poor [[hygiene]] and general self-care, and many of the health risks inherent in administering the drug are often severely exacerbated by this. Poor hydration and infrequent [[dental hygiene]] strongly increase the risks of damage to teeth from smoking or snorting, while infrequent [[bathing]] increases the chance that minor skin rashes or irritations on the arm from needle use will progress to infection and complications. Generally poor maintenance of living conditions can increase the general risk of exposure to illness through a wide variety of malaise-causing agents, such as [[bacteria]] that may grow in poorly cleaned living spaces. Finally, if methamphetamine does in fact attack the immune system, it follows that the ability of the individual to resist any illness is compromised, and that heavy meth users, over time, become more susceptible to poor health and illness in general. Severe cases of addiction are often marked by many of these symptoms and hallmarks, which can work in combination to almost completely destroy the user's health.

==Routes of administration==
Methamphetamine can be swallowed, snorted, smoked, dissolved in water and injected, inserted anally (with or without dissolution in water), or into the [[urethra]]. {{citation needed}} As with all addictive drugs, the potential for addiction is greater when it is delivered by methods that cause the concentration in the blood to rise quickly, principally because the effects desired by the user are felt more quickly and with a higher intensity than through a moderated delivery mechanism. In fact, studies have shown that the subjective pleasure of drug use (the reinforcing component of addiction) is proportional to the rate that the blood level of the drug increases. In general, smoking is the "fastest" mechanism (i.e., it causes the blood concentration to rise the most quickly in the shortest period of time as it allows the substance to travel to brain through a more direct route than intravenous injection), followed by injecting, then snorting, then swallowing. It is not entirely certain where anal insertion would fall on this list, but some scant anecdotal evidence puts the effects somewhere between those of smoking and snorting.

Methamphetamine is a powerful [[decongestant]], so methamphetamine users who snort it will often have very clear nasal cavities. However, there have been rare cases of people snorting so much meth that their [[nose]] [[cartilage]] deteriorates, though snorting cocaine is far more likely to cause nasal degeneration, due to its [[vasoconstrictive]] properties. Snorting methamphetamine may also cause tooth decay, since the nasal passages are directly connected to the [[mouth]] region, and it is theorized that damaging crystalline particles can still attach to the teeth. Another theory is that the drug directly affects calcium balance in the body.
Crystal Meth has also been shown to decrease the production of saliva, the lack of which causes tooth decay.

Methamphetamine is commonly smoked in glass pipes, or in aluminum foil heated by a flame underneath. This method is also known as "chasing the ''white'' dragon". (as derived from the method of smoking heroin known as "chasing the dragon"), Methamphetamine must be heated (not burned) to cause the desired smoke. Smoking methamphetamine is probably the most impure form of ingestion. In addition to the possible effects on teeth, it is very damaging to the [[lung]]s. Methamphetamine users who smoke it sometimes experience mild [[asthma]], which can be countered by inhaling [[salbutamol]] [[aerosol spray]], or [[epinephrine]] aerosol. Another problem with smoking meth is the potential presence of [[oxidation]] byproducts created when the heated drug comes in contact with air. Even if the initial drug is pure methamphetamine, the act of smoking it produces other chemicals, some of which may be toxic.

Injection is a popular method for use, but potentially carries quite serious risks. The [[hydrochloride]] salt of methamphetamine is soluble in water; injection users may use any dose from 200 mg to over a gram in one I.V. dose using a small needle. This dosage range may be fatal to non-addicts; addicts rapidly develop tolerance to the drug. In methamphetamine research, injection users often do not experience severe tooth decay, presumably because there is no residue left as there is through smoking it. But injection users experience greater jaw-clenching than users who snort or smoke it, since injecting methamphetamine has a much more powerful effect. This can cause loose teeth, so injection users still do lose their teeth. Also, this method of ingestion brings the risk of [[infection]]; injection users often experience skin [[rash]]es (sometimes called "speed bumps") and all kinds of infections due to the methamphetamine damage to the skin. As with any injected drug, if a group of users [[needle sharing|shares a common needle]] without sterilization procedures, blood-borne diseases such as [[HIV]] or [[hepatitis]] can be transmitted as well.

Very little research has focused on anal insertion as a method, and anecdotal evidence of its effects is infrequently discussed, possibly due to social [[taboo]]s in many cultures regarding the [[anus]]. This is often known within communities that use meth for sexual stimulation as a "booty bump" or "Keistering," and is anecdotally reported to increase sexual pleasure[http://www.citypages.com/databank/24/1171/article11254.asp] while the effects of the drug last. The [[rectum]] is where the majority of the drug would likely be taken up, through the [[mucous membrane]]s lining its walls. Lack of direct exposure to teeth probably insulates users from the majority of damaging dental effects, but damage to sensitive anal and rectal tissues is a risk. Weakness in these tissues may increase the risk of transmission of [[sexually-transmitted infection]]s during sex. If enough methamphetamine is taken so that not all of it is completely dissolved, abrasion of any [[prophylactic]] devices (such as [[condom]]s) used during sex can occur due to [[friction]] with undissolved meth crystals. This can contribute to breakage of the prophylactic, and increased risk of disease transmission. (See [[Crystal and sex]] for further information on other risk factors.)

The least-detrimental method of taking methamphetamine may be oral administration. The effects are moderated over time to a greater degree, and neither teeth, skin, nor nasal passages are directly exposed to potentially harmful chemicals (assuming the user is careful not to allow pure crystal meth to come in contact with these parts of the body during ingestion). The less-intense "hit" may make this a less popular current choice for administration.

Methamphetamine is classified as a [[Schedule II]] substance by the [[Drug Enforcement II drug under the [[Convention on Psychotropic Substances]] [http://www.incb.org/pdf/e/list/green.pdf]. While there is technically no difference between the laws regarding methamphetamine and other controlled stimulants, most medical professionals are averse to prescribing it due to its status in society. Further, there is some anecdotal evidence that the DEA audits such prescriptions far more often than prescriptions for similar drugs.

Methamphetamine is legally marketed in the United States under the trade name [[Desoxyn]], manufactured by [[Ovation Pharma]]. [[generic drug|Generic]] formulations of the drug are also available.

====Australia====
In Australia
, a program called "Pseudo Watch" was introduced in pharmacies in 2002 in an effort to combat methamphetamine production. This policy mandated that only one box of pseudoephedrine pills could be bought at a time and all pseudoephedrine-only preparations were taken off the shelves, making the analgesic and antihistamine laced blends the only over the counter sources available.

From [[1 April]] [[2006]] all pseudoephidrine containing products will be reschedule up to S3 or S4 medication depending on the amount of pseudoephidrine there is in the particular product. PseudoWatch has also been reemphasised. And now pharmacists have to record all purchases of pseudoephidrine single and multiingredient products.

The Ice Age Reporter: Matthew Carney Broadcast: 20/03/2006
http://www.abc.net.au/4corners/content/2006/s1593168.htm
It’s cheap, highly addictive and ultra-powerful. "Ice", or crystal methamphetamine, is now more popular than heroin, playing havoc with the minds and the bodies of nearly 50,000 Australians.

====Canada====
In August 2005, [[Canada]] moved methamphetamine from Drug Schedule III to Schedule I which increased the maximum penalty for the production and distribution from 10 years to life in prison, placing it on par with [[cocaine]] and [[heroin]] offenses.

====United Kingdom====
In the [[United Kingdom|UK]], methamphetamine is classified as a [[Class B drug|Class B]] drug under the [[Misuse of Drugs Act 1971]]. The maximum penalty for possession is five years imprisonment, and the maximum penalty for supplying is 14 years. If methamphetamine (or any other Class B drug) is prepared for injection, then it is re-classified as a [[Class A drug|Class A]] drug. The maximum penalty for such possession is seven years imprisonment, and the maximum penalty for supplying is life imprisonment.

On [[14 June]] [[2006]] [[Under-secretary of State]] for policing, security and community safety in the [[Home Office]], [[Vernon Coaker]], announced that methamphetamine is to be reclassified as a Class A drug, following a recomendation made by the [[Advisory Council on the Misuse of Drugs]] earlier in the month.<ref>[http://news.bbc.co.uk/1/hi/uk_politics/5079266.stm Crystal meth to be class A drug], BBC News, 14 June 2006</ref> The reasons for the ACMD's recommendation <ref>[http://www.drugs.gov.uk/publication-search/acmd/ACMDFurtherMethylamphetamine?view=Binary Letter from the Chairman of the ACMD to the Home Secretary], 5 June 2006</ref> were that there is now evidence that the drug is becoming more widely used within the United Kingdom, that the police have become aware of several illicit laboratories synthesising the drug, and also that media interest in it has grown.

This replaced the Council's previous advice, which was contained in a November 2005 review<ref>[http://www.drugs.gov.uk/publication-search/acmd/ACMD-meth-report-November-2005?view=Binary Methylamphetamine Review], A Report by the Advisory Council on the Misuse of Drugs, November 2005</ref>, that there was little evidence of use of the drug in the United Kingdom at that time, and that reclassifying it would create unnecessary interest in it from potential recreational users.

====United States====
Methamphetamine has become a major focus of the '[[war on drugs]]' in the [[United States of America|US]] in recent years. In some localities (e.g., [[Pierce County, Washington|Pierce County]] in [[Washington]] state, in [[2000]]), special task forces were formed by police to attack the problem of rampant methamphetamine production.

In some areas of the [[United States]], manufacturing methamphetamine is punishable by a mandatory ten-year [[prison]] sentence. In some cases, however, judges have ruled for life in prison without the possibility of parole, especially in cases where victims were killed by overdoses or impure substances.

In [[Michigan]] (USA) as of 2005, some county prosecutors have begun to charge methamphetamine producers with environmental crimes for reckless and illegal disposal of [[hazardous waste]]s in addition to drug violations as well as [[child abuse]] if children live in or near the site. Such sentences can extend prison terms for an offender by several years should sentencing be consecutive.

Crackdowns on the theft of anhydrous ammonia, a substance used in the manufacture of the drug, have resulted in additional prison time. Persons who steal anhydrous ammonia while exposing livestock or pets to it, resulting in the deaths of such creatures, may also be subjected to charges of [[cruelty to animals]].

On [[April 6]], [[2004]], [[Oklahoma]] (USA) issued a state law prohibiting the non-prescription sale of certain over-the-counter medications known to contain ingredients used in meth production. [[Iowa]] enacted a law concerning the sale of precursors such as pseudoephedrine. This law requires that non-prescription drugs with pseudoephedrine be placed behind the pharmacist's counter. A person can buy only 330 mg of pseudoephedrine per day. The customer must also show identification and sign a logbook when purchasing the drug. [[Oregon]] passed a similar law which adds that names of the purchasers are to be placed on a list which is kept for up to two years. In August 2005, Oregon strengthened its anti-methamphetamine laws even further by passing legislation requiring a prescription to purchase drugs containing pseudoephedrine. [[Alabama]], [[Indiana]], [[Illinois]], [[Michigan]], [[Minnesota]], [[Missouri]], [[North Carolina]], [[Tennessee]], [[Montana]], and [[South Dakota]] also have similar laws, requiring that the drug be kept behind pharmacy counters, not be sold to persons under the age of 18, customers purchasing pseudoephedrine must show identification and sign their names, and limits the amount of the drug that may be bought at a time.

U.S. Drug Enforcement Administration state factsheets, the Substance Abuse & Mental Health Services Administration Treatment Episode Date Set, and the National Alliance for Model State Drug Laws.

On [[March 9]], [[2006]], [[President Bush]] signed The Combat Meth Act, which provides minimum standards for retailers across the country that sell products containing ephedrine and pseudoephedrine. The law limits sales to 3.6 grams of the base ingredient (the pure ephedrine or pseudoephedrine) per day and 9 grams per 30 days, and requires that purchasers provide identification and sign a sales log. In addition, sellers must now keep these products behind the counter or in a locked case and register on-line with the U.S. [[Attorney General]].

==References==
<references/>

*''Methamphetamine Use: Clinical and Forensic Aspects'', by Errol Yudko, Harold V. Hall,and Sandra B. McPherson. CRC Press, Boca Ratan, Fl, 2003.
*''Secrets of Methamphetamine Manufacture'', by [[Uncle Fester (author)|Uncle Fester]]
*[http://www.pa-chouvy.org/yaabaa-methamphetamine-production-traffic-consumption.htm''YAA BAA. Production, Traffic and Consumption of Methamphetamine in Mainland Southeast Asia", by Pierre-Arnaud CHOUVY & Joël MEISSONNIER Singapore University Press, 232 p., 2004.]
*[http://www.usdoj.gov/dea/pubs/cngrtest/ct020604.htm Fighting Methamphetamine in the Heartland: How Can the Federal Government Assist State and Local Efforts?] Statement of Armand McClintock Assistant Special Agent in Charge Indianapolis District Office Drug Enforcement Administration Before the House Committee on Government Reform Subcommittee on Criminal Justice, Drug Policy and Human Resources, February 6, 2004
*''Phenethylamines I Have Known And Loved: A Chemical Love Story'', [[Alexander Shulgin]] and Ann Shulgin, (ISBN 0963009605). a.k.a. [[PiHKAL]]. synthesis. [http://www.erowid.org/library/books_online/pihkal/pihkal.shtml online]
*[http://www.fishoilblog.com/benefits/fish-oil-reverses-brain-damage-from-crystal-meth-addiction.php Fish Oil Reverses Brain Damage from Crystal Meth Addiction] Describes case studies of successfully treating Methamphetamine side effects with fish oil.

==External links==
* [http://www.methconference.org Second National Conference on Methamphetamine ~ Science & Response: 2007] This year's conference will once again be driven by collaboration and diversity - it will introduce the latest in methamphetamine research and innovative programming to the widest audience possible.
* [http://www.nyhealth.gov/diseases/aids/harm_reduction/crystalmeth/docs/meth_literature_index.pdf A Key to Methamphetamine-Related Literature] This is a comprehensive thematic index of methamphetamine-related journal articles with links from citations to the corresponding PubMed abstracts.
* [http://www.lifeormeth.com/ Life or Meth - Content Geared Towards The Gay Community]
* [http://www.msnbc.msn.com/id/8770112/site/newsweek/ Newsweek - "America's Most Dangerous Drug"], see also [http://slate.msn.com/id/2123838/ Slate - "Meth Madness At Newsweek"]
* [http://www.addictionsearch.com/featuredtopic.php Summaries of recent methamphetamine research conducted by various governmental agencies]
* [http://www.erowid.org/chemicals/meth/meth.shtml Erowid Methamphetamine Vault]
*[http://www.pbs.org/wgbh/pages/frontline/meth/ Frontline: The Meth Epidemic (Accessed 2/15/06)]
* [http://www.geopium.org Geopium: Geopolitics of Illicit Drugs in Asia]
* [http://www.erowid.org/archives/rhodium/chemistry/ Rhodium's Archive]
* [http://www.valleymeth.com/ Special Report on Meth in California's Central Valley]
* [http://www.newyorker.com/printables/fact/050523fa_fact "New Yorker" story on the impact of widespread methamphetamine abuse]
* [http://news.bbc.co.uk/1/hi/uk/4604047.stm BBC story on high levels of use of methamphetamine amongst the male gay community]
* [http://www.usdoj.gov/dea/ Drug Enforcement Administration]:
** [http://www.dea.gov/concern/meth_factsheet.html Brief on amphetamines]
* [http://www.apaic.org Asia & Pacific Amphetamine - Type Simulant Information Centre] - a very extensive information source mangaged by the United Nations Office on Drugs and Crime.
* [http://www.rotten.com/library/crime/drugs/methamphetamine/ Rotten Library: Methamphetamine]
* [http://methinmissouri.livejournal.com/ Meth In Missouri] A research blog on meth culture (especially in Missouri) that seeks your input- stories, comments, questions
* [http://www.notevenonce.com/ Montana Meth Project]
* [http://www.reason.com/sullum/090205.shtml Is Meth A Plague, A Wildfire, Or the Next Katrina? ~ Reason.com]
* [http://www.crystalbreaks.org Crystal Breaks] A Chicago-area campaign addressing meth use in the gay community.
* [http://www.crystalmeth.org Crystal Meth Anonymous] A 12-Step-based Meth Recovery group.
* [http://2stopmeth.org/main.php?pg=gallery Meth Strike Force] GALLERY and more
* [http://www.rossettiproductions.com/rossetti_productions_new2_004.htm] Website of the creator of a documentary about a meth user's life
* [http://www.iol.co.za/index.php?set_id=1&click_id=13&art_id=vn20060614022318578C733054 IOL: Tik (crystal meth) pandemic driving people 'insane']
* [http://www.health24.com/child/Abuse/833-859,28041.asp Health24: Tik (crystal meth): Is your child at risk?]
* [http://www.scienceinafrica.co.za/2005/june/tik.htm Science in Africa: Tik (crystal meth), memory loss and stroke]
* [http://www.quihn.org.au Fact sheets on amphetamines and other illicit drugs]

==See also==
* [[Amphetamine]]
* [[Clandestine chemistry]]
* [[Crystal methamphetamine and sex]]
* [[Desoxyn]] (desoxyephedrine)
* [[Dexamphetamine]]
* [[Illegal drug trade]]
* [[Ephedrine]]
* [[Methcathinone]]
* [[Phenethylamine]]s
* [[Pseudoephedrine]]
* [[Drug Enforcement Agency]]
* [[MDMA]]

{{Stimulants}}
{{Phenethylamines}}

[[Category:Alkaloids]]
[[Category:Amphetamines]]
[[Category:Class A drugs]]
[[Category:Class B drugs]]
[[Category:Military drugs]]
[[Category:Schedule II controlled substances]]
[[Category:Stimulants]]

[http://www.addictionswithcrystalmeth.com http://www.addictionswithcrystalmeth.com Addiction With Crystal Meth - Crystal Meth Addiction And Detox pages]

[[cs:Metamfetamin]]
[[de:N-Methylamphetamin]]
[[es:Metanfetamina]]
[[eo:Metamfetamino]]
[[fr:Méthamphétamine]]
[[ms:Metamfetamin]]
[[nl:Methamfetamine]]
[[ja:メタンフェタミン]]
[[pl:Metamfetamina]]
[[pt:Metanfetamina]]
[[simple:Methamphetamine]]
[[sk:Metamfetamín]]
[[fi:Metamfetamiini]]
[[sv:Metamfetamin]]
[[zh:甲基苯丙胺]]

LSD

2006-06-20T06:18:30Z

Quihn: /* General */

{{featured article}}

{| id="drugInfoBox" border="1" cellpadding="2" cellspacing="0" align="right" style="margin-left:1em" class="prettytable"
! colspan=2 | '''LSD'''
|-
| [[IUPAC nomenclature|Chemical name]]
| <small>D</small>-Lysergic acid diethylamide<br>or:<br><small>(6a''R'',9''R'')-''N'',''N''-diethyl-7-methyl-<br>4,6,6a,7,8,9-hexahydroindolo<br>[4,3-''fg'']quinoline-9-carboxamide</small>
|-
| [[Chemical formula]]
| C<sub>20</sub>H<sub>25</sub>N<sub>3</sub>O
|-
| [[Molar mass]]
| 323.43 g/mol
|-
| [[Melting point]]
| 80–85 °C
|-
| [[Properties]]
| Pointed prisms from benzene, mp 80–85°.
|-
| [[Toxicity|Toxicity data]]
| LD<sub>50</sub> in mice, rats, rabbits (mg/kg): 46, 16.5, 0.3 i.v.
|-
| [[CAS registry number|CAS number]]
| 50-37-3
|-
| [[Simplified molecular input line entry specification|SMILES]]
| <small>O=[C@@](N(CC)CC)[C@H]<br>1CN(C)[C@](C2=C1)([H])<br>CC3=CNC4=C3C2=CC=C4</small>
|-
| colspan=2 | <center>[[Image:Lsd-structure.png|The chemical structure of LSD]]</center>
|}
{{otheruses}}
'''Lysergic acid diethylamide''', commonly called '''acid''', '''LSD''', or '''LSD-25''', is a [[semisynthetic]] [[psychedelic drug]] colloquially measured in "hits" or "tabs". A typical single dose of LSD during the 1960s was between 100 and 200 [[kilogram|microgram]]s,<ref name="henderson-glass">"LSD : Still With Us After All These Years" by Epidemiologist Leigh A. Henderson & NIDA Project Officer William J. Glass : [http://www.maps.org/news-letters/v06n1/06154lsd.html A Review of "LSD : Still With Us After All These Years"].</ref> a tiny amount roughly equal to one-tenth the weight of a grain of sand. Today, a typical single dose of LSD can be as low as 25–50 micrograms, although they are more commonly 50–100 micrograms.<ref name="henderson-glass"/> Threshold effects can be felt with as little as 20 micrograms.<ref name="greiner">{{cite journal | author=Greiner T, Burch NR, Edelberg R | title=Psychopathology and psychophysiology of minimal LSD-25 dosage; a preliminary dosage-response spectrum | journal=AMA Arch Neurol Psychiatry | year=1958 | pages=208–10 | volume=79 | issue=2 | id=PMID 13497365}}</ref>

The effects of LSD can vary greatly, depending on factors such as previous experiences, state of mind and environment, as well as dose strength. Generally, LSD causes expansion and altered experience of [[sense]]s, [[emotion]]s, [[memory|memories]], and [[awareness]] for 8 to 14 hours. In addition, LSD may produce visual effects such as moving [[pattern|geometric pattern]]s, "trails" behind moving objects, and brilliant colors. LSD does not produce [[hallucination]]s in the strict sense but instead illusions and vivid daydream-like [[Fantasy (psychology)|fantasies]], in which ordinary objects and experiences can take on entirely different appearances or meanings. At higher doses it can cause [[synaesthesia]]. The drug sometimes spurs long-term or even permanent changes in a user's personality and life perspective.

LSD is [[synthesis|synthesized]] from [[lysergic acid]] derived from [[ergot]], a grain fungus that typically grows on rye. LSD is sensitive to [[oxygen]], [[ultraviolet|ultraviolet light]], and [[chlorine]], especially in [[solution]] (though its potency may last years if the substance is stored away from light and moisture at low temperature). In pure form it is colorless, odorless, and mildly bitter. LSD is typically delivered orally, usually on a substrate such as absorbent blotter paper, a [[sugar cube]], or gelatin.

Introduced by [[Sandoz Laboratories]] as a drug with various [[psychiatric]] uses, LSD quickly became a [[Psychedelic psychotherapy|therapeutic agent]] that appeared to show great promise. However, the extra-medical use of the drug in [[Western society]] in the middle years of the [[twentieth century]] led to a political firestorm and government insider panic that resulted in the [[Hallucinogenic drug#Legal status|banning of the substance]] for medical as well as recreational and spiritual uses. Despite this, it is still considered a promising drug in some intellectual circles.

==Origins and history==
{{main|History of LSD}}
[[Image:LSD blotter paper.jpg|thumb|300px|right|When impregnated with LSD, perforated blotter paper, as illustrated above, is one popular form of dispensing the drug.]]
"LSD" is an [[initialism]] formed from the [[German language|German]] chemical name of the compound, '''''L'''yserg'''s'''äure-'''d'''iethylamid''. It was first synthesized in 1938 by Swiss chemist Dr. [[Albert Hofmann]] at the [[Sandoz Laboratories]] in [[Basel]] as part of a large research program searching for medically useful [[Ergoline|ergot alkaloid]] derivatives. Its psychedelic properties were unknown until 5 years later, when Hofmann, acting on a hunch, returned to work on the chemical. He attributed the discovery of the compound's psychoactive effects to the accidental absorption of a tiny amount through his skin on [[April 16]], which led to him testing a larger amount on himself for [[Psychoactive|psychoactivity]].<ref name="problem-child">Hofmann, Albert. ''LSD – My Problem Child'' (McGraw-Hill, 1980). ISBN 0-07-029325-2. Available online [http://www.psychedelic-library.org/child1.htm here] or [http://www.flashback.se/archive/my_problem_child/chapter1.html here].</ref>

Until 1966, LSD and [[psilocybin]] were provided by Sandoz Laboratories free of charge to interested scientists. (Sandoz gave LSD the [[trade name]] "Delysid".<ref name="problem-child"/>) The use of these compounds by psychiatrists to gain a better subjective understanding of the [[schizophrenia|schizophrenic]] experience was an accepted practice. Many [[clinical trials]] were conducted on the potential use of LSD in [[psychedelic psychotherapy]], generally with very positive results.

[[Cold War]] era intelligence services were keenly interested in the possibilities of using LSD for interrogation and mind control, and also for large-scale [[social engineering (political science)|social engineering]]. The [[CIA]] conducted extensive research on LSD, which was mostly destroyed.<ref>ACHRE Report, chapter 3: "[http://www.eh.doe.gov/ohre/roadmap/achre/chap3_4.html Supreme Court Dissents Invoke the Nuremberg Code: CIA and DOD Human Subjects Research Scandals]".</ref> [[Project MKULTRA]] (also known as MK-ULTRA) was the code name for a CIA mind-control research program begun in the 1950s and continued until the late 1960s. There is much published evidence that the project involved not only the use of drugs to manipulate persons, but also the use of electronic signals to alter brain functioning; for details, see the MKULTRA article proper.

The [[United Kingdom|British]] government also indulged in LSD testing; in 1953 and 1954, scientists working for [[MI6]] dosed servicemen in an effort to find a "truth drug". (In all probability, MI6 was motivated by rumors that the [[Soviet Union]] had developed [[brainwashing]] drugs.) The test subjects were not informed that they were being given LSD, and had in fact been told that they were participating in a medical project to find a cure for the common cold. One subject, aged 19 at the time, reported seeing "walls melting, cracks appearing in people's faces ... eyes would run down cheeks, [[Salvador Dalí]]-type faces ... a flower would turn into a slug". After keeping the trials secret for many years, MI6 agreed in 2006 to pay the former test subjects financial compensation. Like the CIA, MI6 decided that LSD was not a practical drug for brainwashing purposes.<ref>Rob Evans, "[http://politics.guardian.co.uk/homeaffairs/story/0,,1716708,00.html MI6 pays out over secret LSD mind control tests]". ''The Guardian'' 24 February 2006.</ref>
[[Image:Lsdtherapeutic.JPG|thumb|174px|left|Previous to 1967 in the USA (and later in many other countries), LSD was tested for therapeutic and military purposes.]]
LSD first became popular [[recreational drug use|recreationally]] among a small group of mental health professionals such as psychiatrists and psychologists during the 1950s, as well as by socially prominent and politically powerful individuals such as [[Henry Luce|Henry]] and [[Clare Boothe Luce]] to whom the early LSD researchers were connected socially.

Several mental health professionals involved in LSD research, most notably [[Harvard]] psychology professors Drs. [[Timothy Leary]] and [[Ram Dass|Richard Alpert]], became convinced of LSD's potential as a tool for spiritual growth. In 1961, Dr. Timothy Leary received grant money from Harvard University to study the effects of LSD on test subjects. 3,500 doses were given to over 400 people. Of those tested, 90% said they would like to repeat the experience, 83% said they had "learned something or had insight," and 62% said it had changed their life for the better.

Their research became more esoteric and controversial, alleging links between the LSD experience and the state of enlightenment sought after in many [[mysticism|mystical]] traditions. They were dismissed from the traditional academic psychology community, and as such cut off from legal scientific acquisition of the drug.  The experiments lost their scientific accreditation, and the pair evolved into countercultural [[spirituality|spiritual]] [[guru]]s, encouraging people to question authority and challenge the status quo, a concept summarized in their catchphrase, "Turn on, tune in, and drop out". Predictably, the drug was banned in the United States in 1967, with scientific therapeutic research as well as individual research also becoming prohibitively difficult. Many other countries, under pressure from the U.S., quickly followed suit.

Since 1967, underground recreational and therapeutic LSD use has continued in many countries, supported by a black market and popular demand for the drug. Legal, academic research experiments on the effects and mechanisms of LSD are also conducted on occasion, but rarely involve human subjects.

According to Leigh Henderson and William Glass, two researchers associated with the [[National Institute on Drug Abuse|NIDA]] who performed a 1994 review of the literature, LSD use is relatively uncommon when compared to the abuse of alcohol, marijuana, cocaine and prescription drugs. Over the previous fifteen years, long-term usage trends stayed fairly stable, with roughly 5% of the population using the drug and most users being in the 16 to 23 age range. Henderson and Glass found that LSD users typically partook of the substance on an infrequent, episodic basis, then "maturing out" after two to four years. Overall, LSD appeared to have comparatively few adverse health consequences, of which "bad trips" were the most commonly reported (and, the researchers found, one of the chief reasons youths stop using the drug).<ref name="henderson-glass"/>

== Dosage ==
LSD is, by weight, one of the most potent drugs yet discovered. Both subjective reports and pharmacological methods such as [[receptor binding assay]]s determine LSD to be, per [[mole (unit)|mole]], around 100 times more potent than [[Psilocybin|psilocybin]] and [[Psilocin|psilocin]] and around 4,000 times more potent than [[Mescaline|mescaline]]. Dosages of LSD are measured in [[microgram]]s (µg), or millionths of a [[gram]]. By comparison, dosages of almost all other drugs, both recreational and medical, are measured in [[milligram]]s (mg), or thousandths of a gram.

The dosage level that will produce a threshold hallucinogenic effect in humans is generally considered to be 20–30 μg, with the drug's effects becoming markedly more evident at higher dosages.<ref>Stoll, W.A. (1947). Ein neues, in sehr kleinen Mengen wirsames Phantastikum. Schweiz. Arch. Neur. 60,483.</ref><ref name="greiner"/> According to Glass and Henderson's review, black-market LSD is largely unadulterated though sometimes contaminated by manufacturing by-products. Typical doses in the 1960s ranged from 200 to 1000 micrograms, while street samples of the 1970s contained 30 to 300 µg. By the mid-1980s, the average had reduced to about 100 to 125 µg, lowering still further in the 1990s to the 20–80 µg range. (Lower doses, Glass and Henderson found, generally produce fewer bad trips.)<ref name="henderson-glass"/> Dosages by frequent users can be as high as 1,200 µg (1.2 mg), although such a high dosage may precipitate unpleasant physical and psychological reactions.

Estimates for the lethal dosage ([[LD50|LD<sub>50</sub>]]) of LSD range from 200 μg/kg to more than 1 mg/kg of human body-weight, though most sources report that there are no known human cases of such an overdose. Other sources note one report of a suspected fatal overdose of LSD in which there were indications that ~1/3 of a gram (320 mg or 320,000 µg) had been injected intravenously, i.e., over 3,000 more typical oral doses of ~100 µg had been injected.<ref>[http://www.erowid.org/chemicals/lsd/lsd_dose.shtml Dose information] from [[Erowid]]</ref>

LSD is not considered addictive, in that its users do not exhibit the medical community's commonly accepted definitions of [[addiction]] and physical dependence. Rapid tolerance build-up prevents regular use, and there is cross-tolerance shown between LSD, [[mescaline]] and [[psilocybin]]. This tolerance diminishes after a few days' abstention from use. As with any psychotropic substance there is a risk of psychological dependence; however, as with most psychedelics, this risk is relatively low.

== Effects ==
=== Pharmacodynamical ===
LSD's primary effects normally last from eight to twelve hours,<ref name="tihkal">[[Alexander Shulgin|Shulgin, Alex]] and [[Ann Shulgin]]. "[http://www.erowid.org/library/books_online/tihkal/tihkal26.shtml LSD]", in ''[[TiHKAL]]'' (Berkeley: Transform Press, 1997). ISBN 0-963-00969-9.</ref> though as Sandoz's prospectus for "Delysid" warned, "intermittent disturbances of affect may occasionally persist for several days."<ref name="problem-child"/> Contrary to early reports and common belief, LSD effects do not last longer than significant levels of the drug in the blood. Aghajanian and Bing <ref>{{cite journal|author=Aghajanian, George K. and Bing, Oscar H. L.|url=http://www.maps.org/w3pb/new/1964/1964_aghajanian_2224_1.pdf|title=Persistence of lysergic acid diethylamide in the plasma of human subjects|journal=Clin. Pharmacol. Ther.|volume=5|year=1964|pages=611–4|id=PMID 14209776}}</ref> found LSD had an elimination half-life of 175 min, while, more recently, Papac and Foltz <ref>{{cite journal | author=Papac DI, Foltz RL | title=Measurement of lysergic acid diethylamide (LSD) in human plasma by gas chromatography/negative ion chemical ionization mass spectrometry | journal=J Anal Toxicol | year=1990 | pages=189-90 | volume=14 | issue=3 | id=PMID 2374410}}</ref>
reported that 1 µg/kg oral LSD given to a single male volunteer had an apparent plasma half-life of 5.1 h with a peak plasma concentration of 1.9 ng/mL at 3 h post-dose. Notably, Aghajanian and Bing found that blood concentrations of LSD matched the time course of volunteers' difficulties with simple arithmetic problems.

Anecdotal reports indicate that administration of [[chlorpromazine]] (Thorazine) or similar [[typical antipsychotic]] tranquilizers will not end an LSD trip, but rather will just immobilize and numb the patient. While it also may not end an LSD trip, the best chemical treatment for a "bad trip" is an [[anxiolytic]] agent such as [[diazepam]] (Valium) or another [[benzodiazepine]]. There have also been reports of the [[Niacin|nicotinic acid form of vitamin B3]] being useful, a claim that has not been confirmed by multiple research groups using double-blind scientific methods and is therefore questionable.

[[Image:LSDaffinities.GIF|thumb|right|Affinity of LSD for various receptors, averaged from data from the [http://pdsp.cwru.edu/pdsp.php '''PDSP'''] ]]

LSD affects an enormous number of [[receptor (biochemistry)|receptors]], including all [[dopamine receptor]] subtypes, all [[Adrenergic receptor|adrenoreceptor]] subtypes as well as many others. LSD binds to most [[5-HT receptor|serotonin receptor]] subtypes except for 5-HT<sub>3</sub> and 5-HT<sub>4</sub>. However, most of these receptors are affected at too low affinity to be activated by the brain concentration of approximate 10–20 nM.<ref name="nichols">{{cite journal | author=Nichols, David E. | title=Hallucinogens | journal=Pharmacology & Therapeutics | year=2004 | pages=131-81 | volume=101 | issue=2 | url=http://www.erowid.org/references/refs_view.php?A=ShowDoc1&ID=6318 | id=PMID 14761703}}</ref> Recreational doses of LSD can affect 5-HT<sub>1A</sub>, [[5-HT2A receptor|5-HT<sub>2A</sub>]], 5-HT<sub>2C</sub>, 5-HT<sub>5A</sub>, 5-HT<sub>5 B</sub> and 5-HT<sub>6</sub> The hallucinogenic effects of LSD are attributed to its strong partial agonist effects at 5-HT<sub>2A</sub> receptors as specific 5-HT<sub>2A</sub> [[agonist]] drugs are hallucinogenic and largely 5-HT<sub>2A</sub> specific antagonists block the hallucinogenic activity of LSD.<ref name="nichols"/> Exactly how this produces the drug's effects is unknown, but it is thought that it works by increasing [[glutamate]] release and hence excitation in the [[Cerebral cortex|cortex]], specifically in layers IV and V.<ref>BilZ0r. "[http://www.erowid.org/psychoactives/pharmacology/pharmacology_article2.shtml The Neuropharmacology of Hallucinogens: a technical overview]". [[Erowid]], v3.1 (August 2005).</ref>

=== Physical ===
Physical reactions to LSD are highly variable and may include the following: [[uterus|uterine]] contractions, [[hyperthermia]] (body [[temperature]] increase), elevated [[blood sugar]] levels, dry-mouth, [[goose bumps]], heart-rate increase, jaw clenching, nausea, perspiration, [[Mydriasis|pupil-dilation]], [[saliva]]tion, [[mucus]] production, [[sleep]]lessness and [[tremor]]s. [[Cramps]] and muscle tension or soreness are also fairly commonly reported, but rather than being direct effects of LSD in the bloodstream, these symptoms are believed by some to be the result of awkward positions assumed by users experiencing fluctuations in their awareness of the passage of time and their own physical discomfort.

LSD was studied in the 1960s by Eric Kast as a painkiller for serious and chronic pain caused by cancer or other major trauma.<ref>{{cite journal | author=Kast, Eric | title=Attenuation of anticipation: a therapeutic use of lysergic acid diethylamide | journal=Psychiat. Quart. | year=1967 | pages=646-57 | volume=41 | issue=4 | id=PMID 4169685 | url=http://www.maps.org/w3pb/new/1967/1967_kast_3881_1.pdf}}</ref> Even at low (sub-psychedelic) dosages, it was found to be at least as effective as traditional opiates while being much longer lasting (pain reduction lasting as long as a week ''after'' peak effects had subsided). Kast attributed this effect to a decrease in anxiety. This reported effect is being tested (though not using LSD) in an ongoing (as of 2006) study of the effects of the hallucinogen psilocybin on anxiety in terminal cancer patients.

Furthermore, LSD has been illicitly used as a treatment for [[cluster headache]]s, an uncommon but extremely painful disorder. Researcher Peter Goadsby describes the headaches as "worse than natural childbirth or even amputation without anesthetic."<ref>Dr. Goadsby is quoted in "[http://www.maps.org/research/cluster/psilo-lsd/ Research into psilocybin and LSD as cluster headache treatment]", and he makes an equivalent statement in [http://www.abc.net.au/rn/talks/8.30/helthrpt/stories/s42434.htm an ''Health Report'' interview] on Australian [[Radio National]] (9 August 1999).</ref> Although the phenomenon has not been formally investigated, case reports indicate that LSD and [[psilocybin]] can reduce cluster pain and also interrupt the cluster-headache cycle, preventing future headaches from occurring. Currently existing treatments include various [[ergotamine]]s, among other chemicals, so LSD's efficacy may not be surprising. A dose-response study, testing the effectiveness of both LSD and psilocybin is, [[as of 2006]], being planned at [[McLean Hospital]]. Unlike attempts to use LSD or [[MDMA]] in [[psychotherapy]], this research involves non-psychological effects and often sub-psychedelic dosages; therefore, it is plausibly a way that a respected medical use of LSD will arise.<ref>Summarized from "[http://www.maps.org/research/cluster/psilo-lsd/ Research into psilocybin and LSD as cluster headache treatment]" and [http://www.clusterbusters.com/ the Clusterbusters website].</ref>

=== Psychological ===
LSD's psychological effects ([[colloquialism|colloquially]] called a "trip") vary greatly from person to person, from one trip to another, and even as time passes during a single trip. Widely different effects emerge based on ''[[set and setting]]'' — the "set" being the general mindset of the user, and the "setting" being the physical and social environment in which the drug's effects are experienced.

An LSD trip can have long lasting or even permanent neutral, negative, and positive psychoemotional effects. LSD experiences can range from indescribably ecstatic to extraordinarily difficult; many difficult experiences (or "bad trips") result from a panicked user feeling that he or she has been permanently severed from [[reality]] and his or her [[Ego, super-ego, and id|ego]]. If the user is in a hostile or otherwise unsettling environment, or is not mentally prepared for the powerful distortions in perception and thought that the drug causes, effects are more likely to be unpleasant.

Conversely, a comfortable environment and a relaxed, balanced and open mindset will often result in a pleasant experience.

Many users experience a dissolution between themselves and the "outside world": cognitive differences between subject ("I") and object ("me", "you", "it") break down or seem absurd.<ref name="linton-langs">Linton, Harriet B. and Langs, Robert J. "[http://www.maps.org/w3pb/new/1962/1962_linton_2052_1.pdf Subjective Reactions to Lysergic Acid Diethylamide (LSD-25)]". ''Arch. Gen. Psychiat.'' Vol. 6 (1962): 352–68.</ref> This unitive quality may play a role in the spiritual and religious aspects of LSD.

Some experts hypothesize that drugs such as LSD may be useful in psychotherapy, especially when the patient is unable to "unblock" repressed subconscious material through other psychetherapeutic methods,<ref>Cohen, S. (1959). The therapeutic potential of LSD-25. ''A Pharmacologic Approach to the Study of the Mind,'' p251–258.</ref> and also for treating alcoholism. One study concluded, "The root of the therapeutic value of the LSD experience is its potential for producing self-acceptance and self-surrender,"<ref>{{cite journal | author=Chwelos N, Blewett D.B., Smith C.M., Hoffer A. | title=Use of d-lysergic acid diethylamide in the treatment of alcoholism | journal=Quart. J. Stud. Alcohol | year=1959 | pages=577-90 | volume=20 | id=PMID 13810249}}</ref> presumably by forcing the user to face issues and problems in that individual's psyche. Many believe that, in contrast, other drugs (such as [[alcohol]], [[heroin]], and [[cocaine]]) are used to [[escapism|escape]] from reality. Studies in the 1950s that used LSD to treat alcoholism professed a 50% success rate,<ref>Maclean, J.R.; Macdonald, D.C.; Ogden, F.; Wilby, E., "LSD-25 and mescaline as therapeutic adjuvants." In: Abramson, H., Ed., ''The Use of LSD in Psychotherapy and Alcoholism,'' Bobbs-Merrill: New York, 1967, pp. 407–426; Ditman, K.S.; Bailey, J.J., "Evaluating LSD as a psychotherapeutic agent," pp.74–80; Hoffer, A., "A program for the treatment of alcoholism: LSD, malvaria, and nicotinic acid," pp. 353–402.</ref> higher than estimates near 10% for [[Alcoholics Anonymous]].<ref>Minogue, S. J. "Alcoholics Anonymous." ''The Medical Journal of Australia'' May 8 (1948):586–587.</ref>

Some LSD studies were criticized for methodological flaws, and different groups had inconsistent results. Mangini's 1998 paper reviews this history and concludes that the efficacy  of LSD in treating alcoholism remains an open question.<ref>{{cite journal | author=Mangini M | title=Treatment of alcoholism using psychedelic drugs: a review of the program of research | journal=J Psychoactive Drugs | year=1998 | pages=381-418 | volume=30 | issue=4 | id=PMID 9924844}}</ref>

[[List of notable people who have commented on the LSD experience|Many notable individuals]] have commented publicly on their experiences with LSD. Some of these comments date from the era when it was legally available in the US and Europe for non-medical uses, and others pertain to [[psychiatric]] treatment in the 1950s and 60s. Still others describe experiences with illegal LSD, obtained for philosophic, artistic, therapeutic, spiritual, or recreational purposes.

==== Sensory/perception ====
Generally beginning within thirty to ninety minutes after ingestion and continuing for the following six to twelve hours, the user may experience anything from subtle changes in perception to overwhelming [[cognitive shift]]s.

Changes in aural and visual perception are common, ranging from mild to profound.<ref name="linton-langs"/><ref>{{cite journal | author=Katz MM, Waskow IE, Olsson J | title=Characterizing the psychological state produced by LSD | journal=J Abnorm Psychol | year=1968 | pages=1-14 | volume=73 | issue=1 | id=PMID 5639999}}</ref> These sensory changes include basic "high-level" distortions such as the appearance of moving geometrical patterns, new textures on objects, blurred vision, image trailing, shape suggestibility and color variations. Users sometimes describe experiencing new, previously-unseen colors; sights and sounds may take on greater intensity or have more of an impact. Users commonly report that the inanimate world appears to animate in an unexplained way; that is, objects that are static in three dimensions can seem to be moving relative to one or more additional spatial dimensions.<ref>See, ''e.g.,'' Gerald Oster's article "[http://www.maps.org/w3pb/new/1966/1966_oster_3875_1.pdf Moiré patterns and visual hallucinations]". ''Psychedelic Rev.'' No. 7 (1966): 33–40.</ref>

Higher doses often bring about shifts at a lower cognitive level, causing intense and fundamental distortions of sensory perception such as [[synaesthesia]], the experience of additional spatial or temporal dimensions, and temporary dissociation.

==== Spiritual ====
LSD is considered an [[entheogen]] because it often catalyzes intense spiritual experiences where users feel they have come into contact with a greater spiritual or cosmic order. It is common for users to believe that they have achieved insights into the way the mind works and some users experience permanent or long-lasting changes in their life perspective. Some users consider LSD a religious sacrament, or a powerful tool for access to the divine. Many books have been written comparing the LSD trip to the state of [[enlightenment (Buddhism)|enlightenment]] of [[eastern philosophy]].

Such experiences under the influence of LSD have been observed and documented by researchers such as [[Timothy Leary]] and [[Stanislav Grof]]. For example, Walter Pahnke conducted the [[Good Friday]] [[Marsh Chapel Experiment]] under Leary's supervision, performing a double blind experiment on the administration of psilocybin to volunteers who were students in religious graduate programs, ''e.g.,'' divinity or theology.<ref>Video of the experiment can be viewed [http://www.yoism.org/?q=node/52 here].</ref> That study showed that hallucinogens could reliably be used to induce mystical religious states (at least in people with a spiritual predisposition).

=== Physical dangers ===
Although LSD is generally considered nontoxic, it may temporarily impair the ability to make sensible judgments and understand common dangers, thus making the user susceptible to accidents and personal injury.

There is also some indication that LSD may trigger a [[fugue state|dissociative fugue]] state in individuals who are taking certain classes of [[antidepressants]] such as [[lithium salt]]s and [[Tricyclic antidepressant|tricyclics]]. In such a state, the user has an impulse to wander, and may not be aware of his or her actions, which can lead to physical injury.<ref name="lsd-antidepressants">"[http://www.erowid.org/chemicals/lsd/lsd_health3.shtml LSD and Antidepressants]" (2003) via [[Erowid]].</ref> [[Selective serotonin reuptake inhibitor|SSRIs]] are believed to interact more benignly, with a tendency to noticeably reduce LSD's subjective effects.<ref>Kit Bonson, "[http://www.erowid.org/chemicals/maois/maois_info4.shtml The Interactions between Hallucinogens and Antidepressants]" (2006).</ref> Similar and perhaps greater reductions have also been reported with [[MAOI]]s.<ref name="lsd-antidepressants"/>

As Albert Hofmann reports in ''LSD – My Problem Child,'' the early pharmacological testing Sandoz performed on the compound (before he ever discovered its psychoactive properties) indicated that LSD has a pronounced effect upon the mammalian [[uterus]]. Sandoz testing showed that LSD can stimulate uterine contractions with efficacy comparable to [[Ergoline#Lysergic acid amides|ergobasine]], the active uterotonic component of the [[ergot]] fungus. (It is worth noting that Hofmann's work on ergot derivatives also produced a modified form of ergobasine which became a widely accepted medication used in [[obstetrics]], under the trade name [[Ergoline#Lysergic acid amides|Methergine]].) LSD use by pregnant women is therefore contraindicated.<ref name="problem-child"/>

Initial studies in the 1960s and 70s raised concerns that LSD might produce genetic damage or developmental abnormalities in fetuses. However, these initial reports were based on in vitro studies or were poorly controlled and have not been substantiated. In studies of [[chromosome|chromosomal]] changes in human users and in monkeys, the balance of evidence suggests no significant increase in chromosomal damage. For example, studies were conducted with people who had been given LSD in a clinical setting.<ref>{{cite journal | author=Dishotsky NI, Loughman WD, Mogar RE, Lipscomb WR | title=LSD and genetic damage | journal=Science | year=1971 | pages=431-40 | volume=172 | issue=982 | id=PMID 4994465 | url=http://www.maps.org/w3pb/new/1971/1971_dishotsky_5148_1.pdf}}</ref> [[White blood cell]]s from these people were examined for visible chromosomal abnormalities. Overall, there appeared to be no lasting changes. Several studies have been conducted using illicit LSD users and provide a less clear picture. Interpretation of these data is generally complicated by factors such as the unknown chemical composition of "street" LSD and concurrent use of other psychoactive drugs. It seems possible that the small number of congenital abnormalities reported in users of street LSD is either coincidental or related to factors other than a toxic effect of pure LSD.

=== Flashbacks ===
There is also a rarely reported possibility of "[[Flashback (psychological phenomenon)|flashbacks]]", a psychological phenomenon in which an individual experiences an episode of some of the subjective effects of LSD (this may be a positive or negative experience) long after the drug has been consumed and worn off — sometimes weeks, months or even years afterward.

Colloquial usage of the term "flashbacks" refers to any experience reminiscent of LSD effects; these are commonly occasional brief experiences. However, psychiatry recognizes a disorder in which LSD-like effects are persistent and cause clinically-significant impairment or distress. This chronic flashback syndrome is called [[hallucinogen persisting perception disorder|Hallucinogen Persisting Perception Disorder]], a [[Diagnostic and Statistical Manual of Mental Disorders|DSM-IV]] diagnosis. Several journal articles have described the disorder.<ref>See, for example, {{cite journal | author=Abraham HD, Aldridge AM | title=Adverse consequences of lysergic acid diethylamide | journal=Addiction | year=1993 | pages=1327-34 | volume=88 | issue=10 | id=PMID 8251869}}</ref>

Several studies have tried to determine how likely a "normal user" (that is a user not suffering from known psychiatric conditions) of LSD is to experience flashbacks. The larger studies include Blumenfeld's in 1971 <ref>{{cite journal | author=Blumenfield M | title=Flashback phenomena in basic trainees who enter the US Air Force | journal=Military Medicine | year=1971 | pages=39-41 | volume=136 | issue=1 | id=PMID 5005369}}</ref> and Naditch and Fenwick's in 1977 <ref>{{cite journal | author=Naditch MP, Fenwick S | title=LSD flashbacks and ego functioning | journal=Journal of Abnormal Psychology | year=1977 | pages=352-9 | volume=86 | issue=4 | id=PMID 757972}}</ref>, which arrived at figures of 20% and 28%, respectively. A recent review suggests that chronic flashbacks, according to the DSM-IV definition, appear to be rare disorders that affect a distinctly vulnerable subpopulation of users.<ref>{{cite journal | author=Halpern JH, Pope HG Jr | title=Hallucinogen persisting perception disorder: what do we know after 50 years? | journal=Drug Alcohol Depend | year=2003 | pages=109-19 | volume=69 | issue=2 | id=PMID 12609692}}; {{cite journal | author=Halpern JH | title=Hallucinogens: an update | journal=Curr Psychiatry Rep | year=2003 | pages=347-54 | volume=5 | issue=5 | id=PMID 13678554}} [http://www.erowid.org/references/refs_view.php?A=ShowDoc1&ID=6224]</ref> Differences in the estimated prevalence of flashbacks may partly depend on the multiple meanings of the term and the fact that hallucinogen persisting perception disorder can only be diagnosed in a person who admits to their health care practitioner that they have used hallucinogens.

Debate continues over the nature and causes of chronic flashbacks. Some say chronic flashbacks are a manifestation of [[post-traumatic stress disorder]], not directly related to LSD's mechanism, and vary according to the susceptibility of the individual to the disorder. Many emotionally intense experiences can lead to flashbacks when a person is reminded acutely of the original experience. However, not all published case reports of chronic flashbacks appear to describe an anxious hyper-vigilant state reminiscent of post-traumatic stress disorder.

Several [[Drug urban legends|urban legends]] claim that intermittent flashbacks are the result of trace amounts of LSD or related chemicals being dislodged and released into the body after having been crystallized and stored in fat or spinal fluid cells. However, there is no evidence for this and scientific research suggests that it is not the case; LSD (which is water soluble) is metabolized in the liver, as with many other drugs, and its metabolites are excreted normally in the urine.<ref>[http://www.erowid.org/chemicals/lsd/lsd_myth1.shtml LSD Myths] from Erowid</ref>

An alternative theory regarding flashbacks postulates that it is a form of perceptual learning. People having unusual experiences while on LSD may be more likely to make similar interpretations of their sensory input in the future. This theory does not appear to explain why a subset of people develop hallucinogen persisting perception disorder and are unable to 'unlearn' their distressing perceptual patterns.

=== Psychosis ===
There are some cases of LSD inducing or triggering a [[psychosis]] in people who were apparently healthy prior to taking LSD. This issue was reviewed extensively in a 1984 publication by Rick Strassman.<ref>{{cite journal | author=Strassman RJ | title=Adverse reactions to psychedelic drugs. A review of the literature | journal=J Nerv Ment Dis | year=1984 | pages=577-95 | volume=172 | issue=10 | id=PMID 6384428}}</ref> In most cases, the psychosis-like reaction is of short duration, but in other cases it may be chronic. It is difficult to determine if LSD itself induces these reactions or if it merely triggers latent conditions that would have manifested themselves otherwise. The similarities of time course and outcomes between putatively LSD-precipitated and other psychoses suggests that the two types of syndromes are not different and that LSD may have been a nonspecific trigger. Several studies have tried to estimate the prevalence of LSD-induced prolonged psychosis arriving at numbers of around 4 in 1,000 individuals (0.8 in 1,000 volunteers and 1.8 in 1,000 psychotherapy patients in Cohen 1960 <ref>{{cite journal|author=Cohen, Sidney|url=http://www.maps.org/w3pb/new/1960/1960_cohen_1848_1.pdf|title=Lysergic Acid Diethylamide: Side Effects and Complications|journal=Journal of Nervous and Mental Disease|volume=130|issue=1 |pages=30–40|month=January|year=1960|id=PMID 13811003}}</ref>; 9 per 1,000 psychotherapy patients in Melleson 1971 <ref>{{cite journal|author=Malleson, Nicholas|url=http://www.maps.org/w3pb/new/1971/1971_malleson_5136_1.pdf|title=Acute Adverse Reactions to LSD in Clinical and Experimental Use in the United Kingdom|journal=Brit. J. Psychiat.|volume=118|pages=229–30|id=PMID 4995932|issue=543|year=1971}}</ref>). But these rates are far lower than the lifetime prevalence for psychotic conditions: [[schizophrenia]], to pick just one type of psychosis, has a lifetime prevalence of about 1% in populations that are not exposed to LSD. In itself, this suggests no causative link between LSD and chronic psychotic disorders.

== Chemistry ==
[[Image:LSD isomers.png|thumb|240px|The four possible isomers of LSD. Only LSD is psychoactive.]]

LSD is an example of an [[ergoline]] derivative. It is commonly produced from [[lysergic acid]], which is made from ergotamine, a substance derived from the [[ergot]] [[fungus]] on [[rye]], or from [[ergine]] (lysergic acid amide), a chemical found in [[morning glory]] and [[hawaiian baby woodrose]] seeds. It is theoretically possible to manufacture LSD from morning glory or hawaiian baby woodrose seeds although this is not economically feasible, and these seeds have never been found to be a successful starting material for LSD production. Lysergic acid can also be synthesized in the laboratory by relatively complex [[total synthesis|total syntheses]].

LSD is a [[chirality|chiral]] compound with two [[stereocenter]]s at the [[carbon]] atoms C-5 and C-8, so that theoretically four different [[optical isomerism|optical isomers]] of LSD could exist. LSD, also called (+)-<small>D</small>-LSD, has the absolute [[Molecular configuration|configuration]] (5''R'',8''R''). The C-5 [[isomer]]s of lysergamides do not exist in nature and are not formed during the synthesis from <small>D</small>-lysergic acid. However, LSD and iso-LSD, the two C-8 isomers, are rapidly interconverting in the presence of [[base (chemistry)|base]]. Non-psychoactive iso-LSD which has formed during the synthesis can be removed by [[chromatography]] and can be isomerized to LSD.

=== Stability ===

"LSD," writes the chemist [[Alexander Shulgin]], "is an unusally fragile molecule."<ref name="tihkal"/> It is stable for indefinite amounts of time ''if'' stored, as a salt or in water, at low temperature and protected from air and light exposure. Two portions of its molecular structure are particularly sensitive, the carboxamide attachment at the 8-position and the [[covalent bond|double bond]] between the 8-position and the [[aromatic hydrocarbon|aromatic ring]]. The former is affected by high [[pH]], and if perturbed will produce isolysergic acid diethylamide (iso-LSD), which is biologically inactive. If water or alcohol adds to the double bond (especially in the presence of light), LSD converts to "lumi-LSD", which is totally inactive in human beings, to the best of current knowledge. Furthermore, [[chlorine]] destroys LSD molecules on contact; even though chlorinated tap water typically contains only a slight amount of chlorine, because a typical LSD solution only contains an infinitesimal amount of LSD, dissolving LSD in tap water is likely to completely eliminate the substance.<ref name="tihkal"/>

A controlled study was undertaken to determine the stability of LSD in pooled urine samples.<ref>{{cite journal | author=Li Z, McNally AJ, Wang H, Salamone SJ. | url=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9788528&dopt=Abstract | title=Stability study of LSD under various storage conditions. | journal=J Anal Toxicol | volume=22 | issue=6 | pages=520–5 | month=October | year=1998 | id=PMID 9788528}}</ref> The concentrations of LSD in urine samples were followed over time at various temperatures, in different types of storage containers, at various exposures to different wavelengths of light, and at varying pH values. These studies demonstrated no significant loss in LSD concentration at 25 degrees C for up to 4 weeks. After 4 weeks of incubation, a 30% loss in LSD concentration at 37 degrees C and up to a 40% at 45 degrees C were observed. Urine fortified with LSD and stored in amber glass or nontransparent polyethylene containers showed no change in concentration under any light conditions. Stability of LSD in transparent containers under light was dependent on the distance between the light source and the samples, the wavelength of light, exposure time, and the intensity of light. After prolonged exposure to heat in alkaline pH conditions, 10 to 15% of the parent LSD epimerized to iso-LSD. Under acidic conditions, less than 5% of the LSD was converted to iso-LSD. There was also demonstrated that trace amounts of metal ions in buffer or urine could catalyze the decomposition of LSD and that this process can be avoided by the addition of [[EDTA]].

==Production==
[[Image:LSDLabGlassware.jpg|left|thumb|Glassware seized by the DEA]]

Only a small amount of ergotamine tartrate is required to produce LSD in large batches. For example, 25 kg of ergotamine tartrate can produce 5 or 6 kg of pure LSD crystal that, under ideal circumstances, could be processed into 100 million dosage units, assuming a typical "hit" of 125 μg. This is more than enough to meet what is believed to be the entire annual U.S. demand for the drug. LSD manufacturers only need to create a small quantity of the substance, and thus they enjoy an ease of transport and concealment not available to traffickers of other illegal drugs (such as [[cannabis (drug)|cannabis]] and [[cocaine]]).<ref name="DEA-pub">"[http://www.fas.org/irp/agency/doj/dea/product/lsd/lsd-5.htm LSD in the US – Manufacture]", DEA Publications.</ref>

Manufacturing LSD requires laboratory equipment and experience in the field of [[organic chemistry]]. It takes two or three days to produce 30 to 100 grams of pure compound. It is believed that LSD usually is not produced in large quantities, but rather in a series of small batches. This technique minimizes the loss of precursor chemicals in case a synthesis step does not work as expected.<ref name="DEA-pub"/>

===Forms of LSD===
[[Image:Ruby slippers image.jpg|thumb|300px|right|A typical full size sheet of LSD blotter paper is 900 1/4" squares.]]

LSD is produced in crystalline form and then mixed with excipients or diluted as a liquid for production in ingestible forms. Liquid solution is either distributed as-is in small vials or, more commonly, sprayed or soaked onto a distribution medium. Historically, LSD solutions were first sold on sugar cubes, but practical considerations forced a change to tablet form. Early pills or tabs were flattened on both ends and identified by color: "grey flat", "blue flat", and so forth. Next came "domes", which were rounded on one end, then "double domes" rounded on both ends, and finally small tablets known as "microdots". Later still, LSD began to be distributed in thin squares of gelatin ("window panes") and, most commonly, as blotter paper: sheets of paper impregnated with LSD and perforated into small squares of individual dosage units. The paper is then cut into small square pieces called "tabs" for distribution. Individual producers often print designs onto the paper serving to identify different makers, batches or strengths, and such "blotter art" often emphasizes [[psychedelia|psychedelic]] themes.

LSD is sold under a wide variety of street names including Acid, 'Cid, Sid, Barrels, Blotter, Doses, Heavenly blue, L, Liquid, Liquid A, Lucy, Microdots, Mind detergent, Orange cubes, Orange micro, Owsley, Hits, Paper, Sacrament, Sandoz, Sugar, Sugar lumps, Sunshine, Tabs, Ticket, Trips, Twenty-five, Wedding bells, and Windowpane, as well as names that reflect the designs on the sheets of blotter paper.<ref name="erowid-faq">Honig, David. [http://www.erowid.org/chemicals/lsd/lsd_faq.shtml Frequently Asked Questions] via [[Erowid]].</ref> On occasion, authorities have encountered the drug in other forms — including powder or crystal, and capsule — and laced on other substances. More than 200 types of LSD tablets have been encountered since 1969 and more than 350 paper designs have been observed since 1975. Designs range from simple five-point stars in black and white to exotic artwork in full four-color print.

== Legal status ==
The [[United Nations]] [[Convention on Psychotropic Substances]] (adopted in 1971) requires its parties to prohibit LSD. Hence, it is illegal in all parties to the convention, which includes the [[United States]], [[Australia]] and most of [[Europe]]. However, enforcement of extant laws varies from country to country.

LSD is easy to conceal and smuggle. A tiny vial can contain thousands of doses. Not much money is made from retail-level sales of LSD, so the drug is typically not associated with the violent [[organized crime|organized criminal]] organizations involved in [[cocaine]] and [[opiate]] smuggling.

===United States: Prior to 1967===
Prior to 1967, LSD was available legally in the United States as an experimental [[psychiatric]] drug. (LSD "apostle" [[Alfred Matthew Hubbard|Al Hubbard]] actively promoted the drug between the 1950s and the 1970s and introduced thousands of people to it.) The [[US Government|US Federal Government]] classified it as a Schedule I drug according to the [[Controlled Substances Act]] of 1970. As such, the [[Drug Enforcement Administration]] holds that LSD meets the following three criteria: it is deemed to have a high potential for abuse; it has no legitimate medical use in treatment; and there is a lack of accepted safety for its use under medical supervision. (LSD prohibition does not make an exception for religious use.) Lysergic acid and lysergic acid amide, LSD precursors, are both classified in Schedule III of the Controlled Substances Act. Ergotamine tartrate, a precursor to lysergic acid, is regulated under the [[Chemical Diversion and Trafficking Act]].

LSD has been manufactured illegally since the 1960s. Historically, LSD was distributed not for profit, but because those who made and distributed it truly believed that the psychedelic experience could do good for humanity, that it expanded the mind and could bring understanding and love. A limited number of chemists, probably fewer than a dozen, are believed to have manufactured nearly all of the illicit LSD available in the United States. The best known of these is undoubtedly [[Owsley Stanley|Augustus Owsley Stanley III]], usually known simply as Owsley. The former chemistry student set up a private LSD lab in the mid-Sixties in [[San Francisco]] and supplied the LSD consumed at the famous [[Acid Test]] parties held by [[Ken Kesey]] and his [[Merry Pranksters]], and other major events such as the [[Gathering of the Tribes]] in San Francisco in January 1967. He also had close social connections to leading San Francisco bands the [[Grateful Dead]], [[Jefferson Airplane]] and [[Big Brother and The Holding Company]], regularly supplied them with his LSD and also worked as their live sound engineer and made many tapes of these groups in concert. Owsley's LSD activities — immortalized by [[Steely Dan]] in their song "Kid Charlemagne" — ended with his arrest at the end of 1967, but some other manufacturers probably operated continuously for 30 years or more. Announcing Owsley's first bust in 1966, The [[San Francisco Chronicle]]'s headline "LSD Millionaire Arrested" inspired the rare Grateful Dead song "Alice D. Millionaire."

===United States: 1970 to 2003===
[[Image:LSDMissileSilo.jpg|left|thumb|Pickard and Apperson ran an LSD lab in this former missile silo in Kansas.]]

American LSD usage declined in the 1970s and 1980s, then experienced a mild resurgence in popularity in the 1990s. Although there were many distribution channels during this decade, the U.S. [[Drug Enforcement Administration|DEA]] identified continued tours by the [[psychedelic rock]] band [[Grateful Dead|The Grateful Dead]] and the then-burgeoning [[rave]] scene as primary venues for LSD trafficking and consumption. American LSD usage fell sharply circa 2000. The decline is attributed to the arrest of two chemists, [[William Leonard Pickard]], a Harvard-educated organic chemist, and [[Clyde Apperson]].

Pickard was an alleged member of the [[Brotherhood of Eternal Love]] group that produced and sold LSD in California during the late 1960s and early 1970s. It is believed he had links to other "cooks" associated with this group — an original source of the drug back in the 1960's — and his arrest may have forced other operations to cease production, leading to the large decline in street availability.

The DEA claims these two individuals were responsible for the vast majority of LSD sold illegally in the United States and a significant amount of the LSD sold in [[Europe]], and that they worked closely with organized traffickers. While this claim may have some bearing, the extent of Pickard's direct influence on the overall availability in the United States is not fully known. Some attest that "Pickard's Acid" was sold exclusively in Europe, and was not distributed through American music venues.

According to DEA reports, black market LSD availability dropped by 95% after the two were arrested in 2000. These arrests were a result of the largest LSD manufacturing raid in DEA history.<ref>Seper, Jerry. "[http://washingtontimes.com/national/20031126-110958-8471r.htm Man sentenced to life in prison as dealer of LSD]". ''The Washington Times'' 27 November 2003.</ref> Availability has increased slightly as of summer 2005, but still remains limited. {{citation needed}}

In November of 2003, Pickard and Apperson were sentenced to two life sentences and two 30-year sentences, respectively, after being convicted in [[United States federal courts|Federal Court]] of running a large scale LSD manufacturing operation out of several clandestine laboratories, including a former [[missile silo]] near [[Wamego, Kansas]].

LSD manufacturers and traffickers can be categorized into two groups: A few large scale producers, such as the aforementioned Pickard and Apperson, and an equally limited number of small, clandestine chemists, consisting of independent producers who, operating on a comparatively limited scale, can be found throughout the country. As a group, independent producers are of less concern to the [[Drug Enforcement Agency]] than the larger groups, as their product reaches only local markets.

== References ==
<div class="references-small">
<references/>
</div>

== See also ==
=== Chemical ===
* [[ALD-52]]
* [[Entheogen]]
* [[History of LSD]]
* [[Psychedelic drug]]
* [[Psychedelic psychotherapy]]
* [[Psychedelics, dissociatives and deliriants]]
* [[Psychoactive drug]]
* Related [[chemistry|chemical]] compounds: [[ergoline]]s, [[Ergine|LSA]], [[psilocybin]], [[Dimethyltryptamine|DMT]], [[serotonin]]

=== Other ===
* [[List of notable people who have commented on the LSD experience]]
* [[Drug urban legends]]
* [[Project MKULTRA|MKULTRA]] – [[CIA]] experiments with LSD
* [[Bogle-Chandler case]], deaths attributed to LSD overdoses
* [[Freedom of thought]]- a human right linked to the use of psychoactive drugs
* [[Psychedelics in popular culture]]

== External links ==
{{Wikinews|Drug website surveys LSD users and culture}}

=== Media ===
* [http://www.belfasttelegraph.co.uk/news/features/story.jsp?story=675395 Belfast Telegraph] Dr Albert Hofmann - The father of LSD
* [http://www.wired.com/news/technology/0,70015-0.html Wired News: LSD: The Geek's Wonder Drug?], January 16, 2006
* [http://www.wired.com/news/medtech/0,1286,65025,00.html Wired News: Long Trip for Psychedelics], September 27, 2004
* [http://slate.msn.com/id/2098109 Who's Got the LSD? These Days, Almost Nobody]
* [http://www.bayarea.com/mld/mercurynews/news/local/states/california/peninsula/5539149.htm Northern Californian LSD makers found guilty]
* [http://www.dea.gov/pubs/states/newsrel/sanfran112403.html Pickard And Apperson Sentenced On LSD Charges] Official DEA press release on the "Largest LSD Lab Seizure In DEA History"
* [http://www.lysergicbook.com/ LYSERGIC] Book written about Pickard Case
* [http://archive.salon.com/people/feature/2001/04/16/hoffman/ Salon.com: Dr. Hoffman's problem child turns 58], April 16, 2001
* {{cite news | url=http://www.nytimes.com/2006/01/07/international/europe/07hoffman.html?ex=1294290000&en=3f9d07f38d182f59&ei=5090 | title=Nearly 100, LSD's Father Ponders His 'Problem Child' | date=[[January 7]], [[2006]] | publisher=The New York Times}}
* [http://www.nfb.ca/trouverunfilm/fichefilm.php?id=51064&v=h&lg=en&exp=${potion} National Film Board of Canada documentary, "Hofmann's Potion"]
* [[BBC]] [http://news.bbc.co.uk/1/hi/magazine/4877462.stm ''All in the Mind'' special] ([http://www.bbc.co.uk/radio4/science/rams/allinthemind_20060404.ram RealAudio]), 5 April 2006
* [http://www.theage.com.au/news/in-depth/passing-the-acid-test/2006/02/03/1138836410493.html?page=fullpage#contentSwap1 Tripping the light fantasmic, The Age, February 4, 2006]

=== Video ===
* "[http://www.normal-design.com/bicycle-ride.html The Bicycle Ride]", a fanciful depiction of Albert Hofmann's discovery of LSD, created by David Normal
* "[http://www.archive.org/details/redwood_center_2006_02_14_cowan Spontaneous pattern formation in large scale brain activity: what visual migraines and hallucinations tell us about the brain]", lecture by Jack Cowan (via the [[Internet Archive]])

=== Academic ===
* [http://www.maps.org/research/abrahart.html A Critical Review of Theories and Research Concerning LSD and Mental Health]
* [http://www.painmed.org/productpub/statements/pdfs/definition.pdf Definitions of Addiction, Physical Dependence, and Tolerance]
* [http://www.flashback.se/archive/my_problem_child/index.html LSD - My Problem Child] online, by LSD inventor Dr. [[Albert Hofmann]]
* [http://www.sci-con.org/tiki-read_article.php?articleId=86 The Neurochemistry of Psychedelic Experience], ''[[Science & Consciousness Review]]''
* Aldous, F. A. B., Barrass, B. C., Brewster, K., Buxton, D. A., Green, D. M., Finder, R. M., Rich, P., Skeels, M., and Tutt, K. J., [http://www.rhodium.ws/pdf/sar.psychotomimetic.phenylalkylamines.pdf "Structure-Activity Relationships in Psychotomimetic Phenylalkylamines,"] Journal of Medicinal Chemistry, Vol. 17, 1100–1111 (1974)
* [http://www.heffter.org/ Current LSD Research - Heffter Research Institute]
* [http://www.maps.org/research/ Current LSD Research – MAPS]
* [http://www.maps.org/sys/w3pb.pl?face=simple Searchable LSD Bibliography]
* [http://www.cem.msu.edu/~cem181h/projects/96/lsd/drug.html The Effects of LSD on the Human Brain]

=== Urban legends ===
* [http://nepenthes.lycaeum.org/Tattoo/ Blue Star Tattoo myth]
* [http://www.erowid.org/chemicals/lsd/lsd_myth5.shtml Strychnine myth]

=== General ===
* [http://www.lsd.info International 3 day conference on LSD in Basel]
* [http://www.erowid.org/general/conferences/2006_lsd_symposium/2006_lsd_symposium.shtml Erowid vault on Basel conference- includes videos]
* [http://www.erowid.org/chemicals/lsd/lsd.shtml Erowid LSD Vault]
* [http://www.erowid.org/chemicals/lsd/lsd_images_gallery1.shtml Erowid gallery of blotter art]
* [http://www.thegooddrugsguide.com/lsd/index.htm Good Drugs Guide]
* [http://www.cowboybooks.com.au/html/acidtrip1.html LSD Visual experiment]
* [http://www.spiritplants.org/ Spirit Plants Forums]
* [http://www.timothy-leary.com/ Dr. Timothy Leary]
* [http://www.quihn.org.au/ Fact sheets on illicit drugs]
* [http://leda.lycaeum.org/?ID=10 The Lycaeum Archive -> LSD]
* [http://www.yoism.org/?q=node/73 An optical illusion that creates some of the visual effects of LSD]
* [http://www.hppdonline.com/ Hallucinogen Persisting Perception Disorder]
* [http://www.bruceeisner.com/writings/2006/01/lsd_and_aldous_.html LSD and Aldous Huxley’s Island: Setting Sail for a Better Country] essay by [[Bruce Eisner]]

{{Hallucinogenic lysergamides}}





[[Category:Incapacitating agents]]
[[Category:Lysergamides]]
[[Category:Schedule I controlled substances]]
[[Category:Withdrawn drugs]]

[[af:LSD]]
[[als:LSD]]
[[bg:ЛСД]]
[[cs:LSD]]
[[da:LSD]]
[[de:LSD]]
[[et:LSD]]
[[es:LSD]]
[[eo:LSD]]
[[eu:LSD]]
[[fr:N,N-diéthyllysergamide]]
[[hr:LSD]]
[[it:LSD]]
[[he:LSD]]
[[lt:LSD]]
[[hu:LSD]]
[[nl:LSD]]
[[ja:LSD (薬物)]]
[[no:LSD]]
[[pl:LSD]]
[[pt:LSD]]
[[ru:ЛСД]]
[[sk:Dietylamid kyseliny lysergovej]]
[[sl:LSD]]
[[sr:ЛСД]]
[[fi:LSD]]
[[sv:LSD]]
[[tr:LSD]]
[[uk:ЛСД]]
[[zh:LSD]]

Post-concussion syndrome

2006-06-20T05:45:52Z

Quihn: /* References */

{{DiseaseDisorder infobox |
Name = Postconcussion syndrome |
ICD10 = F07.2 |
ICD9 = {{ICD9|310.2}} |
}}
'''Post-concussion syndrome''', or '''PCS''', is a set of symptoms that a person may experience for weeks, months, or even years after a [[concussion]], a mild form of [[traumatic brain injury]]. As many as 50% of patients who have experienced concussion have PCS (Bazarian 1992), and some sources say as many as 90% of patients experience postconcussion symptoms (Legome, 2004).

==Signs and symptoms==
People who have had concussions may experience physical, mental, or emotional symptoms.

Physical symptoms can include:
* [[headache]]
*sensitivity to noise or light
* [[dizziness]]
*[[fatigue]] or sleepiness
*[[inability to sleep]]
*[[nausea]] and/or [[vomiting]]
*[[double vision|double]] or blurred vision (Shepherd, 2004)
*[[tinnitus|ringing in the ears]]
*decreased sense of taste, smell, or hearing
*decreased libido (UCLA, 1999)

Emotional symptoms may include:
*[[irritability]]
*[[anxiety]] (Evans, 1992)
*[[restlessness]] (King, 2003)
*[[Major depression|depression]] or lack of emotion (Merck, 2003)
*[[emotional lability]] or mood swings

Cognitive or mental symptoms can include:
*[[amnesia]] or difficulty remembering things
*confusion or impaired [[cognition]] (Evans, 1992)
*difficulty with abstract thinking (King, 2003)
*difficulty [[attention|concentrating]] (UCLA, 1999)

==Treatment ==
Patients who have suffered a head injury must be examined by emergency medical care providers to ensure that the head injury is not worse than concussion and potentially life threatening. Thus, head injury patients with symptoms that may indicate a dangerous injury are given [[CT scan]]s or [[MRI]]s and are observed by medical staff. Later, the patient may be tested to determine his or her level of cognitive functioning. A test called the Rivermead Postconcussion Symptoms Questionnaire exists to measure the severity of the patient's symptoms.

Post-concussion syndrome is usually not treated, except with pain relievers for headaches and medicine to relieve depression, nausea, or dizziness (Merck, 2003). When patients have ongoing disabilities, they are treated with therapy to help them function at work, socially, or in other contexts (Shepherd, 2004). Patients are aided in gradually returning to work and other preinjury activities as symptoms permit. Since [[emotional stress|stress]] exacerbates post concussion symptoms, and vice versa, an important part of treatment is letting the patient know that symptoms are normal and helping the patient deal with impairments (King, 2003).

==Prognosis==
For most patients, post concussion symptoms go away within a few days to several weeks after the original injury occurs (Merck, 2003). In others, symptoms may remain for three to six months (Evans, 1992; UCLA, 1999). In a small percentage of patients, symptoms may persist for years or may be permanent (UCLA, 1999). If symptoms are not resolved by one year, they are likely to be permanent (Legome, 2004). However, the prognosis for PCS is generally considered excellent, with total resolution of symptoms in the large majority of cases.

If a patient receives another blow to the head after a concussion but before concussion symptoms have gone away, there is a slight risk that he or she will develop the very rare but deadly [[Concussion of the brain#Second impact syndrome|Second Impact Syndrome]] (SIS). In SIS, the brain may rapidly swell and be damaged.

==Epidemiology==
The incidence of PCS is higher in females than in males (Legome, 2004). People over the age of 55 are more likely to have long-lasting symptoms [http://www.5mcc.com/Assets/SUMMARY/TP1074.html]. Since PCS by definition only exists in people who have suffered a head injury, demographics and risk factors are similar to those for head injury; for example, young adults are at higher risk than others for receiving head injury (Legome, 2004).

==History ==
People have known about post-concussion syndrome for hundreds of years (Evans, 1992). Since it is not always possible to find a physical basis for the syndrome, some have claimed that patients are merely [[malingering]] or overreacting. It is not known to exactly what degree the symptoms are due to microscopic damage to the [[brain]] or to other factors, for example psychological factors (Merck, 2003). This question has been heavily debated for many years. Psychological factors are known to affect post concussion symptoms; however, it has been shown that structural damage does occur after some concussions (Evans, 1992, King, 2003).

In the 1860s, a group of doctors began to support the idea that structural features were to blame for symptoms, but the prevailing sentiment was still that psychological factors caused PCS (Fisher, 1998). It was not until a century later, in the 1960s, that such structural damage could be visualized using new brain scanning technology. Now it is generally agreed that PCS does have a physical basis.

The name "post-concussive syndrome" was first coined by [[S. H. Auerbach]] [http://www.neuroskills.com/index.shtml?main=/edu/ceumtbi2.shtml].

==References==
* Bazarian JJ and Atabaki S. 2001. [http://www.aemj.org/cgi/content/abstract/8/8/788 Predicting postconcussion syndrome after minor traumatic brain injury.] ''Academic Emergency Medicine'' Volume 8, Number 8, 788-795.
*Evans RW . 1992. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1435659&dopt=Abstract The postconcussion syndrome and the sequelae of mild head injury.] ''Neurol Clin'' Volume 10 Number 4, 815-847.
*Fisher JD. 1998. [http://www.headinjury.com/faqpcs.htm Post concussion syndrome]. Head Injury Hotline.
*King NS. 2003. [http://www.medical-journals.com/r03109c.htm Post-concussion syndrome: clarity amid the controversy?]
*Legome E. 2004. [http://www.emedicine.com/emerg/topic865.htm Postconcussive syndrome.] eMedicine.com.
*Merck manuals online medical library. 2003. [http://www.merck.com/mmhe/sec06/ch087/ch087c.html Concussion].
*Shepherd S. 2004. [http://www.emedicine.com/med/topic2820.htm Head trauma.] eMedicine.com.
*Tolias C and Sgouros S. 2003. [http://www.emedicine.com/med/topic3216.htm Initial evaluation and management of CNS injury."]
*UCLA Neurosurgery. 1999. [http://neurosurgery.ucla.edu/Diagnoses/BrainInjury/BrainInjuryDis_6.html Brain injury diseases and disorders: Concussion].

==External link==
* [http://www.biaq.com.au Range of fact sheets on brain injury]

[[Category:neurotrauma]]

Acquired brain injury

2006-06-20T05:40:07Z

Quihn:

A [[Neurology|neurological]] condition, '''Acquired Brain Injury''' (''ABI'') is damage to the brain after birth. It usually affects [[Cognition|cognitive]], physical, [[emotion]]al or independent functioning and can result from [[traumatic brain injury]] (i.e. [[accident]]s, falls, assaults, etc.) and non-traumatic brain injury (i.e. [[stroke]], [[brain tumour]]s, [[infection]], [[poison]]ing, lack of oxygen or [[substance abuse]]). Most definitions of ABI exclude [[neurodegenerative disorder]]s.
Acquired brain injury is not to be confused with intellectual disability. People with a brain injury may have difficulty controlling, coordinating and communicating their thoughts and actions but they usually retain their intellectual abilities.
Brain injury has dramatically varied effects and no two people can expect the same outcome or resulting difficulties. The brain controls every part of human life: physically, intellectually and emotionally. When the brain is damaged, some other part of a person's life will also be adversely affected. Even a mild injury can result in a serious disability that will interfere with a person’s daily functioning and personal activities for the rest of their life. While the outcome of the injury depends largely on the nature and severity of the injury itself, appropriate treatment will play a vital role in determining the level of recovery.

==External links==
[http://www.biaq.com.au Broad range of fact sheets on acquired brain injury]

{{neuroscience-stub}}

[[Category:Neurological disorders]]

Acquired brain injury

2006-06-20T05:39:41Z

Quihn:

Acquired brain injury

2006-06-20T05:38:02Z

Quihn:

Traumatic brain injury

2006-06-20T05:36:07Z

Quihn: /* External links */

{{DiseaseDisorder infobox |
Name = Traumatic brain injury¹ |
ICD10 = S06 |
ICD9 = {{ICD9|800.0}}-{{ICD9|801.9}}, {{ICD9|803.0}}-{{ICD9|804.9}}, {{ICD9|850.0}}-{{ICD9|854.1}} |
}}
'''Traumatic brain injury''' (TBI), traumatic injuries to the [[brain]], also called intracranial injury, or simply head injury, occurs when a sudden trauma causes [[brain damage]]. TBI can result from a closed head injury or a [[penetrating head injury]] and is one of two subsets of [[acquired brain injury]] (ABI). The other subset is non-traumatic brain injury (i.e. stroke, meningitis, anoxia). Parts of the brain that can be damaged include the [[cerebral hemisphere]]s, [[cerebellum]], and [[brain stem]] (see [[brain damage]]).
Symptoms of a TBI can be mild, moderate, or severe, depending on the extent of the damage to the brain. Outcome can be anything from complete recovery to permanent [[disability]] or death.

== Epidemiology ==
'''TBI''' is a major public health problem, especially among males ages 15 to 24, and among elderly people of both sexes 75 years and older. Children aged 5 and younger are also at high risk for TBI.

Each year in the United States:
* approximately 1 million head-injured people are treated in hospital emergency rooms,
* approximately 270,000 people experience a moderate or severe TBI,
* approximately 60,000 new cases of epilepsy occur as a result of head trauma,
* approximately 230,000 people are hospitalized for TBI and survive,
* approximately 80,000 of these survivors live with significant disabilities as a result of the injury, and
* approximately 70,000 people die from head injury.

==Signs and Symptoms of TBI==
Some symptoms are evident immediately, while others do not surface until several days or weeks after the injury.

With '''mild TBI''', the patient may remain conscious or may lose consciousness for a few seconds or minutes. The person may also feel dazed or not like him- or herself for several days or weeks after the initial injury. Other symptoms include:
*[[headache]],
*[[mental confusion]],
*lightheadedness,
*[[dizziness]],
*[[diplopia|double vision]], blurred vision, or tired eyes,
*ringing in the ears,
*bad taste in the mouth,
*fatigue or lethargy,
*a change in [[sleep]] patterns,
*behavioral or [[mood]] changes, and
*trouble with memory, concentration, attention, or thinking
*symptoms remain the same or get better; worsening symtptoms indicate a more severe injury.

With '''moderate or severe TBI''', the patient may show these same symptoms, but may also have:
*loss of consciousness
*personality change
*a severe, persistent, or worsening headache,
*repeated vomiting or nausea,
*[[seizure]]s,
*inability to awaken,
*[[dilation]] (widening) of one or both pupils,
*slurred speech,
*weakness or numbness in the extremities,
*loss of coordination, and/or
*increased confusion, restlessness, or agitation
*vomiting and neurological deficit (e.g. weakness in a limb) together are important indicators of prognosis and their presence may warrant early [[computed axial tomography|CT scanning]] and [[neurosurgery|neurosurgical]] intervention.

Small children with moderate to severe TBI may show some of these signs as well as signs specific to young children, including:
*persistent crying,
*inability to be consoled, and/or
*refusal to nurse or eat.

Anyone with signs of moderate or severe TBI should receive immediate emergency medical attention.

==Causes of and Risk Factors for TBI==
Half of all TBIs are due to [[transportation accident]]s involving [[automobile]]s, [[motorcycle]]s, [[bicycle]]s, and [[pedestrian]]s. These accidents are the major cause of TBI in people under age 75.

For those 75 and older, falls cause the majority of TBIs.

Approximately 20 % of TBIs are due to [[violence]], such as [[firearm assault]]s and [[child abuse]], and about 3 % are due to [[sports injuries]]. Fully half of TBI incidents involve [[alcohol]] use.

==Types of TBI==
The damage from TBI can be [[focal brain injury|focal]], confined to one area of the brain, or [[diffuse brain injury|diffuse]], involving more than one area of the brain. Diffuse trauma to the brain is frequently associated with [[concussion]] (a shaking of the brain in response to sudden motion of the head), [[diffuse axonal injury]], or [[coma]]. Localized injuries may be associated with neurobehavioral manifestations, [[hemiparesis]] or other [[focal neurologic deficit]]s.

Types of focal brain injury include bruising of brain tissue called a [[brain contusion|contusion]] and [[intracranial hemorrhage]] or [[hematoma]], heavy bleeding in the skull. Hemorrhage, due to rupture of a [[blood vessel]] in the head, can be [[extra-axial hemorrhage|extra-axial]], meaning it occurs within the [[skull]] but outside of the brain, or [[intra-axial hemorrhage|intra-axial]], occurring within the brain. Extra-axial hemorrhages can be further divided into [[subdural hematoma]], [[epidural hematoma]], and [[subarachnoid hemorrhage]]. An [[epidural hematoma]] involves bleeding into the area between the skull and the [[dura]]. With a [[subdural hematoma]], bleeding is confined to the area between the dura and the [[arachnoid membrane]]. Bleeding within the brain itself is called [[intracerebral hematoma]]. Intra-axial bleeds are further divided into [[intraparenchymal hemorrhage]] which occurs within the brain tissue itself and [[intraventricular hemorrhage]] which occurs in the [[ventricular system]].

TBI can result from a [[closed head injury]] or a [[penetrating head injury]]. A closed injury occurs when the head suddenly and violently hits an object but the object does not break through the skull. A penetrating injury occurs when an object pierces the skull and enters brain tissue.

As the first line of defense, the [[skull]] is particularly vulnerable to injury. [[Skull fracture]]s occur when the bone of the skull cracks or breaks. A [[depressed skull fracture]] occurs when pieces of the broken skull press into the tissue of the brain. A [[penetrating skull fracture]] occurs when something pierces the skull, such as a bullet, leaving a distinct and localized injury to brain tissue. Skull fractures can cause [[cerebral contusion]].

Another insult to the brain that can cause injury is [[anoxia]]. Anoxia is a condition in which there is an absence of oxygen supply to an organ's tissues, even if there is adequate blood flow to the tissue. [[Hypoxia (medical)|Hypoxia]] refers to a decrease in oxygen supply rather than a complete absence of oxygen, and [[ischemia]] is inadequate blood supply, as is seen in cases in which the [[cerebral edema|brain swells]]. In any of these cases, without adequate oxygen, a [[biochemical cascade]] called the [[ischemic cascade]] is unleashed, and the cells of the brain can die within several minutes. This type of injury is often seen in near-drowning victims, in [[heart attack]] patients, or in people who suffer significant blood loss from other injuries that decrease blood flow to the brain.

==Effects on consciousness==
Generally, there are five abnormal states of consciousness that can result from a TBI: [[stupor]], [[coma]], [[persistent vegetative state]], [[locked-in syndrome]], and [[brain death]].

[[Stupor]] is a state in which the patient is unresponsive but can be aroused briefly by a strong stimulus, such as sharp pain. [[Coma]] is a state in which the patient is totally unconscious, unresponsive, unaware, and unarousable.

Patients in a [[persistent vegetative state]] are unconscious and unaware of their surroundings, but they continue to have a sleep-wake cycle and can have periods of alertness. A vegetative state can result from diffuse injury to the cerebral hemispheres of the brain without damage to the lower brain and brainstem. [[Anoxia]], or lack of oxygen to the brain, which is a common complication of [[cardiac arrest]], can also bring about a vegetative state.

[[Locked-in syndrome]] is a condition in which a patient is aware and awake, but cannot move or communicate due to complete paralysis of the body.

[[Brain death]] is the lack of measurable brain function due to diffuse damage to the cerebral hemispheres and the brainstem, with loss of any integrated activity among distinct areas of the brain. Brain death is irreversible. Removal of assistive devices will result in immediate cardiac arrest and cessation of breathing.

==Complications==
Sometimes, health complications occur in the period immediately following a TBI. These complications are not types of TBI, but are distinct medical problems that arise as a result of the injury. Although complications are rare, the risk increases with the severity of the trauma. Complications of TBI include immediate [[seizure]]s, [[hydrocephalus]] or [[post-traumatic ventricular enlargement]], [[cerebrospinal fluid]] leaks, infections, vascular injuries, [[cranial nerve]] injuries, [[pain]], [[bed sore]]s, [[multiple organ system failure]] in unconscious patients, and [[polytrauma]] (trauma to other parts of the body in addition to the brain).

About 25 % of patients with brain contusions or hematomas and about 50 % of patients with penetrating head injuries will develop immediate seizures, seizures that occur within the first 24 hours of the injury. These immediate seizures increase the risk of early seizures - defined as seizures occurring within 1 week after injury - but do not seem to be linked to the development of [[post-traumatic epilepsy]] (recurrent seizures occurring more than 1 week after the initial trauma). Generally, medical professionals use anticonvulsant medications to treat seizures in TBI patients only if the seizures persist.

Hydrocephalus or post-traumatic ventricular enlargement occurs when [[cerebrospinal fluid]] (CSF) accumulates in the brain resulting in dilation of the cerebral ventricles (cavities in the brain filled with CSF) and an increase in ICP. This condition can develop during the acute stage of TBI or may not appear until later. Generally it occurs within the first year of the injury and is characterized by worsening neurological outcome, impaired consciousness, behavioral changes, ataxia (lack of coordination or balance), incontinence, or signs of elevated ICP. The condition may develop as a result of meningitis, subarachnoid hemorrhage, intracranial hematoma, or other injuries. Treatment includes shunting and draining of CSF as well as any other appropriate treatment for the root cause of the condition.

Skull fractures can tear the membranes that cover the brain, leading to CSF leaks. A tear between the dura and the arachnoid membranes, called a [[CSF fistula]], can cause CSF to leak out of the subarachnoid space into the subdural space; this is called a [[subdural hygroma]]. CSF can also leak from the nose and the ear. These tears that let CSF out of the brain cavity can also allow air and bacteria into the cavity, possibly causing infections such as meningitis. [[Pneumocephalus]] occurs when air enters the [[intracranial cavity]] and becomes trapped in the subarachnoid space.

Infections within the intracranial cavity are a dangerous complication of TBI. They may occur outside of the [[dura mater]], below the dura, below the [[arachnoid mater|arachnoid]] ([[meningitis]]), or within the brain itself ([[abscess]]). Most of these injuries develop within a few weeks of the initial trauma and result from [[skull fracture]]s or penetrating injuries. Standard treatment involves antibiotics and sometimes surgery to remove the infected tissue. Meningitis may be especially dangerous, with the potential to spread to the rest of the brain and nervous system.

Any damage to the head or brain usually results in some damage to the [[vascular system]], which provides [[blood]] to the cells of the brain. The body's [[immune system]] can repair damage to small blood vessels, but damage to larger vessels can result in serious complications. Damage to one of the major arteries leading to the brain can cause a stroke, either through bleeding from the artery ([[hemorrhagic stroke]]) or through the formation of a clot at the site of injury, called a [[thrombus]] or thrombosis, blocking blood flow to the brain ([[ischemic stroke]]). Blood clots also can develop in other parts of the head. Symptoms such as headache, vomiting, seizures, paralysis on one side of the body, and semiconsciousness developing within several days of a head injury may be caused by a blood clot that forms in the tissue of one of the sinuses, or cavities, adjacent to the brain. Thrombotic-ischemic strokes are treated with anticoagulants, while surgery is the preferred treatment for hemorrhagic stroke. Other types of vascular injuries include [[vasospasm]] and the formation of [[aneurysm]]s .

Skull fractures, especially at the base of the skull, can cause cranial nerve injuries that result in [[compressive cranial neuropathy|compressive cranial neuropathies]]. All but three of the 12 cranial nerves project out from the brainstem to the head and face. The [[seventh cranial nerve]], called the [[facial nerve]], is the most commonly injured cranial nerve in TBI and damage to it can result in paralysis of facial muscles.

Pain, especially headache, is commonly a significant complication for conscious patients in the period immediately following a TBI. Serious complications for patients who are unconscious, in a coma, or in a vegetative state include bed or [[pressure sores]] of the skin, recurrent [[bladder infection]]s, [[pneumonia]] or other life-threatening infections, and [[progressive multiple organ failure]].

==General Trauma==
Other medical complications that may accompany a TBI include pulmonary (lung) dysfunction; cardiovascular (heart) dysfunction from [[blunt chest trauma]]; gastrointestinal dysfunction; fluid and hormonal imbalances; and other isolated complications, such as fractures, nerve injuries, [[deep vein thrombosis]], excessive blood clotting, and infections.

Trauma victims often develop [[hypermetabolism]] or an increased metabolic rate, which leads to an increase in the amount of heat the body produces. The body redirects into heat the energy needed to keep organ systems functioning, causing muscle wasting and the starvation of other tissues. Complications related to pulmonary dysfunction can include [[neurogenic pulmonary edema]] (excess fluid in lung tissue), [[aspiration pneumonia]] (pneumonia caused by foreign matter in the lungs), and fat and blood clots in the blood vessels of the lungs.

Fluid and hormonal imbalances can complicate the treatment of hypermetabolism and high ICP. Hormonal problems can result from dysfunction of the [[pituitary]], the [[thyroid]], and other glands throughout the body. Two common hormonal complications of TBI are syndrome of inappropriate secretion of antidiuretic hormone ([[SIADH]]) and [[hypothyroidism]].

==Disabilities Resulting From TBI==
Disabilities resulting from a TBI depend upon the severity of the injury, the location of the injury, and the age and general health of the patient. Some common disabilities include problems with cognition (thinking, memory, and reasoning), sensory processing (sight, hearing, touch, taste, and smell), communication (expression and understanding), and behavior or mental health ([[major depression|depression]], [[anxiety]], personality changes, aggression, acting out, and social inappropriateness).

Within days to weeks of the head injury approximately 40 % of TBI patients develop a host of troubling symptoms collectively called [[postconcussion syndrome]] (PCS). A patient need not have suffered a [[concussion]] or loss of consciousness to develop the syndrome and many patients with mild TBI suffer from PCS. Symptoms include [[headache]], [[dizziness]], memory problems, trouble concentrating, sleeping problems, restlessness, irritability, apathy, depression, and anxiety. These symptoms may last for a few weeks after the head injury. The syndrome is more prevalent in patients who had psychiatric symptoms, such as depression or anxiety, before the injury. Treatment for PCS may include medicines for pain and psychiatric conditions, and psychotherapy and occupational therapy.

Most patients with severe TBI, if they recover consciousness, suffer from [[Cognition|cognitive]] disabilities, including the loss of many higher level mental skills. The most common cognitive impairment among severely head-injured patients is memory loss, characterized by some loss of specific memories and the partial inability to form or store new ones. Some of these patients may experience [[post-traumatic amnesia]] (PTA), either [[anterograde amnesia|anterograde]] or [[retrograde amnesia|retrograde]]. Anterograde PTA is impaired memory of events that happened after the TBI, while retrograde PTA is impaired memory of events that happened before the TBI.

Many patients with mild to moderate head injuries who experience cognitive deficits become easily confused or distracted and have problems with concentration and attention. They also have problems with higher level, so-called executive functions, such as planning, organizing, abstract reasoning, problem solving, and making judgments, which may make it difficult to resume pre-injury work-related activities. Recovery from cognitive deficits is greatest within the first 6 months after the injury and more gradual after that.

Patients with moderate to severe TBI have more problems with cognitive deficits than patients with mild TBI, but a history of several mild TBIs may have an additive effect, causing cognitive deficits equal to a moderate or severe injury.

Many TBI patients have sensory problems, especially problems with vision. Patients may not be able to register what they are seeing or may be slow to recognize objects. Also, TBI patients often have difficulty with hand-eye coordination. Because of this, TBI patients may seem clumsy or unsteady. Other sensory deficits may include problems with hearing, smell, taste, or touch. Some TBI patients develop [[tinnitus]], a ringing or roaring in the ears. A person with damage to the part of the brain that processes taste or smell may develop a persistent bitter taste in the mouth or perceive a persistent noxious smell. Damage to the part of the brain that controls the sense of touch may cause a TBI patient to develop persistent skin tingling, itching, or pain. These conditions are rare and hard to treat.

Language and communication problems are common disabilities in TBI patients. Some may experience [[aphasia]], defined as difficulty with understanding and producing spoken and written language; others may have difficulty with the more subtle aspects of communication, such as body language and emotional, non-verbal signals.

In [[non-fluent aphasia]], also called [[Broca's aphasia]] or [[motor aphasia]], TBI patients often have trouble recalling words and speaking in complete sentences. They may speak in broken phrases and pause frequently. Most patients are aware of these deficits and may become extremely frustrated.

Patients with [[fluent aphasia]], also called [[Wernicke's aphasia]] or [[sensory aphasia]], display little meaning in their speech, even though they speak in complete sentences and use correct grammar. Instead, they speak in flowing gibberish, drawing out their sentences with non-essential and invented words. Many patients with fluent aphasia are unaware that they make little sense and become angry with others for not understanding them. Patients with global aphasia have extensive damage to the portions of the brain responsible for language and often suffer severe communication disabilities.

TBI patients may have problems with spoken language if the part of the brain that controls speech muscles is damaged. In this disorder, called [[dysarthria]], the patient can think of the appropriate language, but cannot easily speak the words because they are unable to use the muscles needed to form the words and produce the sounds. Speech is often slow, slurred, and garbled. Some may have problems with intonation or inflection, called prosodic dysfunction.

Most TBI patients have emotional or behavioral problems that fit under the broad category of psychiatric health. Family members of TBI patients often find that personality changes and behavioral problems are the most difficult disabilities to handle. Psychiatric problems that may surface include depression, apathy, anxiety, irritability, anger, paranoia, confusion, frustration, agitation, insomnia or other sleep problems, and mood swings. Problem behaviors may include aggression and violence, impulsivity, disinhibition, acting out, noncompliance, social inappropriateness, emotional outbursts, childish behavior, impaired self-control, impaired selfawareness, inability to take responsibility or accept criticism, egocentrism, inappropriate sexual activity, and alcohol or drug abuse/addiction. Some patients' personality problems may be so severe that they are diagnosed with organic personality disorder, a psychiatric condition characterized by many of the problems mentioned above. Sometimes TBI patients suffer from [[developmental stagnation]], meaning that they fail to mature emotionally, socially, or psychologically after the trauma. This is a serious problem for children and young adults who suffer from a TBI. Attitudes and behaviors that are appropriate for a child or teenager become inappropriate in adulthood. Many TBI patients who show psychiatric or behavioral problems can be helped with medication and psychotherapy.

==Other Long-Term Problems Associated With TBI==
Other long-term problems that can develop after a TBI include [[Parkinson's disease]] and other motor problems, [[Alzheimer's disease]], [[dementia pugilistica]], and [[post-traumatic dementia]].

''Alzheimer's disease'' (AD) - AD is a progressive, neurodegenerative disease characterized by [[dementia]], memory loss, and deteriorating cognitive abilities. Recent research suggests an association between head injury in early adulthood and the development of AD later in life; the more severe the head injury, the greater the risk of developing AD. Some evidence indicates that a head injury may interact with other factors to trigger the disease and may hasten the onset of the disease in individuals already at risk. For example, people who have a particular form of the protein [[apolipoprotein E]] ([[apoE4]]) and suffer a head injury fall into this increased risk category. (ApoE4 is a naturally occurring protein that helps transport cholesterol through the bloodstream.)

''Parkinson's disease'' and other motor problems - Movement disorders as a result of TBI are rare but can occur. Parkinson's disease may develop years after TBI as a result of damage to the [[basal ganglia]]. Symptoms of Parkinson's disease include tremor or trembling, rigidity or stiffness, slow movement ([[bradykinesia]]), inability to move ([[akinesia]]), shuffling walk, and stooped posture. Despite many scientific advances in recent years, Parkinson's disease remains a chronic and progressive disorder, meaning that it is incurable and will progress in severity until the end of life. Other movement disorders that may develop after TBI include tremor, [[ataxia]] (uncoordinated muscle movements), and [[myoclonus]] (shock-like contractions of muscles).

''Dementia pugilistica'' - Also called [[chronic traumatic encephalopathy]], dementia pugilistica primarily affects career [[boxing|boxer]]s. The most common symptoms of the condition are dementia and parkinsonism caused by repetitive blows to the head over a long period of time. Symptoms begin anywhere between 6 and 40 years after the start of a boxing career, with an average onset of about 16 years.

''Post-traumatic dementia'' - The symptoms of post-traumatic dementia are very similar to those of dementia pugilistica, except that post-traumatic dementia is also characterized by long-term memory problems and is caused by a single, severe TBI that results in a [[coma]].

==Treatment==
Medical care usually begins when [[paramedic]]s or [[emergency medical technician]]s arrive on the scene of an accident or when a TBI patient arrives at the emergency department of a hospital. Because little can be done to reverse the initial brain damage caused by trauma, medical personnel try to stabilize the patient and focus on preventing further injury. Primary concerns include insuring proper [[oxygen]] supply, maintaining adequate blood flow, and controlling [[blood pressure]]. Since many head-injured patients may also have [[spinal cord injury|spinal cord injuries]], the patient is placed on a back-board and in a neck restraint to prevent further injury to the head and spinal cord.

Medical personnel assess the patient's condition by measuring [[vital signs]] and reflexes and by performing a neurological examination. They check the patient's temperature, blood pressure, pulse, breathing rate, and pupil size and response to light. They assess the patient's level of consciousness and neurological functioning using the [[Glasgow Coma Scale]].

Imaging tests help in determining the diagnosis and prognosis of a TBI patient. Patients with mild to moderate injuries may receive skull and neck [[X-ray]]s to check for [[bone fracture]]s. For moderate to severe cases, the gold standard imaging test is a [[computed tomography]] (CT) scan, which creates a series of crosssectional X-ray images of the head and brain and can show bone fractures as well as the presence of hemorrhage, hematomas, contusions, brain tissue swelling, and tumors. [[Magnetic resonance imaging]] (MRI) may be used after the initial assessment and treatment of the TBI patient. MRI uses magnetic fields to detect subtle changes in brain tissue content and can show more detail than X-rays or CT. The use of CT and MRI is standard in TBI treatment, but other imaging and diagnostic techniques that may be used to confirm a particular diagnosis include [[cerebral angiography]], [[electroencephalography]] (EEG), [[transcranial Doppler ultrasound]], and [[single photon emission computed tomography]] (SPECT).

Approximately half of severely head-injured patients will need [[surgery]] to remove or repair hematomas or contusions. Patients may also need surgery to treat injuries in other parts of the body. These patients usually go to the intensive care unit after surgery.

Sometimes when the brain is injured swelling occurs and fluids accumulate within the brain space. It is normal for bodily injuries to cause swelling and disruptions in fluid balance. But when an injury occurs inside the skull-encased brain, there is no place for swollen tissues to expand and no adjoining tissues to absorb excess fluid. This increased pressure is called [[intracranial pressure]] (ICP).

Medical personnel measure a patient's ICP using a probe or catheter. The instrument is inserted through the skull to the [[subarachnoid space|subarachnoid]] level and is connected to a monitor that registers the patient's ICP. If a patient has high ICP, he or she may undergo a [[ventriculostomy]], a procedure that drains [[cerebrospinal fluid]] (CSF) from the [[ventricular system|ventricles]] to bring the pressure down. Drugs that can be used to decrease ICP include [[mannitol]] or [[barbiturate]]s.

== Rehabilitation ==
Rehabilitation is an important part of the recovery process for a TBI patient. During the acute stage, moderately to severely injured patients may receive treatment and care in an intensive care unit of a hospital. Once stable, the patient may be transferred to a subacute unit of the medical center, to a rehabilitation inpatient unit within the acute trauma center, or to an independent off-site or 'free-standing' rehabilitation hospital. Moderately to severely injured patients may receive specialized rehabilitation treatment that draws on the skills of many specialists, involving treatment programs in the areas of physical therapy, occupational therapy, speech/language therapy, [[physiatry]] (medical specialist in [[physical medicine and rehabilitation]]), psychology/psychiatry, and social work. The services and efforts of this team of healthcare professionals is generally applied to the practical concerns of and the problems encountered by the brain injury survivor in their daily life. This treatment program is generally provided through a coordinated and self-organized process in the context of a transdisciplinary model of team care delivery.

The overall goal of rehabilitation after a TBI is to improve and optimize the patient's ability to function at home and in society in the face of the residual effects of the injury, which may be complex and multifaceted. An additional goal of the rehabilitation program is to prevent, wherever possible, but otherwise to diagnose and treat, any complications (eg. posttraumatic hydrocephalus) that may cause additional morbidity and mortality in this patient population. Therapists help the patient adapt to disabilities or change the patient's living space to make everyday activities easier. Education and training for identified caregivers is also a critically important component of the rehabilitation program.

Some patients may need medication for psychiatric and physical problems resulting from the TBI, and various medications are available that may lessen or moderate the problematic manifestations of the injury without directly altering the underlying pathology. Great care must be taken in prescribing medications because TBI patients are more susceptible to side effects and may react adversely to some pharmacological agents. It is important for the family caregivers to provide assistance and encouragement for the patient by being involved in the rehabilitation program. Family members may also benefit from psychotherapy and social support services.

==Prevention==
Unlike most neurological disorders, head injuries can be prevented. The [[Centers for Disease Control and Prevention]] (CDC) have issued the following safety tips for reducing the risk of suffering a TBI.

* Wear a [[seatbelt]] every time you drive or ride in a car.
* Buckle your child into a [[child safety seat]], booster seat, or seatbelt (depending on the child's age) every time the child rides in a car.
* Wear a helmet and make sure your children wear [[helmet]]s when
** riding a bike or motorcycle;
** playing a contact sport such as football or ice hockey;
** using in-line skates or riding a skateboard;
** batting and running bases in baseball or softball;
** riding a horse;
** skiing or snowboarding.
* Keep firearms and bullets stored in a locked cabinet when not in use.
* Avoid falls by
** using a step-stool with a grab bar to reach objects on high shelves;
** installing handrails on stairways;
** installing window guards to keep young children from falling out of open windows;
** using safety gates at the top and bottom of stairs when young children are around.
* Make sure the surface on your child's playground is made of shock-absorbing material (e.g., hardwood mulch, sand).

Source: [http://www.cdc.gov/safeusa/home/tbi.htm CDC, Department of Health and Human Services].

== Famous persons with TBI ==
* [[Phineas Gage]]
* [http://Givebackorlando.com Becky Dedo - GiveBack Inc]

==References==
1. [http://www.cdc.gov/doc.do/id/0900f3ec8006c8e0/ Traumatic Brain Injury in the United States: A Report to Congress] (2003) CDC, Department of Health and Human Services
== See also ==
* [[Head injury]]
:* [[Brain damage]]
:* [[Coma]]
:* [[Unconsciousness]]
:* [[Penetrating head injury]]
:* [[Closed head injury]]
* [[Diffuse brain injury]]
:* [[Concussion of the brain]]
:* [[Diffuse axonal injury]]
* [[Focal brain injury]]
:* [[Brain contusion]]
:* [[Intracranial hemorrhage]]
::* [[Intra-axial hemorrhage]]
::* [[Extra-axial hemorrhage]]
:::* [[Subdural hematoma]]
:::* [[Epidural hematoma]]
:::* [[Subarachnoid hemorrhage]]
* [[Spinal cord injury]]
* [[NINDS brain trauma research]]

==External links==
* [http://www.tandf.co.uk/journals/titles/02699052.html Brain Injury] | Official research journal of the International Brain Injury Association (IBIA)
* [http://Givebackorlando.com Becky Dedo - GiveBack Inc] | Road Maps For Recovery From Head Injury - for TBI survivors and their families.
* [http://www.biaq.com.au/ Comprehensive range of fact sheets on brain injury]
*http://www.brainsource.com/brain%20injury.htm
*http://www.tbirecoverycenter.org
*http://www.headway.org.uk/ | UK based charity that provides information and support to people with TBI and their families
*http://www.safar.pitt.edu | A US based research institution part of the University of Pittsburgh located in Pittsburgh, PA, which focuses research on TBI and TBI therapies
*http://www.brain-injury-help.com | Brain Injury Help and Resources
*[http://www.brain-surgery.us/ Brain Surgery-Neurosurgery Patient Help Site]
*http://www.headinjury.com | Brain Injury Resource Center
*http://www.biausa.org | Brain Injury Association of America
*http://www.biaf.org | Brain Injury Association of Florida

''The original version of this article contained text from the NINDS public domain pages on TBI at http://www.ninds.nih.gov/health_and_medical/disorders/tbi_doc.htm and http://www.ninds.nih.gov/health_and_medical/pubs/tbi.htm ''

[[Category:Neurotrauma]]

[[fr:Traumatisme crânien]]
[[it:Trauma cranico]]

Traumatic brain injury

2006-06-20T05:35:30Z

Quihn: /* External links */

{{DiseaseDisorder infobox |
Name = Traumatic brain injury¹ |
ICD10 = S06 |
ICD9 = {{ICD9|800.0}}-{{ICD9|801.9}}, {{ICD9|803.0}}-{{ICD9|804.9}}, {{ICD9|850.0}}-{{ICD9|854.1}} |
}}
'''Traumatic brain injury''' (TBI), traumatic injuries to the [[brain]], also called intracranial injury, or simply head injury, occurs when a sudden trauma causes [[brain damage]]. TBI can result from a closed head injury or a [[penetrating head injury]] and is one of two subsets of [[acquired brain injury]] (ABI). The other subset is non-traumatic brain injury (i.e. stroke, meningitis, anoxia). Parts of the brain that can be damaged include the [[cerebral hemisphere]]s, [[cerebellum]], and [[brain stem]] (see [[brain damage]]).
Symptoms of a TBI can be mild, moderate, or severe, depending on the extent of the damage to the brain. Outcome can be anything from complete recovery to permanent [[disability]] or death.

== Epidemiology ==
'''TBI''' is a major public health problem, especially among males ages 15 to 24, and among elderly people of both sexes 75 years and older. Children aged 5 and younger are also at high risk for TBI.

Each year in the United States:
* approximately 1 million head-injured people are treated in hospital emergency rooms,
* approximately 270,000 people experience a moderate or severe TBI,
* approximately 60,000 new cases of epilepsy occur as a result of head trauma,
* approximately 230,000 people are hospitalized for TBI and survive,
* approximately 80,000 of these survivors live with significant disabilities as a result of the injury, and
* approximately 70,000 people die from head injury.

==Signs and Symptoms of TBI==
Some symptoms are evident immediately, while others do not surface until several days or weeks after the injury.

With '''mild TBI''', the patient may remain conscious or may lose consciousness for a few seconds or minutes. The person may also feel dazed or not like him- or herself for several days or weeks after the initial injury. Other symptoms include:
*[[headache]],
*[[mental confusion]],
*lightheadedness,
*[[dizziness]],
*[[diplopia|double vision]], blurred vision, or tired eyes,
*ringing in the ears,
*bad taste in the mouth,
*fatigue or lethargy,
*a change in [[sleep]] patterns,
*behavioral or [[mood]] changes, and
*trouble with memory, concentration, attention, or thinking
*symptoms remain the same or get better; worsening symtptoms indicate a more severe injury.

With '''moderate or severe TBI''', the patient may show these same symptoms, but may also have:
*loss of consciousness
*personality change
*a severe, persistent, or worsening headache,
*repeated vomiting or nausea,
*[[seizure]]s,
*inability to awaken,
*[[dilation]] (widening) of one or both pupils,
*slurred speech,
*weakness or numbness in the extremities,
*loss of coordination, and/or
*increased confusion, restlessness, or agitation
*vomiting and neurological deficit (e.g. weakness in a limb) together are important indicators of prognosis and their presence may warrant early [[computed axial tomography|CT scanning]] and [[neurosurgery|neurosurgical]] intervention.

Small children with moderate to severe TBI may show some of these signs as well as signs specific to young children, including:
*persistent crying,
*inability to be consoled, and/or
*refusal to nurse or eat.

Anyone with signs of moderate or severe TBI should receive immediate emergency medical attention.

==Causes of and Risk Factors for TBI==
Half of all TBIs are due to [[transportation accident]]s involving [[automobile]]s, [[motorcycle]]s, [[bicycle]]s, and [[pedestrian]]s. These accidents are the major cause of TBI in people under age 75.

For those 75 and older, falls cause the majority of TBIs.

Approximately 20 % of TBIs are due to [[violence]], such as [[firearm assault]]s and [[child abuse]], and about 3 % are due to [[sports injuries]]. Fully half of TBI incidents involve [[alcohol]] use.

==Types of TBI==
The damage from TBI can be [[focal brain injury|focal]], confined to one area of the brain, or [[diffuse brain injury|diffuse]], involving more than one area of the brain. Diffuse trauma to the brain is frequently associated with [[concussion]] (a shaking of the brain in response to sudden motion of the head), [[diffuse axonal injury]], or [[coma]]. Localized injuries may be associated with neurobehavioral manifestations, [[hemiparesis]] or other [[focal neurologic deficit]]s.

Types of focal brain injury include bruising of brain tissue called a [[brain contusion|contusion]] and [[intracranial hemorrhage]] or [[hematoma]], heavy bleeding in the skull. Hemorrhage, due to rupture of a [[blood vessel]] in the head, can be [[extra-axial hemorrhage|extra-axial]], meaning it occurs within the [[skull]] but outside of the brain, or [[intra-axial hemorrhage|intra-axial]], occurring within the brain. Extra-axial hemorrhages can be further divided into [[subdural hematoma]], [[epidural hematoma]], and [[subarachnoid hemorrhage]]. An [[epidural hematoma]] involves bleeding into the area between the skull and the [[dura]]. With a [[subdural hematoma]], bleeding is confined to the area between the dura and the [[arachnoid membrane]]. Bleeding within the brain itself is called [[intracerebral hematoma]]. Intra-axial bleeds are further divided into [[intraparenchymal hemorrhage]] which occurs within the brain tissue itself and [[intraventricular hemorrhage]] which occurs in the [[ventricular system]].

TBI can result from a [[closed head injury]] or a [[penetrating head injury]]. A closed injury occurs when the head suddenly and violently hits an object but the object does not break through the skull. A penetrating injury occurs when an object pierces the skull and enters brain tissue.

As the first line of defense, the [[skull]] is particularly vulnerable to injury. [[Skull fracture]]s occur when the bone of the skull cracks or breaks. A [[depressed skull fracture]] occurs when pieces of the broken skull press into the tissue of the brain. A [[penetrating skull fracture]] occurs when something pierces the skull, such as a bullet, leaving a distinct and localized injury to brain tissue. Skull fractures can cause [[cerebral contusion]].

Another insult to the brain that can cause injury is [[anoxia]]. Anoxia is a condition in which there is an absence of oxygen supply to an organ's tissues, even if there is adequate blood flow to the tissue. [[Hypoxia (medical)|Hypoxia]] refers to a decrease in oxygen supply rather than a complete absence of oxygen, and [[ischemia]] is inadequate blood supply, as is seen in cases in which the [[cerebral edema|brain swells]]. In any of these cases, without adequate oxygen, a [[biochemical cascade]] called the [[ischemic cascade]] is unleashed, and the cells of the brain can die within several minutes. This type of injury is often seen in near-drowning victims, in [[heart attack]] patients, or in people who suffer significant blood loss from other injuries that decrease blood flow to the brain.

==Effects on consciousness==
Generally, there are five abnormal states of consciousness that can result from a TBI: [[stupor]], [[coma]], [[persistent vegetative state]], [[locked-in syndrome]], and [[brain death]].

[[Stupor]] is a state in which the patient is unresponsive but can be aroused briefly by a strong stimulus, such as sharp pain. [[Coma]] is a state in which the patient is totally unconscious, unresponsive, unaware, and unarousable.

Patients in a [[persistent vegetative state]] are unconscious and unaware of their surroundings, but they continue to have a sleep-wake cycle and can have periods of alertness. A vegetative state can result from diffuse injury to the cerebral hemispheres of the brain without damage to the lower brain and brainstem. [[Anoxia]], or lack of oxygen to the brain, which is a common complication of [[cardiac arrest]], can also bring about a vegetative state.

[[Locked-in syndrome]] is a condition in which a patient is aware and awake, but cannot move or communicate due to complete paralysis of the body.

[[Brain death]] is the lack of measurable brain function due to diffuse damage to the cerebral hemispheres and the brainstem, with loss of any integrated activity among distinct areas of the brain. Brain death is irreversible. Removal of assistive devices will result in immediate cardiac arrest and cessation of breathing.

==Complications==
Sometimes, health complications occur in the period immediately following a TBI. These complications are not types of TBI, but are distinct medical problems that arise as a result of the injury. Although complications are rare, the risk increases with the severity of the trauma. Complications of TBI include immediate [[seizure]]s, [[hydrocephalus]] or [[post-traumatic ventricular enlargement]], [[cerebrospinal fluid]] leaks, infections, vascular injuries, [[cranial nerve]] injuries, [[pain]], [[bed sore]]s, [[multiple organ system failure]] in unconscious patients, and [[polytrauma]] (trauma to other parts of the body in addition to the brain).

About 25 % of patients with brain contusions or hematomas and about 50 % of patients with penetrating head injuries will develop immediate seizures, seizures that occur within the first 24 hours of the injury. These immediate seizures increase the risk of early seizures - defined as seizures occurring within 1 week after injury - but do not seem to be linked to the development of [[post-traumatic epilepsy]] (recurrent seizures occurring more than 1 week after the initial trauma). Generally, medical professionals use anticonvulsant medications to treat seizures in TBI patients only if the seizures persist.

Hydrocephalus or post-traumatic ventricular enlargement occurs when [[cerebrospinal fluid]] (CSF) accumulates in the brain resulting in dilation of the cerebral ventricles (cavities in the brain filled with CSF) and an increase in ICP. This condition can develop during the acute stage of TBI or may not appear until later. Generally it occurs within the first year of the injury and is characterized by worsening neurological outcome, impaired consciousness, behavioral changes, ataxia (lack of coordination or balance), incontinence, or signs of elevated ICP. The condition may develop as a result of meningitis, subarachnoid hemorrhage, intracranial hematoma, or other injuries. Treatment includes shunting and draining of CSF as well as any other appropriate treatment for the root cause of the condition.

Skull fractures can tear the membranes that cover the brain, leading to CSF leaks. A tear between the dura and the arachnoid membranes, called a [[CSF fistula]], can cause CSF to leak out of the subarachnoid space into the subdural space; this is called a [[subdural hygroma]]. CSF can also leak from the nose and the ear. These tears that let CSF out of the brain cavity can also allow air and bacteria into the cavity, possibly causing infections such as meningitis. [[Pneumocephalus]] occurs when air enters the [[intracranial cavity]] and becomes trapped in the subarachnoid space.

Infections within the intracranial cavity are a dangerous complication of TBI. They may occur outside of the [[dura mater]], below the dura, below the [[arachnoid mater|arachnoid]] ([[meningitis]]), or within the brain itself ([[abscess]]). Most of these injuries develop within a few weeks of the initial trauma and result from [[skull fracture]]s or penetrating injuries. Standard treatment involves antibiotics and sometimes surgery to remove the infected tissue. Meningitis may be especially dangerous, with the potential to spread to the rest of the brain and nervous system.

Any damage to the head or brain usually results in some damage to the [[vascular system]], which provides [[blood]] to the cells of the brain. The body's [[immune system]] can repair damage to small blood vessels, but damage to larger vessels can result in serious complications. Damage to one of the major arteries leading to the brain can cause a stroke, either through bleeding from the artery ([[hemorrhagic stroke]]) or through the formation of a clot at the site of injury, called a [[thrombus]] or thrombosis, blocking blood flow to the brain ([[ischemic stroke]]). Blood clots also can develop in other parts of the head. Symptoms such as headache, vomiting, seizures, paralysis on one side of the body, and semiconsciousness developing within several days of a head injury may be caused by a blood clot that forms in the tissue of one of the sinuses, or cavities, adjacent to the brain. Thrombotic-ischemic strokes are treated with anticoagulants, while surgery is the preferred treatment for hemorrhagic stroke. Other types of vascular injuries include [[vasospasm]] and the formation of [[aneurysm]]s .

Skull fractures, especially at the base of the skull, can cause cranial nerve injuries that result in [[compressive cranial neuropathy|compressive cranial neuropathies]]. All but three of the 12 cranial nerves project out from the brainstem to the head and face. The [[seventh cranial nerve]], called the [[facial nerve]], is the most commonly injured cranial nerve in TBI and damage to it can result in paralysis of facial muscles.

Pain, especially headache, is commonly a significant complication for conscious patients in the period immediately following a TBI. Serious complications for patients who are unconscious, in a coma, or in a vegetative state include bed or [[pressure sores]] of the skin, recurrent [[bladder infection]]s, [[pneumonia]] or other life-threatening infections, and [[progressive multiple organ failure]].

==General Trauma==
Other medical complications that may accompany a TBI include pulmonary (lung) dysfunction; cardiovascular (heart) dysfunction from [[blunt chest trauma]]; gastrointestinal dysfunction; fluid and hormonal imbalances; and other isolated complications, such as fractures, nerve injuries, [[deep vein thrombosis]], excessive blood clotting, and infections.

Trauma victims often develop [[hypermetabolism]] or an increased metabolic rate, which leads to an increase in the amount of heat the body produces. The body redirects into heat the energy needed to keep organ systems functioning, causing muscle wasting and the starvation of other tissues. Complications related to pulmonary dysfunction can include [[neurogenic pulmonary edema]] (excess fluid in lung tissue), [[aspiration pneumonia]] (pneumonia caused by foreign matter in the lungs), and fat and blood clots in the blood vessels of the lungs.

Fluid and hormonal imbalances can complicate the treatment of hypermetabolism and high ICP. Hormonal problems can result from dysfunction of the [[pituitary]], the [[thyroid]], and other glands throughout the body. Two common hormonal complications of TBI are syndrome of inappropriate secretion of antidiuretic hormone ([[SIADH]]) and [[hypothyroidism]].

==Disabilities Resulting From TBI==
Disabilities resulting from a TBI depend upon the severity of the injury, the location of the injury, and the age and general health of the patient. Some common disabilities include problems with cognition (thinking, memory, and reasoning), sensory processing (sight, hearing, touch, taste, and smell), communication (expression and understanding), and behavior or mental health ([[major depression|depression]], [[anxiety]], personality changes, aggression, acting out, and social inappropriateness).

Within days to weeks of the head injury approximately 40 % of TBI patients develop a host of troubling symptoms collectively called [[postconcussion syndrome]] (PCS). A patient need not have suffered a [[concussion]] or loss of consciousness to develop the syndrome and many patients with mild TBI suffer from PCS. Symptoms include [[headache]], [[dizziness]], memory problems, trouble concentrating, sleeping problems, restlessness, irritability, apathy, depression, and anxiety. These symptoms may last for a few weeks after the head injury. The syndrome is more prevalent in patients who had psychiatric symptoms, such as depression or anxiety, before the injury. Treatment for PCS may include medicines for pain and psychiatric conditions, and psychotherapy and occupational therapy.

Most patients with severe TBI, if they recover consciousness, suffer from [[Cognition|cognitive]] disabilities, including the loss of many higher level mental skills. The most common cognitive impairment among severely head-injured patients is memory loss, characterized by some loss of specific memories and the partial inability to form or store new ones. Some of these patients may experience [[post-traumatic amnesia]] (PTA), either [[anterograde amnesia|anterograde]] or [[retrograde amnesia|retrograde]]. Anterograde PTA is impaired memory of events that happened after the TBI, while retrograde PTA is impaired memory of events that happened before the TBI.

Many patients with mild to moderate head injuries who experience cognitive deficits become easily confused or distracted and have problems with concentration and attention. They also have problems with higher level, so-called executive functions, such as planning, organizing, abstract reasoning, problem solving, and making judgments, which may make it difficult to resume pre-injury work-related activities. Recovery from cognitive deficits is greatest within the first 6 months after the injury and more gradual after that.

Patients with moderate to severe TBI have more problems with cognitive deficits than patients with mild TBI, but a history of several mild TBIs may have an additive effect, causing cognitive deficits equal to a moderate or severe injury.

Many TBI patients have sensory problems, especially problems with vision. Patients may not be able to register what they are seeing or may be slow to recognize objects. Also, TBI patients often have difficulty with hand-eye coordination. Because of this, TBI patients may seem clumsy or unsteady. Other sensory deficits may include problems with hearing, smell, taste, or touch. Some TBI patients develop [[tinnitus]], a ringing or roaring in the ears. A person with damage to the part of the brain that processes taste or smell may develop a persistent bitter taste in the mouth or perceive a persistent noxious smell. Damage to the part of the brain that controls the sense of touch may cause a TBI patient to develop persistent skin tingling, itching, or pain. These conditions are rare and hard to treat.

Language and communication problems are common disabilities in TBI patients. Some may experience [[aphasia]], defined as difficulty with understanding and producing spoken and written language; others may have difficulty with the more subtle aspects of communication, such as body language and emotional, non-verbal signals.

In [[non-fluent aphasia]], also called [[Broca's aphasia]] or [[motor aphasia]], TBI patients often have trouble recalling words and speaking in complete sentences. They may speak in broken phrases and pause frequently. Most patients are aware of these deficits and may become extremely frustrated.

Patients with [[fluent aphasia]], also called [[Wernicke's aphasia]] or [[sensory aphasia]], display little meaning in their speech, even though they speak in complete sentences and use correct grammar. Instead, they speak in flowing gibberish, drawing out their sentences with non-essential and invented words. Many patients with fluent aphasia are unaware that they make little sense and become angry with others for not understanding them. Patients with global aphasia have extensive damage to the portions of the brain responsible for language and often suffer severe communication disabilities.

TBI patients may have problems with spoken language if the part of the brain that controls speech muscles is damaged. In this disorder, called [[dysarthria]], the patient can think of the appropriate language, but cannot easily speak the words because they are unable to use the muscles needed to form the words and produce the sounds. Speech is often slow, slurred, and garbled. Some may have problems with intonation or inflection, called prosodic dysfunction.

Most TBI patients have emotional or behavioral problems that fit under the broad category of psychiatric health. Family members of TBI patients often find that personality changes and behavioral problems are the most difficult disabilities to handle. Psychiatric problems that may surface include depression, apathy, anxiety, irritability, anger, paranoia, confusion, frustration, agitation, insomnia or other sleep problems, and mood swings. Problem behaviors may include aggression and violence, impulsivity, disinhibition, acting out, noncompliance, social inappropriateness, emotional outbursts, childish behavior, impaired self-control, impaired selfawareness, inability to take responsibility or accept criticism, egocentrism, inappropriate sexual activity, and alcohol or drug abuse/addiction. Some patients' personality problems may be so severe that they are diagnosed with organic personality disorder, a psychiatric condition characterized by many of the problems mentioned above. Sometimes TBI patients suffer from [[developmental stagnation]], meaning that they fail to mature emotionally, socially, or psychologically after the trauma. This is a serious problem for children and young adults who suffer from a TBI. Attitudes and behaviors that are appropriate for a child or teenager become inappropriate in adulthood. Many TBI patients who show psychiatric or behavioral problems can be helped with medication and psychotherapy.

==Other Long-Term Problems Associated With TBI==
Other long-term problems that can develop after a TBI include [[Parkinson's disease]] and other motor problems, [[Alzheimer's disease]], [[dementia pugilistica]], and [[post-traumatic dementia]].

''Alzheimer's disease'' (AD) - AD is a progressive, neurodegenerative disease characterized by [[dementia]], memory loss, and deteriorating cognitive abilities. Recent research suggests an association between head injury in early adulthood and the development of AD later in life; the more severe the head injury, the greater the risk of developing AD. Some evidence indicates that a head injury may interact with other factors to trigger the disease and may hasten the onset of the disease in individuals already at risk. For example, people who have a particular form of the protein [[apolipoprotein E]] ([[apoE4]]) and suffer a head injury fall into this increased risk category. (ApoE4 is a naturally occurring protein that helps transport cholesterol through the bloodstream.)

''Parkinson's disease'' and other motor problems - Movement disorders as a result of TBI are rare but can occur. Parkinson's disease may develop years after TBI as a result of damage to the [[basal ganglia]]. Symptoms of Parkinson's disease include tremor or trembling, rigidity or stiffness, slow movement ([[bradykinesia]]), inability to move ([[akinesia]]), shuffling walk, and stooped posture. Despite many scientific advances in recent years, Parkinson's disease remains a chronic and progressive disorder, meaning that it is incurable and will progress in severity until the end of life. Other movement disorders that may develop after TBI include tremor, [[ataxia]] (uncoordinated muscle movements), and [[myoclonus]] (shock-like contractions of muscles).

''Dementia pugilistica'' - Also called [[chronic traumatic encephalopathy]], dementia pugilistica primarily affects career [[boxing|boxer]]s. The most common symptoms of the condition are dementia and parkinsonism caused by repetitive blows to the head over a long period of time. Symptoms begin anywhere between 6 and 40 years after the start of a boxing career, with an average onset of about 16 years.

''Post-traumatic dementia'' - The symptoms of post-traumatic dementia are very similar to those of dementia pugilistica, except that post-traumatic dementia is also characterized by long-term memory problems and is caused by a single, severe TBI that results in a [[coma]].

==Treatment==
Medical care usually begins when [[paramedic]]s or [[emergency medical technician]]s arrive on the scene of an accident or when a TBI patient arrives at the emergency department of a hospital. Because little can be done to reverse the initial brain damage caused by trauma, medical personnel try to stabilize the patient and focus on preventing further injury. Primary concerns include insuring proper [[oxygen]] supply, maintaining adequate blood flow, and controlling [[blood pressure]]. Since many head-injured patients may also have [[spinal cord injury|spinal cord injuries]], the patient is placed on a back-board and in a neck restraint to prevent further injury to the head and spinal cord.

Medical personnel assess the patient's condition by measuring [[vital signs]] and reflexes and by performing a neurological examination. They check the patient's temperature, blood pressure, pulse, breathing rate, and pupil size and response to light. They assess the patient's level of consciousness and neurological functioning using the [[Glasgow Coma Scale]].

Imaging tests help in determining the diagnosis and prognosis of a TBI patient. Patients with mild to moderate injuries may receive skull and neck [[X-ray]]s to check for [[bone fracture]]s. For moderate to severe cases, the gold standard imaging test is a [[computed tomography]] (CT) scan, which creates a series of crosssectional X-ray images of the head and brain and can show bone fractures as well as the presence of hemorrhage, hematomas, contusions, brain tissue swelling, and tumors. [[Magnetic resonance imaging]] (MRI) may be used after the initial assessment and treatment of the TBI patient. MRI uses magnetic fields to detect subtle changes in brain tissue content and can show more detail than X-rays or CT. The use of CT and MRI is standard in TBI treatment, but other imaging and diagnostic techniques that may be used to confirm a particular diagnosis include [[cerebral angiography]], [[electroencephalography]] (EEG), [[transcranial Doppler ultrasound]], and [[single photon emission computed tomography]] (SPECT).

Approximately half of severely head-injured patients will need [[surgery]] to remove or repair hematomas or contusions. Patients may also need surgery to treat injuries in other parts of the body. These patients usually go to the intensive care unit after surgery.

Sometimes when the brain is injured swelling occurs and fluids accumulate within the brain space. It is normal for bodily injuries to cause swelling and disruptions in fluid balance. But when an injury occurs inside the skull-encased brain, there is no place for swollen tissues to expand and no adjoining tissues to absorb excess fluid. This increased pressure is called [[intracranial pressure]] (ICP).

Medical personnel measure a patient's ICP using a probe or catheter. The instrument is inserted through the skull to the [[subarachnoid space|subarachnoid]] level and is connected to a monitor that registers the patient's ICP. If a patient has high ICP, he or she may undergo a [[ventriculostomy]], a procedure that drains [[cerebrospinal fluid]] (CSF) from the [[ventricular system|ventricles]] to bring the pressure down. Drugs that can be used to decrease ICP include [[mannitol]] or [[barbiturate]]s.

== Rehabilitation ==
Rehabilitation is an important part of the recovery process for a TBI patient. During the acute stage, moderately to severely injured patients may receive treatment and care in an intensive care unit of a hospital. Once stable, the patient may be transferred to a subacute unit of the medical center, to a rehabilitation inpatient unit within the acute trauma center, or to an independent off-site or 'free-standing' rehabilitation hospital. Moderately to severely injured patients may receive specialized rehabilitation treatment that draws on the skills of many specialists, involving treatment programs in the areas of physical therapy, occupational therapy, speech/language therapy, [[physiatry]] (medical specialist in [[physical medicine and rehabilitation]]), psychology/psychiatry, and social work. The services and efforts of this team of healthcare professionals is generally applied to the practical concerns of and the problems encountered by the brain injury survivor in their daily life. This treatment program is generally provided through a coordinated and self-organized process in the context of a transdisciplinary model of team care delivery.

The overall goal of rehabilitation after a TBI is to improve and optimize the patient's ability to function at home and in society in the face of the residual effects of the injury, which may be complex and multifaceted. An additional goal of the rehabilitation program is to prevent, wherever possible, but otherwise to diagnose and treat, any complications (eg. posttraumatic hydrocephalus) that may cause additional morbidity and mortality in this patient population. Therapists help the patient adapt to disabilities or change the patient's living space to make everyday activities easier. Education and training for identified caregivers is also a critically important component of the rehabilitation program.

Some patients may need medication for psychiatric and physical problems resulting from the TBI, and various medications are available that may lessen or moderate the problematic manifestations of the injury without directly altering the underlying pathology. Great care must be taken in prescribing medications because TBI patients are more susceptible to side effects and may react adversely to some pharmacological agents. It is important for the family caregivers to provide assistance and encouragement for the patient by being involved in the rehabilitation program. Family members may also benefit from psychotherapy and social support services.

==Prevention==
Unlike most neurological disorders, head injuries can be prevented. The [[Centers for Disease Control and Prevention]] (CDC) have issued the following safety tips for reducing the risk of suffering a TBI.

* Wear a [[seatbelt]] every time you drive or ride in a car.
* Buckle your child into a [[child safety seat]], booster seat, or seatbelt (depending on the child's age) every time the child rides in a car.
* Wear a helmet and make sure your children wear [[helmet]]s when
** riding a bike or motorcycle;
** playing a contact sport such as football or ice hockey;
** using in-line skates or riding a skateboard;
** batting and running bases in baseball or softball;
** riding a horse;
** skiing or snowboarding.
* Keep firearms and bullets stored in a locked cabinet when not in use.
* Avoid falls by
** using a step-stool with a grab bar to reach objects on high shelves;
** installing handrails on stairways;
** installing window guards to keep young children from falling out of open windows;
** using safety gates at the top and bottom of stairs when young children are around.
* Make sure the surface on your child's playground is made of shock-absorbing material (e.g., hardwood mulch, sand).

Source: [http://www.cdc.gov/safeusa/home/tbi.htm CDC, Department of Health and Human Services].

== Famous persons with TBI ==
* [[Phineas Gage]]
* [http://Givebackorlando.com Becky Dedo - GiveBack Inc]

==References==
1. [http://www.cdc.gov/doc.do/id/0900f3ec8006c8e0/ Traumatic Brain Injury in the United States: A Report to Congress] (2003) CDC, Department of Health and Human Services
== See also ==
* [[Head injury]]
:* [[Brain damage]]
:* [[Coma]]
:* [[Unconsciousness]]
:* [[Penetrating head injury]]
:* [[Closed head injury]]
* [[Diffuse brain injury]]
:* [[Concussion of the brain]]
:* [[Diffuse axonal injury]]
* [[Focal brain injury]]
:* [[Brain contusion]]
:* [[Intracranial hemorrhage]]
::* [[Intra-axial hemorrhage]]
::* [[Extra-axial hemorrhage]]
:::* [[Subdural hematoma]]
:::* [[Epidural hematoma]]
:::* [[Subarachnoid hemorrhage]]
* [[Spinal cord injury]]
* [[NINDS brain trauma research]]

==External links==
* [http://www.tandf.co.uk/journals/titles/02699052.html Brain Injury] | Official research journal of the International Brain Injury Association (IBIA)
* [http://Givebackorlando.com Becky Dedo - GiveBack Inc] | Road Maps For Recovery From Head Injury - for TBI survivors and their families.
* [http://www.biaq.com.au] Comprehensive range of fact sheets on brain injury
*http://www.brainsource.com/brain%20injury.htm
*http://www.tbirecoverycenter.org
*http://www.headway.org.uk/ | UK based charity that provides information and support to people with TBI and their families
*http://www.safar.pitt.edu | A US based research institution part of the University of Pittsburgh located in Pittsburgh, PA, which focuses research on TBI and TBI therapies
*http://www.brain-injury-help.com | Brain Injury Help and Resources
*[http://www.brain-surgery.us/ Brain Surgery-Neurosurgery Patient Help Site]
*http://www.headinjury.com | Brain Injury Resource Center
*http://www.biausa.org | Brain Injury Association of America
*http://www.biaf.org | Brain Injury Association of Florida

''The original version of this article contained text from the NINDS public domain pages on TBI at http://www.ninds.nih.gov/health_and_medical/disorders/tbi_doc.htm and http://www.ninds.nih.gov/health_and_medical/pubs/tbi.htm ''

[[Category:Neurotrauma]]

[[fr:Traumatisme crânien]]
[[it:Trauma cranico]]

Traumatic brain injury

2006-06-20T05:34:51Z

Quihn: /* External links */

{{DiseaseDisorder infobox |
Name = Traumatic brain injury¹ |
ICD10 = S06 |
ICD9 = {{ICD9|800.0}}-{{ICD9|801.9}}, {{ICD9|803.0}}-{{ICD9|804.9}}, {{ICD9|850.0}}-{{ICD9|854.1}} |
}}
'''Traumatic brain injury''' (TBI), traumatic injuries to the [[brain]], also called intracranial injury, or simply head injury, occurs when a sudden trauma causes [[brain damage]]. TBI can result from a closed head injury or a [[penetrating head injury]] and is one of two subsets of [[acquired brain injury]] (ABI). The other subset is non-traumatic brain injury (i.e. stroke, meningitis, anoxia). Parts of the brain that can be damaged include the [[cerebral hemisphere]]s, [[cerebellum]], and [[brain stem]] (see [[brain damage]]).
Symptoms of a TBI can be mild, moderate, or severe, depending on the extent of the damage to the brain. Outcome can be anything from complete recovery to permanent [[disability]] or death.

== Epidemiology ==
'''TBI''' is a major public health problem, especially among males ages 15 to 24, and among elderly people of both sexes 75 years and older. Children aged 5 and younger are also at high risk for TBI.

Each year in the United States:
* approximately 1 million head-injured people are treated in hospital emergency rooms,
* approximately 270,000 people experience a moderate or severe TBI,
* approximately 60,000 new cases of epilepsy occur as a result of head trauma,
* approximately 230,000 people are hospitalized for TBI and survive,
* approximately 80,000 of these survivors live with significant disabilities as a result of the injury, and
* approximately 70,000 people die from head injury.

==Signs and Symptoms of TBI==
Some symptoms are evident immediately, while others do not surface until several days or weeks after the injury.

With '''mild TBI''', the patient may remain conscious or may lose consciousness for a few seconds or minutes. The person may also feel dazed or not like him- or herself for several days or weeks after the initial injury. Other symptoms include:
*[[headache]],
*[[mental confusion]],
*lightheadedness,
*[[dizziness]],
*[[diplopia|double vision]], blurred vision, or tired eyes,
*ringing in the ears,
*bad taste in the mouth,
*fatigue or lethargy,
*a change in [[sleep]] patterns,
*behavioral or [[mood]] changes, and
*trouble with memory, concentration, attention, or thinking
*symptoms remain the same or get better; worsening symtptoms indicate a more severe injury.

With '''moderate or severe TBI''', the patient may show these same symptoms, but may also have:
*loss of consciousness
*personality change
*a severe, persistent, or worsening headache,
*repeated vomiting or nausea,
*[[seizure]]s,
*inability to awaken,
*[[dilation]] (widening) of one or both pupils,
*slurred speech,
*weakness or numbness in the extremities,
*loss of coordination, and/or
*increased confusion, restlessness, or agitation
*vomiting and neurological deficit (e.g. weakness in a limb) together are important indicators of prognosis and their presence may warrant early [[computed axial tomography|CT scanning]] and [[neurosurgery|neurosurgical]] intervention.

Small children with moderate to severe TBI may show some of these signs as well as signs specific to young children, including:
*persistent crying,
*inability to be consoled, and/or
*refusal to nurse or eat.

Anyone with signs of moderate or severe TBI should receive immediate emergency medical attention.

==Causes of and Risk Factors for TBI==
Half of all TBIs are due to [[transportation accident]]s involving [[automobile]]s, [[motorcycle]]s, [[bicycle]]s, and [[pedestrian]]s. These accidents are the major cause of TBI in people under age 75.

For those 75 and older, falls cause the majority of TBIs.

Approximately 20 % of TBIs are due to [[violence]], such as [[firearm assault]]s and [[child abuse]], and about 3 % are due to [[sports injuries]]. Fully half of TBI incidents involve [[alcohol]] use.

==Types of TBI==
The damage from TBI can be [[focal brain injury|focal]], confined to one area of the brain, or [[diffuse brain injury|diffuse]], involving more than one area of the brain. Diffuse trauma to the brain is frequently associated with [[concussion]] (a shaking of the brain in response to sudden motion of the head), [[diffuse axonal injury]], or [[coma]]. Localized injuries may be associated with neurobehavioral manifestations, [[hemiparesis]] or other [[focal neurologic deficit]]s.

Types of focal brain injury include bruising of brain tissue called a [[brain contusion|contusion]] and [[intracranial hemorrhage]] or [[hematoma]], heavy bleeding in the skull. Hemorrhage, due to rupture of a [[blood vessel]] in the head, can be [[extra-axial hemorrhage|extra-axial]], meaning it occurs within the [[skull]] but outside of the brain, or [[intra-axial hemorrhage|intra-axial]], occurring within the brain. Extra-axial hemorrhages can be further divided into [[subdural hematoma]], [[epidural hematoma]], and [[subarachnoid hemorrhage]]. An [[epidural hematoma]] involves bleeding into the area between the skull and the [[dura]]. With a [[subdural hematoma]], bleeding is confined to the area between the dura and the [[arachnoid membrane]]. Bleeding within the brain itself is called [[intracerebral hematoma]]. Intra-axial bleeds are further divided into [[intraparenchymal hemorrhage]] which occurs within the brain tissue itself and [[intraventricular hemorrhage]] which occurs in the [[ventricular system]].

TBI can result from a [[closed head injury]] or a [[penetrating head injury]]. A closed injury occurs when the head suddenly and violently hits an object but the object does not break through the skull. A penetrating injury occurs when an object pierces the skull and enters brain tissue.

As the first line of defense, the [[skull]] is particularly vulnerable to injury. [[Skull fracture]]s occur when the bone of the skull cracks or breaks. A [[depressed skull fracture]] occurs when pieces of the broken skull press into the tissue of the brain. A [[penetrating skull fracture]] occurs when something pierces the skull, such as a bullet, leaving a distinct and localized injury to brain tissue. Skull fractures can cause [[cerebral contusion]].

Another insult to the brain that can cause injury is [[anoxia]]. Anoxia is a condition in which there is an absence of oxygen supply to an organ's tissues, even if there is adequate blood flow to the tissue. [[Hypoxia (medical)|Hypoxia]] refers to a decrease in oxygen supply rather than a complete absence of oxygen, and [[ischemia]] is inadequate blood supply, as is seen in cases in which the [[cerebral edema|brain swells]]. In any of these cases, without adequate oxygen, a [[biochemical cascade]] called the [[ischemic cascade]] is unleashed, and the cells of the brain can die within several minutes. This type of injury is often seen in near-drowning victims, in [[heart attack]] patients, or in people who suffer significant blood loss from other injuries that decrease blood flow to the brain.

==Effects on consciousness==
Generally, there are five abnormal states of consciousness that can result from a TBI: [[stupor]], [[coma]], [[persistent vegetative state]], [[locked-in syndrome]], and [[brain death]].

[[Stupor]] is a state in which the patient is unresponsive but can be aroused briefly by a strong stimulus, such as sharp pain. [[Coma]] is a state in which the patient is totally unconscious, unresponsive, unaware, and unarousable.

Patients in a [[persistent vegetative state]] are unconscious and unaware of their surroundings, but they continue to have a sleep-wake cycle and can have periods of alertness. A vegetative state can result from diffuse injury to the cerebral hemispheres of the brain without damage to the lower brain and brainstem. [[Anoxia]], or lack of oxygen to the brain, which is a common complication of [[cardiac arrest]], can also bring about a vegetative state.

[[Locked-in syndrome]] is a condition in which a patient is aware and awake, but cannot move or communicate due to complete paralysis of the body.

[[Brain death]] is the lack of measurable brain function due to diffuse damage to the cerebral hemispheres and the brainstem, with loss of any integrated activity among distinct areas of the brain. Brain death is irreversible. Removal of assistive devices will result in immediate cardiac arrest and cessation of breathing.

==Complications==
Sometimes, health complications occur in the period immediately following a TBI. These complications are not types of TBI, but are distinct medical problems that arise as a result of the injury. Although complications are rare, the risk increases with the severity of the trauma. Complications of TBI include immediate [[seizure]]s, [[hydrocephalus]] or [[post-traumatic ventricular enlargement]], [[cerebrospinal fluid]] leaks, infections, vascular injuries, [[cranial nerve]] injuries, [[pain]], [[bed sore]]s, [[multiple organ system failure]] in unconscious patients, and [[polytrauma]] (trauma to other parts of the body in addition to the brain).

About 25 % of patients with brain contusions or hematomas and about 50 % of patients with penetrating head injuries will develop immediate seizures, seizures that occur within the first 24 hours of the injury. These immediate seizures increase the risk of early seizures - defined as seizures occurring within 1 week after injury - but do not seem to be linked to the development of [[post-traumatic epilepsy]] (recurrent seizures occurring more than 1 week after the initial trauma). Generally, medical professionals use anticonvulsant medications to treat seizures in TBI patients only if the seizures persist.

Hydrocephalus or post-traumatic ventricular enlargement occurs when [[cerebrospinal fluid]] (CSF) accumulates in the brain resulting in dilation of the cerebral ventricles (cavities in the brain filled with CSF) and an increase in ICP. This condition can develop during the acute stage of TBI or may not appear until later. Generally it occurs within the first year of the injury and is characterized by worsening neurological outcome, impaired consciousness, behavioral changes, ataxia (lack of coordination or balance), incontinence, or signs of elevated ICP. The condition may develop as a result of meningitis, subarachnoid hemorrhage, intracranial hematoma, or other injuries. Treatment includes shunting and draining of CSF as well as any other appropriate treatment for the root cause of the condition.

Skull fractures can tear the membranes that cover the brain, leading to CSF leaks. A tear between the dura and the arachnoid membranes, called a [[CSF fistula]], can cause CSF to leak out of the subarachnoid space into the subdural space; this is called a [[subdural hygroma]]. CSF can also leak from the nose and the ear. These tears that let CSF out of the brain cavity can also allow air and bacteria into the cavity, possibly causing infections such as meningitis. [[Pneumocephalus]] occurs when air enters the [[intracranial cavity]] and becomes trapped in the subarachnoid space.

Infections within the intracranial cavity are a dangerous complication of TBI. They may occur outside of the [[dura mater]], below the dura, below the [[arachnoid mater|arachnoid]] ([[meningitis]]), or within the brain itself ([[abscess]]). Most of these injuries develop within a few weeks of the initial trauma and result from [[skull fracture]]s or penetrating injuries. Standard treatment involves antibiotics and sometimes surgery to remove the infected tissue. Meningitis may be especially dangerous, with the potential to spread to the rest of the brain and nervous system.

Any damage to the head or brain usually results in some damage to the [[vascular system]], which provides [[blood]] to the cells of the brain. The body's [[immune system]] can repair damage to small blood vessels, but damage to larger vessels can result in serious complications. Damage to one of the major arteries leading to the brain can cause a stroke, either through bleeding from the artery ([[hemorrhagic stroke]]) or through the formation of a clot at the site of injury, called a [[thrombus]] or thrombosis, blocking blood flow to the brain ([[ischemic stroke]]). Blood clots also can develop in other parts of the head. Symptoms such as headache, vomiting, seizures, paralysis on one side of the body, and semiconsciousness developing within several days of a head injury may be caused by a blood clot that forms in the tissue of one of the sinuses, or cavities, adjacent to the brain. Thrombotic-ischemic strokes are treated with anticoagulants, while surgery is the preferred treatment for hemorrhagic stroke. Other types of vascular injuries include [[vasospasm]] and the formation of [[aneurysm]]s .

Skull fractures, especially at the base of the skull, can cause cranial nerve injuries that result in [[compressive cranial neuropathy|compressive cranial neuropathies]]. All but three of the 12 cranial nerves project out from the brainstem to the head and face. The [[seventh cranial nerve]], called the [[facial nerve]], is the most commonly injured cranial nerve in TBI and damage to it can result in paralysis of facial muscles.

Pain, especially headache, is commonly a significant complication for conscious patients in the period immediately following a TBI. Serious complications for patients who are unconscious, in a coma, or in a vegetative state include bed or [[pressure sores]] of the skin, recurrent [[bladder infection]]s, [[pneumonia]] or other life-threatening infections, and [[progressive multiple organ failure]].

==General Trauma==
Other medical complications that may accompany a TBI include pulmonary (lung) dysfunction; cardiovascular (heart) dysfunction from [[blunt chest trauma]]; gastrointestinal dysfunction; fluid and hormonal imbalances; and other isolated complications, such as fractures, nerve injuries, [[deep vein thrombosis]], excessive blood clotting, and infections.

Trauma victims often develop [[hypermetabolism]] or an increased metabolic rate, which leads to an increase in the amount of heat the body produces. The body redirects into heat the energy needed to keep organ systems functioning, causing muscle wasting and the starvation of other tissues. Complications related to pulmonary dysfunction can include [[neurogenic pulmonary edema]] (excess fluid in lung tissue), [[aspiration pneumonia]] (pneumonia caused by foreign matter in the lungs), and fat and blood clots in the blood vessels of the lungs.

Fluid and hormonal imbalances can complicate the treatment of hypermetabolism and high ICP. Hormonal problems can result from dysfunction of the [[pituitary]], the [[thyroid]], and other glands throughout the body. Two common hormonal complications of TBI are syndrome of inappropriate secretion of antidiuretic hormone ([[SIADH]]) and [[hypothyroidism]].

==Disabilities Resulting From TBI==
Disabilities resulting from a TBI depend upon the severity of the injury, the location of the injury, and the age and general health of the patient. Some common disabilities include problems with cognition (thinking, memory, and reasoning), sensory processing (sight, hearing, touch, taste, and smell), communication (expression and understanding), and behavior or mental health ([[major depression|depression]], [[anxiety]], personality changes, aggression, acting out, and social inappropriateness).

Within days to weeks of the head injury approximately 40 % of TBI patients develop a host of troubling symptoms collectively called [[postconcussion syndrome]] (PCS). A patient need not have suffered a [[concussion]] or loss of consciousness to develop the syndrome and many patients with mild TBI suffer from PCS. Symptoms include [[headache]], [[dizziness]], memory problems, trouble concentrating, sleeping problems, restlessness, irritability, apathy, depression, and anxiety. These symptoms may last for a few weeks after the head injury. The syndrome is more prevalent in patients who had psychiatric symptoms, such as depression or anxiety, before the injury. Treatment for PCS may include medicines for pain and psychiatric conditions, and psychotherapy and occupational therapy.

Most patients with severe TBI, if they recover consciousness, suffer from [[Cognition|cognitive]] disabilities, including the loss of many higher level mental skills. The most common cognitive impairment among severely head-injured patients is memory loss, characterized by some loss of specific memories and the partial inability to form or store new ones. Some of these patients may experience [[post-traumatic amnesia]] (PTA), either [[anterograde amnesia|anterograde]] or [[retrograde amnesia|retrograde]]. Anterograde PTA is impaired memory of events that happened after the TBI, while retrograde PTA is impaired memory of events that happened before the TBI.

Many patients with mild to moderate head injuries who experience cognitive deficits become easily confused or distracted and have problems with concentration and attention. They also have problems with higher level, so-called executive functions, such as planning, organizing, abstract reasoning, problem solving, and making judgments, which may make it difficult to resume pre-injury work-related activities. Recovery from cognitive deficits is greatest within the first 6 months after the injury and more gradual after that.

Patients with moderate to severe TBI have more problems with cognitive deficits than patients with mild TBI, but a history of several mild TBIs may have an additive effect, causing cognitive deficits equal to a moderate or severe injury.

Many TBI patients have sensory problems, especially problems with vision. Patients may not be able to register what they are seeing or may be slow to recognize objects. Also, TBI patients often have difficulty with hand-eye coordination. Because of this, TBI patients may seem clumsy or unsteady. Other sensory deficits may include problems with hearing, smell, taste, or touch. Some TBI patients develop [[tinnitus]], a ringing or roaring in the ears. A person with damage to the part of the brain that processes taste or smell may develop a persistent bitter taste in the mouth or perceive a persistent noxious smell. Damage to the part of the brain that controls the sense of touch may cause a TBI patient to develop persistent skin tingling, itching, or pain. These conditions are rare and hard to treat.

Language and communication problems are common disabilities in TBI patients. Some may experience [[aphasia]], defined as difficulty with understanding and producing spoken and written language; others may have difficulty with the more subtle aspects of communication, such as body language and emotional, non-verbal signals.

In [[non-fluent aphasia]], also called [[Broca's aphasia]] or [[motor aphasia]], TBI patients often have trouble recalling words and speaking in complete sentences. They may speak in broken phrases and pause frequently. Most patients are aware of these deficits and may become extremely frustrated.

Patients with [[fluent aphasia]], also called [[Wernicke's aphasia]] or [[sensory aphasia]], display little meaning in their speech, even though they speak in complete sentences and use correct grammar. Instead, they speak in flowing gibberish, drawing out their sentences with non-essential and invented words. Many patients with fluent aphasia are unaware that they make little sense and become angry with others for not understanding them. Patients with global aphasia have extensive damage to the portions of the brain responsible for language and often suffer severe communication disabilities.

TBI patients may have problems with spoken language if the part of the brain that controls speech muscles is damaged. In this disorder, called [[dysarthria]], the patient can think of the appropriate language, but cannot easily speak the words because they are unable to use the muscles needed to form the words and produce the sounds. Speech is often slow, slurred, and garbled. Some may have problems with intonation or inflection, called prosodic dysfunction.

Most TBI patients have emotional or behavioral problems that fit under the broad category of psychiatric health. Family members of TBI patients often find that personality changes and behavioral problems are the most difficult disabilities to handle. Psychiatric problems that may surface include depression, apathy, anxiety, irritability, anger, paranoia, confusion, frustration, agitation, insomnia or other sleep problems, and mood swings. Problem behaviors may include aggression and violence, impulsivity, disinhibition, acting out, noncompliance, social inappropriateness, emotional outbursts, childish behavior, impaired self-control, impaired selfawareness, inability to take responsibility or accept criticism, egocentrism, inappropriate sexual activity, and alcohol or drug abuse/addiction. Some patients' personality problems may be so severe that they are diagnosed with organic personality disorder, a psychiatric condition characterized by many of the problems mentioned above. Sometimes TBI patients suffer from [[developmental stagnation]], meaning that they fail to mature emotionally, socially, or psychologically after the trauma. This is a serious problem for children and young adults who suffer from a TBI. Attitudes and behaviors that are appropriate for a child or teenager become inappropriate in adulthood. Many TBI patients who show psychiatric or behavioral problems can be helped with medication and psychotherapy.

==Other Long-Term Problems Associated With TBI==
Other long-term problems that can develop after a TBI include [[Parkinson's disease]] and other motor problems, [[Alzheimer's disease]], [[dementia pugilistica]], and [[post-traumatic dementia]].

''Alzheimer's disease'' (AD) - AD is a progressive, neurodegenerative disease characterized by [[dementia]], memory loss, and deteriorating cognitive abilities. Recent research suggests an association between head injury in early adulthood and the development of AD later in life; the more severe the head injury, the greater the risk of developing AD. Some evidence indicates that a head injury may interact with other factors to trigger the disease and may hasten the onset of the disease in individuals already at risk. For example, people who have a particular form of the protein [[apolipoprotein E]] ([[apoE4]]) and suffer a head injury fall into this increased risk category. (ApoE4 is a naturally occurring protein that helps transport cholesterol through the bloodstream.)

''Parkinson's disease'' and other motor problems - Movement disorders as a result of TBI are rare but can occur. Parkinson's disease may develop years after TBI as a result of damage to the [[basal ganglia]]. Symptoms of Parkinson's disease include tremor or trembling, rigidity or stiffness, slow movement ([[bradykinesia]]), inability to move ([[akinesia]]), shuffling walk, and stooped posture. Despite many scientific advances in recent years, Parkinson's disease remains a chronic and progressive disorder, meaning that it is incurable and will progress in severity until the end of life. Other movement disorders that may develop after TBI include tremor, [[ataxia]] (uncoordinated muscle movements), and [[myoclonus]] (shock-like contractions of muscles).

''Dementia pugilistica'' - Also called [[chronic traumatic encephalopathy]], dementia pugilistica primarily affects career [[boxing|boxer]]s. The most common symptoms of the condition are dementia and parkinsonism caused by repetitive blows to the head over a long period of time. Symptoms begin anywhere between 6 and 40 years after the start of a boxing career, with an average onset of about 16 years.

''Post-traumatic dementia'' - The symptoms of post-traumatic dementia are very similar to those of dementia pugilistica, except that post-traumatic dementia is also characterized by long-term memory problems and is caused by a single, severe TBI that results in a [[coma]].

==Treatment==
Medical care usually begins when [[paramedic]]s or [[emergency medical technician]]s arrive on the scene of an accident or when a TBI patient arrives at the emergency department of a hospital. Because little can be done to reverse the initial brain damage caused by trauma, medical personnel try to stabilize the patient and focus on preventing further injury. Primary concerns include insuring proper [[oxygen]] supply, maintaining adequate blood flow, and controlling [[blood pressure]]. Since many head-injured patients may also have [[spinal cord injury|spinal cord injuries]], the patient is placed on a back-board and in a neck restraint to prevent further injury to the head and spinal cord.

Medical personnel assess the patient's condition by measuring [[vital signs]] and reflexes and by performing a neurological examination. They check the patient's temperature, blood pressure, pulse, breathing rate, and pupil size and response to light. They assess the patient's level of consciousness and neurological functioning using the [[Glasgow Coma Scale]].

Imaging tests help in determining the diagnosis and prognosis of a TBI patient. Patients with mild to moderate injuries may receive skull and neck [[X-ray]]s to check for [[bone fracture]]s. For moderate to severe cases, the gold standard imaging test is a [[computed tomography]] (CT) scan, which creates a series of crosssectional X-ray images of the head and brain and can show bone fractures as well as the presence of hemorrhage, hematomas, contusions, brain tissue swelling, and tumors. [[Magnetic resonance imaging]] (MRI) may be used after the initial assessment and treatment of the TBI patient. MRI uses magnetic fields to detect subtle changes in brain tissue content and can show more detail than X-rays or CT. The use of CT and MRI is standard in TBI treatment, but other imaging and diagnostic techniques that may be used to confirm a particular diagnosis include [[cerebral angiography]], [[electroencephalography]] (EEG), [[transcranial Doppler ultrasound]], and [[single photon emission computed tomography]] (SPECT).

Approximately half of severely head-injured patients will need [[surgery]] to remove or repair hematomas or contusions. Patients may also need surgery to treat injuries in other parts of the body. These patients usually go to the intensive care unit after surgery.

Sometimes when the brain is injured swelling occurs and fluids accumulate within the brain space. It is normal for bodily injuries to cause swelling and disruptions in fluid balance. But when an injury occurs inside the skull-encased brain, there is no place for swollen tissues to expand and no adjoining tissues to absorb excess fluid. This increased pressure is called [[intracranial pressure]] (ICP).

Medical personnel measure a patient's ICP using a probe or catheter. The instrument is inserted through the skull to the [[subarachnoid space|subarachnoid]] level and is connected to a monitor that registers the patient's ICP. If a patient has high ICP, he or she may undergo a [[ventriculostomy]], a procedure that drains [[cerebrospinal fluid]] (CSF) from the [[ventricular system|ventricles]] to bring the pressure down. Drugs that can be used to decrease ICP include [[mannitol]] or [[barbiturate]]s.

== Rehabilitation ==
Rehabilitation is an important part of the recovery process for a TBI patient. During the acute stage, moderately to severely injured patients may receive treatment and care in an intensive care unit of a hospital. Once stable, the patient may be transferred to a subacute unit of the medical center, to a rehabilitation inpatient unit within the acute trauma center, or to an independent off-site or 'free-standing' rehabilitation hospital. Moderately to severely injured patients may receive specialized rehabilitation treatment that draws on the skills of many specialists, involving treatment programs in the areas of physical therapy, occupational therapy, speech/language therapy, [[physiatry]] (medical specialist in [[physical medicine and rehabilitation]]), psychology/psychiatry, and social work. The services and efforts of this team of healthcare professionals is generally applied to the practical concerns of and the problems encountered by the brain injury survivor in their daily life. This treatment program is generally provided through a coordinated and self-organized process in the context of a transdisciplinary model of team care delivery.

The overall goal of rehabilitation after a TBI is to improve and optimize the patient's ability to function at home and in society in the face of the residual effects of the injury, which may be complex and multifaceted. An additional goal of the rehabilitation program is to prevent, wherever possible, but otherwise to diagnose and treat, any complications (eg. posttraumatic hydrocephalus) that may cause additional morbidity and mortality in this patient population. Therapists help the patient adapt to disabilities or change the patient's living space to make everyday activities easier. Education and training for identified caregivers is also a critically important component of the rehabilitation program.

Some patients may need medication for psychiatric and physical problems resulting from the TBI, and various medications are available that may lessen or moderate the problematic manifestations of the injury without directly altering the underlying pathology. Great care must be taken in prescribing medications because TBI patients are more susceptible to side effects and may react adversely to some pharmacological agents. It is important for the family caregivers to provide assistance and encouragement for the patient by being involved in the rehabilitation program. Family members may also benefit from psychotherapy and social support services.

==Prevention==
Unlike most neurological disorders, head injuries can be prevented. The [[Centers for Disease Control and Prevention]] (CDC) have issued the following safety tips for reducing the risk of suffering a TBI.

* Wear a [[seatbelt]] every time you drive or ride in a car.
* Buckle your child into a [[child safety seat]], booster seat, or seatbelt (depending on the child's age) every time the child rides in a car.
* Wear a helmet and make sure your children wear [[helmet]]s when
** riding a bike or motorcycle;
** playing a contact sport such as football or ice hockey;
** using in-line skates or riding a skateboard;
** batting and running bases in baseball or softball;
** riding a horse;
** skiing or snowboarding.
* Keep firearms and bullets stored in a locked cabinet when not in use.
* Avoid falls by
** using a step-stool with a grab bar to reach objects on high shelves;
** installing handrails on stairways;
** installing window guards to keep young children from falling out of open windows;
** using safety gates at the top and bottom of stairs when young children are around.
* Make sure the surface on your child's playground is made of shock-absorbing material (e.g., hardwood mulch, sand).

Source: [http://www.cdc.gov/safeusa/home/tbi.htm CDC, Department of Health and Human Services].

== Famous persons with TBI ==
* [[Phineas Gage]]
* [http://Givebackorlando.com Becky Dedo - GiveBack Inc]

==References==
1. [http://www.cdc.gov/doc.do/id/0900f3ec8006c8e0/ Traumatic Brain Injury in the United States: A Report to Congress] (2003) CDC, Department of Health and Human Services
== See also ==
* [[Head injury]]
:* [[Brain damage]]
:* [[Coma]]
:* [[Unconsciousness]]
:* [[Penetrating head injury]]
:* [[Closed head injury]]
* [[Diffuse brain injury]]
:* [[Concussion of the brain]]
:* [[Diffuse axonal injury]]
* [[Focal brain injury]]
:* [[Brain contusion]]
:* [[Intracranial hemorrhage]]
::* [[Intra-axial hemorrhage]]
::* [[Extra-axial hemorrhage]]
:::* [[Subdural hematoma]]
:::* [[Epidural hematoma]]
:::* [[Subarachnoid hemorrhage]]
* [[Spinal cord injury]]
* [[NINDS brain trauma research]]

==External links==
* [http://www.tandf.co.uk/journals/titles/02699052.html Brain Injury] | Official research journal of the International Brain Injury Association (IBIA)
* [http://Givebackorlando.com Becky Dedo - GiveBack Inc] | Road Maps For Recovery From Head Injury - for TBI survivors and their families.
* [http://www.biaq.com.au | Comprehensive range of fact sheets on brain injury]
*http://www.brainsource.com/brain%20injury.htm
*http://www.tbirecoverycenter.org
*http://www.headway.org.uk/ | UK based charity that provides information and support to people with TBI and their families
*http://www.safar.pitt.edu | A US based research institution part of the University of Pittsburgh located in Pittsburgh, PA, which focuses research on TBI and TBI therapies
*http://www.brain-injury-help.com | Brain Injury Help and Resources
*[http://www.brain-surgery.us/ Brain Surgery-Neurosurgery Patient Help Site]
*http://www.headinjury.com | Brain Injury Resource Center
*http://www.biausa.org | Brain Injury Association of America
*http://www.biaf.org | Brain Injury Association of Florida

''The original version of this article contained text from the NINDS public domain pages on TBI at http://www.ninds.nih.gov/health_and_medical/disorders/tbi_doc.htm and http://www.ninds.nih.gov/health_and_medical/pubs/tbi.htm ''

[[Category:Neurotrauma]]

[[fr:Traumatisme crânien]]
[[it:Trauma cranico]]

Brain injury

2006-06-20T05:31:42Z

Quihn: /* External links */

:''For other meanings, see [[Brain damage (disambiguation)]]''

'''Brain damage''' or '''brain injury''' is the destruction or degeneration of [[brain]] [[cell (biology)|cells]].

Brain damage may occur due to a wide range of conditions, [[illness]]es, or [[injury|injuries]]. Possible causes of widespread (''diffuse'') brain damage include prolonged [[Hypoxia (medical)|hypoxia]] (shortage of [[oxygen]]), [[poison]]ing, [[infection]], and [[neurological illness]]. Common causes of focal or localized brain damage are physical [[Physical trauma|trauma]] ([[traumatic brain injury]]), [[stroke]], [[aneurysm]], or neurological illness.

The extent and effect of brain injury is often assessed by the use of [[neurology|neurological examination]], [[neuroimaging]], and [[neuropsychological test |neuropsychological assessment]].

Brain injury does not necessarily result in long-term impairment or [[disability]], although the location and extent of damage both have a significant effect on the likely outcome. In serious cases of brain injury, the result can be permanent [[disability]], including [[neurocognitive deficit]]s, [[delusion]]s (often specifically [[monothematic delusion]]s), speech or movement problems, and [[Mental retardation|mental handicap]]. Severe brain damage may result in [[persistent vegetative state]], [[coma]], or [[death]].

Various professions may be involved in the medical care and [[physical therapy|rehabilitation]] of someone who suffers impairment after brain damage. [[Neurologist]]s, [[neurosurgeon]]s, and [[Physical medicine and rehabilitation|physiatrist]]s are [[physician]]s who specialise in treating brain injury. [[Neuropsychology|Neuropsychologists]] (especially [[clinical neuropsychology|clinical neuropsychologists]]) are [[psychologist]]s who specialise in understanding the effects of brain injury and may be involved in assessing the extent of brain damage or creating [[rehabilitation (neuropsychology)|rehabilitation]] programmes. [[Occupational therapy|Occupational therapists]] may be involved in running rehabilitation programmes to help restore lost function or help re-learn essential skills.

It is a common misconception that brain damage sustained during childhood has a better chance of successful recovery than similar injury acquired in adult life. In fact, the consequences of childhood injury may simply be more difficult to detect in the short term. This is because different [[cerebral cortex|cortical]] areas mature at different stages, with some major cell populations and their corresponding cognitive faculties remaining unrefined until early adulthood. In the case of a child with frontal brain injury, for example, the impact of the damage may be undetectable until that child fails to develop normal executive functions in his or her late teens and early twenties.

The effects of impairment or [[disability]] resulting from brain injury may be treated by a number of methods, including [[medication]], [[psychotherapy]], [[Rehabilitation (neuropsychology)|neuropsychological rehabilitation]], [[snoezelen]], [[surgery]], or physical implants such as [[deep brain stimulation]].

==See also==
* [[Clinical neuropsychology]]
* [[Cognitive neuropsychology]]
* [[Head injury]]
* [[Traumatic brain injury]]
* [[Neurocognitive deficit]]
* [[Neurology]]
* [[Neuropsychology]]
* [[Rehabilitation (neuropsychology)]]
* [[Epilepsy]]

==External links==
*[http://www.nlm.nih.gov/medlineplus/headandbraininjuries.html Head and Brain Injuries] from MedlinePlus
* [http://www.biaq.com.au Broad range of downloadable fact sheets on brain injury]

[[Category:Neurotrauma]]
[[Category:Neurosurgery]]
[[Category:Neurology]]

[[is:Heilaskemmd]]
[[fi:Aivovaurio]]
[[sv:Hjärnskada]]

Epidural hematoma

2006-06-20T05:30:10Z

Quihn: /* References */

{{DiseaseDisorder infobox |
Name = Extradural haemorrhage |
Image = Epidural hematoma.png |
Caption = Nontraumatic epidural hematoma in a young woman. The grey area in the top left is organizing hematoma, causing midline shift and compression of the ventricle. |
ICD10 = {{ICD10|I|62|1|i|60}}, {{ICD10|S|06|4|s|00}} |
ICD9 = {{ICD9|432.0}} |
ICDO = |
OMIM = |
DiseasesDB = 4353 |
MedlinePlus = |
eMedicineSubj = emerg |
eMedicineTopic = 167 |
}}
'''Epidural''' or '''extradural hematoma''' is a buildup of blood occurring between the [[dura mater]] (the [[brain|brain's]] tough outer membrane) and the [[skull]]. Often due to [[head trauma|trauma]], the condition is potentially deadly because the buildup of blood may increase [[intracranial pressure|pressure]] in the [[intracranial space]] and compress delicate brain tissue. 15 to 20% of patients with epidural hematomas die of the [[injury]] (Sanders and McKenna, 2001).

==Causes==
The cause of epidural hematoma is usaully [[brain trauma|traumatic]], although spontaneous hemorrhage is known to occur. Hemorrhages commonly result from [[acceleration-deceleration trauma]] and transverse forces (McCaffrey, 2001; University of Vermont). [[vein|Venous]] epidural bleeds are usually due to [[shearing injury]] from [[angular momentum|rotational]] or linear forces, caused when tissues of different densities slide over one another.

Epidural hematoma commonly results from a blow to the side of the head and is frequently caused by a fracture that passes through an arterial channel in the [[bone]], most commonly a break in [[temporal bone]] interrupting [[middle meningeal artery]], a branch of the [[external carotid]] (Shepherd, 2004). Thus only 20 to 30% of epidural hematomas occur outside the temporal bone (Graham and Gennareli, 2000).

==Features==
Epidural bleeds, like [[subdural hematoma|subdural]] and [[subarachnoid hemorrhage]]s, are [[extra-axial hemorrhage|extra-axial bleeds]], occurring outside of the brain tissue, while [[intra-axial hemorrhage]]s, including [[intraparenchymal hemorrhage|intraparenchymal]] and [[intraventricular hemorrhage]]s, occur within it (Wagner, 2004).

Epidural bleeding is rapid because it is usually from arteries, which are high pressure. Epidural bleeds from arteries can grow until they reach their peak size at six to eight hours post injury, spilling from 25 to 75 [[cubic centimeter]]s of blood into the [[intracranial space]] (University of Vermont; Stock and Singer, 2004). As the hematoma expands, it strips the dura from the inside of the skull, causing an intense headache.

Epidural bleeds can become large and raise [[intracranial pressure]], causing the brain to shift, lose blood supply, or be crushed against the skull. Larger hematomas cause more damage. Epidural bleeds can quickly expand and compress the brain stem, causing [[coma|unconsciousness]], [[abnormal posturing]], and abnormal [[pupil]] responses to light (Stock and Singer, 2004).

10% of epidural bleeds may be venous (Shepherd, 2004).

On images produced by [[CT scan]]s and [[MRI]]s, epidural hematomas usually appear convex in shape because their expansion stops at skull's [[skull suture|sutures]], where the dura mater is tightly attached to the skull. Thus they expand inward toward the brain rather than along the inside of the skull, as occurs in [[subdural hematoma]]. The lens like shape of the hematoma leads the appearance of these bleeds to be called "lentiform".

Epidural hematomas may occur in combination with subdural hematomas, or either may occur alone (Shepherd, 2004). CT scans reveal subdural or epidural hematomas in 20% of unconscious patients (Downie, 2001).

In the hallmark of epidural hematoma, patients may regain consciousness during what is called a [[lucid interval]], only to descend suddenly and rapidly into unconsciousness later. The lucid interval, which depends on the extent of the injury, is a key to diagnosing epidural hemorrhage. If the patient is not treated with prompt surgical intervention, death is likely to follow (Caroline).

==Treatment==
As with other types of [[intracranial hematoma]]s, the blood may be aspirated surgically to remove the mass and reduce the pressure it puts on the brain (McCaffrey, 2001). The hematoma is [[neurosurgery|neurosurgically]] evacuated through a [[burr hole]] or [[craniotomy]]. The diagnosis of epidural hematoma requires a patient to be cared for in a facility with a neurosurgeon on call to decompress the hematoma if necessary and stop the bleed by ligating the injured vessel branches.

==Epidural hematoma in the spine==
Bleeding into the epidural space in the spine may also cause epidural hematoma. These may arise spontaneously (e.g. during [[childbirth]], or as a rare complication of anaesthesia (such as [[epidural]] anaesthesia) or surgery (such as laminectomy).

The anatomy of the epidural space means that spinal epidural hematoma has a different profile from cranial epidural hematoma. In the spine, the epidural space contains loose fatty tissue, and the '''epidural venous plexus''', a network of large, thin-walled veins. This means that bleeding is likely to be venous. Anatomical abnormalities and [[coagulopathy| bleeding disorder]]s make these lesions more likely.

They may cause pressure on the spinal cord or [[cauda equina]], which may present as pain, muscle weakness, or bladder and bowel dysfunction.

The diagnosis may be made on clinical appearance and time course of symptoms. It usually requires [[MRI]] scanning to confirm.

The treatment is surgical decompression.

The incidence of epidural hematoma following epidural anaesthesia is extremely difficult to quantify; estimates vary from 1 per 10,000 to 1 per 100,000 epidural anaesthetics. This means that a typical anaesthetist or [[anesthesiologist]] is statistically unlikely to cause one in a whole career.

==See also==
* [[Intracranial hematoma]]
:* [[Extra-axial hematoma]]
::* [[Subdural hematoma]]
::* [[Subarachnoid hemorrhage]]
:* [[Intra-axial hematoma]]
* [[Diffuse axonal injury]]
* [[Concussion]]
* [[Brain contusion]]

==References==
# Caroline NL. 1991. ''Emergency Medical Treatment''. Little Brown & Company.
# Downie A. 2001. [http://www.radiology.co.uk/srs-x/tutors/cttrauma/tutor.htm "Tutorial: CT in Head Trauma"].
# Graham DI and Gennareli TA. Chapter 5, "Pathology of Brain Damage After Head Injury" Cooper P and Golfinos G. 2000. Head Injury, 4th Ed. Morgan Hill, New York.
# McCaffrey P. 2001. [http://www.csuchico.edu/~pmccaff/syllabi/SPPA336/336unit11.html "The Neuroscience on the Web Series: CMSD 336 Neuropathologies of Language and Cognition."] California State University, Chico.
# Sanders MJ and McKenna K. 2001. ''Mosby’s Paramedic Textbook'', 2nd revised Ed. Chapter 22, "Head and Facial Trauma." Mosby.
# Shepherd S. 2004. [http://www.emedicine.com/med/topic2820.htm "Head Trauma."] Emedicine.com
# Stock A and Singer L. 2004. [http://www.emedicine.com/ped/topic929.htm "Head Trauma."] Emedicine.com.
#University of Vermont College of Medicine. [http://cats.med.uvm.edu/cats_teachingmod/pathology/path302/np/home/neuroindex.html "Neuropathology: Trauma to the CNS."]
# Wagner AL. 2004. [http://www.emedicine.com/radio/topic664.htm "Subdural Hematoma."] Emedicine.com.

==External links==
[http://www.biaq.com.au Broad range of downloadable fact sheets on brain injury]

{{Template:Cerebral hemorrhage}}
[[Category:Neurotrauma]]
[[Category:Neurology]]

[[fr:Hématome extra-dural]]
[[ja:急性硬膜外血腫]]

Subdural hematoma

2006-06-20T05:29:33Z

Quihn: /* References */

{{DiseaseDisorder infobox |
Name = Subdural hemorrhage |
ICD10 = S06.5 |
ICD9 = {{ICD9|432.1}} |
}}
A '''subdural [[hemorrhage]]''' (SDH), is a form of [[traumatic brain injury]] in which [[blood]] collects between the [[dura mater|dura]] (the outer protective covering of the [[brain]]) and the [[arachnoid (brain)|arachnoid]] (the middle layer of the [[meninges]]). Unlike in epidural hematomas, which are usually caused by tears in [[artery|arteries]], subdural bleeding usually results from tears in veins that cross the [[subdural space]]. This bleeding often separates the dura and the arachnoid layers. Subdural hemorrhages may cause an increase in [[intracranial pressure]] (ICP), which can cause compression of and damage to delicate brain tissue. Acute subdural hematoma (ASDH) has a high mortality rate and is a severe [[medical emergency]]. As such, it has become a recurring plot device on current medical dramas such as the television series [[House (TV series)|House]].

==Causes==
Subdural hematomas are most often caused by [[head injury]], when rapidly changing [[velocity|velocities]] within the [[skull]] may stretch and tear small bridging [[vein]]s. Subdural hematomas due to head injury are described as [[Physical trauma|traumatic]]. Much more common than [[epidural hemorrhage]]s, subdural hemorrhages generally result from [[shearing injury|shearing injuries]] due to rotational or linear forces (University of Vermont; Wagner, 2004).

==Signs and symptoms==
Symptoms of subdural hemorrhage have a slower onset than those of [[epidural hemorrhage]]s because the lower pressure veins bleed more slowly than arteries. Thus, signs and symptoms may show up within 24 hours but can be delayed as much as 2 weeks (Sanders and McKenna, 2001). If the bleeds are large enough to put pressure on the brain, signs of increased [[intracranial pressure|ICP]] or damage to part of the brain will be present (Wagner, 2004).

Other [[signs]] and [[symptom]]s of subdural hematoma include the following:

* A history of recent [[head injury]]
* Loss of [[consciousness]] or fluctuating levels of consciousness
* [[Seizures]]
* [[Numbness]]
* [[Headache]] (either constant or fluctuating)
* [[Dizziness]]
* [[Disorientation]]
* [[Amnesia]]
* Weakness or [[lethargy]]
* [[Nausea]] or [[vomit|vomiting]]
* Personality changes
* [[Dysphasia|Inability to speak]] or [[dysarthria|slurred speech]]
* [[Ataxia]], or difficulty walking
* Altered breathing patterns
* [[Deviated gaze]], or abnormal movement of the eyes (Wagner, 2004).

==Features==
Most of the time, subdural hematomas occur around the tops and sides of the [[frontal lobe|frontal]] and [[parietal lobe]]s (University of Vermont; Wagner, 2004). They also occur in the posterior [[fossa]], and near the [[falx cerebri]] and [[tentorium]] (Wagner, 2004). Unlike [[epidural hematoma]]s, which cannot expand past the [[skull suture|sutures of the skull]], subdural hematomas can expand along the inside of the skull, creating a convex shape that follows the curve of the brain, stopping only at the [[dural reflection]]s like the tentorium and falx cerebri.

On a [[CT scan]], subdural hematomas have a crescentic shape, with a concave surface away from the skull. Unlike [[epidural hematoma]]s, subdural bleeds can cross [[skull suture]]s, so they can spread along the inside of the skull. Subdural blood can also be seen as a layering density along the [[tentorium cerebelli]]. This can be a chronic, stable process, since the feeding system is low-pressure. In such cases, subtle signs of bleeding such as effacement of [[sulcus (anatomy)|sulci]] or medial displacement of the junction between [[gray matter]] and [[white matter]] may be apparent. A chronic bleed can be the same density as brain tissue (called [[isodense]] to brain), meaning that it will show up on CT scan as the same shade as brain tissue, potentially obscuring the finding.

==Subtypes==
Subdural hematomas are divided into [[acute]], subacute, and [[chronic (medicine)|chronic]], depending on their speed of onset. Acute subdural hematomas that are due to trauma are the most lethal of all head injuries and have a high [[mortality rate]] if they are not rapidly treated with surgical decompression.

Acute bleeds develop after high speed acceleration or deceleration injuries and are increasingly severe with larger hematomas. They are most severe if associated with [[cerebral contusion]]s (Wagner, 2004). Though much faster than chronic subdural bleeds, acute subdural bleeding is usually venous and therefore slower than the usually arterial bleeding of an [[epidural hemorrhage]]. Acute subdural bleeds have a high mortality rate, higher even than epidural hematomas and [[diffuse brain injury|diffuse brain injuries]], because the velocities necessary to cause them cause other severe injuries as well (Vinas and Pilistis, 2004; National Guideline Clearinghouse, 2005). The mortality rate associated with acute subdural hematoma is around 60 to 80% (Dawodu, 2004).

Chronic subdural bleeds develop over the period of days to weeks, often after minor head trauma, though such a cause is not identifiable in 50% of patients (Downie, 2001). The bleeding from a chronic bleed is slow, probably from repeated minor bleeds, and usually stops by itself (University of Vermont; Graham and Gennareli, 2000). Since these bleeds progress slowly, they present the chance to be stopped before they cause significant damage. Small subdural hematomas, those less than a centimeter wide, have much better outcomes than acute subdural bleeds: in one study, only 22% of patients with chronic subdural bleeds had outcomes worse than "good" or "complete recovery" (Wagner, 2004).

==Pathophysiology==
Collected blood from the subdural bleed may draw in water due to [[osmosis]], causing it to expand, which may compress brain tissue and cause new bleeds by tearing other blood vessels (Downie, 2001). The collected blood may even develop its own membrane (McCaffrey, 2001).

In some subdural bleeds, the [[arachnoid layer]] of the [[meninges]] is torn, and [[cerebrospinal fluid]] (CSF) and blood both expand in the [[intracranial space]], increasing pressure (University of Vermont).

Substances that cause vasoconstriction may be released from the collected material in a subdural hematoma, causing further [[ischemia]] under the site by restricting blood flow to the brain (Graham and Gennareli, 2000). When the brain is denied adequate blood flow, a [[biochemical cascade]] known as the [[ischemic cascade]] is unleashed, and may ultimately lead to brain [[cell (biology)|cell]] death.

The body gradually reabsorbs the clot and replaces it with [[wound healing phases|granulation tissue]].

==Treatment==
It is important that a patient receive medical assessment, including a complete [[neurology|neurological]] examination, after any head trauma. A [[CT scan]] or [[MRI scan]] will usually detect significant subdural hematomas.

Treatment of a subdural hematoma depends on its size and rate of growth. Small subdural hematomas can be managed by careful monitoring until the body heals itself. Large or symptomatic hematomas require a [[craniotomy]], the surgical opening of the [[skull]]. A surgeon then opens the [[dura]], removes the [[blood clot]] with suction or irrigation, and identifies and controls sites of [[bleeding]]. Postoperative complications include increased [[intracranial pressure]], brain [[edema]], new or recurrent [[bleeding]], [[infection]], and [[seizure]].

==Risk factors==
Factors increasing the risk of a subdural hematoma include very young or very old [[senescence|age]]. As the brain shrinks with age, the [[subdural space]] enlarges and the [[vein]]s that traverse the space must travel over a wider distance, making them more vulnerable to tears. This and the fact that the elderly have more brittle veins make chronic subdural bleeds more common in older patients (Downie, 2001). Infants, too, have larger subdural spaces and are more predisposed to subdural bleeds than are young adults (Wagner, 2004).

Other risk factors for subdural bleeds include taking blood thinners ([[anticoagulant]]s), long-term [[alcoholism|alcohol abuse]], and [[dementia]].

==Prevention==
In addition to avoiding risk factors if possible, following safety precautions and wearing [[hard hat]]s, [[helmet]]s, and [[seat belt]]s can prevent serious head injuries.

==See also==
* [[Head injury]]
* [[Traumatic brain injury]]
* [[Intra-axial hemorrhage]]
* [[Extra-axial hemorrhage]]
* [[Epidural hematoma]]
* [[Subarachnoid hematoma]]
* [[Concussion]]
* [[Diffuse axonal injury]]

==References==
# Dawodu S. 2004. [http://www.emedicine.com/pmr/topic212.htm "Traumatic brain injury: Definition, epidemiology, pathophysiology"] Emedicine.com.
# Downie A. 2001. [http://www.radiology.co.uk/srs-x/tutors/cttrauma/tutor.htm "Tutorial: CT in head trauma"]
# Graham DI and Gennareli TA. Chapter 5, "Pathology of brain damage after head injury" Cooper P and Golfinos G. 2000. ''Head Injury'', 4th Ed. Morgan Hill, New York.
# McCaffrey P. 2001. [http://www.csuchico.edu/~pmccaff/syllabi/SPPA336/336unit11.html "The neuroscience on the web series: CMSD 336 neuropathologies of language and cognition."] California State University, Chico.
# [http://www.guideline.gov/summary/summary.aspx?ss=14&doc_id=3122&string= National Guideline Clearinghouse]. 2005. Firstgov.
# Sanders MJ and McKenna K. 2001. ''Mosby’s Paramedic Textbook'', 2nd revised Ed. Chapter 22, "Head and facial trauma." Mosby.
# Surinder KN and Raman K. 2005. [http://www.neurologyindia.com/article.asp?issn=0028-3886;year=2005;volume=53;issue=1;spage=124;epage=124;aulast=Kundra Extracranial redistribution causing rapid spontaneous resolution of acute subdural hematoma]. ''Neuroimage,'' 53(1): 124
# University of Vermont College of Medicine. [http://cats.med.uvm.edu/cats_teachingmod/pathology/path302/np/home/neuroindex.html "Neuropathology: Trauma to the CNS."]
# Wagner AL. 2004. [http://www.emedicine.com/radio/topic664.htm "Subdural hematoma."] Emedicine.com.

==External links==
[http://www.biaq.com.au Broad range of downloadable fact sheets on brain injury]

{{Template:Cerebral hemorrhage}}
[[Category:Neurotrauma]]

[[ja:硬膜下血腫]]
[[no:Subduralt hematom]]

Intracerebral hemorrhage

2006-06-20T05:27:52Z

Quihn: /* External link */

{{DiseaseDisorder infobox |
Name = Intra-axial hemorrhages |
ICD10 = {{ICD10|I|61||i|60}} |
ICD9 = {{ICD9|431}} |
}}
'''Intra-axial hemorrhages''', or '''intra-axial hematomas''', are a subtype of [[intracranial hemorrhage]] that occur within the [[brain]] tissue itself.

Intra-axial hemorrhages are potentially deadly because they can increase [[intracranial pressure]] and crush delicate brain tissue or reduce its blood supply, causing [[ischemia]]. The other category of intracranial hemorrhage is [[extra-axial hemorrhage]], such as [[epidural hematoma|epidural]], [[subdural hematoma|subdural]], and [[subarachnoid hematoma]]s, which all occur within the skull but outside of the brain tissue.

There are two main kinds of intra-axial hemmorrages: intraparenchymal hemorrhage and intraventricular hemorrhages.

==Intraventricular hemorrhage==

Intraventricular hemorrhage (or "IVH") is a bleeding of the [[ventricular system|ventricle]]s, where the [[cerebrospinal fluid]] is normally located.

It is particularly common in infants, especially [[premature]] infants or those of very low birth weight (Annibale and Hill, 2003). Most intraventricular hemorrhages occur in the first 72 hours after birth (Annibale and Hill, 2003).

Intraventricular hemorrhage is rare in adults (Mayfrank et al., 1997) and requires a great deal of force to cause. Thus the hemorrhage usually does not occur without an extensive associated damage, and so the outcome is rarely good (Dawodu, 2004; Vinas and Pilistis, 2004). [[Brain contusion]]s and [[subarachnoid hemorrhage]]s are commonly associated with IVH (LeRoux et al., 1992). The bleeding can involve the [[middle communicating artery]] or the [[posterior communicating artery]]. In both adults and infants, IVH can cause dangerous increases in [[intracranial pressure]], damage to the brain tissue, and [[hydrocephalus]] (Mayfrank et al., 1997; Annibale and Hill, 2003).

==Intraparenchymal hemorrhage==

Intraparenchymal hemorrhage, or intracerebral hemorrhage, another type of intra-axial bleeding, can be caused by [[brain trauma]], or it can occur spontaneously in [[hemorrhagic stroke]]. As with other types of hemorrhages within the skull, intraparenchymal bleeds are a serious [[medical emergency]] because they can increase [[intracranial pressure]]. The mortality rate for intraparenchymal bleeds is over 40% (Sanders and McKenna, 2001).

More common in adults than in children, intraparenchymal bleeds are usually due to penetrating [[head trauma|trauma]], but can also be due to depressed [[skull fracture]]s, [[acceleration-deceleration trauma]] (McCaffrey, 2001; Orlando Regional Healthcare, 2004; Shepherd, 2004), rupture of an [[aneurysm]] or [[arteriovenous malformation]] (AVM), and bleeding within a [[tumor]].

The risk of death from an intraparenchymal bleed is especially high when the injury occurs in the [[brain stem]] (Sanders and McKenna, 2001). Intraparenchymal bleeds within the [[medulla]] are almost always fatal, because they cause damage to cranial nerve X, the [[vagus nerve]], which plays an important role in [[blood circulation]] and breathing (McCaffrey, 2001). This kind of hemorrhage can also occur in the [[cortex]] or subcortical areas, usually in the [[frontal lobe|frontal]] or [[temporal lobe]]s when due to head injury, and sometimes in the [[cerebellum]] (McCaffrey, 2001; Graham and Gennareli, 2000).

Patients with intraparenchymal bleeds have symptoms that correspond to the functions controlled by the area of the brain that is damaged by the bleed (Vinas and Pilistis, 2004). Other symptoms include those that indicate a rise in [[intracranial pressure]] due to a large mass putting pressure on the brain (Vinas and Pilistis, 2004).

Intraparenchymal hemorrhage can be recognized on [[CT scan]]s because blood appears brighter than other tissue and is separated from the inner table of the skull by brain tissue. The tissue surrounding a bleed is often less dense than the rest of the brain due to edema, and therefore shows up lighter on the CT scan.

===Subtypes===
Intracerebral hematomas that occur slowly over the course of hours or days are called delayed intracerebral hematomas. These can occur in [[brain contusion]]s or in areas in which no abnormality was found in CT scans (Vinas and Pilistis, 2004). These patients appear normal after trauma and then suddenly their condition deteriorates (Vinas and Pilistis, 2004).

An intracerebral hemorrhage continuous with subdural hemorrhage is called a [[burst lobe]].

==See also==
* [[Traumatic brain injury]]
* [[Intracranial hemorrhage]]
* [[Extra-axial hematoma]]
:* [[Subdural hematoma]]
:* [[Epidural hematoma]]
:* [[Subarachnoid hemorrhage]]

==External links==
* [http://www.lpch.org/DiseaseHealthInfo/HealthLibrary/neuro/ivh.html LPCH on Intraventricular]
* [http://www.biaq.com.au Broad range of fact sheets on brain injury]

==References==
#Annibale DJ and Hill J. 2003. [http://www.emedicine.com/ped/topic2595.htm Periventricular Hemorrhage-Intraventricular Hemorrhage]. Emedicine.com.
# Dawodu S. 2004. [http://www.emedicine.com/pmr/topic212.htm "Traumatic Brain Injury: Definition, Epidemiology, Pathophysiology"] Emedicine.com.
# Graham DI and Gennareli TA. Chapter 5, "Pathology of Brain Damage After Head Injury" Cooper P and Golfinos G. 2000. ''Head Injury'', 4th Ed. Morgan Hill, New York.
# LeRoux PD, Haglund MM, Newell DW, Grady MS, and Winn HR. 1992. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1407453&dopt=Abstract "Intraventricular hemorrhage in blunt head trauma: an analysis of 43 cases."] ''Neurosurgery''. Volume 4, pp. 678-84. Abstract available.
# Mayfrank L, Kissler J, Raoofi R, Delsing P, Weis J, Kuker W, and Gilsbach JM. 1997. [http://stroke.ahajournals.org/cgi/content/full/28/1/141 Ventricular Dilatation in Experimental Intraventricular Hemorrhage in Pigs: Characterization of Cerebrospinal Fluid Dynamics and the Effects of Fibrinolytic Treatment]. ''Stroke'', 28:141-148. Full text article available.
# McCaffrey P. 2001. [http://www.csuchico.edu/~pmccaff/syllabi/SPPA336/336unit11.html "The Neuroscience on the Web Series: CMSD 336 Neuropathologies of Language and Cognition."] California State University, Chico.
# Orlando Regional Healthcare, Education and Development. 2004. [http://www.orhs.org/classes/nursing/TBI_04.pdf "Overview of Adult Traumatic Brain Injuries."]
# Sanders MJ and McKenna K. 2001. Mosby’s Paramedic Textbook, 2nd revised Ed. Chapter 22, "Head and Facial Trauma." Mosby.
# Shepherd S. 2004. [http://www.emedicine.com/med/topic2820.htm "Head Trauma."] Emedicine.com.
# Vinas FC and Pilitsis J. 2004. [http://www.emedicine.com/med/topic2888.htm "Penetrating Head Trauma."] Emedicine.com.
# Wagner A.L. 2004. [http://www.emedicine.com/radio/topic664.htm "Subdural Hematoma."] Emedicine.com.

[[Category:Neurotrauma]]

{{neuroscience-stub}}

[[de:Intracerebrale Blutung]]

Intracranial hemorrhage

2006-06-20T05:26:54Z

Quihn: /* References */

{{DiseaseDisorder infobox |
Name = Intracranial hemorrhage |
ICD10 = I60-I62, S06 |
ICD9 = {{ICD9|430}}-{{ICD9|432}}, {{ICD9|850}}-{{ICD9|854}} |
}}
An '''intracranial hemorrhage''' is a [[hemorrhage]], or bleeding, within the [[skull]]. Intracranial bleeding occurs when a [[blood vessel]] in the head is ruptured or leaks. It can result from [[physical trauma]] (as occurs in [[head injury]]) or nontraumatic causes (as occurs in [[hemorrhagic stroke]]) such as a ruptured [[aneurysm]] (ballooning [[blood vessel]]).

Intracranial hemorrhage is a serious [[medical emergency]] because the buildup of [[blood]] within the skull can lead to increases in [[intracranial pressure]], which can crush delicate brain tissue or limit its blood supply. Intracranial bleeds with a lot of bleeding are more dangerous than those with not as much blood.

CAT scan ([[computed axial tomography]]) is the definitive tool for accurate diagnosis of an intracranial hemorrhage.

Types of intracranial hemorrhage are roughly grouped into intra-axial and extra-axial.

==Intra-axial hemorrhage==
[[Intra-axial hemorrhage]] is bleeding within the brain itself. This category includes [[Intraparenchymal hemorrhage]], or bleeding within the brain tissue, and [[intraventricular hemorrhage]], bleeding within the brain's [[ventricular system|ventricle]]s (particularly of [[Premature birth|premature infants]]).

==Extra-axial hemorrhage==
[[Extra-axial hemorrhage]], bleeding that occurs within the skull but outside of the brain tissue, falls into three subtypes:
*[[Extradural hemorrhage]] is caused by trauma, and results from laceration of an artery, most commonly the [[middle meningeal artery]]. This is a very dangerous type of injury because the bleed is from a high-pressure system and deadly increases in [[intracranial pressure]] can result rapidly.
*[[Subdural hemorrhage]] results from tearing of the bridging veins in the [[subdural space]] between the [[dura mater|dura]] and [[arachnoid mater]].
*[[Subarachnoid hemorrage]], like intraparenchymal hemorrhage, can result either from trauma or from ruptures of [[aneurysm]]s or [[arteriovenous malformation]]s. Blood is seen layering into the brain along sulci and fissures, or filling cisterns (most often the suprasellar cistern because of the presence of the vessels of the [[circle of Willis]] and their branchpoints within that space). The classic presentation of subarachnoid hemorrhage is the sudden onset of a severe headache. This can be a very dangerous entity, and requires emergent neurosurgical evaluation, and sometimes urgent intervention.

==References==
# Graham DI and Gennareli TA. Chapter 5, "Pathology of Brain Damage After Head Injury" Cooper P and Golfinos G. 2000. ''Head Injury'', 4th Ed. Morgan Hill, New York.
# McCaffrey P. 2001. [http://www.csuchico.edu/~pmccaff/syllabi/SPPA336/336unit11.html "The Neuroscience on the Web Series: CMSD 336 Neuropathologies of Language and Cognition."] California State University, Chico.
# Orlando Regional Healthcare, Education and Development. 2004. [http://www.orhs.org/classes/nursing/TBI_04.pdf "Overview of Adult Traumatic Brain Injuries."]
# Shepherd S. 2004. [http://www.emedicine.com/med/topic2820.htm "Head Trauma."] Emedicine.com.
# Vinas FC and Pilitsis J. 2004. [http://www.emedicine.com/med/topic2888.htm "Penetrating Head Trauma."] Emedicine.com.

==External links==
[http://www.biaq.com.au Broad range of fact sheets on brain injury]

{{Template:Cerebral hemorrhage}}
[[Category:Neurotrauma]]

Cerebral contusion

2006-06-20T05:25:26Z

Quihn: /* References */

'''Cerebral contusion''', latin ''contusio cerebri'', a form of traumatic [[brain injury]], is a [[bruise]] of the brain tissue. Like bruises in other tissues, cerebral contusion can be caused by multiple [[microhemorrhage]]s, small [[blood vessel]] leaks into brain tissue. Head [[CT scan]]s of [[unconsciousness|unconscious]] patients reveal that 20% have [[hemorrhage|hemorrhagic]] contusion (Downie, 2001).

==Causes==
Often caused by a blow to the head, contusions commonly occur in coup or [[contrecoup]] injuries. They occur primarily in the [[cerebral cortex|cortical]] tissue, especially under the site of impact or in areas of the brain located near sharp ridges on the inside of the skull. When, after impact, the brain moves over the sharp protrusions that exist on the base of the skull (Shepherd, 2004), these ridges can cut delicate brain tissue. The protuberances are located on the inside of the skull under the [[frontal lobe|frontal]] and [[temporal lobe]]s and on the roof of the [[orbit (anatomy)|ocular orbit]] (Shepherd, 2004). Thus, the tips of the frontal and temporal lobes located near the bony ridges in the skull are areas where contusions frequently occur (Boone and de Montfort, 2002) and are most severe (Graham and Gennareli, 2000). For this reason, attention, emotional and memory problems, which are associated with damage to frontal and temporal lobes, are much more common in [[head trauma]] survivors than are syndromes associated with damage to other areas of the brain (Bigler, 2000).

==Features==
Contusions, which are frequently associated with edema, are especially likely to cause increases in [[intracranial pressure]] (ICP) and concomitant crushing of delicate brain tissue. Contusions are also more likely to result in hemorrhage than is [[diffuse axonal injury]] because they occur more often in the cortex, an area with more [[blood vessel]]s (GE Healthcare, 2004).

Contusions typically form in a wedge-shape with the widest part in the outermost part of the brain (Vinas and Pilistis, 2004).

==Multiple petechial hemorrhages==
Numerous small contusions from broken capillaries that occur in grey matter under the cortex are called [[multiple petechial hemorrhage]]s or [[multifocal hemorrhagic contusion]] (GE Healthcare, 2004). Caused by [[shearing injury|shearing injuries]] at the time of impact, these contusions occur especially at the junction between grey and white matter and in the upper [[brain stem]], [[basal ganglia]], [[thalamus]] and areas near the third [[ventricular system|ventricle]] (GE Healthcare, 2004; Downie, 2001). The hemorrhages can occur as the result of [[brain herniation]], which can cause arteries to tear and bleed (GE Healthcare, 2004). A type of [[diffuse brain injury]], multiple petechial hemorrhages are not always visible using current imaging techniques like CT and [[MRI]] scans. This may be the case even if the injury is quite severe, though these may show up days after the injury (Downie, 2001). Hemorrhages may be larger than in normal contusions if the injury is quite severe. This type of injury has a poor prognosis if the patient is [[coma]]tose, even with no apparent causes for the coma (Downie, 2001).

==Cerebral lacerations==
[[Cerebral laceration]]s, related to contusions, occur when the [[pia mater|pia]] or [[arachnoid membrane]]s are cut or torn (Vinas and Pilistis, 2004). Frequently associated with [[skull fracture]]s, [[laceration]]s involve a tearing of cortical tissue.

==Outcome==
Contusions are likely to heal on their own without medical intervention (Sanders and McKenna, 2001).

==See also==
* [[Traumatic brain injury]]
* [[Brain damage]]
* [[Focal brain injury]]
* [[Concussion]]
* [[Diffuse axonal injury]]
* [[Intracranial hemorrhage]]
* [[Epidural hematoma]]
* [[Subdural hematoma]]
* [[Subarachnoid hemorrhage]]
* [[intraparenchymal hematoma]]

==References==
*Downie A. 2001. [http://www.radiology.co.uk/srs-x/tutors/cttrauma/tutor.htm "Tutorial: CT in Head Trauma"]
*GE Healthcare. 2004. [http://www.amershamhealth.com/medcyclopaedia/medical/volume%20VI%201/BRAIN%20INJURY%20TRAUMATIC.ASP "Brain injury, traumatic."] The Encyclopedia of Medical Imaging. Amershamhealth.com. Volume VI:1. GE Company.
*Graham DI and Gennareli TA. Chapter 5, "Pathology of Brain Damage After Head Injury" Cooper P and Golfinos G. 2000. ''Head Injury'', 4th Ed. Morgan Hill, New York.
# Shepherd S. 2004. [http://www.emedicine.com/med/topic2820.htm "Head Trauma."] Emedicine.com.
# Vinas FC and Pilitsis J. 2004. [http://www.emedicine.com/med/topic2888.htm "Penetrating Head Trauma."] Emedicine.com.

==External links==
[http://www.biaq.com.au Broad range of fact sheets on brain injury]

[[Category:Neurotrauma]]
[[ja:脳挫傷]]

Concussion

2006-06-20T05:24:25Z

Quihn: /* References */

{{DiseaseDisorder infobox |
Name = Concussion of the brain |
ICD10 = S06.0 |
ICD9 = {{ICD9|850}} |
}}
'''Concussion''', or '''mild traumatic brain injury''' ('''MTBI'''), is the most common and least serious type of [[traumatic brain injury]]. A milder type of [[diffuse axonal injury]], concussion involves a transient loss of mental function. It can be caused by [[acceleration]] or deceleration forces, or by a direct blow. Concussion is generally not associated with [[penetrating head trauma|penetrating injuries]].

==Pathophysiology==
The [[brain]] floats within the [[skull]] surrounded by [[cerebrospinal fluid]] (CSF), one of the functions of which is to cushion the brain from light bounces of everyday movement. However, the fluid may not be able to absorb the [[force]] of a sudden hard blow or a quick stop.

Concussion is considered a type of [[diffuse brain injury|diffuse]], as opposed to [[focal brain injury|focal]], brain injury, meaning that the dysfunction occurs over a more widespread area of the brain.

Excitatory [[neurotransmitter]]s are released as the result of the traumatic [[injury]] and cause the brain to enter a state of hypermetabolism which can last for 7 to 10 days (Orlando Regional Healthcare, 2004). During this time, the brain needs extra nutrients and is especially sensitive to inadequate blood flow.

Areas of the brain whose function is commonly disturbed in concussion include the [[reticular formation]] or the deep structures of the brain, the [[brainstem]] or [[Cerebral cortex|cortices]] (Dawodu, 2004). Damage to cranial nerves and other white matter tracts may be temporary or permanent (BIAUSA). Other theories hold that concussion is a diffuse injury affecting all parts of the brain, caused by [[physical trauma]] that alters [[neuron]]al [[metabolism]] and excitability through molecular commotion. Having a concussion does not mean that the patient does not have another brain injury as well; in fact, concussion almost always accompanies more serious brain trauma (University of Vermont).

==Symptoms==
Symptoms of concussion can include a period of unconsciousness for less than 30 minutes (Smith and Greenwald, 2003), vomiting, confusion, and visual disturbances. [[Amnesia]], the hallmark sign of concussion, can be retrograde amnesia (loss of memories that were formed before the injury) or anterograde amnesia (loss of memories formed post-injury) (Orlando Regional Healthcare, 2004). Patients with concussion may act confused, for example repeating the same sentences or forgetting where they are. Patients with concussion may have [[focal neurological deficit]]s, signs that a specific part of the brain is not working correctly (Boone and De Montfort, 2002).

Since concussions do not include damage to the brain's structure, the condition of patients with uncomplicated concussions always either improves or stay the same. Thus, a deteriorating level of consciousness means that the patient has another problem such as a worse type of head injury. Similarly, persistent vomiting, worsening headache, and increasing disorientation are all indicative of a rise in [[intracranial pressure]] (ICP) (Bernhardt, 2004).

==Grades==
Concussion is classified into five grades, with the mildest, grade I, involving only confusion (Shepherd, 2004). Grade II involves anterograde amnesia that lasts less than five minutes as well as confusion, and grade III involves those symptoms plus retrograde amnesia and unconsciousness for less than five minutes (Shepherd, 2004). Grades IV and V include those symptoms with unconsciousness that lasts between 5 and 10 minutes and longer than 10 minutes respectively (Shepherd, 2004).

==Lasting effects==
Some concussions can have serious, lasting effects. The symptoms of most concussions are resolved in 48 to 72 hours, but in many patients, problems persist (Tolias and Sgouros, 2003; Shepherd, 2004). In [[postconcussive syndrome]] (PCS), concussion symptoms do not resolve for weeks, months, or even years, and the patient may have headaches, light and sound sensitivity, memory and attention problems, dizziness, difficulty with directed movements, depression, and anxiety. Symptoms usually peak 4 to 6 weeks after the concussion, but may go on longer, some even lasting a year or more (Shepherd, 2004). Children commonly experience more severe symptoms of postconcussion syndrome than adults do (Shepherd, 2004). Physical therapy plus rest is the best recovery technique, and symptoms usually go away on their own.

Multiple small head injuries that daze the patient can also result in cognitive and physical deficits that occur in what is commonly known as [[dementia pugilistica]], or "punch drunk" syndrome, which is associated with boxers (Drake and Cifu, 2004).

==Second Impact Syndrome==
If a patient receives a second blow days or weeks after a concussion, before concussion symptoms have gone away, they are at risk of developing Second Impact Syndrome (SIS) or recurrent traumatic brain injury. In this rare condition, the brain swells dangerously after a minor blow. No one is certain of the cause of this often fatal complication, but some think the swelling is due to the brain's [[arteriole]]s' loss of ability to regulate their [[diameter]], and therefore a loss of control over [[cerebral blood flow]] (Tolias and Sgouros, 2003).

In this dangerous condition, intracranial pressure rapidly rises, the brain can [[brain herniation|herniate]], and brainstem failure can occur within five minutes (Drake and Cifu, 2004). When this condition occurs, [[surgery]] does not help and there is little hope for recovery (Tolias and Sgouros, 2003). When it is not fatal, the patient can experience persistent [[muscle spasm]]s and tenseness, emotional instability, [[hallucination]]s, and cognitive problems (BAIUSA). The condition is fairly rare, with only 35 recorded cases in a 13 year period from football injuries, not all of which were confirmed to be due to SIS (Drake and Cifu, 2004).



==See also==
* [[Head injury]]

==External links==
[http://www.biaq.com.au Broad range of fact sheets on brain injury]

==References==
# Bernhardt D. 2004. [http://www.emedicine.com/sports/topic27.htm "Concussion."] Emedicine.com. Available.
# Boon R and de Montfor GJ. 2002. [http://home.iprimus.com.au/rboon/BrainInjury.htm "Brain Injury."] Learning Discoveries Psychological Services. Learningdiscoveries.org.
# Brain Injury Association of America (BIAUSA). [http://www.biausa.org/Pages/types_of_brain_injury.html#diffuse "Types of Brain Injury."]
# Dawodu S. 2004. [http://www.emedicine.com/pmr/topic212.htm "Traumatic Brain Injury: Definition, Epidemiology, Pathophysiology"] Emedicine.com.
# Drake D and Cifu D. 2004. [http://www.emedicine.com/sports/topic113.htm "Repetitive Head Injury Syndrome."] Emedicine.com.
# Graham DI and Gennareli TA. Chapter 5, "Pathology of Brain Damage After Head Injury" In, Cooper P and Golfinos G. 2000. Head Injury, 4th Ed. Morgan Hill, New York.
# NCERx. 2005. [http://www.about-dementia.com/dementia/brain-trauma.php Brain Trauma, Subdural Hematoma and Dementia Pugilistica]. About-dementia.com.
# Orlando Regional Healthcare, Education and Development. 2004. [http://www.orhs.org/classes/nursing/TBI_04.pdf "Overview of Adult Traumatic Brain Injuries."]
# Shepherd S. 2004. [http://www.emedicine.com/med/topic2820.htm "Head Trauma."] Emedicine.com.
# Tolias C and Sgouros S. 2003. [http://www.emedicine.com/med/topic3216.htm "Initial Evaluation and Management of CNS Injury."]
# University of Vermont College of Medicine. [http://cats.med.uvm.edu/cats_teachingmod/pathology/path302/np/home/neuroindex.html "Neuropathology: Trauma to the CNS."]

[[Category:Neurotrauma]]

[[he:זעזוע מוח]]
[[fi:Aivotärähdys]]
[[sv:Hjärnskakning]]
[[de:Gehirnerschütterung]]

Coma

2006-06-20T05:22:37Z

Quihn: /* References */

:''For other meanings of the word "coma", especially in [[astronomy]], see [[coma (disambiguation)]]''

{{SignSymptom infobox |
Name = Coma |
ICD10 = R40.2 |
ICD9 = {{ICD9|780.01}} |
}}

In [[medicine]], a '''coma''' (from the [[Greek language|Greek]] ''koma'', meaning deep sleep) is a profound state of [[unconsciousness]]. A comatose patient cannot be awakened, fails to respond normally to pain or light, does not have sleep-wake cycles, and does not take voluntary actions. Coma may result from a variety of conditions, including [[intoxication]], [[metabolism|metabolic]] abnormalities, central nervous system diseases, acute neurologic injuries such as [[stroke]], and [[Hypoxia (medical)|hypoxia]].

==Contrasts to other conditions==
Some conditions share characteristics with coma and must be ruled out in a [[differential diagnosis]] before coma is conclusively diagnosed. These include [[locked-in syndrome]], [[akinetic mutism]] and [[catatonic stupor]].

The difference between coma and [[stupor]] is that a patient with coma cannot give a suitable response to either noxious or verbal stimuli, whereas a patient in a stupor can give a crude response, such as screaming, to an unpleasant stimulus.

Some psychiatric diseases appear similar to coma. Some forms of [[schizophrenia]], [[catatonia]], and extremely severe [[major depression]] are responsibile for behaviour that appears comatose.

Coma is also to be distinguished from the [[persistent vegetative state]] which may follow it. This is a condition in which the individual has lost cognitive neurological function and awareness of the environment but does have noncognitive function and a preserved sleep-wake cycle. Spontaneous movements may occur and the [[eye]]s may open in response to external stimuli, but the patient does not speak or obey commands. Patients in a vegetative state may appear somewhat normal and may occasionally grimace, cry, or laugh.

Likewise, coma is not the same as [[brain death]], which is the irreversible cessation of ''all'' brain activity. One can be in a coma but still exhibit spontaneous [[Respiration (physiology)|respiration]]; one who is brain-dead, by definition, cannot.

Coma is different from [[sleep]]; sleep is always reversible.

==Outcome==
There are several levels of coma, through which patients may or may not progress. As coma deepens, responsiveness of the brain lessens, normal reflexes are lost, and the patient no longer responds to pain. The chances of recovery depend on the severity of the underlying cause. A deeper coma alone does not necessarily mean a slimmer chance of recovery, because some people in deep coma recover well while others in a so-called milder coma sometimes fail to improve.

The outcome for coma and vegetative state depends on the cause, location, severity and extent of neurological damage: outcomes range from recovery to [[death]]. People may emerge from a coma with a combination of physical, intellectual and psychological difficulties that need special attention. Recovery usually occurs gradually, with patients acquiring more and more ability to respond. Some patients never progress beyond very basic responses, but many recover full awareness. Gaining consciousness again is not instant: in the first days, patients are only awake for a few minutes, and duration of time awake gradually increases.

Comas generally last a few days to a few weeks, and rarely last more than 2 to 4 weeks. After this time, some patients gradually come out of the coma, some progress to a [[Persistent vegetative state|vegetative state]], and others die. Many patients who have gone into a vegetative state go on to regain a degree of awareness. Others may remain in a vegetative state for years or even decades. Predicted chances of recovery are variable due to different techniques used to measure the extent of neurological damage. All the predictions are [[statistical]] rates with some level of chance for recovery present: a person with a low chance of recovery may still awaken. Time is the best general predictor of a chance for recovery, with the chances for recovery after 3 months of [[brain damage]] induced coma being low (less than 10%), and full recovery being very low. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15118882&query_hl=5] [http://www.braininjury.com/coma.html]

The most common cause of death for a person in a vegetative state is secondary [[infection]] such as [[pneumonia]] which can occur in patients who lie still for extended periods.

==Records==

According to the [[Guinness Book of Records]], the longest period of time one spent in a coma was by [[Elaine Esposito]]. She never woke up after being anaesthetized for an appendectomy on August 6, 1941, when aged 6. She died aged 43 years 357 days, having been in a coma for 37 years 111 days.

==Controversy==
There have been controversies and legal cases over whether to keep comatose patients alive for long periods using [[life support|life support equipment]]. Two such cases are those of [[Karen Ann Quinlan]] and [[Terri Schiavo]]. However, these individuals were not in a ''coma'' per se but were in a ''[[persistent vegetative state]]''.

==Diagnosis and treatment==
Diagnosis has the following steps:
Medical History, Physical Exam & Neurological Evaluation, Eye Examination, Laboratory Tests, Imaging Studies(CT,MRI), EEG.

The [[Glasgow Coma Scale]] is used to quantify the severity of a coma. There are three components to the score: '''E'''ye opening response, '''V'''erbal response, and '''M'''otor response.

In Germany, music therapy is used to attempt to arouse patients from coma.

In Belgium a project is being set up to train dogs and cats to warn patients and medical staff that a coma patient has awakened.

==External links==
* [http://www.biaq.com.au Comprehensive range of fact sheets on brain injury]

==References==
* Brain Injury Association of America (BIAUSA). [http://www.biausa.org/Pages/types_of_brain_injury.html#diffuse Types of Brain Injury].
* ''This article contains text from the NINDS public domain pages on TBI at:''
#http://www.ninds.nih.gov/health_and_medical/disorders/tbi_doc.htm
#http://www.ninds.nih.gov/health_and_medical/pubs/tbi.htm
* Some of the information in this section is from the [[public domain resource]] provided by the [http://www.ninds.nih.gov/health_and_medical/disorders/coma_doc.htm National Institute of Neurological Diseases and Stroke].

[[Category:Neurology]]
[[Category:Intensive care medicine]]
[[Category:Emergency medicine]]

[[bs:Koma]]
[[da:Koma]]
[[de:Koma (Medizin)]]
[[es:Coma (medicina)]]
[[eo:Komato]]
[[fr:Coma]]
[[hr:Koma (medicina)]]
[[it:Coma]]
[[he:תרדמת]]
[[ja:昏睡]]
[[nl:Coma (geneeskunde)]]
[[no:Koma]]
[[pl:Śpiączka]]
[[pt:Coma]]
[[ru:Кома (медицина)]]
[[sk:Kóma]]
[[fi:Kooma]]
[[sv:Koma]]

Head injury

2006-06-20T05:20:57Z

Quihn: /* External Links */

{{DiseaseDisorder infobox |
Name = Head injury |
ICD10 = S00.0–S09.9 |
ICD9 = {{ICD9|800}}-{{ICD9|879}} |
}}
'''Head injury''' is a [[trauma]] to the [[head (anatomy)|head]], that may or may not include injury to the [[human brain|brain]] (see also [[brain injury]]).

The [[incidence (epidemiology)|incidence]] (number of new cases) of head injury is 300 per 100,000 per year (0.3% of the population), with a mortality of 25 per 100,000 in [[North America]] and 9 per 100,000 in [[Britain]].

== Head Trauma ==
Head trauma is a common cause of childhood hospitalization.
Serious head trauma is usually secondary to motor vehicle accidents, sports, recreation, and violence.
Presentation varies according to the injury.
A patient may present with neurologic deficit or without neurologic deficit.
Some patients with head trauma may stabilize and other patients may deteriorate.
Children with neurologic deficits may have a history of a lucid interval and relapse into coma, or they may have remained abnormal after the injury.
The physical examination will vary according to the injury.
Some patients may have linear or depressed skull fractures.
Basilar skull fractures are associated with battle sign, a subcutaneous bleed over the mastoid, hemotympanum, and cerebrospinal fluid rhinorrhea and otorrhea.
Cerebral concussion is the most common head injury seen in children.
Patients with concussion may have a history of brief seconds to minutes unconsciousness, then normal arousal.
Disturbance of vision and equilibrium may also occur.

Concussion can be divided into three grades and recommendations if asymptomatic for 1 week:

* In grade I, the patient has confusion only and may return to contact sports in 20 minutes.
* In grade II, the patient has amnesia and confusion and may return to contact sports in 1 week.
* In grade III, the patient has loss of consciousness, amnesia, and confusion and may return to contact sports in 1 month.

* A second time grade 1 concussion may return to play contact sports in 2 weeks after being asymptomatic for a week.
* A second time grade II may return to play contact sports 1 month after being asymptomatic for a week.
* A second time grade III the season is over.

However, if the patient has repeated concussions after contact sports, grade I x 3, grade II x 2, and especially grade III x 2, then it should be recommended that the season is over and a thorough medical evaluation should be considered mandatory.

==Causes==
Common causes of head injury are [[motor vehicle accident|traffic accident]]s, home and occupational accidents, falls, and assaults. Contrary to public opinion, riding a bicycle is actually very safe and is a small cause of head injury.

==Types of Head Injuries==
Head injuries include both injuries to the brain and those to other parts of the head, such as the [[scalp]] and [[skull]].

Head injuries may be closed or open. A closed (non-missile) head injury is one in which the skull is not broken. A [[penetrating head injury]] occurs when an object pierces the skull and breaches the [[dura mater]]. Brain injuries may be [[diffuse brain injury|diffuse]], occurring over a wide area, or focal, located in a small, specific area.

A head injury may cause a [[skull fracture]], which may or may not be associated with injury to the brain.

If intracranial [[hemorrhage]], or [[intracranial hemorrhage|bleeding within the brain]] occurs, a [[hematoma]] within the skull can put pressure on the brain. Types of [[intracranial hematoma]] include [[subdural hemorrhage|subdural]], [[subarachnoid hemorrhage|subarachnoid]], [[extradural hematoma|extradural]], and [[intraparenchymal hematoma]]. [[Craniotomy]] surgeries are used in these cases to lessen the pressure by draining off blood.

[[Brain injury]] can be at the site of impact, but can also be at the opposite side of the skull due to a ''[[contrecoup]]'' effect (the impact to the head can cause the brain to move within the skull, causing the brain to impact the interior of the skull opposite the head-impact).

If the impact causes the head to move, the injury may be worsened, because the brain may ricochet inside the skull (causing additional impacts), or the brain may stay relatively still (due to inertia) but be hit by the moving skull.

Specific problems after head injury can include:
* Skull fracture
* [[Laceration]]s to the scalp and resulting [[hemorrhage]] of the skin
* Traumatic subdural hematoma, a bleeding below the [[dura mater]] which may develop slowly
* Traumatic extradural, or epidural hematoma, bleeding between the dura mater and the skull
* Traumatic subarachnoid hemorrhage
* [[Cerebral contusion]], a bruise of the brain
* [[Concussion]], a temporary loss of function due to trauma
* [[Dementia pugilistica]], or "punch-drunk syndrome", caused by repetitive head injuries, for example in boxing or other contact sports
* A severe injury may lead to a [[coma]] or [[death]]

==Symptoms==
Common symptoms of head injury include those indicitave of traumatic brain injury:
*[[coma|loss of consciousness]],
*confusion,
*drowsiness,
*personality change,
*[[seizure|seizures]],
*[[nausea]] and [[vomiting]],
*[[headache]],
*a [[lucid interval]], during which a patient appears conscious only to deteriorate later

Symptoms of skull fracture can include:
*leaking [[cerebrospinal fluid]] (a clear fluid drainage from [[nose]], [[mouth]] or [[ear]]) may be and is strongly indicative of [[skull fracture|basilar skull fracture]] and the tearing of sheaths surrounding the brain, which can lead to secondary brain [[infection]].
*visible deformity or depression in the head or face; for example a sunken eye can indicate a [[maxilla]]r fracture
*an eye that cannot move or is deviated to one side can indicate that a broken facial bone is pinching a [[nerve]] that innervates eye muscles
*[[wound]]s or bruises on the scalp or face.

Because brain injuries can be life threatening, even people with apparently slight injuries, with no noticeable signs or complaints, require close observation. The caretakers of those patients with mild trauma who are released from the hospital are frequently advised to rouse the patient several times during the next 12 to 24 hours to assess for worsening symptoms.

The [[Glasgow Coma Scale]] is a tool for measuring degree of unconsciousness and is thus a useful tool for determining severity of injury. The [[Pediatric Glasgow Coma Scale]] is used in young children.

== Mild concussion ==
Mild concussion are not associated with any sequelae.
However, a slightly greater injury can be associated with both anterograde and retrograde amnesia not be able to remember events before or after the injury.
The amount of time that the amnesia is present correlates with the severity of the injury.
In some cases the patients may develop postconcussion syndrome, which includes memory difficulties, dizziness, and depression.

== Epidural hematoma ==
Epidural hematoma is a rapidly accumulating hematoma between the dura and the cranium.
These patients have a history of head trauma with loss of consciousness, then a lucid period, followed by loss of consciousness.
Clinical onset occurs over minutes to hours.
Many of these injuries are associated with lacerations of the middle meningeal artery.
A lenticular extracerebral hemorrhage will be noted on CT of the head.
The need for an operation should be determined by a neurosurgeon.
Although death is a potential complication, the prognosis is good when this injury is recognized and treated.

== Subdural hematoma ==

This occurs when there is tearing of the bridging vein between the cerebral cortex and a draining venous sinus.
At times they may be cause by arterial lacerations on the brain surface.
Patients may have a history of loss of consciouness but they recover and do not relapse.
Clinical onset occurs over hours.
A crescent shaped hemorrhage compressing the brain will be noted on CT of the head.
Surgical evacuation is the treatment.
Complications include uncal herniation, focal neurologic deficits, and death.
The prognosis is guarded.

== Cerebral contussion ==

This is bruising of the brain parenchyma.
The majority of them occur in the frontal and temporal lobes.
Multiple low density areas and punctate hemorrhages will be noted on the CT of the head.
Complications may include cerebral edema and transtentorial herniation.
The goal of treatment should be to treat the increased intracranial pressure.
The prognosis is guarded.

== Diagnosis ==
A CT of the head should be performed on children who have a history of loss of consciousness for
> 1 minute.
A CT of the head should be performed on children for whom the time of LOC is unknown.
A CT of the head should be performed on children with abnormal neurologic findings.
A CT of the head should be performed on those who have a neurologic status that is deteriorating.
Cevical spine films should be obtained on children with head trauma suspected of having an associated neck injury.
Attention should be paid to airway, breathing, and circulation.
Bleeding should be controlled if present.
Head injury may be associated with a neck injury.
Bruises on the back or neck, back pain,painradiating to the arms is a sign of cervical spine injury and should be immobilizied and a cervical collar applied.
It is common for head trauma patients to have drowsiness but easily aroused, headaches, and vomiting after injury.
If exam and consciousness are preserved, this is of no concern.
But if these symptoms persist > 1 or 2 days, a CT of the head should be performed.
In some cases transient neurologic disturbance may occur, lasting minutues to hours and causing occiptal blindness and a state of confusion.
Malignant posttraumatic cerebral swelling can develop unexpectedly in stable patients after an injury, as can postraumatic seizures.
The child with worsening neurologic signs change in level of consciousness, respirations, blood pressure, pulse, seizures) must be suspected of having subarachnoid or subdural bleeding.
Recovery in children with neurologic deficits will vary.
Children with neurologic deficits who improve daily are more likely to recover.
Children who are vegetative for months are less likely to improve.
Most patients without deficits have full recovery.

==External Links==
* [http://www.biaq.com.au Comprehensive range of fact sheets on head injury]
*[http://www.seattlechildrens.org/child_health_safety/health_advice/head_injury.asp What to do if your child has a head injury] from Seattle Children's Hospital
*[http://www.ii.bham.ac.uk/clinicalimmunology/Neuroimmunology/Tau.htm Neuroimmunology, The Medical School, Birmingham University] - '''Abid R Karim, Birmingham UK'''

== See also ==
* [[Skull fracture]]
* [[Brain injury]]
* [[Traumatic brain injury]]
* [[Coma]]
* [[Unconsciousness]]
* [[Diffuse brain injury]]
* [[Concussion of the brain]]
* [[Diffuse axonal injury]]
* [[Focal brain injury]]
* [[Brain contusion]]
* [[Intracranial hemorrhage]]
* [[Hematoma]]
* [[Intra-axial hemorrhage]]
* [[Intraparenchymal hemorrhage]]
* [[Intraventricular hemorrhage]]
* [[Extra-axial hemorrhage]]
* [[Subdural hematoma]]
* [[Epidural hematoma]]
* [[Subarachnoid hemorrhage]]
* [http://www.bikeroute.com/AwakeAgain Awake Again, All the way back from head injury]

[[Category:Neurotrauma]]
[[Category:Injury]]

[[de:Schädel-Hirn-Trauma]]
[[nl:Hersenschudding]]
[[no:Hodeskade]]

Traumatic brain injury

2006-06-20T05:19:07Z

Quihn: /* External links */

{{DiseaseDisorder infobox |
Name = Traumatic brain injury¹ |
ICD10 = S06 |
ICD9 = {{ICD9|800.0}}-{{ICD9|801.9}}, {{ICD9|803.0}}-{{ICD9|804.9}}, {{ICD9|850.0}}-{{ICD9|854.1}} |
}}
'''Traumatic brain injury''' (TBI), traumatic injuries to the [[brain]], also called intracranial injury, or simply head injury, occurs when a sudden trauma causes [[brain damage]]. TBI can result from a closed head injury or a [[penetrating head injury]] and is one of two subsets of [[acquired brain injury]] (ABI). The other subset is non-traumatic brain injury (i.e. stroke, meningitis, anoxia). Parts of the brain that can be damaged include the [[cerebral hemisphere]]s, [[cerebellum]], and [[brain stem]] (see [[brain damage]]).
Symptoms of a TBI can be mild, moderate, or severe, depending on the extent of the damage to the brain. Outcome can be anything from complete recovery to permanent [[disability]] or death.

== Epidemiology ==
'''TBI''' is a major public health problem, especially among males ages 15 to 24, and among elderly people of both sexes 75 years and older. Children aged 5 and younger are also at high risk for TBI.

Each year in the United States:
* approximately 1 million head-injured people are treated in hospital emergency rooms,
* approximately 270,000 people experience a moderate or severe TBI,
* approximately 60,000 new cases of epilepsy occur as a result of head trauma,
* approximately 230,000 people are hospitalized for TBI and survive,
* approximately 80,000 of these survivors live with significant disabilities as a result of the injury, and
* approximately 70,000 people die from head injury.

==Signs and Symptoms of TBI==
Some symptoms are evident immediately, while others do not surface until several days or weeks after the injury.

With '''mild TBI''', the patient may remain conscious or may lose consciousness for a few seconds or minutes. The person may also feel dazed or not like him- or herself for several days or weeks after the initial injury. Other symptoms include:
*[[headache]],
*[[mental confusion]],
*lightheadedness,
*[[dizziness]],
*[[diplopia|double vision]], blurred vision, or tired eyes,
*ringing in the ears,
*bad taste in the mouth,
*fatigue or lethargy,
*a change in [[sleep]] patterns,
*behavioral or [[mood]] changes, and
*trouble with memory, concentration, attention, or thinking
*symptoms remain the same or get better; worsening symtptoms indicate a more severe injury.

With '''moderate or severe TBI''', the patient may show these same symptoms, but may also have:
*loss of consciousness
*personality change
*a severe, persistent, or worsening headache,
*repeated vomiting or nausea,
*[[seizure]]s,
*inability to awaken,
*[[dilation]] (widening) of one or both pupils,
*slurred speech,
*weakness or numbness in the extremities,
*loss of coordination, and/or
*increased confusion, restlessness, or agitation
*vomiting and neurological deficit (e.g. weakness in a limb) together are important indicators of prognosis and their presence may warrant early [[computed axial tomography|CT scanning]] and [[neurosurgery|neurosurgical]] intervention.

Small children with moderate to severe TBI may show some of these signs as well as signs specific to young children, including:
*persistent crying,
*inability to be consoled, and/or
*refusal to nurse or eat.

Anyone with signs of moderate or severe TBI should receive immediate emergency medical attention.

==Causes of and Risk Factors for TBI==
Half of all TBIs are due to [[transportation accident]]s involving [[automobile]]s, [[motorcycle]]s, [[bicycle]]s, and [[pedestrian]]s. These accidents are the major cause of TBI in people under age 75.

For those 75 and older, falls cause the majority of TBIs.

Approximately 20 % of TBIs are due to [[violence]], such as [[firearm assault]]s and [[child abuse]], and about 3 % are due to [[sports injuries]]. Fully half of TBI incidents involve [[alcohol]] use.

==Types of TBI==
The damage from TBI can be [[focal brain injury|focal]], confined to one area of the brain, or [[diffuse brain injury|diffuse]], involving more than one area of the brain. Diffuse trauma to the brain is frequently associated with [[concussion]] (a shaking of the brain in response to sudden motion of the head), [[diffuse axonal injury]], or [[coma]]. Localized injuries may be associated with neurobehavioral manifestations, [[hemiparesis]] or other [[focal neurologic deficit]]s.

Types of focal brain injury include bruising of brain tissue called a [[brain contusion|contusion]] and [[intracranial hemorrhage]] or [[hematoma]], heavy bleeding in the skull. Hemorrhage, due to rupture of a [[blood vessel]] in the head, can be [[extra-axial hemorrhage|extra-axial]], meaning it occurs within the [[skull]] but outside of the brain, or [[intra-axial hemorrhage|intra-axial]], occurring within the brain. Extra-axial hemorrhages can be further divided into [[subdural hematoma]], [[epidural hematoma]], and [[subarachnoid hemorrhage]]. An [[epidural hematoma]] involves bleeding into the area between the skull and the [[dura]]. With a [[subdural hematoma]], bleeding is confined to the area between the dura and the [[arachnoid membrane]]. Bleeding within the brain itself is called [[intracerebral hematoma]]. Intra-axial bleeds are further divided into [[intraparenchymal hemorrhage]] which occurs within the brain tissue itself and [[intraventricular hemorrhage]] which occurs in the [[ventricular system]].

TBI can result from a [[closed head injury]] or a [[penetrating head injury]]. A closed injury occurs when the head suddenly and violently hits an object but the object does not break through the skull. A penetrating injury occurs when an object pierces the skull and enters brain tissue.

As the first line of defense, the [[skull]] is particularly vulnerable to injury. [[Skull fracture]]s occur when the bone of the skull cracks or breaks. A [[depressed skull fracture]] occurs when pieces of the broken skull press into the tissue of the brain. A [[penetrating skull fracture]] occurs when something pierces the skull, such as a bullet, leaving a distinct and localized injury to brain tissue. Skull fractures can cause [[cerebral contusion]].

Another insult to the brain that can cause injury is [[anoxia]]. Anoxia is a condition in which there is an absence of oxygen supply to an organ's tissues, even if there is adequate blood flow to the tissue. [[Hypoxia (medical)|Hypoxia]] refers to a decrease in oxygen supply rather than a complete absence of oxygen, and [[ischemia]] is inadequate blood supply, as is seen in cases in which the [[cerebral edema|brain swells]]. In any of these cases, without adequate oxygen, a [[biochemical cascade]] called the [[ischemic cascade]] is unleashed, and the cells of the brain can die within several minutes. This type of injury is often seen in near-drowning victims, in [[heart attack]] patients, or in people who suffer significant blood loss from other injuries that decrease blood flow to the brain.

==Effects on consciousness==
Generally, there are five abnormal states of consciousness that can result from a TBI: [[stupor]], [[coma]], [[persistent vegetative state]], [[locked-in syndrome]], and [[brain death]].

[[Stupor]] is a state in which the patient is unresponsive but can be aroused briefly by a strong stimulus, such as sharp pain. [[Coma]] is a state in which the patient is totally unconscious, unresponsive, unaware, and unarousable.

Patients in a [[persistent vegetative state]] are unconscious and unaware of their surroundings, but they continue to have a sleep-wake cycle and can have periods of alertness. A vegetative state can result from diffuse injury to the cerebral hemispheres of the brain without damage to the lower brain and brainstem. [[Anoxia]], or lack of oxygen to the brain, which is a common complication of [[cardiac arrest]], can also bring about a vegetative state.

[[Locked-in syndrome]] is a condition in which a patient is aware and awake, but cannot move or communicate due to complete paralysis of the body.

[[Brain death]] is the lack of measurable brain function due to diffuse damage to the cerebral hemispheres and the brainstem, with loss of any integrated activity among distinct areas of the brain. Brain death is irreversible. Removal of assistive devices will result in immediate cardiac arrest and cessation of breathing.

==Complications==
Sometimes, health complications occur in the period immediately following a TBI. These complications are not types of TBI, but are distinct medical problems that arise as a result of the injury. Although complications are rare, the risk increases with the severity of the trauma. Complications of TBI include immediate [[seizure]]s, [[hydrocephalus]] or [[post-traumatic ventricular enlargement]], [[cerebrospinal fluid]] leaks, infections, vascular injuries, [[cranial nerve]] injuries, [[pain]], [[bed sore]]s, [[multiple organ system failure]] in unconscious patients, and [[polytrauma]] (trauma to other parts of the body in addition to the brain).

About 25 % of patients with brain contusions or hematomas and about 50 % of patients with penetrating head injuries will develop immediate seizures, seizures that occur within the first 24 hours of the injury. These immediate seizures increase the risk of early seizures - defined as seizures occurring within 1 week after injury - but do not seem to be linked to the development of [[post-traumatic epilepsy]] (recurrent seizures occurring more than 1 week after the initial trauma). Generally, medical professionals use anticonvulsant medications to treat seizures in TBI patients only if the seizures persist.

Hydrocephalus or post-traumatic ventricular enlargement occurs when [[cerebrospinal fluid]] (CSF) accumulates in the brain resulting in dilation of the cerebral ventricles (cavities in the brain filled with CSF) and an increase in ICP. This condition can develop during the acute stage of TBI or may not appear until later. Generally it occurs within the first year of the injury and is characterized by worsening neurological outcome, impaired consciousness, behavioral changes, ataxia (lack of coordination or balance), incontinence, or signs of elevated ICP. The condition may develop as a result of meningitis, subarachnoid hemorrhage, intracranial hematoma, or other injuries. Treatment includes shunting and draining of CSF as well as any other appropriate treatment for the root cause of the condition.

Skull fractures can tear the membranes that cover the brain, leading to CSF leaks. A tear between the dura and the arachnoid membranes, called a [[CSF fistula]], can cause CSF to leak out of the subarachnoid space into the subdural space; this is called a [[subdural hygroma]]. CSF can also leak from the nose and the ear. These tears that let CSF out of the brain cavity can also allow air and bacteria into the cavity, possibly causing infections such as meningitis. [[Pneumocephalus]] occurs when air enters the [[intracranial cavity]] and becomes trapped in the subarachnoid space.

Infections within the intracranial cavity are a dangerous complication of TBI. They may occur outside of the [[dura mater]], below the dura, below the [[arachnoid mater|arachnoid]] ([[meningitis]]), or within the brain itself ([[abscess]]). Most of these injuries develop within a few weeks of the initial trauma and result from [[skull fracture]]s or penetrating injuries. Standard treatment involves antibiotics and sometimes surgery to remove the infected tissue. Meningitis may be especially dangerous, with the potential to spread to the rest of the brain and nervous system.

Any damage to the head or brain usually results in some damage to the [[vascular system]], which provides [[blood]] to the cells of the brain. The body's [[immune system]] can repair damage to small blood vessels, but damage to larger vessels can result in serious complications. Damage to one of the major arteries leading to the brain can cause a stroke, either through bleeding from the artery ([[hemorrhagic stroke]]) or through the formation of a clot at the site of injury, called a [[thrombus]] or thrombosis, blocking blood flow to the brain ([[ischemic stroke]]). Blood clots also can develop in other parts of the head. Symptoms such as headache, vomiting, seizures, paralysis on one side of the body, and semiconsciousness developing within several days of a head injury may be caused by a blood clot that forms in the tissue of one of the sinuses, or cavities, adjacent to the brain. Thrombotic-ischemic strokes are treated with anticoagulants, while surgery is the preferred treatment for hemorrhagic stroke. Other types of vascular injuries include [[vasospasm]] and the formation of [[aneurysm]]s .

Skull fractures, especially at the base of the skull, can cause cranial nerve injuries that result in [[compressive cranial neuropathy|compressive cranial neuropathies]]. All but three of the 12 cranial nerves project out from the brainstem to the head and face. The [[seventh cranial nerve]], called the [[facial nerve]], is the most commonly injured cranial nerve in TBI and damage to it can result in paralysis of facial muscles.

Pain, especially headache, is commonly a significant complication for conscious patients in the period immediately following a TBI. Serious complications for patients who are unconscious, in a coma, or in a vegetative state include bed or [[pressure sores]] of the skin, recurrent [[bladder infection]]s, [[pneumonia]] or other life-threatening infections, and [[progressive multiple organ failure]].

==General Trauma==
Other medical complications that may accompany a TBI include pulmonary (lung) dysfunction; cardiovascular (heart) dysfunction from [[blunt chest trauma]]; gastrointestinal dysfunction; fluid and hormonal imbalances; and other isolated complications, such as fractures, nerve injuries, [[deep vein thrombosis]], excessive blood clotting, and infections.

Trauma victims often develop [[hypermetabolism]] or an increased metabolic rate, which leads to an increase in the amount of heat the body produces. The body redirects into heat the energy needed to keep organ systems functioning, causing muscle wasting and the starvation of other tissues. Complications related to pulmonary dysfunction can include [[neurogenic pulmonary edema]] (excess fluid in lung tissue), [[aspiration pneumonia]] (pneumonia caused by foreign matter in the lungs), and fat and blood clots in the blood vessels of the lungs.

Fluid and hormonal imbalances can complicate the treatment of hypermetabolism and high ICP. Hormonal problems can result from dysfunction of the [[pituitary]], the [[thyroid]], and other glands throughout the body. Two common hormonal complications of TBI are syndrome of inappropriate secretion of antidiuretic hormone ([[SIADH]]) and [[hypothyroidism]].

==Disabilities Resulting From TBI==
Disabilities resulting from a TBI depend upon the severity of the injury, the location of the injury, and the age and general health of the patient. Some common disabilities include problems with cognition (thinking, memory, and reasoning), sensory processing (sight, hearing, touch, taste, and smell), communication (expression and understanding), and behavior or mental health ([[major depression|depression]], [[anxiety]], personality changes, aggression, acting out, and social inappropriateness).

Within days to weeks of the head injury approximately 40 % of TBI patients develop a host of troubling symptoms collectively called [[postconcussion syndrome]] (PCS). A patient need not have suffered a [[concussion]] or loss of consciousness to develop the syndrome and many patients with mild TBI suffer from PCS. Symptoms include [[headache]], [[dizziness]], memory problems, trouble concentrating, sleeping problems, restlessness, irritability, apathy, depression, and anxiety. These symptoms may last for a few weeks after the head injury. The syndrome is more prevalent in patients who had psychiatric symptoms, such as depression or anxiety, before the injury. Treatment for PCS may include medicines for pain and psychiatric conditions, and psychotherapy and occupational therapy.

Most patients with severe TBI, if they recover consciousness, suffer from [[Cognition|cognitive]] disabilities, including the loss of many higher level mental skills. The most common cognitive impairment among severely head-injured patients is memory loss, characterized by some loss of specific memories and the partial inability to form or store new ones. Some of these patients may experience [[post-traumatic amnesia]] (PTA), either [[anterograde amnesia|anterograde]] or [[retrograde amnesia|retrograde]]. Anterograde PTA is impaired memory of events that happened after the TBI, while retrograde PTA is impaired memory of events that happened before the TBI.

Many patients with mild to moderate head injuries who experience cognitive deficits become easily confused or distracted and have problems with concentration and attention. They also have problems with higher level, so-called executive functions, such as planning, organizing, abstract reasoning, problem solving, and making judgments, which may make it difficult to resume pre-injury work-related activities. Recovery from cognitive deficits is greatest within the first 6 months after the injury and more gradual after that.

Patients with moderate to severe TBI have more problems with cognitive deficits than patients with mild TBI, but a history of several mild TBIs may have an additive effect, causing cognitive deficits equal to a moderate or severe injury.

Many TBI patients have sensory problems, especially problems with vision. Patients may not be able to register what they are seeing or may be slow to recognize objects. Also, TBI patients often have difficulty with hand-eye coordination. Because of this, TBI patients may seem clumsy or unsteady. Other sensory deficits may include problems with hearing, smell, taste, or touch. Some TBI patients develop [[tinnitus]], a ringing or roaring in the ears. A person with damage to the part of the brain that processes taste or smell may develop a persistent bitter taste in the mouth or perceive a persistent noxious smell. Damage to the part of the brain that controls the sense of touch may cause a TBI patient to develop persistent skin tingling, itching, or pain. These conditions are rare and hard to treat.

Language and communication problems are common disabilities in TBI patients. Some may experience [[aphasia]], defined as difficulty with understanding and producing spoken and written language; others may have difficulty with the more subtle aspects of communication, such as body language and emotional, non-verbal signals.

In [[non-fluent aphasia]], also called [[Broca's aphasia]] or [[motor aphasia]], TBI patients often have trouble recalling words and speaking in complete sentences. They may speak in broken phrases and pause frequently. Most patients are aware of these deficits and may become extremely frustrated.

Patients with [[fluent aphasia]], also called [[Wernicke's aphasia]] or [[sensory aphasia]], display little meaning in their speech, even though they speak in complete sentences and use correct grammar. Instead, they speak in flowing gibberish, drawing out their sentences with non-essential and invented words. Many patients with fluent aphasia are unaware that they make little sense and become angry with others for not understanding them. Patients with global aphasia have extensive damage to the portions of the brain responsible for language and often suffer severe communication disabilities.

TBI patients may have problems with spoken language if the part of the brain that controls speech muscles is damaged. In this disorder, called [[dysarthria]], the patient can think of the appropriate language, but cannot easily speak the words because they are unable to use the muscles needed to form the words and produce the sounds. Speech is often slow, slurred, and garbled. Some may have problems with intonation or inflection, called prosodic dysfunction.

Most TBI patients have emotional or behavioral problems that fit under the broad category of psychiatric health. Family members of TBI patients often find that personality changes and behavioral problems are the most difficult disabilities to handle. Psychiatric problems that may surface include depression, apathy, anxiety, irritability, anger, paranoia, confusion, frustration, agitation, insomnia or other sleep problems, and mood swings. Problem behaviors may include aggression and violence, impulsivity, disinhibition, acting out, noncompliance, social inappropriateness, emotional outbursts, childish behavior, impaired self-control, impaired selfawareness, inability to take responsibility or accept criticism, egocentrism, inappropriate sexual activity, and alcohol or drug abuse/addiction. Some patients' personality problems may be so severe that they are diagnosed with organic personality disorder, a psychiatric condition characterized by many of the problems mentioned above. Sometimes TBI patients suffer from [[developmental stagnation]], meaning that they fail to mature emotionally, socially, or psychologically after the trauma. This is a serious problem for children and young adults who suffer from a TBI. Attitudes and behaviors that are appropriate for a child or teenager become inappropriate in adulthood. Many TBI patients who show psychiatric or behavioral problems can be helped with medication and psychotherapy.

==Other Long-Term Problems Associated With TBI==
Other long-term problems that can develop after a TBI include [[Parkinson's disease]] and other motor problems, [[Alzheimer's disease]], [[dementia pugilistica]], and [[post-traumatic dementia]].

''Alzheimer's disease'' (AD) - AD is a progressive, neurodegenerative disease characterized by [[dementia]], memory loss, and deteriorating cognitive abilities. Recent research suggests an association between head injury in early adulthood and the development of AD later in life; the more severe the head injury, the greater the risk of developing AD. Some evidence indicates that a head injury may interact with other factors to trigger the disease and may hasten the onset of the disease in individuals already at risk. For example, people who have a particular form of the protein [[apolipoprotein E]] ([[apoE4]]) and suffer a head injury fall into this increased risk category. (ApoE4 is a naturally occurring protein that helps transport cholesterol through the bloodstream.)

''Parkinson's disease'' and other motor problems - Movement disorders as a result of TBI are rare but can occur. Parkinson's disease may develop years after TBI as a result of damage to the [[basal ganglia]]. Symptoms of Parkinson's disease include tremor or trembling, rigidity or stiffness, slow movement ([[bradykinesia]]), inability to move ([[akinesia]]), shuffling walk, and stooped posture. Despite many scientific advances in recent years, Parkinson's disease remains a chronic and progressive disorder, meaning that it is incurable and will progress in severity until the end of life. Other movement disorders that may develop after TBI include tremor, [[ataxia]] (uncoordinated muscle movements), and [[myoclonus]] (shock-like contractions of muscles).

''Dementia pugilistica'' - Also called [[chronic traumatic encephalopathy]], dementia pugilistica primarily affects career [[boxing|boxer]]s. The most common symptoms of the condition are dementia and parkinsonism caused by repetitive blows to the head over a long period of time. Symptoms begin anywhere between 6 and 40 years after the start of a boxing career, with an average onset of about 16 years.

''Post-traumatic dementia'' - The symptoms of post-traumatic dementia are very similar to those of dementia pugilistica, except that post-traumatic dementia is also characterized by long-term memory problems and is caused by a single, severe TBI that results in a [[coma]].

==Treatment==
Medical care usually begins when [[paramedic]]s or [[emergency medical technician]]s arrive on the scene of an accident or when a TBI patient arrives at the emergency department of a hospital. Because little can be done to reverse the initial brain damage caused by trauma, medical personnel try to stabilize the patient and focus on preventing further injury. Primary concerns include insuring proper [[oxygen]] supply, maintaining adequate blood flow, and controlling [[blood pressure]]. Since many head-injured patients may also have [[spinal cord injury|spinal cord injuries]], the patient is placed on a back-board and in a neck restraint to prevent further injury to the head and spinal cord.

Medical personnel assess the patient's condition by measuring [[vital signs]] and reflexes and by performing a neurological examination. They check the patient's temperature, blood pressure, pulse, breathing rate, and pupil size and response to light. They assess the patient's level of consciousness and neurological functioning using the [[Glasgow Coma Scale]].

Imaging tests help in determining the diagnosis and prognosis of a TBI patient. Patients with mild to moderate injuries may receive skull and neck [[X-ray]]s to check for [[bone fracture]]s. For moderate to severe cases, the gold standard imaging test is a [[computed tomography]] (CT) scan, which creates a series of crosssectional X-ray images of the head and brain and can show bone fractures as well as the presence of hemorrhage, hematomas, contusions, brain tissue swelling, and tumors. [[Magnetic resonance imaging]] (MRI) may be used after the initial assessment and treatment of the TBI patient. MRI uses magnetic fields to detect subtle changes in brain tissue content and can show more detail than X-rays or CT. The use of CT and MRI is standard in TBI treatment, but other imaging and diagnostic techniques that may be used to confirm a particular diagnosis include [[cerebral angiography]], [[electroencephalography]] (EEG), [[transcranial Doppler ultrasound]], and [[single photon emission computed tomography]] (SPECT).

Approximately half of severely head-injured patients will need [[surgery]] to remove or repair hematomas or contusions. Patients may also need surgery to treat injuries in other parts of the body. These patients usually go to the intensive care unit after surgery.

Sometimes when the brain is injured swelling occurs and fluids accumulate within the brain space. It is normal for bodily injuries to cause swelling and disruptions in fluid balance. But when an injury occurs inside the skull-encased brain, there is no place for swollen tissues to expand and no adjoining tissues to absorb excess fluid. This increased pressure is called [[intracranial pressure]] (ICP).

Medical personnel measure a patient's ICP using a probe or catheter. The instrument is inserted through the skull to the [[subarachnoid space|subarachnoid]] level and is connected to a monitor that registers the patient's ICP. If a patient has high ICP, he or she may undergo a [[ventriculostomy]], a procedure that drains [[cerebrospinal fluid]] (CSF) from the [[ventricular system|ventricles]] to bring the pressure down. Drugs that can be used to decrease ICP include [[mannitol]] or [[barbiturate]]s.

== Rehabilitation ==
Rehabilitation is an important part of the recovery process for a TBI patient. During the acute stage, moderately to severely injured patients may receive treatment and care in an intensive care unit of a hospital. Once stable, the patient may be transferred to a subacute unit of the medical center, to a rehabilitation inpatient unit within the acute trauma center, or to an independent off-site or 'free-standing' rehabilitation hospital. Moderately to severely injured patients may receive specialized rehabilitation treatment that draws on the skills of many specialists, involving treatment programs in the areas of physical therapy, occupational therapy, speech/language therapy, [[physiatry]] (medical specialist in [[physical medicine and rehabilitation]]), psychology/psychiatry, and social work. The services and efforts of this team of healthcare professionals is generally applied to the practical concerns of and the problems encountered by the brain injury survivor in their daily life. This treatment program is generally provided through a coordinated and self-organized process in the context of a transdisciplinary model of team care delivery.

The overall goal of rehabilitation after a TBI is to improve and optimize the patient's ability to function at home and in society in the face of the residual effects of the injury, which may be complex and multifaceted. An additional goal of the rehabilitation program is to prevent, wherever possible, but otherwise to diagnose and treat, any complications (eg. posttraumatic hydrocephalus) that may cause additional morbidity and mortality in this patient population. Therapists help the patient adapt to disabilities or change the patient's living space to make everyday activities easier. Education and training for identified caregivers is also a critically important component of the rehabilitation program.

Some patients may need medication for psychiatric and physical problems resulting from the TBI, and various medications are available that may lessen or moderate the problematic manifestations of the injury without directly altering the underlying pathology. Great care must be taken in prescribing medications because TBI patients are more susceptible to side effects and may react adversely to some pharmacological agents. It is important for the family caregivers to provide assistance and encouragement for the patient by being involved in the rehabilitation program. Family members may also benefit from psychotherapy and social support services.

==Prevention==
Unlike most neurological disorders, head injuries can be prevented. The [[Centers for Disease Control and Prevention]] (CDC) have issued the following safety tips for reducing the risk of suffering a TBI.

* Wear a [[seatbelt]] every time you drive or ride in a car.
* Buckle your child into a [[child safety seat]], booster seat, or seatbelt (depending on the child's age) every time the child rides in a car.
* Wear a helmet and make sure your children wear [[helmet]]s when
** riding a bike or motorcycle;
** playing a contact sport such as football or ice hockey;
** using in-line skates or riding a skateboard;
** batting and running bases in baseball or softball;
** riding a horse;
** skiing or snowboarding.
* Keep firearms and bullets stored in a locked cabinet when not in use.
* Avoid falls by
** using a step-stool with a grab bar to reach objects on high shelves;
** installing handrails on stairways;
** installing window guards to keep young children from falling out of open windows;
** using safety gates at the top and bottom of stairs when young children are around.
* Make sure the surface on your child's playground is made of shock-absorbing material (e.g., hardwood mulch, sand).

Source: [http://www.cdc.gov/safeusa/home/tbi.htm CDC, Department of Health and Human Services].

== Famous persons with TBI ==
* [[Phineas Gage]]
* [http://Givebackorlando.com Becky Dedo - GiveBack Inc]

==References==
1. [http://www.cdc.gov/doc.do/id/0900f3ec8006c8e0/ Traumatic Brain Injury in the United States: A Report to Congress] (2003) CDC, Department of Health and Human Services
== See also ==
* [[Head injury]]
:* [[Brain damage]]
:* [[Coma]]
:* [[Unconsciousness]]
:* [[Penetrating head injury]]
:* [[Closed head injury]]
* [[Diffuse brain injury]]
:* [[Concussion of the brain]]
:* [[Diffuse axonal injury]]
* [[Focal brain injury]]
:* [[Brain contusion]]
:* [[Intracranial hemorrhage]]
::* [[Intra-axial hemorrhage]]
::* [[Extra-axial hemorrhage]]
:::* [[Subdural hematoma]]
:::* [[Epidural hematoma]]
:::* [[Subarachnoid hemorrhage]]
* [[Spinal cord injury]]
* [[NINDS brain trauma research]]

==External links==
* [http://www.tandf.co.uk/journals/titles/02699052.html Brain Injury] | Official research journal of the International Brain Injury Association (IBIA)
* [http://Givebackorlando.com Becky Dedo - GiveBack Inc] | Road Maps For Recovery From Head Injury - for TBI survivors and their families.
* [http://www.biaq.com.au Comprehensive range of fact sheets on brain injury]
*http://www.brainsource.com/brain%20injury.htm
*http://www.tbirecoverycenter.org
*http://www.headway.org.uk/ | UK based charity that provides information and support to people with TBI and their families
*http://www.safar.pitt.edu | A US based research institution part of the University of Pittsburgh located in Pittsburgh, PA, which focuses research on TBI and TBI therapies
*http://www.brain-injury-help.com | Brain Injury Help and Resources
*[http://www.brain-surgery.us/ Brain Surgery-Neurosurgery Patient Help Site]
*http://www.headinjury.com | Brain Injury Resource Center
*http://www.biausa.org | Brain Injury Association of America
*http://www.biaf.org | Brain Injury Association of Florida

''The original version of this article contained text from the NINDS public domain pages on TBI at http://www.ninds.nih.gov/health_and_medical/disorders/tbi_doc.htm and http://www.ninds.nih.gov/health_and_medical/pubs/tbi.htm ''

[[Category:Neurotrauma]]

[[fr:Traumatisme crânien]]
[[it:Trauma cranico]]

Narcotic

2006-06-20T03:04:40Z

Quihn: /* External links */

== Disambiguation ==

In [[scuba diving]], '''[[nitrogen narcosis]]''' is a condition that results from overexposure to high-pressure [[nitrogen]].''

== Etymology ==

The term '''''narcotic''''', derived from the [[Greek language|Greek]] word ''narkotikos'', meaning "benumbing or deadening," originally referred to a variety of substances that induced sleep (such state is '''narcosis'''). In the [[United States|U.S.]] legal context, ''narcotic'' refers to [[opium]], opium derivatives, and their semisynthetic or totally synthetic substitutes as well as [[cocaine]] and [[coca]] leaves, which although classified as "narcotics" in the U.S. [[Controlled Substances Act]] (CSA), are chemically not narcotics.

Because the term is often used broadly, inaccurately and/or pejoratively outside medical contexts, most medical professionals prefer the more precise term [[opioid analgesic|opioid]] for all natural, semi-synthetic and synthetic substances that behave pharmacologically like [[morphine]], the primary constituent of natural [[opium]].

== Administration ==

Narcotics can be administered in a variety of ways. Some are taken orally, transdermally (skin patches) or injected. They are also available in suppositories. As recreational drugs, they are often smoked, snorted, or self-administered by the more direct routes of subcutaneous ("skin popping") and intravenous ("mainlining") injection.

== Effects ==

Drug effects depend heavily on the dose, route of administration, previous exposure to the drug, and the expectation of the user. Aside from their clinical use in the treatment of pain, cough suppression and acute diarrhoea, narcotics produce a general sense of well-being known as euphoria by reducing tension, [[anxiety]], and [[aggression]]. These effects are helpful in a therapeutic setting and contribute to their popularity as recreational drugs, as well as helping to produce dependency.

Narcotic use is associated with a variety of effects including drowsiness, itching, sleeplessness, inability to concentrate, apathy, lessened physical activity, constriction of the pupils, dilation of the [[subcutis|subcutaneous]] blood vessels causing flushing of the face and neck, constipation, nausea, vomiting and, most significantly, respiratory depression. As the dose is increased, the subjective, [[analgesic]], and toxic effects become more pronounced. Except in cases of acute intoxication, there is no loss of motor coordination or slurred speech as occurs with many depressants such as alcohol or barbiturates.

== Hazards ==

Among the hazards of careless or excessive drug use are the increasing risk of infection, disease and overdose. Medical complications common among recreational narcotic users arise primarily from the non-sterile practices of injecting. Skin, lung and brain abscesses, [[endocarditis]], [[hepatitis]] and [[HIV]]/[[AIDS]] are commonly found among persons with narcotic dependencies who share syringes or inhale the drug. There has been much discussion about the dangers related to the [[adulterant]]s/diluents found in street drugs, such as [[heroin]], where rumours abound about what is used to "cut" street drugs, e.g., ground glass, talcum powder, rat poison, domestic cleaning powders, and other [[cutting agent]]s. Recent evidence shows that this kind of "dangerous adulteration" is largely mythical and that far less cutting of drugs than is normally assumed actually takes place. However, since there is no simple way to determine the purity of a drug that is sold on the street, the effects of using street narcotics are unpredictable. It remains the case that the greatest risk presented by most illicit drugs relates to the drugs themselves and how they are used, e.g., in conjunction with other drugs (alcohol is a particularly risky drug to use whilst also using other street drugs), in excess (most recreational and non-excessive drug use does not result in harm), and how a drug is administered (such as the sharing of needles). [[HIV]] and [[hepatitis]] infection rates drop among opioid injectors who have access to clean syringes and take advantage of that provision.

== Tolerance and dependence ==

With repeated use of narcotics, tolerance and dependence develop. The development of tolerance is characterized by a shortened duration and a decreased intensity of [[analgesia]], [[euphoria]] and [[sedation]], which creates the need to administer progressively larger doses to attain the desired effect. Tolerance does not develop uniformly for all actions of these drugs, giving rise to a number of toxic effects. Although the lethal dose is increased significantly in tolerant users, there is always a dose at which death can occur from respiratory depression. It is clear, however, that tolerance and dependence, both part of the conventional idea of addiction, are insufficient to explain in totality what addiction is. Addiction proper is a broader behavioural phenomena that also encapsulates nonsubstance based activity that has many of the same characteristics that substance based dependency displays, e.g., excessive and compulsive gambling, excessive and compulsive eating, and a range of other excessive and compulsive behaviours. Moreover, it isn't always the case that those with a physical dependency to opiates find it too difficult to get over their "addiction," because so-called medical addicts (those that become physically dependent on opiates given for pain relief after treatment) only have to "give-up" the physical symptoms - they don't also have the all important psychological and life-style attachment to the drug which goes to make up the all-encompassing "addiction."

Physical dependence refers to an alteration of normal body functions that necessitates the continued presence of a drug in order to prevent the withdrawal or abstinence syndrome. The intensity and character of the physical symptoms experienced during withdrawal are directly related to the particular drug in use, the total daily dose, the interval between doses, the duration of use and the health and personality of the user. In general, narcotics with shorter durations of action tend to produce shorter, more intense withdrawal symptoms, while drugs that produce longer narcotic effects have prolonged symptoms that tend to be less severe.

The withdrawal symptoms experienced from [[heroin]]- or [[morphine]]-like addiction are usually first felt shortly before the time of the next scheduled dose. Early symptoms include watery eyes, runny nose, yawning and sweating. Restlessness, irritability, loss of appetite, tremors and severe sneezing appear as the syndrome progresses. Severe depression and vomiting are not uncommon. The heart rate and blood pressure are elevated. Chills alternating with flushing and excessive sweating are also characteristic symptoms. Pains in the bones and muscles of the back and extremities occur as do muscle spasms and kicking movements, which may be the source of the expression "kicking the habit." At any point during this process, a suitable dose of opioid can be administered that will dramatically reverse the withdrawal symptoms. Without intervention, the syndrome will run its course and most of the overt physical symptoms will disappear within 7 to 10 days.

The psychological dependence that is associated with narcotic addiction is complex and protracted. Long after the physical need for the drug has passed, the addict may continue to think and talk about the use of drugs. There is a high probability that relapse will occur after narcotic withdrawal when neither the physical environment nor the behavioral motivators that contributed to the abuse have been altered.

There are two major patterns of narcotic dependence seen in the United States. One involves individuals whose drug use was initiated within the context of medical treatment who escalate their dose through "doctor shopping" or branch out to illicit drugs. A very small percentage of addicts are in this group.

The other more common pattern of non-medical use is initiated outside the therapeutic setting with experimental or recreational use of narcotics. The majority of individuals in this category may use narcotics sporadically for months or even years. These occasional users are called "chippers." Although they are neither tolerant of nor dependent on narcotics, the social, medical and legal consequences of their behavior can be very serious. Some experimental users will escalate their narcotic use and will eventually become dependent, both physically and psychologically. The earlier drug use begins, the more likely it is to progress to dependence. [[Heroin]] use among males in inner cities is generally initiated in adolescence, and dependence often develops in about 1 or 2 years.

'''''[[Signs and symptoms]]''''' of narcotic/opioid '''overdose''' include the following: euphoria, arousable somnolence ("nodding"), nausea, pinpoint pupils (except with [[Pethidine|Pethidine/Meperidine]] [''Demerol''], hypoxia, or in combination with other types of drugs), coma, and seizures.

== External links ==
{{Wiktionary}}
* [http://www.geopium.org Geopium: Geopolitics of Illicit Drugs in Asia]
* [http://www.pharmer.org/imprints/narcotics Pharmer.org] A non-profit site providing detailed descriptions of most narcotic analgesics.
* [http://www.geopium.org/Photos/Maroc_Rif2005/Maroc_Rif2005.htm Photos of cannabis cultivation in Morocco (Rif) on www.geopium.org]
* [http://www.deadiversion.usdoj.gov/schedules/alpha/alphabetical.htm List of drugs, some of which are classified as "narcotics," in the U.S. [[Controlled Substances Act]] (CSA). Not all of the classified ones are chemically narcotic, as described on the top of this page.]
* [http://www.drugtext.org/library/articles/97842.htm Drugtext.org] How Often Does the Adulteration/Dilution of Heroin Actually Occur?
* [http://www.heroinhelper.com/curious/glossary.shtml Heroinhelper.com] A glossary of heroin related terms.
* [http://www.erowid.com Erowid.com] A complete list of drugs
* [http://www.quihn.org.au Fact sheets on illicit drugs]

== See also ==

* [[Hard and soft drugs]]
* [[Addiction]]
* [[Narcotics Anonymous]]
* [[Narcoterrorism]]

[[Category:Opioids]]

[[de:Droge]]
[[es:Narcótico]]
[[eu:Droga]]
[[fr:Stupéfiant]]
[[ko:마약]]
[[id:Narkotika]]
[[ja:麻薬]]
[[pl:Narkotyk]]
[[pt:Narcótico]]
[[sv:Narkotika]]
[[uk:Наркотик]]

Network Against Prohibition

2006-06-20T03:02:45Z

Quihn: /* External links */

{{POV}}
{{Unencyclopedic}}
'''Network Against [[Prohibition]] (NAP)''' is the name given to the [[drug law reform]] and [[human rights]] [[activist]] group that began on [[March 7]], [[2002]], in [[Darwin, Northern Territory|Darwin]], [[Australia]] in response to the [[Northern Territory]] [[Australian Labor Party|Labor]] Government's [[drug house legislation]]. NAP members aim to end the [[prohibition]] of [[recreational drug use|drugs]], and specifically, to end the [[War on Drugs]] and the [[human rights abuses]] faced by people who ingest illicit drugs. NAP, as it has become widely known, has amassed a series of upcoming court cases in which NAP members will state and defend their cause. At this stage, there is only one active 'chapter' of NAP - the group based in Darwin in the Northern Territory of [[Australia]], however, there are NAP members throughout Australia and across the globe.

== About the Network Against Prohibition (NAP) ==

The Network Against Prohibition (NAP) is a group dedicated to promoting and protecting the health and human rights of illicit drug users around the globe as well as the rights of those living in communities in developing countries who rely on opium, coca, cannabis etc for their survival. NAP originally formed in Darwin in the Northern Territory of Australia, however the group claims to be undergoing an expansion.

As well as engaging in [[activism]] and [[direct action]] activities, NAP provide a number of health and other services to people who use illicit [[recreational drug use|drugs]] in the [[Northern Territory]] of [[Australia]], including an after-hours [[Needle exchange]] program.

NAP is made up entirely of [[volunteer]]s and the network does not receive any [[funding]] from [[government]] or [[corporate]] sources.

The [[Darwin, Northern Territory|Darwin]]-based chapter of NAP (currently the only active chapter) maintains an extensive website [http://www.napnt.org] which includes an archive of the latest [[Northern Territory]] drug news. The group also publish a regular email newsletter [http://groups.yahoo.com/group/napnt/].

== Activities of the Northern Territory Chapter of the Network Against Prohibition ==

NAPNT members engage in a range of activities. The network originally formed as a [[direct action]] group on [[March 7]], [[2002]]. As part of the network's [[direct action]] and [[civil disobedience]] activities, the network holds five 'Community Smoke-Ins' each year in Darwin's [[Raintree Park]]. Members of the network are encouraged to [[graffiti]] [[drug law-reform]] [[slogans]] and paste up relevant posters in their neighbourhood. Other [[direct action]] and [[civil disobedience]] activities are undertaken from time to time.

Over the years NAPNT has evolved into an extensive [[community]] network. The network provides a number of health and other services to people who use illicit [[recreational drug use|drugs]] in the [[Northern Territory]] of [[Australia]], including a free after hours [[Needle exchange]] program, articles and other resources on pertinent health issues, referral to other agencies as required, basic legal advice and informal support. NAP members also correspond with [[prison]]ers around the world.

[[NAPNT]] has an extensive (read only) library on [[illicit drug]], [[harm reduction]], and [[blood borne virus]] issues and this is open to the public.

The NT Drug News Vault [http://www.napnt.org/ntdrugnews.html] is another resource provided for the [[NAPNT]] community. This is an archive of [[Northern Territory]] drug news/stories. There are more than 850 archived articles. All [[NAPNT]] members are encouraged to [[newshawk]] and to that end the network works closely with the [[Media Awareness Project]].

Some [[NAPNT]] members write letters to the editors of their local [[newspapers]] to promote [[drug law-reform]] messages and to affirm the [[human rights]] of people who use illicit drugs.

The [[NAPNT]] website [http://www.napnt.org] features articles on Australians in trouble for [[drug offences]] overseas, for example [[Schapelle Corby]] and the [[Bali Nine]]. NAPNT members regularly publish articles on issues such as [[petrol sniffing]] and other "[[law and order (politics)|law and order]]" issues.

The [[Darwin, Northern Territory|Darwin]]-based [[NAPNT]] receives regular coverage within the [[Northern Territory]], Australian and global [[media]], including [[TV]] and [[radio]] coverage.

Each year since [[2002]], the NT Chapter of [[NAP]] has facilitated the [[Darwin International Syringe Festival]]. This is a [[protest]] as well as a celebration, focussing on the [[war on drugs]].

As part of their ongoing [[community education]] activities, NAPNT members regularly conduct information stalls around [[Darwin, Northern Territory|Darwin]], including a stall at the [[Nightcliff]] markets every Sunday.

== The Parliament Invasion ==

On [[May 14]], [[2002]], ten people associated with [[NAPNT]] interrupted the [[Legislative Assembly]] of Australia's [[Northern Territory]]. Nine of these became the first people charged under Section 61 of the [[Northern Territory]] [[Criminal]] Code: "disturbing the [[legislative assembly]] whilst it is in session."

This is the first time that [[legislation]] like this has been used anywhere in the [[Westminster]] system since the days of [[Oliver Cromwell]].

Of the nine, [[Andrew Albert Tasman Deacon]] pleaded [[guilty]] at the first instance, and after an initial 14-day [[County jail|jail]] sentence this was replaced with community work on appeal.

[[Luke Masters]] and [[Aaron Stallard-Bryce]] changed their plea to [[guilty]] at the end of a marathon 16-day hearing in the [[Darwin, Northern Territory|Darwin]] [[magistrate's court]]. They were each sentenced to a period of community work, although [[Luke Masters]] spent 14 days in [[Darwin, Northern Territory|Darwin]] [[Prison]] for failing to complete it.

On [[June 5]], [[2003]], [[Ema Birkland-Corro]], [[Stuart Highway]], [[Gary William Meyerhoff]], [[Robert Paul Inder-Smith]] and [[Michael Lambe]] were sentenced to periods of [[detention]] between 14 and 21 months, suspended after serving four or five months.

[[Stuart Highway]], [[Gary William Meyerhoff]], [[Robert Paul Inder-Smith]] and [[Michael Lambe]] appealed against their [[conviction (law)|conviction]] to the [[Northern Territory]] [[Supreme Court]] however their appeal was dismissed by [[Justice David Angel]] on [[September 17]], [[2004]].

Highway, Meyerhoff and Inder-Smith have appealed against their conviction to the full bench of the [[Northern Territory]] [[Supreme Court]] and this is expected to be heard on [[February 22]], [[2006]].

If their appeal to the full bench fails, the NAPNT activists will appeal against their sentences.

[[Ema Birkeland-Corro]] was also charged with aggravated assault and she was found guilty in the Darwin Magistrate's Court in [[2003]]. Her conviction was overturned by the NT Supreme Court. Ema faces another trial in the Darwin Magistrate's Court in June [[2006]].

One more [[NAPNT]] member, [[Scott White]], was charged for this incident. He was interstate when the original case was heard in the Darwin Magistrate's Court. White was [[extradited]] from [[Tasmania]] in [[2003]]. He originally elected to have a trial by [[jury]] in the [[Northern Territory]] [[Supreme Court]]. This trial was set down to proceed in late January [[2006]]. On [[January 10]], [[2006]], Scott entered a plea of guilty. On January 12, 2006, NT Chief Justice [[Brian Martin]] sentenced Scott to 10-weeks’ jail suspended. The suspended sentence was on the condition that Scott not associate or communicate with fellow members of the Network Against Prohibition.

== Bill-pasting ==

On [[August 26]], [[2003]], [[Northern Territory]] [[police]] arrested two NAP members, [[Gary William Meyerhoff]] and [[Michael John Barry]] and charged them with two counts each of [[criminal damage]]. The charges were subsequently dropped but the [[Darwin City Council]] issued the [[NAPNT]] members with infringement notices for “affixing a handbill to a pole without a permit”, a breach of section 97 of the [[Darwin City Council]] by-laws.

Meyerhoff elected to have the matter dealt with in the [[Darwin, Northern Territory|Darwin]] [[magistrate's court]] and he was found [[guilty]] of the offence by Magistrate [[Antony Gillies]] on [[October 28]], [[2004]].

He is the first person to be charged with the offence in the [[Northern Territory]].

On [[April 5]], [[2005]], Meyerhoff appeared before [[Justice Stephen Southwood]] in the [[Northern Territory]] [[Supreme Court]] to appeal against the bill-pasting [[conviction (law)|conviction]]. He argued (unsuccessfully) that section 97 of the By-Laws breaches his right to [[freedom of speech]], as implied by the [[Australian Constitution]].

Southwood dismissed the appeal on [[April 6]], [[2005]].

Meyerhoff lodged an appeal with the Court of Appeal and he appeared before the full bench of the [[Northern Territory]] [[Supreme Court]] on [[November 1]], [[2005]]. His appeal was unsuccessful and the [[conviction (law)|conviction]] for bill-pasting was upheld.

== Community Smoke-Ins and court ==

The [[Northern Territory]] Chapter of [[NAP]] hold regular [[Community Smoke-Ins]] in [[Raintree Park]] in the [[Darwin]] CBD. The group has held twenty-five of these events since the chapter was established in [[Darwin]] in March 2002.

The [[NT Police]] intervened at the first [[Smoke-In]], held on [[April 20]], [[2002]], arresting five [[NAP]] members.

All charges were subsequently dropped.

[[Police]] intervened again at the sixth [[Community Smoke-In]], held on [[October 12]], [[2002]].

Five [[NAP]] members were arrested - [[Ema Corro]], [[Gary Meyerhoff]], [[Michael John Barry]], [[Nicolette Burrows]] and [[Stuart Highway]]. Highway and Meyerhoff were remanded in custody but were released on bail by Magistrate [[Daynor Trigg]] on October 14, 2002.

The [[NAP]] members were charged with criminal damage to two police vehicles and other charges including assault police and escaping lawful custody.

A jury trial commenced in the [[NT Supreme Court]] on Monday, [[October 17]], [[2005]].

[[Nicolette Burrows]] and [[Michael Barry]] pleaded guilty to the charges they faced, avoiding a trial and giving them the benefit of the discount that you get if you plead guilty.

[[Gary Meyerhoff]] was suffering from pneumonia and was not forced to proceed with the trial. He faces trial for these charges in [[2006]].

[[Stuart Highway]] pleaded not guilty to the charges and on the afternoon of [[October 18]], the jury returned a unanimous guilty verdict. Highway was remanded in custody.

On Wednesday, [[October 19]], [[Stuart Highway]] was sentenced by [[Justice Trevor Riley]] to eight months' jail, suspended after he serves three months. He was released on [[January 17]], [[2006]].

[[Nicolette Burrows]] and [[Michael Barry]] each received a five-month suspended sentence.

== Other NAPNT court cases ==

Members of the [[Northern Territory]] Chapter of NAP have a number of [[criminal]] matters outstanding in the [[Darwin]] Magistrate's and Northern Territory Supreme Courts.

== An alternative view on NAPNT ==

Critics of [[NAPNT]] state that it has very limited support from the people of the [[Northern Territory]]. The population of the [[Northern Territory]] is almost 200,000 people.

In the [[2005 Northern Territory election]] [[NAPNT]] ran 5 candidates in a total of 25 electorates.

Critics claim that the main members of [[NAPNT]] are unemployed and therefore rely on unemployment benefits from the Australian Government to enable then to pursue their protest activities.

== Election campaigns ==
This is a very one sided description of the activities of the group known as N.A.P. N.A.P has very limited support from the Population of the Northern Territory. The population of the Northern Territory is almost 200,000 people. In the last Northern Territory election N.A.P ran 3 candiates out of a total of 25 electorates. The 3 N.A.P candidates polled less than 100 primary votes between them. I believe that this is an accurate representation of their support within the general community.

The main members of the N.A.P organisation are unemployed and rely on the generous unemployment benefits supplied by the Australian Government to enable then to pursue their protest activities.

== Affiliations ==

NAPNT is a member of the [[Australian Injecting and Illicit Drug Users League]] (AIVL) and The [[International Coalition of NGO's for Just and Effective Drugs Policy]] (ICN). The network has strong connections with [[drug user activists]] from across the globe.

In Darwin, NAPNT members work closely with the NT AIDS and Hep C Council (NTAHC) [http://www.ntahc.org.au] and a range of other community-based agencies.

== See also ==

*[[Activism]]
*[[Arguments for and against drug prohibition]]
*[[Civil disobedience]]
*[[Civil rights]]
*[[Direct action]]
*[[Recreational drug use]]
*[[Free speech]]
*[[Harm reduction]]
*[[Human rights]]
*[[Human rights in Australia]]
*[[Illegal drug trade]]
*[[Incarceration]]
*[[International Covenant on Civil and Political Rights]]
*[[International human rights instruments]]
*[[Jails]]
*[[May 14]]
*[[Narcotic]]
*[[Northern Territory legislative election, 2005]]
*[[On liberty]]
*[[Prohibition]]
*[[Rockefeller drug laws]]
*[[Social justice]]
*[[Universal Declaration of Human Rights]]
*[[War on Drugs]]

== External links ==

*[http://www.napnt.org Network Against Prohibition]
*[http://groups.yahoo.com/group/napnt/ Network Against Prohibition email list]
*[http://www.napnt.org/ntdrugnews.html Northern Territory Drug News Vault]
*[http://www.aivl.org.au Australian Injecting and Illicit Drug Users League]
*[http://www.drugsense.org DrugSense]
*[http://garywmeyerhoff.blogspot.com Web log of Gary William Meyerhoff, one of the founding members of the Network Against Prohibition]
*[http://www.encod.org/icn.htm The International Coalition of NGO's for Just and Effective Drugs Policy]
*[http://www.leap.cc Law Enforcement Against Prohibition (LEAP)]
*[http://www.mapinc.org Media Awareness Project]
*[http://www.ntahc.org.au Northern Territory AIDS and Hep C Council]
*[http://www.nt.gov.au Northern Territory Government]
*[http://www.nt.gov.au/lant/ Northern Territory Legislative Assembly]
*[http://www.nt.gov.au/pfes Northern Territory Police, Fire and Emergency Services]
*[http://www.nt.gov.au/ntsc Northern Territory Supreme Court]
*[http://www.tuf.org.au Territory Users Forum Inc.]
*[http://www.candoclemency.com/pages/v_rosepiler.html Vicki Rosepiler - a prisoner in the United States that NAP members correspond with]
*[http://www.napnt.org/Links.htm#nt_activism More Northern Territory activism]
* [http://www.quihn.org.au Fact sheets, harm reduction tips and discussion on illicit drugs]

[[Category:Organisations based in Australia]]
[[Category:Prohibition]]

Illegal drug trade

2006-06-20T03:00:36Z

Quihn: /* External links */

{| class="messagebox" style="width: 28em; background: AntiqueWhite;"
|-
| [[Image:Stop_hand.svg|none|40px]]
| '''The [[Wikipedia:Neutral point of view|neutrality]] of this article is [[Wikipedia:NPOV dispute|disputed]].''' <br> Please see the discussion on the [[:{{NAMESPACE}} talk:{{PAGENAME}}|talk page]][[Category:NPOV disputes|{{PAGENAME}}]].
|-
|}

[[Image:Lollipops with h.jpg|right|frame|These lollipops were found to contain [[heroin]] when inspected by the US [[Drug Enforcement Administration|DEA]]]]

The '''[[trade]] of illegal drugs''' is a global [[black market]] activity consisting of production, distribution, packaging and sale of illegal [[psychoactive]] substances.

==Introduction==
In jurisdictions where [[legislation]] restricts or prohibits the sale of certain popular [[Psychoactive drug|drug]]s without a certain, practically impossible to get license, it is common for an illegal drugs trade to develop. For example, the [[United States]] [[United States Congress|Congress]] has identified a number of [[controlled substance]]s which each have corresponding illegal drug trades.

Some estimates placed the value of the global trade in illegal drugs at around four hundred billion U.S. dollars in the year 2000, that, added to the global trade value of legal drugs at the same time, totals to an amount higher than the amount of money spent for food in the same period of time. In the 2005 United Nations World Drug Report, the retail market of the global drug market is reported to be valued at 312 billion U.S. dollars.

Major consumer countries include the [[United States]] and [[Europe]]an nations, although consumption is world-wide. Major producer countries include [[Afghanistan]] (Heroin) and [[Colombia]] (primarily [[Cocaine]], but to a rising level Heroin, too); see below for further details.

==Trafficking and distribution==
[[Image:Balininelawrenceevidence.jpg|280px|thumb|right|Police evidence photograph showing heroin strapped to the body of a drug smuggler.]]
We can distinguish international trafficking, which involves [[smuggling]] across [[border]]s, and distribution within the demand country, the latter being usually on a much smaller scale.

With regard to crossing borders we can distinguish:
*avoiding border checks, such as by small ships, small aircraft, and through overland smuggling routes
*submitting to border checks with the drugs hidden in a vehicle, between other merchandise, in luggage, in or under cloths, inside the body, etc.

A [[Mule (smuggling)|mule]] is a lower-echelon criminal recruited by a smuggling organization to cross a border carrying drugs, or sometimes an unknowing person in whose bag or vehicle the drugs are planted, for the purpose of retrieving them elsewhere.

There are two primary means of distribution: a hierarchy and a [[Spoke-hub distribution paradigm|hub-and-spoke]] layout. A hierarchical arrangement includes the manufacturer who uses his own men to smuggle, wholesale and store, and distribute the drugs. A hub-and-spoke layout takes advantage of local gangs and other localized criminal organizations. The cartel is at the center, with satellite organizations that may provide certain services to the manufacturer, and then there is a plurality of distinct groups, each with its own chain.

Smuggling is also often accomplished via small boats and yachts, air vehicles, and by gangs paid with some of the merchandise.

Sometimes small aircraft are disposed of and destroyed (burnt) immediately after the unloading process, resulting in e.g. the "aircraft graveyard" in the northern [[Peten area]] of [[Guatemala]].

Wholesalers routinely accept the materials from the smugglers (often more than one and of varying types), cut it (for obvious reasons of economy, most of all times, adulteration takes place only after the smuggled substance has crossed the last expected border), and sell it to the distribution chain or chains. For the most part, wholesalers are not individual people; it is typically an expansionary endeavor by already-established rogue enterprises, such as Mafias and sometimes local gangs. The chemically more experienced instances may re-manufacture the wares to alter the drug's purity, or altering the chemical composition of the material (such as turning cocaine into [[Cocaine#Crack cocaine|crack]] or [[freebase]]). Wholesalers may also manufacture and disseminate general contraband, including non-narcotic controlled substances (like [[date rape drug]]s), [[paraphernalia]] (where it can't be legally obtained by head shops or the like), or any panoptic, high-demand item that they may receive.

Distribution and adulteration may traverse a selectively chosen group of cartel employees who purchase from a wholesaler and utilize a prominent population of mules or it may encompass a heavy chain of users who are selling to finance their own use.

See also [[Cocaine#Trafficking and distribution|trafficking and distribution of cocaine]], [[Heroin#Trafficking|trafficking and distribution of heroin]], and [[Cannabis#Cannabis trade|trafficking and distribution of cannabis]].

==Drug cartels==

The most well known recent drug cartels are the [[Cali Cartel|Cali]], [[Medellín Cartel|Medellín]] and [[Norte del Valle Cartel|Norte del Valle]] cartels in [[Colombia]] and the [[Juarez Cartel|Juarez]], [[Tijuana Cartel|Tijuana]] and [[Tamaulipas Cartel|Tamaulipas]] cartels in [[Mexico]].

Allegedly, the United States' [[CIA|Central Intelligence Agency]] has itself smuggled cocaine and heroin, currently the most profitable illegal drugs, via the CIA-controlled airline [[Air America]]. It has also been alleged that the CIA has maintained secret agreements with various regional Mafia organizations and armies, with military or paramilitary (guerilla) aid given in return for US non-interference in profitable drug trafficking.{{Citation needed}}

The main organized drug cartels deal primarily with the most compact (thus easy to smuggle) and profitable substances [[cocaine]], [[heroin]], [[MDMA]] (ecstasy), and [[methamphetamine]], and it is these that are the primary focus of the United States [[Drug Enforcement Administration]]. Large-scale manufactured illegal drugs also induce the foundation of satellite organizations that supply some of the most important needed chemical precursors.

===Mexican cartels ===

Since the late 1980s, illegal drugs trafficking organizations headed and comprised of Mexican nationals became the dominant force of the illicit drug trade in the United States. Mexican trafficking organizations usurped control from Colombian trafficking organizations.

In the early 1980s, cocaine emerged as a drug of choice for many Americans and its use became prevalent through-out the socio-economic spectrum. Initially, Colombians were responsible for growing, processing and distributing cocaine in the U.S., but their strongholds were limited to South Florida and [[New York]] along with other metropolitan areas that housed smaller Colombian populations. As demand for larger quantities of [[cocaine]] began to take hold in the U.S. in the late 1980s, Colombian traffickers came to rely on Mexican organizations to assist with the transportation and distribution of cocaine through-out the U.S. After a period of time, powerful Mexican cartels realized that they could more effectively handle the smuggling and distribution of ton-quantities of cocaine in the U.S.

Colombians had been limited to predominantly a Caribbean smuggling route into South Florida. Mexicans, on the other hand, had access to an expansive 2,000 mile border with the Southwestern U.S. and then a vast network of Mexican immigrants residing in major metropolitan areas such as [[Los Angeles]] and [[Chicago]], and later through-out a number of large and small communities in all corners of the U.S.


The ample number of Mexican nationals residing in the U.S. without a [[Valid U.S. Visa]] occurred as a result of a bombardment of migrant workers in search of higher-paying jobs, but the increased Mexican presence also brought with it a large number of Mexican narcotics traffickers that came to the U.S. with one specific purpose: to sell drugs and earn a significant profit in doing so. Mexican [[Black tar heroin]], which is produced in Mexico and smuggled into the U.S. predominantly by Mexican nationals is the most frequently consumed heroin in the western and Midwestern U.S. The [[Drug Enforcement Administration]] (DEA) estimates that 80% of the [[methamphetamine]] in the U.S. is either manufactured in Mexico or is manufactured in the U.S. by Mexican national drug traffickers operating under the direction of Mexican drug kingpins. These illicit drug sales in the U.S. have resulted in a boom of revenues for Mexico. In fact, after petroleum revenues, the second biggest revenue source for Mexico comes from illegal alien Mexican nationals sending money into Mexico from the U.S., and a significant part of those monies are illicit drug proceeds.[http://www.dea.gov/concern/drug_trafficking.html]

In the last ten years, [[United States Department of Justice]] (DOJ) statistics indicate that the percentage of Latin American non-U.S. citizens that were federally arrested in the U.S. for illegal drug offenses has increased from the low 20 percentile to over 30 percent as of 2003. For example, in 1999, regarding all federal drug arrests, 26.8% were non-U.S. citizens and 45.5% were Hispanic. Other DOJ BJS statistics showed that "in addition to immigration offenses, U.S. attorneys prosecuted an increased number of non-citizens for other crimes, especially for drug trafficking, which increased from 1,799 cases in 1985 to 7,803 in 2000." [http://www.ojp.usdoj.gov/bjs/pub/press/iofc00pr.htm]

Other noteworthy facts, according to National Criminal Justice Reference Service: "Of noncitizens prosecuted in Federal courts during 1994, 55 percent were in the United States legally. During 1984, about 35 percent of noncitizens prosecuted in Federal courts were charged with a drug offense. By 1994, the proportion charged with a drug offense increased to 45 percent." [http://www.ncjrs.gov/App/Publications/abstract.aspx?ID=160934]

[[Image:CKS Airport drugs sign.JPG|thumb|Trafficking of illegal drugs carries the death penalty in some countries. This sign posted at the [[Chiang Kai-shek International Airport]] warns passengers disembarking in [[Taiwan]] of the potential consequences.|250px]]

==Illegal trade of legal drugs==
Legal [[Psychoactive drug|drug]]s like [[tobacco]] can be the subject of [[smuggling]] and illegal trading if the price difference between the smuggled-from and the smuggled-to country are high enough to make it profitable.

===Prescription drugs===
Some [[prescription drug]]s are also available by illegal means, eliminating the need to manufacture and process the drugs. (Prescription [[opioid]]s for example, are sometimes much stronger than heroin found on the street, example: the group of the [[fentanyl]] analogs.) They are sold either via stolen or partly divided prescriptions sold by medical practices and occasionally from Internet sale. However, it is much easier to control traffic in prescription drugs than in illegal drugs because the source is usually an originally legal enterprise and thus can often be readily found and neutralized.

=== Internet and controlled substances ===
"No Prescription Websites" (NPWs) offer to sell controlled substances without a valid prescription. NPWs were first recognized by the [[U.S. Justice Department]] in 1999, indicating that such sites had been operating at least through the late 1990s. NPWs enable dealers and users to complete transactions without direct contact. While many NPWs accept credit cards, others only accept cash thereby further reducing any paper trail. Many NPWs are hosted in countries in which specific categories of controlled substances are locally legal (e.g. prescription opioids in Mexico), but because of the global nature of the internet, NPWs are able to do (mostly illegal) business with customers around the globe. In addition to prescription (weaker) opioids, stimulants, and sedatives, steroids are often widely distributed. To date, no websites have been found offering directly to sell illegal drugs like heroin, illegal amphetamine or methamphetamine derivatives, or cocaine, however the police have uncovered several instances of dealers/drug rings using [[Craigslist]] personal ads to solicit drug business using code words and phrases. All other categories of drugs are readily available online.

2004 saw the conclusion of [[Operation Web Tryp]], focusing on companies selling so-called [[research chemicals]], legal psychedelic phenethylamines and tryptamines on the Internet.

==Violent resolutions==
Because disputes cannot be resolved through legal means, participants at every level of the illegal drug industry, often at the top levels and, primarily in the USA, but, to a lesser extent also on the second major illegal drug consuming continent, Europe, also at the bottom levels, are inclined to compete with one another through [[violence]]. The larger and more often violent drug trafficking organizations are known as drug [[cartel]]s. For this (and other reasons, namely the inability for governments to control, regulate and tax distribution, and also concerncing the unnecessarily suffering, often addicted, consumers of drugs affected of prohibitionist laws), many have argued that the arbitrariness of drug prohibition laws from the medical point of view, especially the theory of [[harm reduction]], worsens the problems around these substances.

== Trade of specific drugs ==
The price per gram of heroin is typically 8 to 10 times that of cocaine on US streets.[http://www.dea.gov/pubs/cngrtest/ct110905.html]
Generally in Europe (except the transit countries Portugal and the Netherlands), a purported gram of street Heroin, which is usually actually between 0.7 and 0.8 grams light to dark brown powder consisting of 5-10%, less commonly up to 20%, heroin base, is between 30 and 70 Euros, which makes for an effective price of pure heroin per gram of between 300 and 2000 Euros.
The purity of street cocaine in Europe is usually in the same range as it is for heroin, the price being between 50 and 100 Euros per between 0.7 and 1.0 grams. This totals to a cocaine price range between 500 and 2000 Euros.

=== Anabolic steroids ===
{{main|Anabolic steroids}}

According to the [[Office of National Drug Control Policy]], drug smugglers have an easier time smuggling them into the United States. When they have arrived in the United States, they are often sold at gyms and competitions as well as through mail operations.

=== Cannabis ===
{{main|Cannabis}}

=== LSD ===
{{main|LSD}}

[[LSD]] (also known as "acid") is a highly potent [[Psychedelics, Dissociatives and Deliriants|hallucinogenic drug]] which is synthesized artificially from certain metabolism products of the ergot fungus which grows on certain grain strains. The availability of LSD in the United States dropped sharply starting in the [[2000]], when two distributors alleged by the government to have been manufacturing 95% of all LSD available in the US were captured (see [[LSD#LSD in the United States|LSD in the United States]]), but availability has started to rise again (possibly due to law enforcement focusing more heavily on [[methamphetamine]]).

=== Psilocybin mushrooms ===
Psychedelic Mushrooms grow naturally in most climates, thus this drug market is financially less lucrative, even though there is no doubt a certain kind of commercial growing of the Psilocybe mushrooms, half-legally in the Netherlands and illegally from different stages of maturity/manufacture of chewable dried mushroom tissue. [[Psychonaut]]s will often grow these mushrooms or pick them for themselves as they are common to find in many places of the world.

=== Alcohol ===
{{main|Alcoholic beverage}}

In some areas of the world, particularly the in and around the Arabian peninsula, the trade of alcohol is strictly prohibited. For example, [[Pakistan]] bans the trade because of its large Muslim population. Similarly, [[Saudi Arabia]] forbids the importation of alcohol into its kingdom. Also, the US state of [[Alaska]] has rural villages that are considered "dry" and prohibit the sale, trade, and even consumption of alcoholic beverages.

=== Tobacco ===
{{not verified}}
{{main|Tobacco}}

The illegal trade of tobacco is motivated primarily by increasingly heavy taxation. When tobacco products such as name-brand cigarettes are traded illegally, the cost is as little as one third that of retail price due to the lack of taxes being applied as the product is sold from manufacturer to buyer to retailer. It has been reported that smuggling one truckload of cigarettes within the United States leads to a profit of 2 million U.S. dollars.[http://www.washingtonpost.com/wp-dyn/articles/A23384-2004Jun7.html]

The source of the illegally-traded tobacco is often the proceeds from other crimes, such as store and transportation robberies.

Sometimes, the illegal trade of tobacco is motivated by differences in taxes in two jurisdictions, including smuggling across international borders. Smuggling of tobacco from the US into Canada has been problematic, and sometimes political where trans-national native communities are involved in the illegal trade.

===Opium===
{{main|Opium}}

International illicit trade in opium is relatively rare. Major smuggling organizations prefer to further refine opium into [[heroin]] before shipping to the consumer countries, since a given quantity of heroin is worth much more than an equivalent amount of opium, so heroin is more profitable, because heroin is a substance that is made of the main naturally-occurring psychoactive substance in opium, morphine and thus much stronger than opium, and even stronger a relevant proportion compared to morphine.

===Heroin===
{{main|Heroin}}

Heroin is smuggled into the [[United States]] and [[Europe]]. Purity levels vary greatly by region with, for the most part, Northeastern cities having the most pure heroin in America (according to a recently released report by the DEA, [[Elizabeth, New Jersey|Elizabeth]] and [[Newark, New Jersey|Newark]], [[New Jersey]], have the purest street grade heroin in the country).

=== Methamphetamine ===
{{main|Methamphetamine}}

In some areas of the United States, the trade of methamphetamines is rampant. Because of the ease in production and its addiction rate, methamphetamines are a favorite amongst many drug distributors.

==Fiction==
Drug smuggling was the topic of:
*''[[Midnight Express (film)|Midnight Express]]'' (1978)
*''[[Traffic (film)|Traffic]]'' (2000)
*''[[Blow (film)|Blow]]'' (2001)
*''[[Maria Full of Grace]]'' (2004)
*''[[Layer Cake]]'' (2004)

== See also ==
* [[Counterfeit drug]]
* [[Arguments for and against drug prohibition]]
* [[Drug paraphernalia]]
* [[Drugs and prostitution]]
* [[Legal issues of cannabis]]
* [[List of famous drug smugglers]]
* [[Money laundering]]
* [[Narco-capitalism]]
* [[Prohibition (drugs)]]
* [[War on Drugs]]
* [[United Nations Convention Against Illicit Traffic in Narcotic Drugs and Psychotropic Substances|United Nations convention against illicit drugs]]
* [[Demand reduction]]
* [[Smuggling]]
* [[Opium Wars]]

==References==
* Background Q&A by the Council on Foreign Relations: [http://www.cfr.org/publication/10373/forgotten_drug_war.html "The Forgotten Drug War"]
*[http://www.unodc.org/unodc/undcp.html United Nations - Drug Programme]
*[http://www.pa-chouvy.org/ Geopium: Geopolitics of Illicit Drugs in Asia] (English and French)
*[http://observer.guardian.co.uk/drugs/story/0,11908,1076002,00.html Dagga brings riches to new drug barons]
*[http://www.pa-chouvy.org/Chouvy-JIR-DEC2005-Moroccos_smuggling_rackets_hashish_people_and_contraband.html Publication on hashish production and trafficking in Morocco] (December 2005)
*[http://www.cannabis.net/drugsmuggle/ The smuggling culture]
*[http://www.usdoj.gov/dea/deamuseum/museum_ida.html Illegal Drugs in America: A Modern History] from the U.S. DOJ
*[http://www.whitehousedrugpolicy.gov/drugfact/steroids/index.html Office of National Drug Control Policy - Steroids]
*[http://www.fas.org/irp/agency/doj/dea/product/cocaine.htm The South American Cocaine Trade]
*[http://web.kitsapsun.com/meth/methseries3.html Tricks of the Trade: Tracing meth's route into Kitsap County]
*[http://www.pueblo.gsa.gov/cic_text/state/tips_sasia.html Tips for Travelers to South Asia]
*[http://www.wordtravels.com/Travelguide/Countries/Saudi+Arabia/Basics Saudi Arabia Basics]
*[http://www.napnt.org Network Against Prohibition]
*[http://www.unodc.org/unodc/en/world_drug_report.html United Nations World Drug Report]
*[http://www.whitehousedrugpolicy.gov/publications/drugfact/pulsechk/january04/index.html Pulse Check: Drug Markets and Chronic Users in 25 of America's Largest Cities] (January 2004)
*[http://www.cia.gov/cia/publications/factbook/fields/2086.html Illicit drug issues by country, by the CIA]
*[http://www.havocscope.com/Drugs/drugs.htm Market Size for various illegal drugs.]

==External links==
* [http://asiadeathpenalty.blogspot.com Asia Death Penalty blog] focuses on the death penalty in Asia, including its widespread use for drug offences
* [http://www.ciadrugs.com Website engaged in uncovering the covert involvement of the Central Intelligence Agency in trade with illegal drugs, both directly and indirectly]
* [http://www.quihn.org.au Fact sheets on illegal drugs]

[[Category:Illegal drug trade| ]]
[[Category:Smuggling]]
[[Category:Crime objects]]

[[de:Drogenhandel]]
[[es:Narcotráfico]]
[[fr:Trafic de drogue]]
[[lt:Narkobaronas]]
[[pt:Tráfico de drogas]]
[[zh:贩毒]]

War on drugs

2006-06-20T02:56:28Z

Quihn: /* External links and sources */

[[Image:DEA Operation Mallorca, 2005.jpg|caption|frame|Operation Mallorca, U.S. [[Drug Enforcement Administration]], 2005 [http://www.usdoj.gov/dea/pubs/pressrel/pr061405.html] ]]
[[Image:Drugs-PriceMarkUp2.jpg|280px|thumb|right|Massive mark-ups for drugs, [http://www.strategy.gov.uk/work_areas/drugs/index.asp UK Govt report]]]
[[Image:DrugWarEffectsOnPrices.jpg|280px|thumb|right|No significant impact on retail or wholesale prices, [http://www.strategy.gov.uk/work_areas/drugs/index.asp UK Govt report]]]
The '''War on Drugs''' is an initiative undertaken by the [[United States]] to carry out an "all-out offensive" (as [[Richard Nixon|President Nixon]] described it) against the [[prohibition (drugs)|prohibited]] use of certain legally controlled [[drug]]s.
The [[Congressional Research Service]] of the [[Library of Congress]] noted in a 1989 report that the nation's war on drugs could be considered to have started in [[public policy]] dating to November [[1880]], when the U.S. and [[China]] completed an agreement which prohibited the shipment of [[opium]] between the two countries. By February 1887, the [[Forty-ninth United States Congress|49th Congress]] enacted legislation making it a misdemeanor for anyone on American soil to be found guilty of violating this ban. It became officially the "war on drugs" in the 1930s, with the marijuana scare that banned possession and cultivation of [[cannabis]] (including [[hemp]]).

The "War on Drugs" has sought to cause a massive surge in cost for illicit mind-altering substances, which it has succeeded in doing, from the perspective of mark-ups, in turn raising the market value of the trade in highly targeted drugs such as [[cocaine]] and [[heroin]] to over a trillion dollars, but failed in terms of retail prices in the long term. This has had several prominent sociological, economic and political effects. A case in point is the South American country of [[Colombia]], which had developed a commodity market to manage their imports and exports by the late [[1960]]s. The subsequent actions taken by the American government included dumping surplus corn and grain into the Colombian market below market prices, depressing domestic production. The following decade showed a substantial rise in demand for [[cocaine]] in America. The economically depressed Colombian farmer turned willingly to the new [[cash crop]] for its high resale value and cheap manufacturing process.

Nixon's modern-day "War on Drugs" began in [[1971]]. He characterized the abuse of illicit substances as "America's public enemy number one." This coincided with Colombia's destroyed domestic market, providing a fertile ground for the exploitation of the American hunger for narcotics. Thus began the rise of a culture that is still romanticized in popular media; [[drug cartel]] groups and families including [[Pablo Escobar]]'s reign over [[Medellín]] became the norm in areas where the drug trade was an important part of the local economy. The political implications of the "War on Drugs" are extensive and the impact of the program has been severe.

Furthermore, according to a report released in [[March 2006]] by the [[Justice Policy Institute]], commissioned by the [[Drug Policy Alliance]], America's "[[Drug-free school zone|Drug-Free Zones]]" are ineffective at keeping youths away from drugs, and instead create strong [[racism|racial disparities]] in the judicial system. [http://www.justicepolicy.org/article.php?id=575]

Around the turn of the [[20th century]], a perception of widespread abuse of [[cocaine]] caused policy-makers in the U.S. to consider [[drug abuse]] a serious social problem rather than as cases of personal failures.

In 1988, towards the close of the [[Ronald Reagan|Reagan Administration]], the [[Office of National Drug Control Policy]] (ONDCP) was created to centrally coordinate legislative, security, diplomatic, research and health policy throughout the government. In recognition of his central role, the director of ONDCP is commonly known as the ''[[Drug Czar]]''.

Another milestone occurred in [[1996]], when 56% of California voters voted yes to [[California Proposition 215 (1996)|Proposition 215]], legalizing the growing and use of [[marijuana]] for [[Medical cannabis|medical purposes]]. This act has created significant legal and policy tensions between the Federal and State governments. Courts have since decided that neither this, nor any similar acts, will protect users from federal prosecution.

It should be noted, however, that regardless of public opinion, marijuana could be the single most targeted drug in the drug war. It contitutes almost half of all drug arrests, and between 1990-2002, out of the overall drug arrests, 82% of the increase was for marijuana. In this same time period, New York experienced an increase of 2,640% for marijuana possession arrests.

For U.S. public policy purposes, drug abuse is any personal use of a drug contrary to law. The definition includes legal [[pharmaceutical]]s if they are obtained by illegal means or used for nonmedicinal purposes. This differs from what mental health professionals classify as drug abuse per the [[DSM-IV]], which is defined as more problematic drug misuse, both of which are different from drug use.

Many senior officials of the Reagan administration illegally trained and armed the [[Nicaraguan]] [[Contras]], which they funded by the shipment of large quantities of cocaine into the United States using U.S. government aircraft and U.S. military facilities ([[National Security Archives]], Documentation of Official U.S. Knowledge of Drug Trafficking and the Contras [http://www2.gwu.edu/~nsarchiv/NSAEBB/NSAEBB2/nsaebb2.htm]; "Whiteout, the CIA, Drugs and the Press" by Cockburn and St. Clair). The funding for the Contras was also gained through the illegal sale of weaponry to [[Iran]]. When this practice was discovered and condemned in the media, it was referred to as the [[Iran-Contra]] affair.

The United States has also initated a number of military actions as part of its "War on Drugs", such as the 1989 invasion of Panama codenamed [[Operation Just Cause]] involving 25,000 United States troops. The U.S. alleged that Gen. [[Manuel Noriega]], head of government of Panama, was involved in drug trafficking ([[Panama]]). As part of [[Plan Colombia]], the U.S. has funded [[coca eradication]] through private contractors such as [[DynCorp]] and helped train the Colombian armed forces to eradicate coca and fight the [[FARC]] (Revolutionary Armed Forces of Colombia).

== See also ==
*[[Arguments for and against drug prohibition]]
*[[Law Enforcement Against Prohibition]]
*[[Gary Webb]] (an investigative journalist who discovered ties between the massive increase in [[crack]] use in Los Angeles and the funding of the [[Contras]] terrorist group)
*[[Illegal drug trade]]
*[[Legal issues of cannabis]]
*[[Prison-industrial complex]]
*[[Prohibition (drugs)]]
*[[Students for Sensible Drug Policy]]
*[[Supremacy Clause]]
*[[Harm reduction]]
*[[Demand reduction]]
*[[United Nations Drug Control Programme]]
*[[Opium War]], first war against illegal drugs

== External links and sources ==
{{cleanup-spam}}
* [http://www.usdoj.gov/ndic/pubs11/18862/index.htm National Drug Threat Assessment 2006] from the [[United States Department of Justice]]
* [http://www.whitehousedrugpolicy.gov/publications/price_purity/ The Price and Purity of Illicit Drugs: 1981 Through the Second Quarter of 2003]
* [http://www.cfr.org/publication/10373/forgotten_drug_war.html Background Q&A: The Forgotten Drug War] From the [[Council on Foreign Relations]]
* [http://fpc.state.gov/documents/organization/19493.pdf War On Drugs: Legislation in the 108th Congress and Related Developments], a 2003 report (in PDF format) from the [[Congressional Research Service]] via the [[United States Department of State|State Department]] website
* [http://www.theantidrug.com National Youth Anti-Drug Media Campaign]
* [http://www.drugpolicy.org/homepage.cfm Drug Policy Alliance]
* [http://www.encod.org European Coalition for Just and Effective Drug Policies (ENCOD)]
* [http://www.mapinc.org/ The Media Awareness Project]
* [http://www.pbs.org/wgbh/pages/frontline/shows/drugs/ Frontline: drug wars] by [http://www.pbs.org/ PBS]
* [http://cgi.omroep.nl/cgi-bin/streams?/tv/vpro/tegenlicht/bb.20030622.rm?title=Bekijk%20de%20uitzending%20WAR%20ON%20DRUGS%20DEEL%20I%20in%20realvideo%20BREEDBAND%20tot%20500%20kbs War on drugs] ''Part I: Winners,'' documentary (50 min) explaining 'War on Drugs' by [http://www.vpro.nl/programma/tegenlicht/service_info/19361409/ Tegenlicht] of VPRO [[Netherlands|Dutch]] television. After short introduction in Dutch (1 min), English spoken. Broadband internet needed.
* [http://cgi.omroep.nl/cgi-bin/streams?/tv/vpro/tegenlicht/bb.20030629.rm?title=Bekijk%20de%20uitzending%20WAR%20ON%20DRUGS%20DEEL%20II%20in%20realvideo%20BREEDBAND%20tot%20500%20kbs War on drugs] ''Part II: Losers,'' documentary (50 min) showing downside of the 'War on Drugs' by [http://www.vpro.nl/programma/tegenlicht/service_info/19361409/ Tegenlicht] of VPRO [[Netherlands|Dutch]] television. After short introduction in Dutch (1 min), English spoken. Broadband internet needed.
* [http://www.drugwarfacts.org/ Drug War Facts]
* [http://www.drugsense.org/html/ DrugSense]
* [http://www.alternet.org/drugreporter/24690/ Smoked Out]
* [http://www.libcom.org/history/articles/war-on-drugs/index.php The War on (certain) drugs]
* [http://www.drugwarprisoners.org/ The Committee on Unjust Sentencing]
* [http://www.tdpf.org.uk/ Transform Drug Policy Foundation]
* [http://www.tdpf.org.uk/Transform_After_the_War_on_Drugs.pdf After the War on Drugs: Options for Control (Report)]
* [http://deoxy.org/pdfa/index.htm Partnership for Drug Freedom in America]
* [http://www.druglibrary.org/special/friedman/socialist.htm ''The Drug War as a Socialist Enterprise'' by Milton Friedman]
* [http://www.napnt.org Network Against Prohibition]
* [http://www.erowid.org Erowid: Drug facts, legality and other information]
* [http://www.mtholyoke.edu/~cmguhnkn/plancolombia/ Plan Colombia - By Carmen Guhn-Knight]
* [http://www.luminist.org/archives/lsd.htm Confessions of an Amerikan LSD Eater] - essay
* [http://www.pbs.org/wgbh/pages/frontline/shows/drugs/special/math.html Do the Math:Why the Illegal Drug Business is Thriving] from [[Frontline (PBS)]]
* [http://druglibrary.org/schaffer/Library/nylawyer.htm A WISER COURSE: ENDING DRUG PROHIBITION] by the [[New York City]] [[Bar association|Bar Association]]
* [http://www.journals.uchicago.edu/JPE/journal/issues/v114n1/31017/brief/31017.abstract.html?erFrom=1243145922870840605Guest The Market for Illegal Goods: The Case of Drugs] an analysis of the [[social cost]]s of the War on Drugs by [[Gary Becker|Gary S. Becker]] and [[Kevin M. Murphy]]
* [http://www.harmreductionjournal.com/content/3/1/6 The war on marijuana: The transformation of the war on drugs in the 1990s] by Ryan S. King and Marc Mauer from ''Harm Reduction Journal''
* [http://www.huffingtonpost.com/walter-cronkite/telling-the-truth-about-t_b_16605.html ''Telling the Truth About the War on Drugs'' by Walter Cronkite]
* [http://www.quihn.org.au Fact sheets, personal stories and discussions on illicit drug use]

[[Category:Drugs]]
[[Category:Law enforcement in the United States]]
[[Category:Moral panics]]
[[Category:Political neologisms]]
[[Category:Richard Nixon]]
[[Category:United States controlled substances law]]
[[Category:War on something|Drugs]]

[[es:Guerra contra las drogas]]
[[de:Krieg gegen Drogen]]

Substance abuse

2006-06-20T02:54:05Z

Quihn: /* External links */

{{selfref|See also: [[Recreational drug use]].}}
'''Drug abuse''' has a wide range of definitions, all of them relating either to the misuse or overuse of a [[psychoactive drug]] or [[performance enhancing drug]] for a non-therapeutic or non-medical effect, or referring to any use of illegal drug in the absence of a required, yet practically impossible to get, license from a government authority, in the USA this is the [[DEA]]. Some of the most commonly abused drugs include [[Ethanol|alcohol]], [[amphetamines]], [[barbiturate]]s, [[caffeine]], [[cannabis]], [[cocaine]], [[methaqualone]], [[nicotine]], [[opioid|opium alkaloids]], and minor [[tranquilizer]]s. Use of these drugs may lead to criminal penalty in addition to possible physical, social, and psychological harm, both strongly depending on local jurisdiction.<ref name="mosby">(2002). ''Mosby's Medical, Nursing, & Allied Health Dictionary''. Sixth Edition. Drug abuse definition, p. 552. Nursing diagnoses, p. 2109. ISBN 0323014305.</ref> Other definitions of drug abuse fall into four main categories: public health definitions, mass communication and vernacular usage, medical definitions, and political and criminal justice definitions.{{fact}}

==Definitions==
===Public health definitions===
[[Image:Spectrum Diagram.PNG|thumb|right|400px|Source: [http://www.cfdp.ca/bchoc.pdf A Public Health Approach to Drug Control in Canada, Health Officers Council of British Columbia, 2005]]]

In recent decades, [[public health]] practitioners have attempted to look at drug abuse from a broader perspective than the individual, emphasising the role of society, culture and availability. Rather than accepting the loaded terms alcohol or drug "abuse," many public health professionals have adopted phrases such as "alcohol and drug problems" or "harmful/problematic use" of drugs.

The Health Officers Council of [[British Columbia]] — in their 2005 policy discussion paper, ''[http://www.cfdp.ca/bchoc.pdf A Public Health Approach to Drug Control in Canada]'' — has adopted a public health model of psychoactive substance use that challenges the simplistic black-and-white construction of the binary (or complementary) [[antonym]]s "use" vs. "abuse". This model explicitly recognizes a spectrum of use, ranging from beneficial use to [[addiction|chronic dependence]] (see diagram to the right).

===Mass communication and vernacular usage===

The term "drug abuse" may be used in newspapers, television, etc. in an ambiguous, catch-all sense<ref name="schaeffer">[http://www.druglibrary.org/schaffer/library/studies/ota/appc.htm Schaffer Library on Drug Policy - Perspectives on Defining Substance Abuse]</ref> rather than as a [[medical]] or legal term, sometimes disapprovingly to refer to any drug use at all, particularly of illicit drugs<ref name="wholexicon">[http://www.who.int/substance_abuse/terminology/who_lexicon/en/ World Health Organization Lexicon]</ref>.

===Medical definitions===

In the modern medical profession, the two most used diagnostic tools in the world, the [[American Psychiatric Association]]'s [[Diagnostic and Statistical Manual of Mental Disorders]] (DSM) and the [[World Health Organization]]'s [[ICD|International Statistical Classification of Diseases and Related Health Problems]] (ICD), no longer recognise 'drug abuse' as a current medical diagnosis. Instead, they have adopted ''[[substance abuse]]'' as a blanket term to include drug abuse and other things. However, other definitions differ; they may entail psychological or physical ''[[substance dependence|dependence]]'', and may focus on treatment and prevention in terms of the social consequences of substance use.

====Historical positions of the American Psychiatric Association====

In the early 1950s, the first edition of the [[American Psychiatric Association]]'s ''[[Diagnostic and Statistical Manual of Mental Disorders]]'' referred to both alcohol and drug abuse as part of [[Sociopathic Personality Disturbances]], which were thought to be symptoms of deeper psychological disorders or moral weakness <ref name="schaeffer" />. By the third edition, in the 1980s, drug abuse was grouped into 'substance abuse'.

In 1972, the American Psychiatric Association created a definition that used legality, social acceptability, and even cultural familiarity as qualifying factors:

<blockquote>''…as a general rule, we reserve the term drug abuse to apply to the illegal, nonmedical use of a limited number of substances, most of them drugs, which have properties of altering the mental state in ways that are considered by social norms and defined by statute to be inappropriate, undesirable, harmful, threatening, or, at minimum, culture-alien.'' <ref name="apa1972">Glasscote, R.M., Sussex, J.N., Jaffe, J.H., Ball, J., Brill, L. (1972). ''The Treatment of Drug Abuse: Programs, Problems, Prospects''. Washington, D.C.: Joint Information Service of the American Psychiatric Association and the National Association for Mental Health.</ref></blockquote>

====Historical positions of the American Medical Association====

In 1966, the [[American Medical Association]]'s Committee on Alcoholism and Addiction defined abuse of stimulants (amphetamines, primarily) in terms of "medical supervision":

<blockquote>''…"use" refers to the proper place of stimulants in medical practice; "misuse" applies to the physician's role in initiating a potentially dangerous course of therapy; and "abuse" refers to self-administration of these drugs without medical supervision and particularly in large doses that may lead to psychological dependency, tolerance and abnormal behavior.''</blockquote>

====Handbook on Drug and Alcohol Abuse====

The ''[[Handbook on Drug and Alcohol Abuse]]'' defines drug abuse as "''nonmedical use of drugs, both drugs that have and those that do not have generally accepted medical value''".<ref name="winger">Winger, Gail. (1992). ''A Handbook on Drug and Alcohol Abuse: The Biomedical Aspects''. Oxford University Press. ISBN 019506397X</ref>

===Political and criminal justice definitions===

Most countries have [[legislation]] designed to criminalise some drug use. Usually however the legislative process is self-referential, defining abuse in terms of what is made illegal. The legislation concerns lists of drugs specified by the legislation. These drugs are often called ''illegal drugs'' but, generally, what is illegal is their [[license|unlicensed]] production, supply and possession. The drugs are also called ''controlled drugs'' or ''controlled substances''.

====World Health Organization====

The World Health Organization (WHO), a public health agency comprised of delegates appointed by the governments of member nations, is considered by many to be a medical authority. Definitions found in WHO reports are often used as the basis for legislation at national, regional and local levels. The WHO also produces the ''ICD'', a major diagnostic resource used by medical professionals worldwide.

Although it consists largely of public health professionals, the WHO is an arm of the [[United Nations]] political body, and is therefore responsive to the needs of, demands from, and prevailing views among the UN member states that appoint WHO delegates. The manner in which the WHO has recognized and dealt with 'drug abuse' over the years reflects a continuing struggle to reconcile conflicting historical, political, social, cultural, and medical viewpoints.

In its early reports, the WHO Expert Committee on Addiction-Producing Drugs used the terms 'abuse' and 'addiction' interchangeably. Beginning in 1950s, attempts were made to distinguish between scientific and emotionally-charged terminology. However, the term 'abuse' was still inserted into definitions of addiction and dependency.

In 1957, while not explicitly saying that 'drug abuse' was synonymous with 'addiction', the committee first attempted to clarify existing definitions of addiction and habituation as had been in common parlance since at least 1931:

<blockquote>''Drug addiction is a state of periodic or chronic intoxication produced by the repeated consumption of a drug (natural or synthetic). Its characteristics include: (i) an overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means; (ii) a tendency to increase the dose; (iii) a psychic (psychological) and generally a physical dependence on the effects of the drug; and (iv) detrimental effects on the individual and on society.''</blockquote>

<blockquote>''Drug habituation (habit) is a condition resulting from the repeated consumption of a drug. Its characteristics include (i) a desire (but not a compulsion) to continue taking the drug for the sense of improved well-being which it engenders; (ii) little or no tendency to increase the dose; (iii) some degree of psychic dependence on the effect of the drug, but absence of physical dependence and hence of an abstinence syndrome [withdrawal], and (iv) detrimental effects, if any, primarily on the individual.''</blockquote>

In 1964, a new WHO committee found these definitions to be inadequate, and suggested using the blanket term 'drug dependence':

<blockquote>''The definition of addiction gained some acceptance, but confusion in the use of the terms addiction and habituation and misuse of the former continued. Further, the list of drugs '''abused''' increased in number and diversity. These difficulties have become increasingly apparent and various attempts have been made to find a term that could be applied to '''drug abuse''' generally. The component in common appears to be dependence, whether psychic or physical or both. Hence, use of the term 'drug dependence', with a modifying phase linking it to a particular drug type in order to differentiate one class of drugs from another, had been given most careful consideration. The Expert Committee recommends substitution of the term 'drug dependence' for the terms 'drug addiction' and 'drug habituation'.'' <ref name="eddy">Eddy, N.B., Halbach, H., Isbell, H., Seevers, M.H. (1965) Drug dependence: its significance and characteristics. ''Bulletin of the World Health Org.'', 23:721–722</ref> (emphasis added)</blockquote>

The committee did not clearly define dependence, but did go on to clarify that there was a distinction between physical and psychological ('psychic') dependence. It said that drug abuse was "''a state of psychic dependence or physical dependence, or both, on a drug, arising in a person following administration of that drug on a periodic or continued basis.''" Psychic dependence was defined as a state in which "''there is a feeling of satisfaction and psychic drive that requires periodic or continuous administration of the drug to produce pleasure or to avoid discomfort''" and all drugs were said to be capable of producing this state:

<blockquote>''There is scarcely any agent which can be taken into the body to which some individuals will not get a reaction satisfactory or pleasurable to them, persuading them to continue its use even to '''the point of abuse''' — that is, to excessive or persistent use beyond medical need.'' <ref name="eddy" /> (emphasis added)</blockquote>

This is believed to be the first reference to "medical need" as a factor in the distinction between use and abuse. <ref name="zinberg">Zinberg, Norman E. (1984). ''Drug, Set and Setting: The Basis for Controlled Intoxicant Use''. Oxford University Press. ISBN 0-300-03110-6. p. 38</ref>

In 1965, the same WHO committee commented further<ref name="who1965">United Nations. Office of Drugs and Crime. [http://www.unodc.org/unodc/en/bulletin/bulletin_1965-01-01_4_page007.html World Health Organization Expert Committee on Dependence-producing Drugs: Fourteenth Report]. Last accessed: August 7, 2005.</ref>, now providing a specific definition of abuse:

<blockquote>''Drug abuse is the consumption of a drug apart from medical need or in unnecessary quantities. Its nature and significance may be considered from two points of view: one relates to the interaction between the drug and the individual, the other to the interaction between drug abuse and society. The first viewpoint is concerned with drug dependence and the interplay between the pharmacodynamic actions of the drug and the physiological and psychological status of the individual. The second — the interaction between drug abuse and society — is concerned with the interplay of a wide range of conditions, environmental, sociological, and economic.''</blockquote>

<blockquote>''Individuals may become dependent upon a wide variety of chemical substances that produce central nervous system effects ranging from stimulation to depression. All of these drugs have one effect in common: they are capable of creating, in certain individuals, a particular state of mind that is termed "psychic dependence ".''</blockquote>

<blockquote>''Some drugs… induce physical dependence, which is an adaptive state that manifests itself by intense physical disturbances when the administration of the drug is suspended or when its action is affected by the administration of a specific antagonist.''</blockquote>

The committee offered several disclaimers of its definitions:

<blockquote>''It must be emphasized that drug dependence and drug abuse, as used by the Committee, are general terms and carry no connotation of the degree of risk to public health or of the need for drug control or for a particular type of drug control. The Committee would point out again that the recommendation for the use of the terms drug abuse and drug dependence of this or that type must not be regarded as a re-definition; rather, these terms are intended as descriptive expressions for clarification in scientific reference, interdisciplinary discussions, and national and international procedures.''</blockquote>

The 1969 edition of the WHO's [[ICD|International Statistical Classification of Diseases and Related Health Problems]] (ICD) manual defined drug abuse as "''persistent or sporadic excessive drug use inconsistent with or unrelated to acceptable medical practice''", modern editions have not used the term because of its ambiguity<ref name="wholexicon" />, preferring instead to refer to the cluster of symptoms previously called 'drug abuse' as 'substance abuse'.

In 1973, these statements and recent legislation based upon the term "dependence" rather than "addiction" or "abuse" were praised by President Richard M. Nixon's National Commission on Marihuana and Drug Abuse in its final report:

<blockquote>''The Commission applauds the much-belated attempt by the scientific community to sever its conceptual apparatus from the vocabulary of politics and emotion. "Addiction," like "narcotics" and "drug abuse," has a general connotation of evil, suggesting illicit ecstasy, guilt and sin. Because the public image is conditioned more by cultural perceptions than by medical ones, medically-precise meanings simply cannot be harmonized with common parlance.'' <ref name="ncmda1973">National Commission on Marihuana and Drug Abuse. (1973) Report: ''Drug Use In America: Problem in Perspective''. Washington, D.C.: Government Printing Office.</ref></blockquote>

And in 1975, the WHO further distanced itself from the term 'drug abuse':

<blockquote>''"Drug abuse" is a term in need of some clarification. …The term is really a convenient, but not very precise, way of indicating that (1) an unspecified drug is being used in an unspecified manner and amount … and (2) such use has been judged by some person or group to be wrong (illegal or immoral) and/or harmful to the user or society, or both. What might be called "drug abuse" by some would not necessarily be considered so by others. … For these reasons, the term "drug abuse" is avoided here'' <ref name="kramer">Kramer, J.F., Cameron, D.C., (eds.). (1975). A Manual on Drug Dependence. Geneva: WHO. p. 16.</ref></blockquote>

The World Health Organization presently prefers to use the terms ''harmful use'' and ''hazardous use'' (of drugs), in order to distinguish between the health effects of drug abuse rather than the social consequences. Another preferred term is ''drug misuse'', defined as the "''use of a substance for a purpose not consistent with legal or medical guidelines, as in the non-medical use of prescription medications.''" According to WHO, the term misuse is preferred by some in the belief that it is less judgmental. <ref name="wholexicon" />

However, the 1957 and 1964–1965 WHO definitions of addiction, dependence and drug abuse persist to the present day in medical literature and have become entrenched in global legislation, despite the disclaimers and reliance on contentious assumptions. The WHO itself continues to use 'drug abuse' in its publications, and uses the term 'abuse' consistently and exclusively when discussing the control and consumption of illegal substances. This is in keeping with guidelines issued by the WHO's parent organization, the United Nations, which discourages any recognition of "recreational" or "responsible" use of drugs. <ref name="un1987">(1987) ''The United Nations and Drug Abuse Control''. New York: United Nations. p.49.</ref>

Researchers may take note that somewhat less contentious definitions of addiction, dependence, and tolerance (with no speculation as to their roles in the definition of drug abuse) were jointly issued in 2001 by the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine in the publication "Definitions Related to the Use of Opioids for the Treatment of Pain".

====NIDA====

The US [[National Institute on Drug Abuse]] defines drug abuse as "''The use of illegal drugs or the inappropriate use of legal drugs. The repeated use of drugs to produce pleasure, to alleviate stress, or to alter or avoid reality (or all three)''."

====Nixon Administration====

In 1975, psychiatrist [[Jerome H. Jaffe]] (in his role as [[Drug Policy Director]] in the [[Richard M Nixon|Nixon]] Administration) defined drug abuse as "''the use, usually by self-administration, of any drug in a manner that deviates from the approved medical or social patterns within a given culture''". According to Jaffe, the term "''conveys the notion of social disapproval, and it is not necessarily descriptive of any particular pattern of drug use or its potential adverse consequences''".<ref name="jaffe">Jaffe, J.H. (1975). Drug addiction and drug abuse. In L.S. Goodman & A. Gilman (Eds.) ''The pharmacological basis of therapeutics (5th ed.)''. New York: MacMillan. pp. 284–324.</ref>

==Abuse potential==

Some of the most commonly abused drugs are [[alcohol]], [[anabolic steroids]], [[amphetamines]], [[analgesic]]s, [[barbiturates]], [[benzodiazepines]], [[caffeine]], [[cannabis (drug)|cannabis]], [[cocaine]], [[laxative]]s, [[methaqualone]], [[opiates]], and [[tobacco]]. Depending on the actual compound, drug abuse may lead to health problems, social problems, physical dependence, or psychological addiction.

Some drugs that are subject to abuse have [[central nervous system]] (CNS) effects, which produce changes in mood, levels of awareness or perceptions and sensations. Most of these drugs also alter systems other than the CNS. But, not all centrally acting drugs are subject to abuse, which suggests that altering consciousness is not sufficient for a drug to have abuse potential. Among drugs that are abused, some appear to be more likely to lead to uncontrolled use than others, suggesting a possible hierarchy of drug-induced effects relative to abuse potential.<ref name="jaffe" />

==Approaches to managing drug abuse==

Attempts by government-sponsored drug control policy to interdict drug supply and eliminate drug abuse have been largely unsuccessful. In the [[United States]], the number of nonviolent drug offenders in prison exceeds by 100,000 the total incarcerated population in the [[EU]], despite the fact that the EU has 100 million more citizens. In spite of the huge efforts by the U.S., drug supply and purity has reached an all time high, with the vast majority of resources spent on interdiction and [[law enforcement]] instead of [[public health]].{{fn|6}}

In addition to being a major public health problem, some consider drug abuse to be a social problem with far-reaching implications. Stress, poverty, domestic and societal violence, and various diseases (i.e., injecting drug users as a source for HIV/AIDS) are sometimes thought to be spread by drug use. Studies have also shown that individuals dependent on illicit drugs experience higher rates of comorbid psychiatric syndromes. {{fn|diala}}

===Harm reduction===
{{Main|Harm reduction}}
One alternative involves replacing failed law enforcement policies with harm-reduction strategies, which focus on reducing the societal costs of drug abuse and other drug use. Techniques include education to avoid overdose, [[needle exchange]] programs to reduce the spread of [[blood-borne disease]]s, and opioid substitution therapy to reduce crime related to the procurement of drugs. This pragmatic approach is known as the [[harm reduction]] paradigm. Harm reduction also addresses special populations, such as drug-using parents, pregnant drug users and users with psychiatric comorbidity. The philosophy of harm reduction accepts that drug use is part of the community, but that it must be addressed as a public health issue rather than a criminal one.<ref name="phillips">Phillips, Prashant. (Oct, 2004). "Care of Drug Users in General Practice: a harm reduction approach." Book review. ''Mental Health Practice'' 8:i2. p. 29.</ref>

Harm-reduction measures are at odds with the prevailing framework of international drug control, which rests on law enforcement and the criminalization of behaviors related to illicit [[drug use]]. However, harm-reduction has had a notable impact and is slowly gaining popularity. In [[Brazil]] alone, a comprehensive harm-reduction and drug-access program successfully reduced [[AIDS]] mortality among injection drug users by 50%.<ref name="cmaj2005">Editorial. (Mar 1, 2005) "HIV, harm reduction and human rights/VIH, reduction des prejudices et droits de la personne." ''Canadian Medical Association Journal''. 172:(5). p.605.</ref>

===Medical treatment===

Beyond the sociological issues, many drugs of abuse can lead to [[addiction]], [[chemical dependency]], or adverse health effects, such as [[lung cancer]] or [[emphysema]] from [[cigarette]] smoking.

Medical treatment therefore centers on two aspects: 1) breaking the addiction, 2) treating the health problems.

Most countries have health facilities that specialize in the treatment of drug abuse, although access may be limited to larger population centers and the social taboos regarding drug use may make those who need the medical treatment reluctant to take advantage of it. For example, it is estimated that only fifteen percent of injection drug abusers thought to be in need are receiving treatment.<ref name="appel">Appel, P.W., Ellison, A.A., Jansky, H.K., Oldak, R. (Feb 2004). "Barriers to enrollment in drug abuse treatment and suggestions for reducing them: opinions of drug injecting street outreach clients and other system stakeholders". ''[http://www.findarticles.com/p/articles/mi_m0978/is_1_30/ai_n6170830/pg_1 American Journal of Drug and Alcohol Abuse]''.</ref> Patients may require acute and long-term maintenance treatment and relapse prevention, complemented by suitable rehabilitation. <ref name="qureshi">Qureshi N.A., al-Ghamdy Y.S., al-Habeeb T.A. (2000). "Drug addiction: a general review of new concepts and future challenges". ''[http://www.emro.who.int/Publications/EMHJ/0604/13.htm East Mediterr Health J.]'' Jul;6(4):723-33. PMID 11794078</ref>

====Therapy====

The development of pharmacotherapies for drug dependency treatment are currently in progress. New immunotherapies that prevent drugs like cocaine, methamphetamine, [[phencyclidine]], [[nicotine]], and [[opioids]] from reaching the brain are in the early stages of testing as is [[ibogaine]], an alkaloid found in the Tabernanthe [[iboga]] plant of West Central Africa. Medications such as [[Buprenorphine]], which block the drugs active site in the brain are another new option for the treatment of opioid addiction. Depot forms of medications, which require only weekly or monthly dosing, are also under investigation.

Traditionally, new pharmacotherapies are quickly adopted in primary care settings, however, drugs for substance abuse treatment have faced many barriers . [[Naltrexone]], a drug marketed under the name "ReVia," is a medication approved for the treatment of alcohol dependence. Unfortunately, this drug has reached very few patients. This may be due to a number of factors, including resistance by addiction treatment providers and lack of resources. <ref name="bcsse">Board on Behavioral, Cognitive, and Sensory Sciences and Education (BCSSE). (2004) ''[http://www.nap.edu/books/0309091284/html/ New Treatments for Addiction: Behavioral, Ethical, Legal, and Social Questions]''. The National Acadamies Press. pp. 7–8, 140–141</ref>

===Legal treatment===

''Related articles: [[Prohibition (drugs)]], [[Arguments for and against drug prohibition]]''

Most countries have [[legislation]] designed to criminalise drug abuse. Usually however this is limited to drugs specified by the legislation. These drugs are often called ''illegal drugs'' but, generally, what is illegal is their [[license|unlicensed]] production, supply and possession. The drugs are also called ''controlled substances''. Legal punishments, even for simple possession, can be quite severe (including the [[death penalty]] in some countries). Legal regimes vary across countries, and even within them, and have fluctuated widely throughout history.

Despite (and perhaps because of) the legislation many large, organized criminal [[drug cartel]]s operate world-wide. Advocates of decriminalization argue that it is the legislation which makes drug dealing such a lucrative business, and leads to much of the associated criminal activity.

==See also==
* [[Drug addiction]]
* [[List of street names of drugs]]
* [[Rat Park]]
* [[Doping]]
* [[Opium Wars]]
* [[Inhalant]]

==Notes==

<references />







==External links==

* [http://www.nida.nih.gov/NIDAHome.html National Institute on Drug Abuse], Part of US National Institute of Health. Focused on research of drug abuse and addiction.
* [http://taylorandfrancis.metapress.com/(ekjf0k454rmuiibwonxynf55)/app/home/journal.asp?referrer=parent&backto=linkingpublicationresults,1:101223,1 American Journal of Drug and Alcohol Abuse], Focusing on the pre-clinical, clinical, pharmacological, administrative, and social aspects of substance misuse, this journal provides an exchange of ideas between the various modalities involved in the study and treatment of drug abuse and alcoholism.
* [http://www.interventionguide.com/ Drug Abuse and Intervention]
* [http://www.drugskilled.com/ Drug Information and Action - Wall of Dead Addicts]
* [http://www.ibogaine.org/ The Ibogaine Dossier] A resource library of ibogaine and ibogaine related information.
* [http://www.quihn.org.au Fact sheets and personal stories concerning illicit drug use]

[[Category:Drug rehabilitation]]
[[Category:Substance-related disorders]]

[[de:Drogenmissbrauch]]
[[fr:Toxicomanie]]

Needle and syringe programmes

2006-06-20T02:52:09Z

Quihn: /* References */

A '''needle-exchange programme''' is a [[controversy|controversial]] [[social policy]], based on the philosophy of [[harm reduction]], whereby people can obtain [[hypodermic needle]]s and [[syringe]]s without a [[Medical prescription|prescription]] for little or no cost. They may require the exchange of a ''dirty'' (used) needle for the clean needle, and education on [[drug abuse]] and [[blood-borne disease]]s may be provided. As the primary function of such services is to disseminate clean injecting equipment (safe disposal of used equipment is a secondary aim) the more accurate term '''needle and syringe programme''' is sometimes used.

The policy is aimed at injection [[recreational drug use|drug]] users. The idea is to prevent the reuse and sharing of contaminated needles. Needle sharing is a major cause of the spread of certain diseases, notably [[HIV]] and [[hepatitis]] C. In the [[United States]] a third of all new [[HIV]] infections can be traced to needle sharing and almost 50% of long-term addicts have hepatitis C. The provision of a needle exchange therefore provides a social benefit in reducing health costs and also provides a means to dispose of used needles in a safe manner.
Countries where these programmes exist include: [[Australia]], [[Canada]], [[New Zealand]], [[United Kingdom]] and the [[United States]]; however in the United States such programs may not receive federal funding.

The provision of needle-exchange programmes is opposed by certain groups on the grounds that it represents a weakening of the "[[War on Drugs]]" and encourages drug use and associated criminality. European studies have found the provision of needles does not cause a rise in drug use. In the US the use of federal funds for needle-exchange programmes was banned in 1988 and most states criminalise the possession of needles without a prescription, even so far as to arrest people as they leave private needle-exchange centres. Nonetheless, every state of the United States except [[Delaware]] and [[New Jersey]] has a program that supports needle exchange in some form or the purchase of new needles without a prescription at pharmacies.<ref>{{cite news
|author = Chris Barrish
|url = http://www.delawareonline.com/apps/pbcs.dll/article?AID=/20060610/NEWS/606100309
|title = To stop AIDS 'breeding ground' needle exchange a must, many say
|publisher = [[The News Journal]]
|pages = A1, A5 |date = 10 June 2006 |accessdate = 10 June 2006
}} ''Note: this article contains a picture of the interior of a "shooting gallery"''</ref>

[[Critic]]s state these programmes endorse injection drug use and don't provide encouragement to drug users to become abstinent. However, all existing credible scientific evidence flatly refutes such notions; the exchange programs are very effective and do not promote use. These findings have been endorsed by, among others, former United States Surgeon General Dr. Davis Satcher, former Director of the [[National Institutes of Health]] Dr. Harold Varmus, and former Secretary of the [[Department of Health and Human Services]], [[Donna Shalala]].

==See also==
*[[War on drugs]]
*[[Arguments for and against drug prohibition]]
*[[Demand reduction]]
*[[Recreational drug use]]
*[[Hard and soft drugs]]
*[[Drug abuse]]
*[[Drug possession]]
*[[Drug addiction]]
*[[Moral panic]]
*[[Taboo]]

==References==
* {{cite web | title=Syringe Exchange | work="Common Sense for Drug Policy Presents the Facts: Syringe Exchange & Safe Injection Facilities" | url=http://www.drugwarfacts.org/syringee.htm | accessdate=May 1| accessyear=2005}}
*{{cite web
| last = Perry| first = Michael| date = 16 March 2001
| url = http://www.freerepublic.com/forum/a3ab26d744005.htm
| title = Sydney Heroin Injecting Room Ready for Business
| format = Blog| publisher = FreeRepublic.com
| accessdate = 10 June 2006
}} ''Note: the original article is attributed to the cited author; the content was posted to the blog by 'GeekDejure' and attributed to Reuters via DailyNews.Yahoo.com
* {{cite journal
| last = Day | first = Carolyn
| coauthors = Louisa Degenhardt, Stuart Gilmour, Wayne Hall
| year = 2004 | month = August
| title = Effects of reduction in heroin supply on injecting drug use: analysis of data from needle and syringe programmes
| journal = BMJ (British Medical Journal) | volume = 329 | issue = 7463 | pages = 428–429
| doi = 10.1136/bmj.38201.410255.55
| url = http://bmj.bmjjournals.com/cgi/content/full/329/7463/428
| accessdate = 10 June 2006
}}
==External links==
[http://www.quihn.org.au Needle Syringe Programs in Queensland and illicit drug information]

===Notes===
<References/>

[[Category:Drugs]]
[[Category:Medical ethics]]
[[Category:Prevention]]

[[de:Spritzentausch]]

Drug harmfulness

2006-06-20T00:05:56Z

Quihn:

'''Hard and soft drugs''' are loose categories of [[psychoactive drug]]s. This distinction is used in both official and casual discourse. The term '''hard drug''' generally refers to drugs illegal for nonmedical use that lead to profound and severe [[addiction]], as opposed to '''soft drugs''' that are either only mildly psychologically addictive or non-addictive.

==Hard drugs==
[[Cocaine]] (in powder form or in smokable form as ''crack''), the [[amphetamine]]s, and the [[opiate]]s such as [[heroin]] and [[morphine]], are most commonly referred to as ''hard drugs''. According to some researchers, [[alcohol]]{{Citation needed}} and [[nicotine]]{{Citation needed}}, while freely available for sale in many countries, should be described as hard drugs because they are both addictive and associated with high mortality rates. In most popular discourse, however, ''hard drugs'' refers to drugs illegal for nonmedical use associated with highly visible problematic users, namely heroin, cocaine, and methamphetamine.

==Soft drugs==
The term ''soft drug'' is most usually applied to cannabis ([[marijuana]] or [[hashish]]) because it is not associated with deaths, crime or violence amongst users and is without evidence of physical addiction. This distinction between soft drugs and hard drugs is important in the [[drug policy of the Netherlands]], where [[Cannabis cultivation|cannabis production]], [[Coffeehouse#Cannabis coffee shops|retailing]] and use come under official tolerance ([[Dutch language|NL]] ''gedoogbeleid''), subject to certain conditions.

==Hallucinogens==
Some consider certain [[hallucinogens]] to be hard drugs, but as most hallucinogens are non-addictive, nor are they known for causing deaths, such drugs generally occupy a middle ground - neither hard nor soft{{Citation needed}}. The possible exceptions are [[phencyclidine|PCP]], [[DXM]] and the [[phenethylamine]]-based [[empathogen]]s such as [[MDMA]], many of which are closely related to amphetamines; being relatively new to the drug culture more research is needed to ascertain the addictive potential and potential harms of these drugs.

The drug policy of the Netherlands classifies synthetic hallucinogens such as [[LSD]] (acid) and [[MDMA]] (ecstasy) as hard drugs, although they have very similar action to naturally occurring drugs such as [[mescaline]], which is considered a soft drug in its natural form of [[peyote]], or [[psilocybin]] in its natural form as [[psilocybe]] (magic mushrooms). Both are sold legally in the Netherlands in their unprocessed natural form.

==External links==
* [http://www.quihn.org.au Information and harm reduction strateiges on a range of soft and hard illicit drugs]

[[Category:Drugs]]
{{med-stub}}

[[de:Weiche Drogen]]
[[nl:Softdrug]]
[[sv:Lätta droger]]

Harm reduction

2006-06-20T00:01:43Z

Quihn: /* External links */

'''Harm reduction''' is a [[philosophy]] of [[public health]] intended to be a [[progressivism|progressive]] alternative to the prohibition of certain [[lifestyle]] choices. The central idea of harm reduction is the recognition that some people always have and always will engage in behaviours which carry risks, such as [[casual sex]] and [[substance abuse]]. Harm reduction seeks to mitigate the potential harm associated with these behaviours without attempting to prohibit the behaviors. Harm reductionists contend that no one should be denied services such as [[healthcare]] and [[social security]] merely because they take risks. Further, harm reduction seeks a social justice response to substance abuse, as opposed to a criminalizing one.

Some critics of harm reduction contend that it appears to condone and even facilitate behaviors seen by some as immoral, dangerous, or socially destabilizing. For this reason, harm reduction has been very controversial in the [[United States]], but less so in [[Europe]], [[Australia]] and [[New Zealand]].

Discussion about harm reduction in the United States is very polarized. Advocates are often characterized as "pro-drug" and critics are often characterized as responding from "[[moral panic]]". There is a third group that advocates an approach sometimes referred to as gradualism. Gradualism advocates are concerned that harm reduction programs are sometimes rooted in pessimism about the ability of addicts to recover and represent the "soft bigotry of low expectations." They are unlikely to categorize interventions as "good" or "bad". Rather, they tend to be more concerned that programs move clients toward abstinence when windows of opportunity open.

Harm reduction initiatives range from widely accepted [[designated driver]] campaigns, to more controversial initiatives like the provision of [[condom]]s in schools, safe injection rooms, drug legalization, and [[heroin]] maintenance programs.

== Drugs ==
=== Cannabis ===
Perhaps most commonly, harm reduction advocates view the prohibition of [[cannabis]] as outdated, ineffective and counter-productive. Among other arguments, they point out that [[Health issues and the effects of cannabis|health risks of cannabis]] use are relatively low, that cannabis is used anyway despite attempts to outlaw it, and that the prohibition might have the effect of criminalizing and marginalizing otherwise law-abiding cannabis users.

Some harm reductionists favor outright [[legalization]] of cannabis, allowing its sale e.g. through [[Netherlands|Dutch]]-style "[[Coffee shop#Cannabis coffee shops|coffee shop]]s". Others think the best option would be some degree of [[decriminalization]], such as allowing the possession of small amounts of cannabis and possibly its cultivation for personal use, while concentrating law-enforcement resources on more serious crimes.

Cannabis decriminalization has been a hotly debated issue in many parts of the world, especially in many Western European countries such as [[Belgium]], [[Germany]], [[United Kingdom]], [[Portugal]], and [[Spain]], where some measures have been taken towards lifting the ban on cannabis.

''Related articles'': [[Legal issues of cannabis]], [[Health issues and the effects of cannabis]], [[Cannabis rescheduling in the United States]]

=== Methadone ===

{{POV-section}}

Some harm reductionists advocate the availability of the synthetic drug [[methadone]] (or, more recently, of [[buprenorphine]]) for users who are dependent on [[opiates]] (e.g. [[heroin]], [[codeine]]). Methadone does not cause as strong a sense of euphoria in the user, but it does reduce or eliminate the cravings associated with [[withdrawal]]. Therefore, harm reductionists maintain, methadone should be made widely available to people, temporarily or permanently, to promote leading a fulfilling and healthy lifestyle. Critics of methadone treatment claim that this is merely a substitution of one addiction for another, or that methadone treatment does not work.
There is an international literature to show that methadone programmes can help heroin users stabilise their lifestyles by obtaining a legal, regulated substitute drug. This could potentially help them look after themselves, their families, and re-enter the work force or pursue further education. These are the building blocks for regaining dignity and self esteem and are imperative for those who want to re-enter mainstream society. Harm reduction is a flexible philosophy that stresses understanding of the needs of the drug user, and responding to these needs in a flexible and realistic way, working at the pace and to achieve the goals that the person wants. However, for those drug users who want to change their life substitute medication should be complemented by psychological and practical support, enabling the person to reach their stated goals. In the UK methadone prescribing is seen as a way of reducing drug related crime — the provision of substitute medication removes the need to buy drugs through the underground street market.

====Benefits of methadone treatment====

These are benefits as stated by a [[Belgium|Belgian]] [[Consensus Conference]] on Methadone Treatment, conducted by the Belgian Minister of Health. The following conclusions were sent to every Belgian doctor [http://www.habitsmart.com/meth2.htm 1].
*Methadone is an effective medication for the treatment of heroin addiction.
*Methadone reduces heroin consumption and injection, reduces mortality related to heroin addiction, reduces the risk of infection with HIV as well as hepatitis B and C, improves therapeutic compliance of HIV-positive drug addicts, facilitates detection of illness and health education strategies and is associated with an improvement in socio-professional aptitude and a reduction in delinquency.
*Prolonged treatment with proper doses of methadone is medically safe. At present, methadone has not been shown to be toxic for any organ.
*There is no scientific reason to limit the overall number of heroin addicts admitted for methadone treatment.
*Availability of methadone treatment should be increased to respond to the need for such treatment, including by private practitioners.
*Psycho-social support is not compulsory and should be adapted to the individual needs of patients.

=== Syringe Exchange and Related Programs ===
[[Image:800px-Caernarfon womens toilets.jpg|thumb|300px|right|A [[bin]] allowing for safe disposal of [[syringe|needle]]s in a [[washroom|public toilet]] in [[Caernarfon]], [[Wales]].]]
The use of heroin and certain other illicit drugs can involve hypodermic syringes. In some areas (notably in many parts of the US), these are available solely by prescription. Where availability of syringes is limited users of heroin and other drugs frequently share the syringes. As a result, one user's infection, such as [[HIV]] or Hepatitis, can quickly spread to other users through the reuse of syringes contaminated with infected blood.

The principles of harm reduction propose that syringes should be made more easily available (i.e. without a prescription). Where syringes are provided in sufficient quantities, rates of HIV are much lower than in places where supply is restricted. Harm reductionists also argue that users should be supplied free of charge at clinics set up for this purpose: so-called [[needle exchange program]]s. Critics claim that these measures will encourage addiction by making it easier to inject illicit drugs, although this has never been shown to be the case in the many evaluations of needle exchange programs.

A closely related harm reduction based initiative is the "safe injection" site (see below).

=== DanceSafe and Related Programs ===

[[DanceSafe]] is a not-for-profit organization in the [[United States]], wherein volunteers situated at [[rave party|raves]] and similar events perform free-of-charge tests on pills that participants bought on the assumption they were [[ecstasy (drug)|Ecstasy]]. These tests are viewed by proponents as a viable means of Harm Reduction because Ecstasy sold on the black market has gained somewhat of a reputation for being impure, containing unknown chemicals which can occasionally be harmful to the user. DanceSafe does not sell Ecstasy or other drugs; rather, they perform chemical tests after being provided with a sample of a pill by its owner. Harm reductionists support these programs as informing drug users of the purity of their drugs, thus decreasing the possibility of accidental overdoses and adverse drug reactions. Similar programs have been proposed and, in some cases, implemented to test the purity of other drugs. Critics of these policies claim that such programs encourage drug use by making it seem safer.

=== Drunk Driving and Alcohol-Related Programs ===

A high amount of media coverage exists informing users of the dangers of [[drunk driving|driving drunk]]. Most alcohol users are now aware of these dangers and safe ride techniques like '[[designated driver]]s' and free taxicab programs are reducing the number of drunk-driving accidents. Many cities have free-ride-home programs during holidays involving high alcohol abuse, and some bars and clubs will provide a visibly drunk patron with a free cab ride.

In New South Wales [Australia] groups of licensees have formed local liquor accords and collectively developed, implemented and promoted a range of harm minimisation programs including designated driver, late night patron transport schemes. Many of the transport schemes are free of charge to patrons to encourage them to avoid drink-driving and reduce the impact of noisy patrons loitering around late night venues.

[[Moderation Management]] is a program which helps drinkers to cut back on their consumption of alcohol and which encourages safe drinking behavior.

== Sex ==
=== Safer Sex Programs ===

Many schools now provide [[safer sex]] education to teen and pre-teen students, some of whom engage in sexual activity. Given the premise that some, if not most, kids are going to have sex, a harm-reductionist approach supports sexual education which emphasizes the use of protective devices like [[condoms]] and [[dental dam]]s to protect against unwanted pregnancy and the transmission of [[sexually transmitted disease|STD]]s. This runs contrary to the ideology of [[sexual abstinence|abstinence]]-only sex education, which holds that telling kids about sex can encourage them to engage in it.

Supporters of this approach cite statistics which they claim demonstrate that this approach is significantly more effective at preventing teenage pregnancy and STDs than abstinence-only programs; social conservatives disagree with these claims -- see the [[sex education]] article for more details on this controversy.

=== Legalized prostitution ===

There are many advocates of the legalization of [[prostitution]] in jurisdictions where it is illegal. Proponents state that there are several benefits:
* legalization allows prostitutes to escape the influence of [[pimp]]s and [[organized crime]]
* legalization allows more effective [[public health]] measures against [[sexually transmitted disease]]s
* legalization removes a [[victimless crime]] (although one could argue that the customers' families are victims, [[adultery]] is not considered a crime in most Western jurisdictions)

=== Self harm ===

Harm reduction programs work with people who are at risk of harming themselves (eg cutting, burning themselves with cigarettes etc}}. Such programs aim at education and the provision of medical services for wounds etc. The hope is that the harmful behaviour will be moderated and the person helped to keep safe as they learn to take more responsibility for their behaviour.

== Other forms of harm reduction initiative ==
Other harm reduction programs to be expanded on:
*Encouragement of the use of safer smoking practices such as vaporizers, as opposed to water pipes, cigarettes and straight pipes
*Not notifying parents about their children receiving [[contraception]]
*Not notifying parents for youth abortions
*State regulated production and distribution of currently illegal drugs

== Safer Injection Sites ==

"Safe injection rooms" are legally sanctioned, supervised facilities designed to reduce the health and public order problems associated with illegal injection drug use.

Safe injection rooms provide sterile injection equipment, information about drugs and health care, treatment referrals, and access to medical staff. Some offer counseling, hygienic and other services of use to itinerant and impoverished individuals. Most prohibit the sale or purchase of illegal drugs. Many programs require identification cards. Some restrict access to local residents and apply other admission criteria.

Evaluations of safe injection rooms generally find them successful in reducing injection-related risks and harms, including vein damage, overdose and transmission of disease. They also appear to be successful in reducing public order problems associated with illicit drug use, including improper syringe disposal and public drug use.

The first and only safe injection site in North America opened in Vancouver, B.C. in September 2003. It is called [http://www.vch.ca/sis/index.htm Insite].

There are some 47 safer injection sites in cities in Europe. Generally in Europe they are referred to as "safer consumption rooms".

Some facts about safer injection sites can be found at [http://www.drugwarfacts.org/scfsif.htm Drug War Facts].Å

== Heroin Maintenance Programs ==

Providing a medical prescription for pharmaceutical heroin (diamorphine) to heroin addicts has been seen in some countries as a way of solving the ‘heroin problem’ with potential benefits to the individual addict and to society.

In Switzerland '''Heroin Assisted Treatment''' is fully a part of the national health program. There as some 38 centers throughout the country at which dependent persons can receive heroin maintenance. The Swiss heroin maintenance [http://www.parl.gc.ca/37/1/parlbus/commbus/senate/com-e/ille-e/presentation-e/ucht1-e.htm program] is generally regarded as a success and a valuable component of that country's overall approach to managing drug use in a harm decreasing manner. See the [http://www.druglibrary.org/schaffer/Library/studies/OVERALLS.htm Report]on the Evaluation of the Swiss Scientific Studies of Medically Prescribed Narcotics to Drug Addicts.

The British have had system of heroin maintenance since the 1920's. It was de-empahsized somewhat during the 1960s-1980s as a result of the U.S. led "war on drugs". However, in recent years the British are again moving toward heroin maintenance as a legitimate component of their National Health Service. This is because evidence is clear that methadone maintenance is not the answer for all opiate dependent addicts and that heroin is a viable maintenance drug which has shown equal or better rates of success in terms of assisting hardcore users establish stable, crime-free lives. Access a British report on heroin maintenance entitled [http://www.jrf.org.uk/knowledge/findings/socialpolicy/943.asp Prescribing Heroin: what is the evidence?]

The Netherlands in another country which has has several successful studies of medically supervised heroin mainentance. Results of two major clinical studies involving 547 heroin treatment patients is available from the [http://www.ccbh.nl/ENG/index.htm CCBH] (Central Committee on the Treatment of Heroin Addicts) website.

The first, and only, North American heroin maintenance project is in Vancouver, B.C. Currently some 80+ long-term heroin addicts are taking part in the [http://www.naomistudy.ca/ NAOMI]trials. It is intended that this study will be extended to Toronto and Montreal.

== External links ==

*[http://www.harmreduction.org/idu/idu_manual.pdf Harm Reduction Coaltion], Getting Off Right: A Safety Manual for Injection Drug Users: A how-to survival guide for injection drug users.
*[http://www.anypositivechange.org The Chicago Recovery Alliance]
*[http://www.drugpolicy.org/docUploads/aboutmethadone.pdf Drug Policy Alliance], About Methadone
*[http://www.bluelight.ru Bluelight], Bluelight is an international message board that educates the public about responsible drug use by promoting free discussion.
*[http://www.erowid.org Erowid], Erowid is a member-supported organization providing access to reliable, non-judgmental information about psychoactive plants and chemicals and related issues.
*[http://TheDEA.org TheDEA.org] provides extensive, research-based information about [[MDMA]] ('ecstasy').
*[http://www.canadianharmreduction.com The Canadian Harm Reduction Network](includes content from the Toronto Harm Reduction Task Force)
*[http://www.harmredux.org Harm Reduction Project]Provides support and resourses to both the marginalized and their providers.
*[http://www.ukhra.org UK Harm Reduction Alliance]
*[http://www2.potsdam.edu/hansondj/YouthIssues/1046349581.html Harm Reduction Works]
*[http://www.harmreduction2006.ca/ 17th International Conference on the Reduction of Drug Related Harm] International Harm Reduction conference to be held in Vancouver, May 2006
*[http://www.tripproject.ca/ TRIP! Project] A Toronto-based, harm reduction-focused nightlife awareness project.
* [http://www.quihn.org.au/ Harm reduction strategies concerning illicit drug use]

{{enPW|Harm reduction}}

[[Category:Alcohol abuse]]
[[Category:Medical ethics]]
[[Category:Addiction]]
[[Category:Sex trade]]

[[fr:Réduction des risques]]
[[pl:Redukcja szkód]]

Benzodiazepine

2006-06-20T00:00:25Z

Quihn: /* External links */

[[Image:Xanax2mg.jpg|thumb|right|250px|alprazolam 2mg tablets]]

The '''benzodiazepines''' (pronounced <span class="IPA">ˌbenzəʊdaɪˈæzəpiːns</span>, also known [infrequently] as '''minor tranquilizers''') are a class of [[medication|drugs]] with [[sedative]], [[hypnotic]], [[anxiolytic]], [[anticonvulsant]], [[amnesia|amnestic]] and [[muscle relaxant]] properties. Benzodiazepines are often used for short-term relief of severe, disabling [[anxiety]] or [[insomnia]]. Long-term use can be problematic due to the development of [[drug tolerance|tolerance]] and [[addiction|dependency]]. They are believed to act on the [[GABA receptor]] [[GABA A receptor|GABA<sub>A</sub>]], the activation of which dampens higher neuronal activity. They began to be widely prescribed for stress-related ailments in the [[1960s]] and [[1970s]].

==Members==
Benzodiazepines are commonly divided into three groups: Short-acting compounds act for less than six hours and have few residual effects if taken before bedtime, but rebound insomnia may occur and they might cause wake-time anxiety. Intermediate-acting compounds have an effect for 6-10 hours, may have mild residual effects but rebound insomnia is not common. Long-acting compounds have strong [[sedative]] effects that persist. Accumulation of the compounds in the body may occur.

The various benzodiazepines are listed in order of the shortest acting to the longest acting (by the approximate [[elimination half-life]] of the drug). The elimination half life may greatly vary between individuals, especially the elderly.

===How Supplied===

{{limitedgeographicscope}}

{| class="wikitable" style="float:center; margin-left:3px;text-size:100%; text-align:right"
|-
|'''Drug Name''' || '''Common Brand Names*'''||'''[[elimination half-life|Elimination Half-Life]] (hrs)** [active metabolite]'''|| '''Primary Effects''' || '''Approximate Equivalent Dose***'''
|-
|[[Alprazolam]]||Xanax, Xanor||6-12 hours ||[[anxiolytic]]||0.5mg
|-
|[[Bromazepam]] ||Lexotan, Lexomil, Somalium||10-20 hours||[[anxiolytic]]||5-6mg
|-
|[[Chlordiazepoxide]]||Librium, Tropium||5-30 hours [36-200 hours]||[[anxiolytic]]||25mg
|-
|[[Clobazam]] ||Frisium||12-60 hours||[[anxiolytic]], [[anticonvulsant]]||20mg
|-
|[[Clonazepam]] ||Klonopin, Klonapin, Rivotril||18-50 hours||[[anxiolytic]], [[anticonvulsant]]||0.5mg
|-
|[[Clorazepate]] ||Tranxene||[36-100 hours]||[[anxiolytic]]||15mg
|-
|[[Diazepam]] ||Valium, Apzepam, Stesolid||20-100 hours [36-200]||[[anxiolytic]]||10mg
|-
|[[Estazolam]] ||ProSom||10-24 hours||[[hypnotic]]||1-2mg
|-
|[[Flunitrazepam]] ||Rohypnol, Fluscand||18-26 hours [36-200 hours]||[[hypnotic]]||1mg
|-
|[[Flurazepam]] ||Dalmane||[40-250 hours]||[[hypnotic]]||15-30mg
|-
|[[Halazepam]] ||Paxipam||[30-100 hours]||[[anxiolytic]]||20mg
|-
|[[Ketazolam]] ||Anxon||2 hours||[[anxiolytic]]||15-30mg
|-
|[[Loprazolam]] ||Dormonoct||6-12 hours||[[hypnotic]]||1-2mg
|-
|[[Lorazepam]] ||Ativan, Temesta||10-20 hours||[[anxiolytic]]||1mg
|-
|[[Lormetazepam]] ||Noctamid||10-12 hours||[[hypnotic]]||1-2mg
|-
|[[Medazepam]] ||Nobrium||36-200 hours||[[anxiolytic]]||10mg
|-
|[[Midazolam]]|| Versed, Hypnovel||3 hours (1.8-6 hours) || ||?
|-
|[[Nitrazepam]] ||Mogadon, Apodorm||15-38 hours||[[hypnotic]]||10mg
|-
|[[Nordazepam]] ||Madar, Stilny||50-120 hours||[[anxiolytic]]||?
|-
|[[Oxazepam]]||Serax, Serenid, Serepax, Sobril, Oxascand||4-15 hours ||[[anxiolytic]]||20mg
|-
|[[Prazepam]] ||Centrax||[36-200 hours]||[[anxiolytic]]||10-20mg
|-
|[[Quazepam]] ||Doral||25-100 hours||[[hypnotic]]||20mg
|-
|[[Temazepam]]||Restoril, Normison, Euhypnos||8-22 hours||[[hypnotic]]||20mg
|-
|[[Tetrazepam]]||Mylostan|| 3-26 hours ||[[Skeletal muscle relaxant]]||?
|-
|[[Triazolam]]||Halcion||2 hours ||[[hypnotic]]||0.5mg
|-
|[[DMCM]] || ? || ? ||[[anxiogenic]], [[convulsant]] || not used therapeutically
|}

<nowiki>*</nowiki>Not all trade names are listed. Click on drug name to see a more conclusive list.
<br>
<nowiki>**</nowiki>The duration of apparent action is usually considerably less than the half-life. With most benzodiazepines, noticeable effects usually wear off within a few hours. Nevertheless, as long as the drug is present it will exert subtle effects within the body. These effects may become apparent during continued use or may appear as withdrawal symptoms when dosage is reduced or the drug is stopped.
<br>
<nowiki>***</nowiki>Equivalent doses are based on clinical experience but may vary between individuals.

==Uses==
Benzodiazepines are used in many situations, depending on the [[pharmacokinetics]] of each of the constituent drugs. The main use of the short-acting benzodiazepines is in insomnia, while anxiety responds better to medium- to long-acting substances that will be required all day.

Midazolam is mostly used as an [[intravenous]] injection for [[sedation]] before surgical procedures or for emergency [[intubation]].

==Effects==
All benzodiazepines have the following, predictable effects, though some may be relatively stronger anxiolytics and others relatively stronger amnesics. Each effect is more likely to occur at higher doses. Selecting the right type of benzodiazepine for a particular patient and then prescribing it at the minimum effective dose will lessen the likelihood of adverse effects.

* Anxiolytic (reduce anxiety).
* Anticonvulsant (used against epileptic seizures).
* Antispasmodic (muscle relaxant).
* Sedative / hypnotic ("sleeping tablet" effect).
* Amnesic (producing [[anterograde amnesia]]).

==Side effects==
The side effects are predictable as they are intrinsic effects of the drug class of benzodiazepines. Knowing the relative effects of benzodiazepine types will help clinicians prescribe the most appropriate type. For example, lorazepam may not be best choice for longer term treatment in the elderly due to its stronger amnesic effects potentially aggravating forgetfulness and confusion. But then lorazepam may be a better choice for short term treatment of a younger, non-drinking patient as it is relatively less sedating.

Benzodiazepines have replaced the [[barbiturate]]s because they have a lower abuse potential and relatively lower adverse reactions (chiefly, death is a relatively common result in barbiturate overdoses) and interactions. Still, drowsiness, [[ataxia]], confusion, [[vertigo (medical)|vertigo]], impaired judgement, and a number of other effects are common.

Benzodiazepines may impair the ability to drive vehicles and to operate machinery. The impairment is worsened by consumption of alcohol, because both act as [[central nervous system]] depressants. The effects of long-acting benzodiazepines can also linger over to the following day.

==Tolerance==
Tolerance develops to many of the therapeutic effects of benzodiazepines rapidly with daily or frequent use. Unlike tolerance to other drugs such as opioids, stimulants, and nicotine, tolerance to benzodiazepines can put the patient at risk for experiencing an [[iatrogenic]] syndrome, consisting of a spectrum of side effects that can be worse than their original condition. This is why current established guidelines restrict benzodiazepine treatment to a maximum of 2-4 weeks use. Typically, tolerance to the [[hypnotic]] effects occurs within days and the [[anxiolytic]] effects usually do not persist beyond a few months. After that, the dosage may need to be increased on a regular basis to minimize the numerous unpleasant symptoms that can emerge during long-term (>4 weeks) benzodiazepine use. Eventually the patient can reach a point where increasing the dose is ineffective in relieving the side effects caused by the drug. This is why it is important for physicians to adhere to the established guidelines of 2-4 weeks maximum (including a taper). Tolerance to benzodiazepines can cause a wide range of symptoms related to nervous system dysfunction to emerge, many of these symptoms are identical to benzodiazepine withdrawal symptoms. It is important for physicians not to misinterpret benzodiazepine tolerance symptoms as a separate disease. This can result in misdiagnosis and inappropriate treatment. These symptoms may include:
* Abdominal pain and discomfort
* Agitation
* Dizziness
* Flu-like symptoms
* Tremor
* Agoraphobia
* Depersonalization
* Depression
* Irrational fear and paranoid thoughts
* Lack of concentration and confusion
* Rapid mood changes

==Abuse and dependence==
Long-term benzodiazepine usage generally leads to some form of [[drug tolerance|tolerance]] and/or [[physical dependence|dependence]]. As a Schedule IV drug, benzodiazepines are considered moderately [[addiction|addictive]]. [[Withdrawal]] symptoms may include:

* [[Insomnia]]
* Rebound REM (or dreaming) sleep
* [[Anxiety]], possible [[panic attacks]]
* [[Tachycardia]]
* [[Hypertension]]
* [[Depression (mood)|Depression]], possible [[suicidal]] ideation
* [[Tremor]]
* [[Perspiration]]
* [[Anorexia|Loss of appetite]]
* [[Delusion]]s
* [[Dysphoria]]

An abrupt discontinuation of benzodiazepines may result in a severe and very unpleasant withdrawal syndrome that may additionally result in:

* [[Seizure|Convulsions]]
* Confusion
* [[Psychosis]]
* Effects similar to [[delirium tremens]]

Hence, every person on long-term or high dosage of any benzodiazepine should be carefully weaned off the drug, preferably under medical supervision by a professional who is knowledgeable about the long-term effects of benzodiazepines. It is important to note that the withdrawal syndrome from long-term benzodiazepine use, even at low doses, can be extremely severe and debilitating, lasting months to years. This can usually be avoided or minimized by very gradually tapering off of the drug over a period of many months.

Onset of the withdrawal syndrome might be delayed, and it might be delayed longer than the barbiturate withdrawal syndrome, although withdrawal from short-acting benzodiazepines often presents early.

Some of the withdrawal symptoms are identical to the symptoms for which the medication was originally prescribed. Benzodiazepines are valued by many patients for their ability to ameliorate existing conditions, while benzodiazepine dependency can cause them.

==Intoxication==
Overdosage of benzodiazepines, particularly when combined with [[Ethanol|alcohol]], may lead to [[coma]], but does not cause severe biochemical disturbances and therefore carries a relatively good prognosis. The antidote for all benzodiazepines is [[flumazenil]] (Annexate®), which is occasionally used empirically in patients presenting with unexplained loss of consciousness in an [[emergency room]] setting.

==Legal status==
Nearly all medically-used benzodiazepines are [[Controlled Substances Act#Schedule IV drugs|Schedule IV]] in the USA under the Federal [[Controlled Substances Act]].

Flunitrazepam (Rohypnol) is treated more severely under Federal law than other benzodiazepines. For example, despite being Schedule IV like any other benzodiazepine, it is not commercially available in the United States. It also carries tougher Federal penalties for trafficking and possession than other Schedule IV drugs. With the exception of cases involving 5 grams or more of crack, flunitrazepam is the only [[controlled substance]] in which first-offense simple possession is a Federal felony.
Various other countries limit the availability of benzodiazepines legally.
Even though it is a commonly prescribed class of drugs, the [[Medicare Prescription Drug, Improvement, and Modernization Act]] specifically states that insurance companies that provide [[Medicare Part D]] plans are not required to cover benzodiazepines

==History==
The first benzodiazepine, chlordiazepoxide (Librium®) was discovered [[serendipity|serendipitously]] in [[1954]] by the Austrian scientist Dr [[Leo Sternbach]] (1908-2005), working for the [[pharmaceutical company]] [[Hoffmann-La Roche]]. Initially, he discontinued his work on the compound ''Ro-5-0690'', but he "rediscovered" it in 1957 when an assistant was cleaning up the laboratory. Although initially discouraged by his employer, Sternbach conducted further research that revealed the compound was a very effective [[sedative|tranquilizer]].

In 1963 approval for use was given to [[diazepam]] (Valium®) - a simplified version of Librium - primarily to counteract anxiety symptoms. Sleep-related problems were treated [[nitrazepam]] (Mogadon®), which was introduced in 1965 and [[flurazepam]] (Dalmane®), which was introduced in 1973.

==Pharmacology==
Benzodiazepines produce their variety of effects by modulating the [[GABA A receptor|GABA<sub>A</sub>]] receptor, the most prolific inhibitory receptor within the brain. The [[GABA A receptor|GABA<sub>A</sub>]] receptor is made up from 5 subunits out of a possible 19, and [[GABA A receptor|GABA<sub>A</sub>]] receptors made up of different combinations of subunits have different properties, different locations within the brain and importantly, different activities in regards to benzodiazepines.

In order for [[GABA A receptor|GABA<sub>A</sub>]] receptors to be sensitive to the action of benzodiazepines they need to contain an α and a γ subunit, where the benzodiazepine binds. Once bound, the benzodiazepine locks the [[GABA A receptor|GABA<sub>A</sub>]] receptor into a conformation where the neurotransmitter [[GABA]] has much higher affinity for the [[GABA A receptor|GABA<sub>A</sub>]] receptor, increasing the frequency of opening of the associated Chloride ion channel and hyperpolarising the membrane. This potentiates the inhibitory effect of the available [[GABA]] leading to sedatory and anxiolytic effects. As mentioned, different benzodiazepines can have different affinities for [[GABA A receptor|GABA<sub>A</sub>]] receptors made up of different collection of subunits. For instance, benzodiazepines with high activity at the α<sub>1</sub> are associated with sedation whereas those with higher affinity for [[GABA A receptor|GABA<sub>A</sub>]] receptors containing α<sub>2</sub> and/or α<sub>3</sub> subunits have good anti-anxiety activity.

==See also==
*[[Sedative]]
*[[Hypnotic]]
*[[Psychoactive drug]]

==References==
* Ashton H. Benzodiazepines: How They Work And How to Withdraw. 2002 Aug. [http://benzo.org.uk/manual/index.htm Fulltext].
* Atack JR. Anxioselective compounds acting at the GABA(A) receptor benzodiazepine binding site. Current drug targets. CNS and neurological disorders. 2003 Aug;2(4):213-32.
* Gerada C, Ashworth M. ABC of mental health. Addiction and dependence--I: Illicit drugs. [[British Medical Journal|BMJ]] 1997;315:297-300. [http://bmj.bmjjournals.com/cgi/content/full/315/7103/297 Fulltext]. PMID 9274553.
* Sternbach LH. ''The discovery of librium.'' Agents Actions 1972;2:193-6. PMID 4557348

==External links==
* [http://www.benzo.org.uk/ Benzo.org.uk - Benzodiazepine addiction and withdrawal]
* [http://www.drugs.com/cons/benzodiazepines_systemic.html Drugs.com - Benzodiazepines (advanced consumer information)]
* [http://www.inchem.org/documents/pims/pharm/pimg008.htm Inchem.org - Benzodiazepines]
* [http://web4health.info/en/answers/bio-benzo-menu.htm Web4Health.info - A collection of articles about Benzodiazepines]
* [http://www.quihn.org.au Information on dependency, withdrawals and harm reduction strategies on recreational use of benzodiazepines and other drugs]

{{Benzodiazepines}}

[[Category:Anticonvulsants]]
[[Category:Anxiolytics]]
[[Category:Benzodiazepines|*]]
[[Category:Hypnotics]]
[[Category:Muscle relaxants]]
[[Category:Nitrogen heterocycles]]
[[Category:Schedule IV controlled substances]]
[[Category:Sedatives]]

[[af:Benzodiasepien]]
[[cs:Benzodiazepin]]
[[da:Benzodiazepin]]
[[de:Benzodiazepine]]
[[es:Benzodiazepina]]
[[fr:Benzodiazépine]]
[[he:בנזודיאזפינים]]
[[nl:Benzodiazepine]]
[[ja:ベンゾジアゼピン]]
[[no:Benzodiazepin]]
[[nn:Benzodiazepin]]
[[pl:Benzodiazepiny]]
[[pt:Benzodiazepina]]
[[fi:Bentsodiatsepiini]]
[[sv:Bensodiazepiner]]
[[zh:苯二氮䓬类药物]]

Cold turkey

2006-06-19T23:58:28Z

Quihn:

{{otheruses}}
"'''Cold turkey'''" is a slang expression describing the actions of a person who gives up a habit or [[addiction]] all at once, rather than gradually (easing the process through tapering off or using supplemental [[medication]]). This is, of course, the cheapest method of quitting any habit, and its supposed advantage is that by not actively using supplemental methods, the person avoids thinking about the habit and therefore, the temptation.

The term allegedly derives from the comparison of a cold [[Turkey (bird)|turkey]] carcass and the state of a withdrawing addict — most notably, the cold sweats and [[goose bumps]]. It is often preceded by the verb "to go," as in "going cold turkey."

Sudden [[withdrawal]] from drugs such as [[benzodiazepines]] and [[barbiturate]]s can be extremely dangerous, leading to potentially fatal seizures. In long-time [[Alcoholism|alcoholics]], going cold turkey can cause life-threatening [[delirium tremens]] and thus is not an appropriate method for breaking an alcohol addiction. Although many people disagree, it has been said that [[nicotine]] cessation can be the most difficult form of cold turkey, more difficult than even [[heroin]] or [[cocaine]].

In the case of most other drugs, going cold turkey may be extremely unpleasant, but not actually dangerous. Stopping to take a medication that has been prescribed, however, may be dangerous.

{{seealso|Asceticism}}
{{treatment-stub}}
[[Category:Addiction]]
[[Category:Alcohol abuse]]

[[da:Kold tyrker]]
[[de:Totalentzug]]
[[nl:Cold Turkey]]

==External links==
* [http://www.quihn.org.au Information on addiction, withdrawals and harm reduction strategies concerning illicit drugs]

Addiction

2006-06-19T23:56:46Z

Quihn: /* External links */

'''Addiction''' is [[chronic disease|chronic disorder]] proposed to be precipitated by a combination of [[genetics|genetic]], [[biology|biological]]/[[pharmacology|pharmacological]] and [[sociology|social]] factors. Addiction is characterized by the repeated use of substances or behaviors in spite of serious consequences.

There is a lack of consensus as to what may properly be termed 'addiction.' Some within the medical community maintain a rigid definition of addiction and contend that the term is only applicable to a process of escalating [[drug]] or [[alcohol]] use as a result of repeated exposure. However, addiction is often applied to compulsive [[behavior]]s other than drug use, such as [[overeating]] or [[gambling]]. In all cases, the term addiction describes a chronic pattern of behavior that continues despite the direct or indirect adverse consequences that result from engaging in the behavior. It is quite common for an addict to express the desire to stop the behavior, but find himself or herself unable to cease.

Addiction is often characterized by a craving for more of the drug or behavior, increased [[drug tolerance|physiological tolerance]] to exposure, and [[withdrawal]] symptoms in the absence of the stimulus. Many drugs and behaviors that provide either pleasure or relief from pain pose a risk of addiction or [[chemical dependency|dependency]].

==Terminology and usage==
The medical community now makes a careful theoretical distinction between ''physical dependence'' (characterized by symptoms of [[withdrawal]]) and ''psychological addiction'' (or simply ''addiction''). Addiction is now narrowly defined as "uncontrolled, compulsive use despite harm"; if there is no harm being suffered by, or damage done to, the patient or another party, then clinically it may be considered compulsive, but within this narrow definition it is not categorized as "addiction". In practice, however, the two kinds of addiction are not always easy to distinguish. Addictions often have both physical and psychological components.

There is also a lesser known situation called [[pseudo-addiction]], where a patient will exhibit drug-seeking behavior reminiscent of psychological addiction, however in this case, the patients tend to have genuine pain or other symptoms that have been undertreated. Unlike true psychological addiction, however, these behaviors tend to stop as soon as their pain is adequately treated.

The term "''[[dry drunk]]''" is sometimes attached to patterns of behavior that persist after an object of dependence and/or misuse
has been removed from daily living routines. This type of behavior is fairly common in early recovery for those recovering from substance misuse.

The obsolete term ''physical addiction'' is deprecated, because of its connotations. In modern pain management with opioids: physical dependence is nearly universal but addiction is rare. Some of the highly addictive drugs (''[[hard drug]]s''), such as [[cocaine]], induce relatively little physical dependence.

Not all doctors do agree on what addiction or dependency is*, particularly because traditionally, addiction has been defined as being possible only to a psychoactive substance (for example [[alcoholism|alcohol]], [[Tobacco smoking|tobacco]], or [[drug addiction|drugs]]), which is ingested, crosses the [[blood-brain barrier]], and alters the natural chemical behavior of the brain temporarily. Many people, both psychology professionals and laypersons, now feel that there should be accommodation made to include psychological dependency on such things as [[gambling]], [[overeating|food]], [[hypersexuality|sex]], [[pornography addiction|pornography]], [[computer addiction|computers]], [[workaholic|work]], and [[shopping]] / spending. However, these are things or tasks which, when used or performed, cannot cross the blood-brain barrier and hence, do not fit into the traditional view of addiction. Symptoms mimicking withdrawal may occur with abatement of such behaviors; however, it is said by those who adhere to a traditionalist view that these withdrawal-like symptoms are not strictly reflective of an addiction, but rather of a behavioral disorder. In spite of traditionalist protests and warnings that overextension of definitions may cause the wrong treatment to be used (thus failing the person with the behavioral problem), popular media, and some members of the field, do represent the aforementioned behavioral examples as addictions.

In the contemporary view the trend is to respect the possibility that the [[hypothalmus]] creates [[peptides]] in the mind that meet and/or exceed the power of externally applied chemicals ([[alcohol, nicotine]] when addictive activities take place. Such that when an addicted gambler or shopper is satisfying their craving, unique chemicals are produced and released within the brain creating further positive reinforcement in the individual.

*note: the Diagnostic Statistical Manual (DSM IVR) specifically spells out criteria to define abuse and dependence conditions.

==Varied forms of addiction==
===Physical dependency===
''[[Physical dependence]]'' on a substance is defined by the appearance of characteristic [[withdrawal]] symptoms when the drug is suddenly discontinued. While opioids, benzodiazepines, barbiturates, alcohol and nicotine are all well known for their ability to induce physical dependence, other drugs share this property that are not considered addictive: cortisone, [[beta-blockers]] and most antidepressants are examples. So while physical dependency can be a major factor in the psychology of addiction, the primary attribute of an addictive drug is its ability to induce euphoria while causing harm.

Some drugs induce physical dependence or [[physiological tolerance]] - but not addiction - for example many [[laxative]]s, which are not psychoactive; nasal [[decongestants]], which can cause rebound congestion if used for more than a few days in a row; and some [[antidepressants]], most notably [[Effexor]] and [[Paxil]], as they have quite short [[half-lives]], so stopping them abruptly causes a more rapid change in the neurotransmitter balance in the brain than many other antidepressants. Many non-addictive prescription drugs should not be suddenly stopped, so a doctor should be consulted before abruptly discontinuing them.

The speed with which a given individual becomes addicted to various substances varies with the substance, the frequency of use, the means of ingestion, and the individual. Some [[alcoholic]]s report they exhibited alcoholic tendencies from the moment of first intoxication, while most people can drink socially without ever becoming addicted. Because of this variation, some people hypothesize that physical dependency and addiction are in large part genetically moderated. [[Nicotine]] is one of the most addictive [[psychoactive]] substances: although 35 million smokers make an attempt to quit every year, less than 7% achieve even one year of abstinence.*

[[Eating disorders]] are complicated pathological mental illnesses and thus are not considered addictions. More information about eating disorders can be found at http://www.edap.org or http://www.something-fishy.org

* From the NIDA research report on nicotine addiction.

===Psychological addiction===

''[[Psychological addictions]]'' are a dependency of the mind, and lead to psychological withdrawal symptoms. Addictions can theoretically form for any rewarding behavior, or as a habitual means to avoid undesired activity, but typically they only do so to a clinical level in individuals who have emotional, social, or [[Mental illness|psychological dysfunctions]], taking the place of normal positive stimuli not otherwise attained (see [[Rat Park]]).

{{Unreferenced}}
{{verify}}
'''Psychological [[addiction]]''', as opposed to [[addiction|physiological addiction]], is a person's need to use a drug or engage in a behavior dispite the harm caused out of desire for the effects it produces, rather than to relieve [[withdrawal]] symptoms. Instead of an actual physiological dependence on a drug, such as [[heroin]], psychological addiction usually develops out of habits that relieve symptoms of [[loneliness]] or [[anxiety]]. As the drug is indulged, it becomes associated with the release of pleasure-inducing [[endorphins]], and a cycle is started that is similar to physiological addiction. This cycle is often very difficult to break.

It is also considered possible to be both psychologically and physically addicted at the same time. Some doctors make little distinction between the two types of addiction, for the result -- [[substance abuse]] -- is the same. However, the cause of the addiction in either case is quite different, as is the type of treatment preferred.

Psychological addiction does not have to be limited only to substances; even various activities and behavioral patterns may be considered addictions if they are harmful, e.g. [[gambling]], [[Internet addiction|Internet use]], [[computer addiction|usage of computers]], [[sexual addiction|sex]]/[[pornography addiction|pornography]], [[eating disorder|eating]], [[self-harm]] or [[workaholic|work]]. A [[wikipediholic]] behavior is another example of psychological addiction.

[[Category:Abnormal psychology]]
[[Category:Addiction]]

== Addiction and drug control legislation ==

Most countries have legislation which brings various drugs and drug-like [[substance]]s under the control of licensing systems. Typically this legislation covers any or all of the opiates, cannabinoids, cocaine, barbiturates, hallucinogens and a variety of more modern synthetic drugs, and unlicensed production, supply or possession is a criminal offense.

Usually, however, drug classification under such legislation is not related simply to addictiveness. The substances covered often have very different addictive properties. Some are highly prone to cause physical dependency, whilst others rarely cause any form of compulsive need whatsoever.

Also, although the legislation may be justifiable on moral or public health grounds, it can make addiction or dependency a much more serious issue for the individual: reliable supplies of a drug become difficult to secure, and the individual becomes vulnerable to both criminal abuse and legal punishment.

==Methods of care==

Early editions of the [[American Psychiatric Association|American Psychiatric Association's]] ''[[Diagnostic and Statistical Manual of Mental Disorders]]'' (DSM) described addiction as a physical dependency to a substance that resulted in withdrawal symptoms in its absence. Recent editions, including DSM-IV, have moved toward a diagnostic instrument that classifies such conditions as dependency, rather than addiction. The [[American Society of Addiction Medicine]] recommends treatment for people with chemical dependency based on [[patient placement criteria]] (currently listed in PPC-2), which attempt to match levels of care according to clinical assessments in six areas, including:
* Acute intoxication and/or withdrawal potential
* Biomedical conditions or complications
* Emotional/behavioral conditions or complications
* Treatment acceptance/resistance
* [[Relapse]] potential
* Recovery environment

Some medical systems, including those of at least 15 states of the United States, refer to an [[Addiction Severity Index]] to assess the severity of problems related to substance use. The index assesses problems in six areas: medical, employment/support, alcohol and other drug use, legal, family/social, and psychiatric.

While addiction or dependency is related to seemingly uncontrollable urges, and may have roots in genetic predisposition, treatment of dependency is always classified as behavioral medicine. Early treatment of acute withdrawal often includes medical [[detoxification]], which can include doses of [[anxiolytic]]s or narcotics to reduce symptoms of withdrawal. An experimental drug, [[ibogaine]], is also proposed to treat withdrawal and craving. Alternatives to medical detoxification include [[acupuncture detoxification]]. In chronic opiate addiction, a surrogate drug such as [[methadone]] is sometimes offered as a form of [[opiate replacement therapy]]. But treatment approaches universal focus on the individual's ultimate choice to pursue an alternate course of action.

Therapists often classify patients with chemical dependencies as either interested or not interested in changing. Treatments usually involve planning for specific ways to avoid the addictive stimulus, and therapeutic interventions intended to help a client learn healthier ways to find satisfaction. Clinical leaders in recent years have attempted to tailor intervention approaches to specific influences that effect addictive behavior, using therapeutic interviews in an effort to discover factors that led a person to embrace unhealthy, addictive sources of pleasure or relief from pain.

{| class="prettytable" Cellpadding=4 width=60% align=center bgcolor="FOF8FF"
|- style="background-color:#AFEEEE;font-size:large"
!colspan=3|'''Treatment Modality Matrix'''
|- style="background-color:#BFEFFF"
!'''''Behavioral Pattern'''''
!'''''Intervention'''''
!'''''Goals'''''
|-
|Low self esteem, anxiety, verbal hostility
|Relationship therapy, client centered approach
|Increase self esteem, reduce hostility and anxiety
|-
|Defective personal constructs, ignorance of interpersonal means
|Cognitive restructuring including directive and group therapies
|Insight
|-
|Focal anxiety such as fear of crowds
|Desensitization
|Change response to same cue
|-
|Undesirable behaviors, lacking appropriate behaviors
|Aversive conditioning, operant conditioning, counter conditioning
|Eliminate or replace behavior
|-
|Lack of information
|Provide information
|Have client act on information
|-
|Difficult social circumstances
|Organizational intervention, environmental manipulation, family counseling
|Remove cause of social difficulty
|-
|Poor social performance, rigid interpersonal behavior
|Sensitivity training, communication training, group therapy
|Increase interpersonal repertoire, desensitization to group functioning
|-
|Grossly bizarre behavior
|Medical referral
|Protect from society, prepare for further treatment
|- style="text-align:center;font-size:small"
|colspan=3|Adapted from: ''Essentials of Clinical Dependency Counseling'', Aspen Publishers
|}

==Diverse explanations==
Several explanations (or "models") have been presented to explain addiction:

*The ''[[moral]] model'' states that addictions are the result of human weakness, and are defects of [[moral character|character]]. Those who advance this model do not accept that there is any biological basis for addiction. They often have scant sympathy for people with serious addictions, believing either that a person with greater moral strength could have the force of will to break an addiction, or that the addict demonstrated a great moral failure in the first place by starting the addiction. The moral model is widely applied to dependency on illegal substances, perhaps purely for social or political reasons, but is no longer widely considered to have any therapeutic value. Elements of the moral model, especially a focus on individual choices, have found enduring roles in other approaches to the treatment of dependencies.

*The ''[[opponent-process]] model'' generated by Richard Soloman states that for every psychological event A will be followed by its opposite psychological event B. For example, the pleasure one experiences from heroin is followed by an opponent process of withdrawal, or the terror of jumping out of an airplane is rewarded with intense pleasure when the parachute opens. This model is related to the opponent process color theory. If you look at the color red then quickly look at a gray area you will see green. There are many examples of opponent processes in the nervous system including taste, motor movement, touch, vision, and hearing. Opponent-processes occurring at the sensory level may translate "down-stream" into addictive or habit-forming behavior.

*The ''[[disease]] model'' holds that addiction is an illness, and comes about as a result of the impairment of healthy [[neurochemistry|neurochemical]] or behavioral processes. While there is some dispute among clinicians as to the reliability of this model, it is widely employed in therapeutic settings. Most treatment approaches involve recognition that dependencies are behavioral dysfunctions, and thus involve some element of physical or mental disease. Critics like [[Stanton Peele]] point to the absence of medical evidence for an implied physiological process (beyond that of simple mood state changes) that can be equated with the disease of addiction.

*The ''[[genetics|genetic]] model'' posits a genetic predisposition to certain behaviors. It is frequently noted that certain addictions "run in the family," and while researchers continue to explore the extent of genetic influence, there is strong evidence that genetic predisposition is often a factor in dependency. Researchers have had difficulty assessing differences, however, between social causes of dependency learned in family settings and genetic factors related to [[heredity]].

*The ''[[culture|cultural]] model'' recognizes that the influence of culture is a strong determinant of whether or not individuals fall prey to certain addictions. For example, alcoholism is rare among [[Saudi Arabia]]ns, where obtaining alcohol is difficult and using alcohol is prohibited. In North America, on the other hand, the incidence of [[gambling]] addictions soared in the last two decades of the [[20th century]], mirroring the growth of the gaming industry. Half of all patients diagnosed as alcoholic are born into families where alcohol is used heavily, suggesting that familiar influence, genetic factors, or more likely both, play a role in the development of addiction. What also needs to be noted is that when people don't gain a sense of moderation through their development they can be just as likely, if not more, to abuse substances than people born into alcoholic families.

*The ''blended model'' attempts to consider elements of all other models in developing a therapeutic approach to dependency. It holds that the mechanism of dependency is different for different individuals, and that each case must be considered on its own merits.

*The ''[[habit]] model'' proposed by [[Thomas Szasz]] questions the very concept of "addiction." He argues that addiction is a metaphor, and that the only reason to make the distinction between habit and addiction "is to persecute somebody." [http://www.szasz.com/drugsandfreedom1973.html (Szasz, 1973)]

==Neurobiological basis==
The development of addiction is thought to involve a simultaneous process of 1) increased focus on and engagement in a particular behavior and 2) the attenuation or "shutting down" of other behaviors. For example, animals allowed the unlimited ability to self-administer psychoactive drugs will show such a strong preference that they will forgo food, sleep, and sex for continued access. The neuro-anatomical correlate of this that the brain regions involved in driving goal-directed behavior grow increasingly selective for particular motivating stimuli and rewards, to the point that the brain regions involved in the inhibition of behavior can no longer effectively send "stop" signals. A good analogy is to imagine flooring the gas pedal in a car with very bad brakes. In this case, the limbic system is thought to be the major "driving force" and the orbitofrontal cortex is the substrate of the top-down inhibition.

A specific portion of the limbic circuit known as the mesolimbic dopaminergic system is hypothesized to play an important role in translation of motivation to motor behavior- and reward-related learning in particular. It is typically defined as the [[ventral tegmental area]] (VTA), the nucleus accumbens, and the bundle of dopamine-containing fibers that connecting them. This system is commonly implicated in the seeking out and consumption of rewarding stimuli or events, such as sweet-tasting foods or sexual interaction. However, its importance to addiction research goes beyond its role in "natural" motivation: while the specific site or mechanism of action may differ, all known drugs of abuse have the common effect in that they elevate the level of dopamine in the nucleus accumbens. This may happen directly, such as through blockade of the dopamine re-uptake mechanism (see [[cocaine]]). It may also happen indirectly, such as through stimulation of the dopamine-containing neurons of the VTA that synapse onto neurons in the accumbens (see [[opiates]]). The euphoric effects of drugs of abuse are thought to be a direct result of the acute increase in accumbal dopamine.

The human body has a natural tendency to maintain [[homeostasis]], and the central nervous system is no exception. Chronic elevation of dopamine will result in a decrease in the number of dopamine [[Transmembrane receptor|receptors]] available in a process known as [[downregulation]]. The decreased number of receptors changes the permeability of the cell membrane located post-synaptically, such that the post-synaptic neuron is less excitable- i.e.: less able to respond to chemical signaling with an electrical impulse, or [[action potential]]. It is hypothesized that this dulling of the responsiveness of the brain's reward pathways contributes to the inability to feel pleasure, known as [[anhedonia]], often observed in addicts. The increased requirement for dopamine to maintain the same electrical activity is the basis of both [[physiological tolerance]] and [[withdrawal]] associated with addiction.

Downregulation can be classically conditioned. If a behavior consistently occurs in the same environment or contingently with a particular cue, the brain will adjust to the presence of the conditioned cues by decreasing the number of available receptors in the absence of the behavior. It is thought that many drug overdoses are not the result of a user taking a higher dose than is typical, but rather that the user is administering the same dose in a new environment.

In cases of physical dependency on [[depressant]]s of the [[central nervous system]] such as opioids, [[barbiturate]]s, or alcohol, the absence of the substance can lead to symptoms of severe physical discomfort. Withdrawal from alcohol or sedatives such as barbiturates or benzodiazepines (valium-family) can result in seizures and even death. By contrast, withdrawal from opioids, which can be extremely uncomfortable, is rarely if ever life-threatening. In cases of dependence and withdrawal, the body has become so dependent on high concentrations of the particular chemical that it has stopped producing its own natural versions (endogenous ligands) and instead produces opposing chemicals. When the addictive substance is withdrawn, the effects of the opposing chemicals can become overwhelming. For example, chronic use of sedatives (alcohol, [[barbiturate]]s, or benzodiazepines) results in higher chronic levels of stimulating [[neurotransmitter]]s such as glutamate. Very high levels of glutamate kill nerve cells (called excitatory neurotoxicity)

==Criticism==
[[Levi Bryant]] has criticized the term and concept of ''addiction'' as counterproductive in psychotherapy as it defines a patient's identity and makes it harder to become a ''non-addict''. "The signifier 'addict' doesn't simply describe what I am, but initiates a way of relating to myself that informs how I relate to others."

A stronger form or criticism comes from [[Thomas Szasz]], who denies that addiction is a psychiatric problem. In many of his works, he argues that addiction is a choice, and that a drug addict is one who simply prefers a socially taboo substance rather than, say, a low risk lifestyle. In 'Our Right to Drugs', Szasz cites the biography of [[Malcolm X]] to corroborate his economic views towards addiction: Malcolm claimed that quitting cigarettes was harder than shaking his heroin addiction. Szasz postulates that humans always have a choice, and it is foolish to call someone an 'addict' just because they prefer a [[drug]] induced [[euphoria]] to a more popular and socially welcome lifestyle.

A similar conclusion to that of Thomas Szasz may also be reached through very different [[reasoning]]. This is the somewhat extreme, yet tenable, view that humans do not have [[free will]]. From this perspective, being 'addicted' to a substance is no different from being 'addicted' to a job that you work everyday. Without the assumption of free will, every human action is the result of the naturally occurring reactions of particle matter in the physical brain, and so there is no longer room for the concept of 'addiction', since, in this view, choice is an illusion of the [[human]] experience.

==Casual addiction==
The word ''addiction'' is also sometimes used colloquially to refer to something for which a person has a passion, such as [[bibliophilia|books]], [[chocoholism|chocolate]], [[workaholic|work]], or [[Webaholic|the web]].

==See also==
{{col-begin}}
{{col-break}}
* [[Akrasia]]
* [[Alcohol-related traffic crashes]]
* [[Alcohol tolerance]]
* [[Alcoholics Anonymous]]
* [[Cold turkey]]
* [[Computer addiction]]
* [[Drug addiction]]
* [[Higher order desire]]
* [[ibogaine]]
{{col-break}}
* [[E. Morton Jellinek]]
* [[Junkie]]
* [[Love-hate relationship]]
* [[Moderation Management]]
* [[Narcotics Anonymous]]
* [[Sexual addiction]]
* [[Tanha]]
* [[12-step programs]]
{{col-end}}

==External links==
* [http://gslc.genetics.utah.edu/units/addiction The New Science of Addiction: Genetics and the Brain]
* [http://www.nature.com/neuro/focus/addiction/index.html nature neurosience - Focus on Neurobiology of addiction] (freely available online through January 2006)
* [http://www.nida.nih.gov/ National Institute on Drug Abuse]
* [http://www.who.int/substance_abuse/terminology/who_lexicon/en/ World Health Organization terminology for substance use and dependence]
* [http://www.nicd.us/ National Institute on Chemical Dependency]
* [http://www.janushead.org/6-2/index.cfm Special Issue on Addiction I], ''Janus Head: Journal of Interdisciplinary Studies''
* [http://www.janushead.org/7-1/index.cfm Special Issue on Addiction II], ''Janus head: Journal of Interdisciplinary Studies''
* [http://www.quihn.org.au Information on addiction, withdrawals and harm reduction strategies concerning illicit drugs]

[[Category:Addiction|*]]
[[Category:Motivation]]
[[Category:Unsolved problems in neuroscience]]

[[ca:Addicció]]
[[cs:Závislost]]
[[de:Sucht]]
[[es:Adicción]]
[[fr:Addiction]]
[[ko:중독]]
[[hr:Ovisnost]]
[[is:Fíkn]]
[[he:התמכרות]]
[[nl:Verslaving]]
[[ja:依存症]]
[[pl:Uzależnienie]]
[[ro:Dependenţă]]
[[simple:Addiction]]
[[fi:Riippuvuus]]
[[sv:Beroende]]

Drug withdrawal

2006-06-19T23:54:44Z

Quihn:

:''For other meanings, see [[Withdrawal (disambiguation)]].''

'''Withdrawal''' refers to the characteristic signs and symptoms that appear when a drug that causes a [[physical dependency]] is regularly used for a long time and then suddenly discontinued or decreased in dosage.

==Overview==
The sustained use of many kinds of drugs causes reversible adaptations within the body that tend to lessen the drug's original effects over time, a phenomenon known as [[drug tolerance]]. To have these adaptations to a drug is to have a [[physical dependency]] on it, for when the drug is suddenly discontinued or decreased, the adaptations do not immediately disappear. Unopposed by the drug, the adaptations appear as '''withdrawal''' signs and symptoms that are generally the opposite of the drug's direct effects. Depending primarily on the drug's [[elimination half-life]], withdrawal symptoms can appear within a few hours to several days after discontinuation.

The withdrawal symptoms associated with many [[recreational drug use|recreational drugs]] are well-known. However, many drugs that do not generally cause euphoria, and are therefore not generally abused or thought of as addictive, also induce physical dependence with associated withdrawal. Examples include [[beta blockers]], [[corticosteroids]] such as cortisone, many [[anticonvulsants]] and most [[antidepressants]]. Nevertheless, sudden withdrawal from these medications can be harmful or even fatal; this is why many prescription labels explicitly warn the patient not to discontinue the drug without doctor approval.

==Withdrawal from drugs of abuse==
Central to the role of nearly all drugs that are commonly abused to produce [[euphoria]] is the [[nucleus accumbens]], the brain's "pleasure center". Neurons in the nucleus accumbens use the neurotransmitter [[dopamine]], so while specific mechanisms vary, nearly every drug of abuse either stimulates dopamine release or enhances its activity, directly or indirectly. Sustained use of the drug results in less and less stimulation of the nucleus accumbens until eventually it produces no euphoria at all. Discontinuation of the drug then produces a withdrawal syndrome characterized by [[dysphoria]] — the opposite of euphoria — as nucleus accumbens activity declines below normal levels.

Withdrawal symptoms can vary significantly among individuals, but there are some commonalities. Subnormal activity in the nucleus accumbens is often characterized by [[depression (mood)|depression]], [[anxiety]] and [[craving]], and if extreme can help drive the individual to continue the drug despite significant harm — the definition of [[addiction]] — or even to suicide.

However, addiction is to be carefully distinguished from physical dependence. Addiction is a psychological compulsion to use a drug despite harm that often persists long after all physical withdrawal symptoms have abated. On the other hand, the mere presence of even profound physical dependence does not necessarily denote addiction, e.g., in a patient using large doses of opioids to control chronic pain under medical supervision.

As the symptoms vary, some people are, for example, able to quit smoking "[[cold turkey]]" (i.e., immediately, without any tapering off) while others may never find success despite repeated efforts. However, the length and the degree of an [[addiction]] can be indicative of the severity of withdrawal.

Withdrawal is a more serious medical issue for some substances than for others. While [[nicotine]] withdrawal, for instance, is usually managed without medical intervention, attempting to give up a [[benzodiazepine]] or [[Alcoholic_beverage|alcohol]] [[Chemical dependency|dependency]] can result in [[seizures]] and worse if not carried out properly. An instantaneous full stop to a long, constant alcohol use can lead to [[delirium tremens]], which may be fatal.

An interesting side-note is that while physical dependence (and withdrawal on discontinuation) is virtually inevitable with the sustained use of certain classes of drugs, notably the opioids, psychological addiction is much less common. Most chronic pain patients, as mentioned earlier, are one example. There are also documented cases of soldiers who used [[heroin]] recreationally in Vietnam during the war, but who gave it up when they returned home (see [[Rat Park]] for experiments on rats showing the same results). It is thought that the severity or otherwise of withdrawal is related to the person's preconceptions about withdrawal. In other words, people can prepare to withdraw by developing a rational set of beliefs about what they are likely to experience. [[Self-help]] materials are available for this purpose.

==Withdrawal from prescription medicine==
As mentioned earlier, many drugs should not be stopped abruptly <ref>{{cite book
| first =
| last =
| authorlink =
| coauthors =
| year = 2002
| month =
| title = '''Coming off Psychiatric Drugs'''
| chapter =
| editor =Peter Lehmann
| others =
| edition =
| pages =
| publisher =Peter Lehmann Publishing
| location = Germany
| id = 1-891408-98-4
| url =http://www.peter-lehmann-publishing.com
}}
</ref>without the advice and supervision of a physician, especially if the medication induces dependence and the condition they are being used to treat is potentially dangerous and likely to return once medication is stopped, such as [[diabetes]], [[asthma]], [[cardiovascular disease|heart conditions]] and many brain-affecting ones - [[epilepsy]], [[hypertension]], [[schizophrenia]] and [[psychosis]], for example. To be safe, consult a doctor before discontinuing any prescription medication, unless otherwise directed, or the medication is taken only occasionally as needed.

An unsupervised acute withdrawal from the use of an [[antidepressant]] can deepen the feel of depression significantly (see "''rebound''" below), and some specific antidepressants can cause a unique set of other symptoms as well when stopped abruptly. A combination of these factors has been reported by many patients to be quite horrible to endure.

The drugs [[Venlafaxine|Effexor (venlafaxine)]] and [[Paroxetine|Paxil (paroxetine)]], both of which have relatively short [[half-lives]] in the body, are the most likely of the antidepressants to cause withdrawals. [[Fluoxetine|Prozac (fluoxetine)]], on the other hand, is the least likely of [[SSRI]] and [[SNRI]] antidepressants to cause any withdrawal symptoms, due to its exceptionally long half-life.

==Rebound==
Many substances can cause '''rebound''' effects (significant return of the original symptom in absence of the original cause) when discontinued, regardless of their tendency to cause other withdrawal symptoms. Rebound [[clinical depression|depression]] is common among users of any antidepressant who stop the drug abruptly, whose states are sometimes worse than the original before taking medication. This is somewhat similar (though generally less intense and more drawn out) than the 'crash' users of [[Ecstacy (drug)|Ecstacy]], [[amphetamines]], and other [[stimulants]] experience. Occasionally light users of [[opiates]] that would otherwise not experience much in the way of withdrawals will notice some rebound depression as well. Extended use of drugs that increase the amount of [[serotonin]] or other [[neurotransmitters]] in the brain can cause some [[receptor (biochemistry)|receptors]] to 'turn off' temporarily or become desensitized, so, when the amount of the neurotransmitter available in the [[synapse]] returns to an otherwise normal state, there are fewer receptors to attach to, causing feelings of depression until the brain re-adjusts.

Other drugs that commonly cause rebound are:
* Nasal [[decongestants]], such as Afrin ([[oxymetazoline]]) and Otrivin ([[xylometazoline]]), which can cause rebound congestion if used for more than a few days
* Many [[analgesics]] including Advil, Motrin ([[ibuprofen]]), Aspirin ([[ASA|aspirin]]), Tylenol ([[acetaminophen]] or paracetamol), and some prescription but non-[[narcotic]] painkillers, which can cause rebound headaches when taken for extended periods of time.

With these drugs, the only way to relieve the rebound symptoms is to stop the medication causing them and weather the symptoms for a few days; if the original cause for the symptoms is no longer present, the rebound effects will go away on their own.

==See also==
* [[Chemical dependency]]
* [[Drug tolerance]]

==Literature==
<references/>

==External links==
* [http://www.quihn.org.au Fact sheets, detox information and harm reduction strategies concerning illicit drugs]

[[Category:Addiction]]

[[de:Entzug (körperlich)]]
[[es:Síndrome de abstinencia]]
[[fr:Sevrage (toxicologie)]]
[[he:גמילה]]
[[fi:Vieroitusoire]]
[[tr:Yokluk sendromu]]

Arguments for and against drug prohibition

2006-06-19T23:51:35Z

Quihn: /* References and external links */

The [[prohibition (drugs)|prohibition of drugs]] is a subject of considerable controversy. The following is a presentation of '''arguments for and against drug prohibition'''.

=Arguments for prohibition=

===Health===
A common reason given for banning drug use is that drug use is unhealthy, with possible effects ranging from lowered intelligence to insanity to death by overdose, or little or no health effects at all. Some illegal drugs are statistically more dangerous than other unhealthy things. Unlike alcohol, many illegal drugs were once legal until their health problems and addictive properties were realized.

===Drug prohibition as a solution to perceived problems of society===
Some proponents of drug [[prohibition]], such as members of the [[Temperance movement]], support drug prohibition on the basis that many of the perceived problems or flaws of society are caused by the use of drugs or drug addiction. As to maintain consistency with this stance, these proponents often call for prohibition of alcohol. Proponents of drug prohibition fear a society with more addicts and drug pushers (attracted by profits) if drugs are legalized. They believe addicts are more likely to commit more crimes because their minds are altered (some drugs may cause harmful behaviour), much as drunk criminals do sometimes.

===Commercial exploitation of drug addiction===
Some people, especially those who might otherwise support drug legalization, are against it because of the impact upon society of the commercial exploitation of the addictive potential of drugs. The basic concept is that [[tobacco]] and [[alcoholic beverage|alcohol]] are extremely popular even though they are relatively more dangerous than many illegal drugs and are subjectively less pleasurable. This, critics say, is attributable to the large [[marketing]] campaigns of tobacco and alcohol companies. If these same companies were able to sell drugs that were arguably more [[addiction|addictive]] and pleasurable, then chances are even more people would become addicted. This genre of critics is pessimistic that a system could ever be created whereby drugs could be legalized but not be commercially exploited. They often call for reinstated prohibition of alcohol. One factor critics point to is the tremendous lobbying power of alcohol and tobacco companies, as well as the large areas of commerce that are already related to illegal drugs, such as t-shirts about drugs, or songs about drugs. These critics also dismiss the idea that legalizing drugs will make them cheaper, pointing to the fact that most brands of alcohol are more expensive than most illegal drugs for an equivalent level of inebriation (this might be true in the USA, UK, Scandinavian, Muslim and some other countries, but is not true in many other, most, countries; also, prescription drugs, as [[opioids]], are much cheaper, when legally bought, than similar illegal drugs). Many of these critics feel that those involved in the production of certain currently legal drugs such as tobacco and [[medical prescription|prescription]] [[opioid]]s are already profiting off of the addiction of their users. This criticism is directed not only toward the commercial exploitation of physiological addiction, but also of [[psychological addiction]], which in addition to drug use can occur in relation to many types of behavior, for example [[gambling]], [[binge eating disorder|overeating]] and economic [[conspicuous consumption|consumption]].

=Arguments against prohibition=
Arguments against drug prohibition tend to fall into one of these categories:
===Philosophic Arguments===

'''Personal freedom:'''
What persons do in their residences, according to some, should not be regulated by the government. Many argue that persons should be able to do whatever they want with their bodies, as long as they do not harm others. The argument is that drug use is a [[victimless crime]] and as such the government has no right to prohibit it or punish drug consumers, much like the government does not forbid overeating, which causes significantly more deaths per year. This can be equated with the quest for [[freedom of thought]].

'''Consistency:'''
It has been shown that ending prohibition reduces the use of hard drugs as it has in countries such as the Netherlands.
Since alcohol [[prohibition]] ended and the [[War on Drugs]] began, there has been much debate over the issue of consistency among legislators with regard to drug prohibition. Many anti-prohibition activists like to bring up the dangers of alcohol which can be severe when compared to drugs. In addition to [[anecdotal evidence]], they cite statistics to show more deaths caused by drunk driving than by drivers under the influence of marijuana, more assaults instigated by drunks than by smokers, and more property damage. Some activists argue that it is inconsistent that alcohol is legal for those over 21 in the [[United States]], while marijuana is absolutely illegal. This discrepancy is explained by the longer history of alcohol in Western society, which has caused it to be more accepted than marijuana.

===Crime/terrorism===

Critics of drug prohibition often cite the fact that the end of alcohol prohibition in 1933 led to immediate decreases in murders and robberies to support the argument that legalization of drugs could have similar effects. Once those involved in the narcotics trade have a legal method of settling business disputes, the number of murders and violent crime could drop. Robert W. Sweet, a federal judge, strongly agrees: "The present policy of trying to prohibit the use of drugs through the use of criminal law is a mistake" (Riga 53). When alcohol use was outlawed during prohibition, it gave rise to gang warfare and spurred the formation of some of the most well known criminals of the era, among them the infamous [[Al Capone]]. Similarly, drug dealers today resolve their disputes through violence and intimidation, something which legal drug vendors do not do. Prohibition critics also point to the fact that police are more likely to be corrupted in a system where bribe money is so available. Police corruption due to drugs is widespread enough, even in the US, that one pro-legalization newsletter has made it a weekly feature.[http://www.stopthedrugwar.org]

Drug money is also known as a major source of income for terrorist organizations, as President [[George W. Bush]] has mentioned. Critics assert that legalization would remove this central source of support for terror. While politicians blame drug users for financing terrorists, no clear evidence of this link has been provided.

===Proven Ineffectiveness===
The "[[War on Drugs|war on drugs]]" started in a $350 million budget in 1971 and is currently (in 2006) a $20 billion campaign. {{fact}}
After more than 30 years in practice the war on drugs is having little or no effect on the trafficking of drugs, except to make them more expensive. Since the use of all major recreational drugs except opiates has increased since the passing of the laws which illegalized them, the increase in cost cannot be said to discourage the use of the drugs.

===Romanticizing the forbidden fruit===
The war on drugs is counterproductive to the goal of discouraging drug use. The primary mechanism for this is reverse psychology. Forbidden things become fodder for rebellion, and illegal drugs have been popularized by this perception. In addition there is a great disparity of The United States' ability to enforce drug laws among those above and below the age of 18, and this causes highschool aged children to become the conduit through which drugs are distributed, contravening our "[[Fascism|protect the children]]" intentions. This argument is often summed up as "[[Adam and Eve]] didn't eat the [[forbidden fruit]] because they were hungry, but because it was forbidden."

===Criminalization increases profits for drug dealers===
Legalization would reduce the profits of drug dealing.
The illegal drug business is very profitable since the price of a product increases when it is made illegal. "''Whenever there is a great demand for a product and (the) government makes it illegal, a [[black market]] always appears to supply the demand''" (Official [[Libertarian Party (United States)|United States Libertarian Party]] Platform).

Yearly drug trafficking earnings average to about 60 billion dollars and range as high as 100 billion dollars a year (Duke and Gross 33). Marijuana is the largest cash crop in ten states and the second largest cash crop in the U.S., after corn.

"''Revenues from drug trafficking in Miami, FL., are greater than those from tourism, exports, health care, and all other legitimate businesses combined''" (Wink 108).
The U.S. illegal drug market is one-eighth of the total world market, making it the largest illegal drug market in the world (Rodriguez).

[[Janet Crist]] of the White House Office of [[National Drug Policy]] mentioned that the anti-drug efforts have had "no direct effect on either the price or the availability of cocaine on our streets" (qtd. in Boaz). Additionally, drug dealers show off expensive jewelry and clothing to young kids (Duke and Gross 33). Some of these kids are interested in making fast money instead of working legitimate jobs (Kane 157). Drug legalization would remove the "glamorous Al Capone-type traffickers who are role-models for the young" (Wink 111).

===Diverted resources increase non drug related crimes===
The War on Drugs is extremely costly to such societies that outlaw drugs in terms of taxpayer money, lives, productivity, the inability of law enforcement to pursue [[mala in se]] crimes, and social inequality. [http://www.druglibrary.org/special/friedman/socialist.htm Some proponents ] of legalization say that the financial and social costs of drug law enforcement far exceed the damages that the drugs themselves cause. For instance, in 1999 close to 60,000 prisoners (3.3% of the total incarcerated population) convicted of violating marijuana laws were behind bars at a cost to taxpayers of some $1.2 billion per year. In 1980, the total jail and prison population was 540,000, about one-quarter the size it is today. Drug offenders accounted for 6% of all prisoners. Today drug offenders account for nearly 25%.{{fact}}

===Illegal drugs are far less toxic than legal drugs===
Although there hasn't been a single substantiated case in medical history for the last 100 years of a marijuana overdose(death), two other '''legal''' drugs have caused more than half a million deaths a year in the U.S.A alone: 480,000 deaths from tobacco-related illnesses and 80,000 from alcohol abuse.[http://www.drugwarfacts.org/causes.htm] Although these drugs constitute about 20% of all yearly deaths in the U.S, and although preventable by direct prohibition, they are legal to use.

===Drug addiction as a public health issue===
If drugs were legalized, drug addiction and abuse would become a health issue, and public health would be enhanced. For one, cleaner drugs would lead to improved health. By selling drugs in state clinics or stores, the government would be able to maintain quality control over drug sales. As with [[ethanol|alcohol]], the [[Food and Drug Administration]] (in US) would guarantee purity and safety (Wink 111-113). [[Steven B. Duke]] and [[Albert C. Gross]] conclude that drug legalization would result in a reduced risk of drug poisoning or overdose. Producers and traffickers currently sell poisonously diluted drugs because they are cheaper and easier to import. Legalization would allow a control of the diluted form and extent.

''"If drug purities were standardized and clearly and accurately labeled, the likelihood of a person accidentally overdosing would be much less than it is under the present regime"'' (37-38). Administration of clean needles would lessen disease transmitted by drug abusers, including [[AIDS]]. Pregnant women with drug problems would receive better prenatal care (Duke 116-117).
Furthermore, the introduction of addictive agents added into the drug can also be regulated.

Judge [[James P. Gray]], an advocate of drug legalization, believes that the only way to solve a progressively unsuccessful [[War on Drugs|war on drugs]] is to decriminalize it and make it a health issue (Luna). Currently, it is difficult for drug users to ask for help or seek treatment because of the criminal status of drugs; drug abuse should be considered an illness. Peter J. Riga believes "it is shameful and irrational that users of [[cocaine]] and [[heroin]] are labeled criminals and go to jail—with almost no hope of therapy or [[drug rehabilitation|rehabilitation]]—while the users of the powerful drug alcohol are considered sick and given therapy." The government provides very little funding for drug treatment (53), resulting in the abuse of addicted people. New York City imprisons one drug abuser for more than 150 dollars per day, but ignores the need of the user. Convicted addicts without money have to wait at least four months for therapy (Kane 155). Treatment is "available for only about 15 [percent] of the nation's drug addicts." Recurrently, judges have to follow mandatory sentencing guidelines when prosecuting drug users. The New York Times mentions that in New York in April 1993, two federal judges were fed up with the guidelines and refused to hear any case that was drug-related (Riga 53).

Drugs cannot be used for medical purposes because of prohibition. [[Cannabis]] is a [[Controlled Substances Act|Schedule I]] drug, which means that it has no accepted medical uses. The benefits of its use include easing the pain of terminally ill patients. For chemotherapy and AIDS patients, cannabis increases their appetite and counters nausea. The [[American Medical Association]] protested the 1937 [[Marijuana]] Tax Act due to its interest in cannabis for medical purposes (McGrath 123+).

The [[Drug policy of the Netherlands|Netherlands government]] treats drug use as a health problem, not a criminal problem (although there is criminal punishment for trafficking in some "harder drugs"). Because of the country's decision, treatment for drug addiction is widely available in the [[Netherlands]]. In Amsterdam 75 percent of heroin addicts are on treatment. "[[HIV]] infection rate among injective drug users in cities like Amsterdam has dropped from 11 percent to 4 percent and is now one of the lowest in the world" (Wink 111-113).

A key component of this argument is that many of the health dangers associated with recreational drugs exist precisely because they are illegal. The government cannot enforce quality control on products sold and manufactured illegaly. Examples would include: heroin/cocaine overdoses occurring as users don't know exactly how much they are taking, heroin users injecting brick dust with which their heroin had been cut, the more toxic (and easier to make) derivative MDA sold as MDMA etc.

===User cost of drugs ===
When the cost of drugs increases, drugs users are more likely to commit crimes in order to obtain money to buy the expensive drugs (Duke 115). Legalizing drugs would make drugs reasonably cheap (Kane 155). Poor addicts or recreational users would be capable of honest work and would not be driven to commit criminal acts to support their habits.

===Racism and unequal enforcement of drug laws===
Some consider the war on drugs, at least in the United States, to be a "war on some drugs"...and some drug users. Current drug laws are enforced in such a way as to penalize African-Americans more harshly and more often than other ethnic groups, and to penalize the poor of all races more harshly and more often than the middle and upper classes. The belief that "hard" drugs such as crack cocaine warrant stronger sentences[citation needed] than "soft" drugs such as marijuana or even powder cocaine represents a double standard not supported by scientific evidence. Defendants convicted of selling crack cocaine receive equal sentences to those convicted of selling 100 times the same amount of powder cocaine. Perhaps unsurprisingly, the majority of offenders convicted for selling crack are poor and/or black, while the majority of those convicted for selling cocaine are not. In fact, Blacks only constitute 13% of all known drug users, but represent 35% of all arrests for drug possession and 74% of all those sentenced to prison for drug possession[http://www.lindesmith.org/library/factsheets/effectivenes/index.cfm]. In addition, the convention of selling crack in heavily patrolled neighborhoods makes crack dealers easier targets for arrest than cocaine dealers, who tend to operate in private areas, such as dance clubs and college campuses. If this does not demonstrate that antidrug laws are useless in themselves (so the argument goes), it shows that they are clearly being implemented inequitably.

===The creation of drug cartels===
Massive arrests of local growers of marijuana, for example, not only increases the price of local drugs, but protects the major drug cartels from any competition. Only major retailers that can handle massive shipments, have their own small fleet of aircraft, troops to defend the caravans and other sophisticated methods of eluding the police (such as lawyers), can survive by this regulation of the free market by the government.

[[Milton Friedman]] :".''..it is because it's prohibited. See, if you look at the drug war from a purely economic point of view, the role of the government is to protect the drug cartel. That's literally true''."

===Effect on producer countries===
The United States' "[[War on Drugs]]" has added considerably to the political instability in [[South America]]. The huge profits to be made from cocaine and other South American-grown drugs are largely due to the fact that it is illegal in the wealthy neighbouring nation. This drives people in the relatively poor countries of [[Colombia]], [[Peru]] and [[Brazil]] to break their own laws in organising the cultivation, preparation and trafficking of cocaine to the States. This has allowed criminal, [[paramilitary]] and [[guerrilla]] groups to reap huge profits, exacerbating already serious law-and-order and political problems. Coca farming has been practiced for centuries in [[Andes|Andean]] countries, producing coca leaves which are then chewed for their mild stimulant effect. Many of these farmers' livelihoods (whether or not they are supplying the cocaine trade) are destroyed by U.S. sponsored herbicide spraying, usually by air.

Furthermore, the sale of the illegal drugs produces an influx of dollars that is outside the formal economy, and puts pressure on the currency exchange keeping the dollar low and making the export of legal products more difficult.

===Same policy for distinctive drugs===
Many drug policies group all illegal drugs a single category. Since drugs drastically vary in their effects, dosages, methods of production, and consumption the arguments for or against drug prohibition are blurred.

In contrast the medical community will group drugs based upon common effects. This allows them to properly regulate the usage of the drugs. Should all prescription drugs be regulated under the same system, doctors may find it difficult to prescribe antibiotics due to the fact they are in the same catagory as addictive prescription drugs.

=Possible compromises=
Partial legalization of drugs, or [[decriminalization]], might satisfy both pro and con of this issue, as well as solving many of the problems that drugs cause. In a compromise, drugs would remain illegal, but drug addicts who are non-violent and are convicted for drug possession would go to a [[drug rehabilitation]] clinic instead of prison. (Currently, treatment is available for only about 15% of the U.S.'s drug addicts. Now, some people convicted of minor drug offenses may be sentenced to rehabilitation instead of prison.) Drug addicts would then be treated as the diseased, and not treated as criminals. It is said that the drug addict already lives in a cage for life --- his/her addiction. Possession of drugs would be an [[infraction]] rather than a [[felony]]. Drug dealers, violent drug addicts/possessers, and addicts who possess a large quantity of drugs (probably for sale and not personal use) would continue to go to jail as before, as felons.

This would greatly reduce overcrowded prison populations and increase real prison time for serious criminals such as murderers. For example, a murderer who is sentenced 20 years to life, but who only serves 7 actual years due to prison overcrowding, will serve about 10 years of real time when the compromise reduces prison population. By being soft on minor criminals, penalties become harder on major criminals who commit victim crimes.

[[Decriminalization]] of drugs would allow addicts to receive medical aid and free drugs from the clinic. Drug addicts would come back to the clinic regularly for the free drugs. Drug dealers would be unable to sell their drugs to addicts who get the drugs for free. The drug dealer would have to move to another country where drugs are illegal in order to sell drugs. With no dealers to catch, police can focus their limited resources on hunting down murderers, rapists, kidnappers, and other serious criminals. The number of robberies would be reduced - formerly committed by addicts who spend the stolen money on drugs. There would be fewer police deaths because there would be no shootouts between drug dealers and police. Drug pushers would not be walking around asking people if they want to buy drugs as in the Netherlands (where light drug usage is [http://www.thesite.org.uk/travelandfreetime/travel/beingthere/amsterdamdruglaws "tolerated"]), because they will go to jail, as usual.

Decriminalization has several central problems. Providing addicts with drugs requires additional funding, especially to distinguish recreational users from addicts. Since clinics would be supplied by corporations, this essentially constitute partial legalization. Without the clinic scenario, decriminalization may exacerbate problems. Since the vast majority of negative impact to society stems from black market culture (i.e. organized crime and dealer disputes), prohibition will gain more support. Decriminalization would not eliminate the black market culture. Some claim it may not be morally acceptable to incarcerate people for selling products that are legal to possess (although gun sales are accepted in some countries), or if not actually legal, only a civil offense.

Critics of partial decriminalization — who may either be on the side of prohibition or legalization — warn that the decriminalization of a soft drug (for example, [[cannabis (drug)|cannabis]]) in an area may lead to increased sale of harder drugs (for example, [[heroin]]). The problems associated with illegal heroin use — fatalities, muggings, burglaries, use of infected needles — would rise in the area, possibly leading the authorities to conclude that the full legalization of cannabis would exacerbate the situation. Furthermore, in the case of cannabis decriminalization the sale of the drug would still be illegal, and revenue from it would still go into the pockets of criminals instead of the government's treasury.

= See also =
*[[Law Enforcement Against Prohibition]]
*[[Drug addiction]]
*[[Drug possession]]
*[[Freedom of thought]]
*[[Illegal drug trade]]
*[[Perverse incentive]]
*[[Prohibition (drugs)]]
*[[Recreational drug use]]
*[[War on Drugs]]
*[[Demand reduction]]
*[[Harm reduction]]
*[[Transform Drug Policy Foundation (charity)]]
*[[Drug policy of the Netherlands]]

= References and external links =
*[http://www.encod.org European coalition for Just and effective drugs policies]
*[http://www.cato.org/dailys/06-16-99.html Drug Legalization, Criminalization, and Harm Reduction. David Boaz. CATO Institute. 16 June 1999. 2 Feb. 2004]
*[http://dictionary.reference.com/search?q=cannabis Cannabis. American Heritage Dictionary of the English Language. Fourth Edition. 2000. Rpt. in Dictionary.com 25 Mar 2004]
*[http://researcher.sirs.com War on Drugs. Mary H. Cooper. Congressional Quarterly 13 Mar. 1993: 243-258. SIRS. 1 Feb. 2004.]
*[http://www.druglibrary.org/schaffer/Misc/friedm1.htm An interview with Pro legelization Nobel laurette economist [[Milton Friedman]]]
* [http://www.quihn.org.au Information, discussions and harm reduction strategies concerning illicit drugs]
*[http://www.druglibrary.org/special/friedman/socialist.htm ''The Drug War as a Socialist Enterprise''] by [[Milton Friedman]]
*"Toward a Policy on Drugs: Decriminalization? Legalization?" [[Elliot Currie|Currie, Elliot]]. Dissent. 1993. Rpt. in "Drug Use Should Be Decriminalized." At Issue: Legalizing Drugs. Karin L. Swisher, ed., San Diego, CA.: Greenhaven Press, Inc., 1996: 55-64.
*"How Legalization Would Cut Crime." [[Steven B. Duke|Duke, Steven B.]] Los Angeles Times. 21 Dec. 1993. Rpt. in "Legalizing Drugs Would Reduce Crime." Current Controversies: Illegal Drugs. Charles P. Cozic, ed., San Diego, CA.: Greenhaven Press, Inc., 1998: 115-117.
*Rolles S. Kushlick D. Jay M. 2004 [http://www.tdpf.org.uk/Policy_General_AftertheWaronDrugsReport.htm/ "After the War on Drugs, Options for Control"] [http://www.tdpf.org.uk/ Transform Drug Policy Foundation]
*America's Longest War: Rethinking Our Tragic Crusade Against Drugs. [[Steven B. Duke|Duke, Steven B.]] and [[Albert C. Gross]]. New York: Putnam Books, 1993. Rpt. In "Legalizing Drugs Would Benefit the United States." At Issue: Legalizing Drugs. Karin L. Swisher, ed., San Diego, CA.: Greenhaven Press, Inc., 1996: 32-48.
*"Legalization Madness." [[James A. Inciardi|Inciardi, James A.]] and [[Christine A. Saum]]. Public Interest 123 (1996): 72-82. Rpt. in "Legalizing Drugs Would Increase Violent Crime." Current Controversies: Illegal Drugs. Charles P. Cozic, ed., San Diego, CA.: Greenhaven Press, Inc., 1998: 142-150.
*"Poll Shows Most Russians Against Legalization of Soft Drugs." ITAR-TASS. BBC Monitoring 26 June 2003. Newsbank. 1 Feb 2004.
*[[Mehru Jaffer|Jaffer, Mehru]], "U.N. Firm Against Legalization of Drugs." [[Inter Press Service]] 17 Apr. 2003. [[Newsbank]]. 1 Feb. 2004 [http://infoweb.newsbank.com].
*[[Joseph P. Kane|Kane, Joseph P.]] "The Challenge of Legalizing Drugs." America 8 Aug. 1992. Rpt. in "Should Drugs Be Legalized?" Taking Sides: Clashing Views on Controversial Issues in Health and Society. 2nd ed., Eileen L. Daniel, ed., Guilford, CT.: Dushkin Publishing Group, 1996: 154-158.
*[[Claire Luna|Luna, Claire]]. "Orange County Judge Gray, a Drug-War Foe, Will Run for Senate Now a [[Libertarian]], the Longtime Advocate of Legalization Will Challenge Boxer in 2004." Los Angeles Times 20 Nov. 2003: B3. Newsbank. 1 Feb. 2004 [http://infoweb.newsbank.com].
*[[Gerald W. Lynch|Lynch, Gerald W.]] "Legalizing Drugs Is Not the Solution." America 13 Feb. 1993. Rpt. in "Legalizing Drugs Would Not Reduce Crime." At Issue: Legalizing Drugs. Karin L. Swisher, ed., San Diego, CA.: Greenhaven Press, Inc., 1996: 110-113.
*[[Matt McGrath|McGrath, Matt]]. "Economic Considerations on the Legalization of Cannabis." Tufts 13 Dec. 1994. 30 July 1997. [http://www.tufts.edu/~mmcgrath/econ.html]. Rpt. in "Marijuana Should Be Legalized." Current Controversies: Illegal Drugs. Charles P. Cozic, ed., San Diego, CA.: Greenhaven Press, Inc., 1998: 112-130.
*[[Jennifer McNeely|McNeely, Jennifer]]. "Methadone Maintenance Treatment." Lindesmith Center 1997. Rpt. in "Methadone Is an Effective Treatment for Heroin Addiction." Current Controversies: Illegal Drugs. Charles P. Cozic, ed., San Diego, CA.: Greenhaven Press, Inc., 1998: 91-95.
*[[Peter McWilliams|McWilliams, Peter]]. ''[[Ain't Nobody's Business If You Do]]''. Los Angeles, CA. : Prelude Press, 1996 [http://www.mcwilliams.com/books/books/aint/ (full text)]
*[[Julia de Cruz Mendez|Mendez, Julia de Cruz]] and [[Ralf Winkler]]. "Marihuana Tax Act of 1937." Jan. 1996. 24 Mar. 2004 [http://www.dhm.de/museen/hanf/hemp9132.htm].
*[[Alastair Paulin|Paulin, Alastair]]. "Taxation Without Legalization." Mother Jones June 2003: 26. Newsbank. 1 Feb. 2004 [http://infoweb.newsbank.com].
*[[Peter J. Riga|Riga, Peter J.]] "The Drug War Is a Crime: Let's Try Decriminalization." Commonweal. 16 July 1993. Rpt. in "Legalization Would Help Solve the Nation's Drug Problem." At Issue: Legalizing Drugs. Karin L. Swisher, ed., San Diego, CA.: Greenhaven Press, Inc., 1996: 52-54.
*[[L. Jacabo Rodriguez|Rodriguez, L. Jacabo]]. "Time to End the Drug War." CATO Institute 13 Dec. 1997. 23 Feb. 2004 [http://www.cato.org/dailys/12-03-97.html].
*"Should We Re-Legalize Drugs?" [[United States Libertarian Party]]. 22 Feb. 2004 [http://www.lp.org/issues/relegalize.html].
*[[Mark Thornton|Thornton, Mark]]. "Alcohol Prohibition Was a Failure." CATO Institute 17 July 1991. 24 Mar. 2004 [http://www.cato.org/pubs/pas/pa-157.html].
*[[Walter Wink|Wink, Walter]]. "Getting Off Drugs: The Legalization Potion." Friends Journal Feb. 1996. Rpt. in "Illegal Drugs Should Be Legalized." Current Controversies: Illegal Drugs. Charles P. Cozic, ed., San Diego, CA.: Greenhaven Press, Inc., 1998: 107-114.
*[[Mortimer B. Zuckerman|Zuckerman, Mortimer B.]] "Great Idea for Ruining Kids." U.S. News & World Report 24 Feb. 1997. Rpt. in "Legalizing Drugs Would Increase Drug Use." Current Controversies: Illegal Drugs. Charles P. Cozic, ed., San Diego, CA.: Greenhaven Press, Inc., 1998: 151-152.
*[[Fred Leavitt|Leavitt, Fred]]. (2003) The REAL Drug Abusers. Rowman & Littlefield.
*[[Paul Armentano|Armentano, Paul]]. "Drug War Mythology" in You Are Being Lied To. China: The Disinformation Company Ltd., 2001. Pages 234-240
*Goldstein, P.J., Brownstein, H.H., Ryan, P.J. & Bellucci, P.A., "Crack and Homicide in New York City: A Case Study in the Epidemiology of Violence," in Reinarman, C. and Levine, H. (eds.), Crack in America: Demon Drugs and Social Justice (Berkeley, CA: University of California Press, 1997), pp. 113-130.

[[Category:Debates]]
[[Category:Drugs]]

[[de:Legalisierung von Drogen]]

Polysubstance use

2006-06-19T23:46:51Z

Quihn:

'''Poly drug use''' refers to the use two or more [[Psychotropic_drugs|drugs]] in combination to achieve a particular effect.

There are many popular drug combinations, including, but not limited to; [[marijuana]] and [[alcohol]] (sometimes known as "getting [[Crunk#Other_Meaning|crunk]]"), [[cocaine]] and [[heroin]] (known as a [[speedball (drug)|speedball]]), [[LSD]] and ecstasy (known as "[[candy flipping]]"), [[Psychedelic mushroom|mushrooms]] and ecstasy (known as "flower flipping" or "[[hippie]] flipping"), [[benzodiazepines]] and alcohol, cocaine and alcohol, heroin and marijuana, and ecstasy and [[Ketamine]].

While many recreational drug users use multiple drugs to increase intoxication for pleasurable effects, poly drug use can pertain to an increase in spiritual [[entheogenic]] properties, for example [[2C-I]] and LSD or [[morning glory]] seeds and [[San Pedro cactus]].

Poly drug use carries with it more risk than use of a single drug, due to an increase in side effects, and unique pharmacological interactions.

The phenomenon is the subject of established academic literature (e.g., Scholey AB, Parrott AC, Buchanan T, Heffernan TM, Ling J, Rodgers J (2004). "Increased intensity of Ecstasy and polydrug use in the more experienced Ecstasy/[[MDMA]] users: a WWW study." ''Addictive Behaviors'', 29, 743-752).

{{med-stub}}
[[Category:Drugs]]
External links
* [http://www.quihn.org.au Fact sheets and harm reduction strategies concerning recreational drugs]

Substance-related disorder

2006-06-19T23:44:21Z

Quihn:

'''Substance abuse''' refers to the overindulgence in and dependence on a [[stimulant]], [[depressant]], [[chemical substance]], [[herb]] ([[plant]]) or [[fungus]] leading to effects that are detrimental to the individual's [[physical health]] or [[mental health]], or the [[Quality of life|welfare]] of others.{{fn|1}}

The disorder is characterized by a pattern of continued pathological use of a medication, [[drug abuse|non-medically indicated drug or toxin]], that results in repeated adverse social consequences related to drug use, such as failure to meet work, family, or school obligations, interpersonal conflicts, or legal problems. There are on-going debates as to the exact distinctions between substance abuse and [[substance dependence]], but current practice standard distinguishes between the two by defining substance dependence in terms of physiological and behavioral symptoms of substance use, and substance abuse in terms of the social consequences of substance use.{{fn|2}}

Substance abuse may lead to addiction or substance dependence. Medically, dependence requires the development of [[physiological tolerance|tolerance]] leading to [[withdrawal]] symptoms. Both abuse and dependence are distinct from [[addiction]] which involves a [[compulsion]] to continue using the substance despite the negative consequences, and may or may not involve [[chemical dependency]]. Dependence almost always implies abuse, but abuse frequently occurs without dependence, particularly when an individual first begins to abuse a substance. Dependence involves [[physiological]] processes while substance abuse reflects a complex interaction between the individual, the abused substance and society. [http://www.mclean.harvard.edu/research/adarc/]

Substance abuse is sometimes used as a synonym for [[drug abuse]], [[drug addiction]], and [[chemical dependency]], but actually refers to the use of substances in a manner outside sociocultural conventions. All use of [[illicit drug]]s and all use of licit drugs in a manner not dictated by convention (e.g. according to physician's orders) is abuse according to this definition, however there is no universally accepted definition of substance abuse.

In the early 1950s, the first edition of the [[American Psychiatric Association]]'s [[Diagnostic and Statistical Manual of Mental Disorders]] grouped alcohol and drug abuse under Sociopathic Personality Disturbances, which were thought to be symptoms of deeper psychological disorders or moral weakness.

The third edition, in the 1980s, was the first to recognise substance abuse (including drug abuse) and substance dependence as conditions separate from substance abuse alone, bringing in social and cultural factors. The definition of dependence emphasised tolerance to drugs, and withdrawal from them as key components to diagnosis, whereas abuse was defined as "problematic use with social or occupational impairment" but without withdrawal or tolerance.

In 1987 the [[DSM-III]]R category "psychoactive substance abuse", which includes former concepts of drug abuse is defined as "a maladaptive pattern of use indicated by...continued use despite knowledge of having a persistent or recurrent social, occupational, psychological or physical problem that is caused or exacerbated by the use (or by) recurrent use in situations in which it is physically hazardous". It is a residual category, with dependence taking precedence when applicable. It was the first definition to give equal weight to behavioural and physiological factors in diagnosis.

By 1988, the DSM-IV defines substance dependence as "a syndrome involving compulsive use, with or without tolerance and withdrawal"; whereas substance abuse is "problematic use without compulsive use, significant tolerance, or withdrawal".

The fourth edition of the [[Diagnostic and Statistical Manual of Mental Disorders]] (DSM) issued by the [[American Psychiatric Association]] defines substance abuse as:{{fn|3}}

:*A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
::#Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions or expulsions from school; neglect of children or household)
::#Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
::#Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct
::#Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
:*B. The symptoms have never met the criteria for Substance Dependence for this class of substance.

==Notes==
*{{fnb|1}}(1998). ''Mosby's Medical, Nursing, & Allied Health Dictionary''. Edition 5.
*{{fnb|2}}Pham-Kanter, Genevieve. (2001). "Substance abuse and dependence." ''The Gale Encyclopedia of Medicine''. Second Edition. Jacqueline L. Longe, Ed. 5 vols. Farmington Hills, MI: Gale Group.
*{{fnb|3}}American Psychiatric Association (1994). ''Diagnostic and statistical manual of mental disorders'' (4th edition). Washington, DC.

==See also==
*[[Behavioural sciences]]
*[[Substance-abuse rehabilitation]]
*[[Arguments for and against drug prohibition]]

==External links==
*[http://www.medterms.com/script/main/art.asp?articlekey=24405 MedicineNet]
*[http://www.druglibrary.org/schaffer/library/studies/ota/appc.htm Schaffer Library of Drug Policy], Perspectives on defining substance abuse
*[http://www.interventionguide.com Substance Abuse and Intervention]
* [http://www.quihn.org.au Fact sheets, detox information and harm reduction strategies concerning illicit drugs]

[[Category:Substance-related disorders]]

[[fr:Toxicomanie]]

Depressant

2006-06-19T23:43:12Z

Quihn:

''See also [[sedative]].''

A '''depressant''' is a [[chemical]] agent that diminishes the function or activity of a specific part of the body. The term is used in particular with regard to the [[central nervous system]] (CNS). In that case these chemicals are known as [[neurotransmitter]]s. Depressants intended to act on the CNS do so by increasing the activity of a particular neurotransmitter known as [[gamma-aminobutyric acid]] (GABA).

GABA's task is to calm the CNS and to promote [[sleep]]. Drugs that stimulate the production of this [[amino acid]] produce slowed brain activity and a drowsy or calm feeling, and so depressants are generally prescribed to relieve symptoms of [[anxiety]] or [[insomnia]]. Internal systems regulate the body's production of GABA, but when [[medication]] is taken to stimulate GABA production, it is possible to induce hazardously high levels, which can dangerously slow breathing and heart rates, and may result in death.

CNS depressants require a period of [[Adaptation (biology)|adaptation]]. Typically, initial [[Adverse drug reaction|side effects]] include slurred speech, dizziness, and loss of coordination, in many respects similar to the effects of [[alcohol]] (which is itself a CNS depressant).

Depressants generally fall into two classes, ''[[barbiturate]]s'' and ''[[benzodiazepine]]s'', but also include [[narcotic]]s (or [[opioids]]) and [[sedative]]-[[hypnotic]]s. Also there are tranquilizers.

Barbiturates are effective in relieving the conditions they are designed to address; they are also readily abused, and when, in the late [[1960s]], it became clear that the [[social cost]] of barbiturates was beginning to outweigh the medical benefit, a serious search began for a replacement drug. Most people still using barbiturates do so to prevent seizures.

Benzodiazepines mediate the same symptoms as barbiturates, but without the same degree of toxic hazard. This is not to say they are not without their own risks; where barbiturates pose a greater "front-end" risk in that overdose or drug/alcohol interactions may result in fatality, benzodiazepines pose a greater "back-end" risk in the possibility of [[addiction]] and serious physical and psychological [[withdrawal]] symptoms. Even so, any suggestion that it is safe to consume alcohol while using benzodiazepines, or to attempt to stop barbiturate use "[[cold turkey]]" is foolish in the extreme.

==See also==
*[[Psychoactive drug]]
*[[Alcohol]]

==External links==

*[http://www.painfullyobvious.com/depressants_7.asp Painfully Obvious - A Community Resource]
*[http://www.rimrock.org/html/facts/pdf/CNSDepressants.pdf Rimrock Foundation Addiction Treatment Center - Depressants (in Adobe PDF format)]
* [http://www.quihn.org.au Fact sheets and harm reduction strategies about depressants and other recreational drugs]

[[Category:Psychoactive drugs]]

[[fi:Depressantti]]
[[fr:Dépresseur]]

Stimulant

2006-06-19T23:42:11Z

Quihn:

A '''stimulant''' is a [[psychoactive drug|drug]] that increases the activity of the [[sympathetic nervous system]] and produces a sense of [[euphoria]] or the feeling of being more awake. Stimulants can be used as [[recreational drug]]s or therapeutic drugs to increase alertness. They are also used and sometimes abused to boost endurance and productivity as well as to [[anorectic|suppress appetite]]. Examples of common stimulants include [[caffeine]], [[amphetamine]]s, [[cocaine]], [[Ritalin|Ritalin]] and [[ecstasy (drug)|ecstasy]].

==Amphetamines==
{{main|Amphetamine}}
Amphetamines are synthetic stimulants. They were first discovered in the 1800s, but their medical uses were not recognized until the 1930s. Then they were used to counter [[Hypotension|low blood pressure]], help [[asthma]]tics breathe more easily and decrease appetite. However, taking a lot, especially over a few days, can produce panic and [[paranoia]]. Injecting amphetamine is particularly dangerous. If injecting equipment is shared, there is the risk of infection including [[hepatitis]] and [[HIV]].

[[Attention deficit disorder]] is often treated using stimulant medications pharmacologically similar to amphetamines. The most common drugs include [[Ritalin|Ritalin (methylphenidate)]], [[Adderall|Adderall (amphetamine)]], and [[Dexedrine|Dexedrine (dextroamphetamine)]].

==Cocaine==
{{main|Cocaine}}
Cocaine is made from the leaves of the [[coca]] shrub, which grows in the mountain regions of South American countries such as [[Bolivia]], [[Colombia]], and [[Peru]]. In Europe and North America, the most common form of cocaine is a white crystalline powder. Most users [[insufflate]] it intranasally.

[[Crack cocaine]] is a smokeable form of cocaine. It is usually smoked in a pipe, glass tube, or foil. Cocaine and crack are powerful, but short-acting stimulant drugs. Crack in particular has strong but short-lived effects. Both drugs tend to make users feel more alert and energetic. Many users say that they feel very confident and physically strong. Common effects include dry mouth, sweating, loss of appetite, and increased heart and pulse rates. Excessive doses can cause death from respiratory failure or heart failure.

==Caffeine==
{{main|Caffeine}}
Caffeine is a drug that is found in [[tea]], [[coffee]], [[cocoa]] (contained in [[chocolate]]), and many [[soft drinks]] particuarly [[energy drink]]s. There is no law prohibiting the sale of any of these products in most countries. Caffeine stimulates the body, increasing [[heart rate]] and [[blood pressure]], and alertness, making some people feel better able to concentrate. Caffeine is a [[diuretic]]. Some people have suggested that children that consume a lot of caffeine may become [[hyperactive]] even after the caffiene has been metabolized.{{fact}}

==MDMA==
{{main|Methylenedioxymethamphetamine}}
Methylenedioxymethamphetamine (MDMA) is an illegally-manufactured drug that comes either in tablet or capsule form (known as [[ecstasy (drug)|ecstasy]]), as a powder or crystal. Stimulant effects of MDMA include increased blood pressure and heart rate, loss of appetite, rapid sweating, and a dry mouth and throat. It is very unusual for an ecstasy pill to contain only MDMA; they frequently contain amounts of other drugs which may include any of a wide range of substances such as [[MDA]], [[MDEA]], [[MDBD]], [[Phencyclidine|PCP]], [[DXM]], [[PMA]], [[Ketamine]], [[Caffeine]], [[Amphetamine]], [[Methamphetamine]], [[Ephedrine]], [[Pseudoephedrine]], [[Aspirin]], [[Paracetamol]], [[Fentanyl]] and, in a small number of cases, [[Heroin]], [[Cocaine]], [[Mescaline]], [[DOB]], or [[LSD]]. In some cases the substance sold as ecstasy may not contain MDMA at all.

==Antidepressants==
{{main|Antidepressant}}
Antidepressants are not considered stimulants, as they do not act directly on the sympathetic nervous system and generally do not produce an immediate effect on mood. A possible exception is [[bupropion]] (Wellbutrin), whose chemical and [[pharmacological]] properties are similar to those of stimulants.

==Other==
Recently, there have been improvements in the area of stimulant pharmacology, producing a class of chemicals known as ''[[eugeroic]]s'', or ''good arousal''. These stimulants tend to increase alertness without the peripheral (body) effects or addiction/tolerance/abuse potential of the traditional stimulants. They have minimal effect on sleep structure, and do not cause rebound hypersomnolence or "come down" effects. Currently, there are two stimulants in this class being used: [[modafinil]] and [[adrafinil]], marketed as Provigil and Olmifon, respectively.

In Russia, [[Carphedon]] is sold as a general stimulant under the brand name Phenotropil.

==See also==
*[[Psychoactive drug]]
*[[Recreational drug]]

==External links==
*[http://www.licadd.org/aboutdrugs.htm Long Island Council on Alcohol & Drug Dependence - About Drugs - Stimulants]
*[http://www.health.org/govpubs/rpo926/#Stim Prevention Online - Publications - Drugs of Abuse - Stimulants]
* [http://www.quihn.org.au Fact sheets, detox information and harm reduction strategies about stimulants and other recreational drugs]

{{stimulants}}

[[Category:Stimulants]]
[[Category:Psychoactive drugs]]



[[da:Stimulans]]
[[de:Stimulans]]
[[et:Stimulant]]
[[es:Estimulante]]
[[fr:Stimulant]]
[[ja:覚醒剤]]
[[pl:Stymulanty]]

Drug addiction

2006-06-19T23:40:42Z

Quihn:

{{neutrality}}
{{inappropriate tone}}
'''Drug addiction''', '''substance dependence''' or '''chemical dependency''' is the [[compulsion|compulsive]] use of [[psychoactive drug]]s, to the point where the user has no effective choice but to continue use. The phenomenon of drug [[addiction]] has occurred to some degree throughout recorded [[history]] (see "[[opium]]"), though modern [[agriculture|agricultural]] practices, improvements in access to drugs, and advancements in [[biochemistry]] have exacerbated the problem significantly in the [[20th century]] with the introduction of purified forms of active biological agents, and with the synthesis of hitherto unknown substances, such as [[methamphetamine]]. While "addiction" has been replaced by "dependency" as a clinical term, the terms are used interchangeably here.

The addictive nature of drugs varies from substance to substance, and from individual to individual. Drugs such as [[codeine]] or [[alcohol]], for instance, typically require many more exposures to addict their users than drugs such as [[heroin]] or [[cocaine]]. Likewise, a person who is psychologically or [[Genetics|genetically]] predisposed to addiction is much more likely to become dependent.

Although dependency on hallucinogens like [[LSD]] and [[psilocybin]] is listed as Substance-Related Disorder in the [[DSM-IV_Codes#Hallucinogen-Related_Disorders|DSM-IV]], most psychologists do not classify them as addictive drugs. Experts on addiction say that the use of LSD and psilocybin causes neither psychological nor physical dependency. There is anecdotal evidence which emerges of psychological addiction to recreational psychedelics such as MDMA (Ecstasy) and Ketamine.

Drug addiction has two components: [[body|physical]] dependency, and [[psychological]] dependency. Physical dependency occurs when a drug has been used habitually and the body has become accustomed to its effects. The person must then continue to use the drug in order to feel normal, or its absence will trigger the symptoms of [[withdrawal]]. Psychological dependency occurs when a drug has been used habitually and the mind has become emotionally reliant on its effects, either to elicit pleasure or relieve pain, and does not feel capable of functioning without it. Its absence produces intense cravings, which are often brought on or magnified by [[stress (medicine)|stress]]. A dependent person may have either aspects of dependency, but often has both.

"Chipping" is also a term used to describe a pattern of drug use in which the user is not physically dependent and sustains 'controlled use' of a drug. This is done by avoiding influences that reinforce dependence, such that the drug is used for relaxation and not for escape.

==The basis for addiction==

Scientists have long accepted that there is a [[biology|biological]] basis for drug addiction, though the exact mechanisms responsible are only now being identified. It is believed that addictive substances create dependence in the user by changing the brain's reward functions, located in the [[Mesolimbic pathway|mesolimbic]] [[dopamine]] system—the part of the brain that reinforces certain behaviors such as [[eating]], [[sexual intercourse]], [[exercise]], and social interaction. Addictive substances, through various means and to different degrees, cause the synapses of this system to flood with excessive amounts of dopamine, creating a brief rush of euphoria more commonly called a "high".

Although the high may last only a few minutes, it also produces more longer-lasting effects in the [[brain]]. Dopamine signals occurring normally in the reward system (traveling from the [[ventral tegmental area]] to the [[nucleus accumbens]]) lead to the activation of [[protein|proteins]] designed to calm the initial reaction and foster a continued desire to pursue the behavior responsible. Addictive substances create a greater than normal dopamine release, and the subsequent reactions of the brain are greatly exaggerated as well. The [[amygdala]], [[hippocampus]], and [[Frontal lobe|frontal]] [[Cerebral cortex|cortex]] associate the use of the drug with intense pleasure and well-being; an association that is strengthened with each exposure, and which over time comes to dominate normal thoughts and desires. When cravings for the drug are no longer controllable, the user is considered addicted. (For a contrary view of drug addiction, see [[Rat Park]].)''''''

Some in the medical field believe that what we call addiction is [http://powerandcontrol.blogspot.com/2004/09/addiction-or-self-medication.html self medication] for [[PTSD]]. In addition Dr. Lonny Shavelson, in his book "Hooked," has reported that 70% of [http://powerandcontrol.blogspot.com/2004/09/heroin.html female heroin addicts] were sexually abused as children. There also seems to be a [http://powerandcontrol.blogspot.com/2004/12/genetic-discrimination.html genetic] component to addiction. It is a little researched but [http://powerandcontrol.blogspot.com/2005/10/well-known-secret.html well known secret] in practicing medical circles that many addicts are self medicating for what we commonly call anxiety problems. PTSD is thought to be a common cause as is ADD/ADHD, and bipolar disorder. Some research is being done on the subject, more needs to be done.

==Evolutionary psychology view of addiction==

It is obvious that genes for addiction would not be
directly selected. Since evolution theory claims that
every physical and behavioral trait is a direct or
side effect of selection, then the capacity to be
addicted to drugs must be a side effect of something
that was selected.

A number of writers including [[Keith Henson]]
[http://human-nature.com/nibbs/02/cults.html] have
suggested that the capacity to be addicted to drugs is
a side effect of social attention rewards. It is easy
to understand how sensitivity to social rewards would
evolve in social primates. For example, [[Jane Goodall]]'s observation that chimpanzees who hunt get
additional mating opportunities. The proposed evolved
mechanism for social rewards is that attention causes
the release of endorphins and dopamine into the
brain's reward circuits.

It is proposed that addictive drugs activate brain
reward circuits that are normally activated by attention,
without the need to kill a large, dangerous animal and
drag it back to camp (or modern equivalents.)

==The chemicals responsible==

The [[CREB]] protein, a [[transcription factor]] activated by [[cyclic adenosine monophosphate]] (cAMP) immediately after a high, triggers [[gene]]s that produce proteins such as [[dynorphin]], which cuts off dopamine release and temporarily inhibits the reward circuit. In chronic drug users, a sustained activation of CREB leaves the user feeling depressed and dissatisfied, and unable to find pleasure in previously enjoyable activities, often leading to a return to the drug for an additional "fix". It also leads to a short term tolerance of the substance, necessitating that a greater amount be taken in order to reach the same high.

Another transcription factor, known as [[delta FosB]], is thought to activate genes that, counter to the effects of CREB, actually increase the user's sensitivity to the effects of the substance. Delta FosB slowly builds up with each exposure to the drug and remains activated for weeks after the last exposure—long after the effects of CREB have faded. The hypersensitivity that it causes is thought to be responsible for the intense cravings associated with drug addiction, and is often extended to even the peripheral cues of drug use, such as related behaviors or the sight of drug paraphernalia. There is some evidence that delta FosB even causes structural changes within the nuclear accumbens, which presumably helps to perpetuate the cravings, and may be responsible for the high incidence of relapse that occur in treated drug addicts.

Regulator of G-protein Signaling 9-2 (RGS 9-2) has recently been the subject of several animal knockout studies. Animals lacking RGS 9-2 appear to have increased sensitivity to dopamine receptor agonists such as cocaine and amphetamines; over-expression of RGS 9-2 causes a lack of responsiveness to these same agonists. RGS 9-2 is believed to catalyze inactivation of the G-protein coupled D2 receptor by enhancing the rate of GTP hydrolysis of the G alpha subunit which transmits signals into the interior of the cell.

==Mechanisms of effect==

The mechanisms by which different substances activate the reward system vary among drug classes.

* [[Depressant]]s such as [[alcohol]] and [[benzodiazepine]]s, and [[narcotic]]s such as [[morphine]] and [[methadone]], work by mimicking [[endorphin]]s—chemicals produced naturally by the body which have effects similar to dopamine—or by disabling the [[neuron]]s that normally inhibit the release of dopamine. These substances (sometimes called "downers") typically facilitate relaxation and pain-relief.

* [[Stimulant]]s such as [[amphetamine]]s and [[nicotine]] increase dopamine signaling, either by directly stimulating its release, or by blocking its absorption (see "[[reuptake]]"). These substances (sometimes called "uppers") typically cause heightened alertness and energy.

The most common drug addictions are to legal substances such as:
* [[Alcohol]]
* [[Nicotine]] in the form of [[tobacco]], particularly [[cigarette]]s
* [[Caffeine]] in the form of [[tea]], [[coffee]], and caffeinated sodas

Many [[prescription]] or [[over the counter]] drugs can become addictive if abused. [[anabolic steroid|Steroidal]] medications, for example, are extremely addictive. In addition, a large number of other substances are currently considered to have no medical value and are not available over the counter or by prescription. Depending on the jurisdiction, these drugs may be legal only as part of a government sponsored study, illegal to use for any purpose, illegal to sell, or even illegal to merely possess.

In [[1972]], [[United States]] President [[Richard Nixon]] declared a [[War on Drugs|war on illegal drugs]] in an attempt to control the growing problem of drug addiction and drug-related [[crime]]. It is unclear, though, whether laws against drugs do anything to stem usage and dependency. In jurisdictions where addictive drugs are illegal, they are generally supplied by [[drug dealer]]s, who are often involved with [[organized crime]]. Even though the cost of producing most illegal addictive substances is very low, their illegality combined with the addict's need permits the seller to command a premium price, often hundreds of times the production cost. As a result, the addict must often turn to crime to support their habit.

==Recovery from drug addiction==

Methods of recovery from addiction to drugs vary widely according to the types of drugs involved, amount of drugs used, duration of the drug addiction, medical complications and the social needs of the individual. Treatment is just as important for the addicted individual as for the significant others in the addicted individuals sphere of contact.

One of many recovery methods is the [[Twelve-step program|12 Step]] recovery program, with prominent examples including [[Alcoholics Anonymous]] and [[Narcotics Anonymous]]. They are commonly known and used for a variety of addictions for the individual addicted and the family of the individual. [[Substance-abuse rehabilitation]] (or "rehab") centers frequently offer a residential treatment program for the seriously addicted in order to isolate the patient from drugs and interactions with other users and dealers. Outpatient clinics usually offer a combination of individual [[counseling]] and group counseling. Frequently a physician or psychiatrist will assist with [[pharmacology|prescriptions]] to assist with the side effects of the addiction (the most common side effect that the medications can help is anxiety). People interested in not using drugs to detoxify from drugs should consider [[acupuncture detoxification]].

12 Step programs are the most common and well-known, but there are many other types of treatment programs. These other programs may use Cognitive-Behavioral Therapy, Rational-Emotive Therapy, or other types of psychological behavior modification methods. Other forms of treatment involve replacement drugs such as [[methadone]]. Although methadone is itself addictive, opium dependency is often so strong that the gradual tapering of a less-addictive substance is the only way to reliably treat the user. Other treatments, such as [[acupuncture]], may be used to help alleviate symptoms as well. Determining the best type of recovery program for an addicted person depends on a number of factors, including: personality, drug(s) of addiction, concept of spirituality or religion, mental or physical illness, and local availability and affordability of programs.

Many different ideas circulate regarding what is considered a "successful" outcome in the recovery from addiction. It has widely been established that abstinence from addictive substances is generally accepted as a "successful" outcome.

==Medical definitions==

The 1957 [[World Health Organization]] (WHO) Expert Committee on Addiction-Producing Drugs defined addiction and habituation as components of [[drug abuse]]:

<blockquote>''Drug addiction is a state of periodic or chronic intoxication produced by the repeated consumption of a drug (natural or synthetic). Its characteristics include: (i) an overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means; (ii) a tendency to increase the dose; (iii) a psychic (psychological) and generally a physical dependence on the effects of the drug; and (iv) detrimental effects on the individual and on society.''</blockquote>

<blockquote>''Drug habituation (habit) is a condition resulting from the repeated consumption of a drug. Its characteristics include (i) a desire (but not a compulsion) to continue taking the drug for the sense of improved well-being which it engenders; (ii) little or no tendency to increase the dose; (iii) some degree of psychic dependence on the effect of the drug, but absence of physical dependence and hence of an abstinence syndrome [withdrawal], and (iv) detrimental effects, if any, primarily on the individual.''</blockquote>

In 1964, a new WHO committee found these definitions to be inadequate, and suggested using the blanket term 'drug dependence':

<blockquote>''The definition of addiction gained some acceptance, but confusion in the use of the terms addiction and habituation and misuse of the former continued. Further, the list of drugs abused increased in number and diversity. These difficulties have become increasingly apparent and various attempts have been made to find a term that could be applied to drug abuse generally. The component in common appears to be dependence, whether psychic or physical or both. Hence, use of the term 'drug dependence', with a modifying phase linking it to a particular drug type in order to differentiate one class of drugs from another, had been given most careful consideration. The Expert Committee recommends substitution of the term 'drug dependence' for the terms 'drug addiction' and 'drug habituation'.''</blockquote>

The committee did not clearly define dependence, but did go on to clarify that there was a distinction between physical and psychological ('psychic') dependence. It said that drug abuse was "''a state of psychic dependence or physical dependence, or both, on a drug, arising in a person following administration of that drug on a periodic or continued basis.''" Psychic dependence was defined as a state in which "''there is a feeling of satisfaction and psychic drive that requires periodic or continuous administration of the drug to produce pleasure or to avoid discomfort''" and all drugs were said to be capable of producing this state:

<blockquote>''There is scarcely any agent which can be taken into the body to which some individuals will not get a reaction satisfactory or pleasurable to them, persuading them to continue its use even to the point of abuse — that is, to excessive or persistent use beyond medical need.''</blockquote>

The 1957 and 1964 definitions of addiction, dependence and abuse persist to the present day in medical literature. It should be noted that at this time (2006) the Diagnostic Statistical Manual (DSM IVR) now spells out specific criteria for defining abuse and dependence.

In 2001, the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine jointly issued "Definitions Related to the Use of Opioids for the Treatment of Pain," which defined the following terms:

<blockquote>''Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.''</blockquote>

<blockquote>''Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.''</blockquote>

<blockquote>''Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time.''</blockquote>

<blockquote>''Pseudoaddiction is a term which has been used to describe patient behaviors that may occur when pain is undertreated. Patients with unrelieved pain may become focused on obtaining medications, may “clock watch,” and may otherwise seem inappropriately “drug seeking.” Even such behaviors as illicit drug use and deception can occur in the patient's efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that the behaviors resolve when pain is effectively treated.''</blockquote>

== Drugs considered to be addictive (Some may be debatable) ==

* [[Alcohol]]
* [[Analgesic]]s
* [[Barbiturate]]s
* [[Buprenorphine]]
* [[Butorphanol]]
* [[Cannabis (drug)|Cannabis]]
* [[Chloral hydrate]], [[trichloroethanol]] and derivatives
* [[Cocaine]]
* [[Codeine]]
* [[Dextropropoxyphene]]
* [[Dextromethorphan]]
* [[Ethchlorvynol]]
* [[Fentanyl]] and its analogs
* [[Gamma-hydroxybutyrate]] (GHB)
* [[Glutethimide]]
* [[Heroin]] (Diacetylmorphine)
* [[Hydrocodone]]
* [[Hydromorphone]] (Dilaudid®)
* [[Ketamine]]
* [[Laxative]]s
* [[Levo-alpha-acetylmethadol]] (LAAM)
* [[Meperidine]]
* [[Meprobamate]]
* [[Methamphetamine]] and other [[Amphetamine]]s
* [[Methaqualone]] and related sedative-hypnotics
* [[Methadone]]
* [[Methcathinone]]
* [[Morphine]]
* [[Nicotine]]
* [[Oxycodone]]
* [[Opium]]
* Synthetic [[opioid]] agonists and partial agonists not considered here
* Semi-synthetic [[opiates]] not considered here
* [[Alprazolam|Xanax]]
* [[Paraldehyde]] (Paral®)
* [[Phencyclidine]] (PCP)
* [[Flunitrazepam]] (Rohypnol®)

== Addiction and drug control legislation ==

Most countries have legislation which brings various drugs and drug-like [[substance]]s under the control of licensing systems. Typically this legislation covers any or all of the opiates, canaboids, cocaine, barbiturates, hallucinogenics and a variety of more modern synthetic drugs, and unlicensed production, supply or possession is a criminal offence.

Usually, however, drug classification under such legislation is not related simply to addictiveness. The substances covered often have very different addictive properties. Some are highly prone to cause physical dependency, whilst others rarely cause any form of compulsive need whatsoever. Also, under legislation specifically about drugs, [[alcohol]] is not usually included.

Although the legislation may be justifiable on moral or public health grounds, it can make addiction or dependency a much more serious issue for the individual: reliable supplies of a drug become difficult to secure, and the individual becomes vulnerable to both criminal abuse and legal punishment.

==See also==
*[[List of heroin addicts]]
*[[Drug Mix]]
*[[Alcoholism]]
*[[Drug abuse]]
*[[Drug tolerance]]
*[[Drugs and prostitution]]
*[[Tachyphylaxis]]
*[[Rat Park]]
*''[[Robinson v. California]]'' ([[1964]]), decision by the [[U.S. Supreme Court]] that states cannot criminalize narcotics addiction itself
*[[Harm reduction]]
*[[Demand reduction]]
*[[Arguments for and against drug prohibition]]

==External links==
* [http://www.iop.kcl.ac.uk/iopweb/departments/home/default.aspx?locator=346 The National Addiction Centre]
* [http://www.acudetox.com National Acupuncture Detoxification Association]
* [http://www.peele.net/lib/cultconc.html Addiction as a Cultural Concept - Stanton Peele]
* [http://www.usdoj.gov/dea/concern/concern.htm DEA list of drugs and drug types]
* [http://www.ericdigests.org/1993/abuse.htm Substance Abuse Policy]
* [http://www.samhsa.gov U.S. Substance Abuse and Mental Health Administration]
* [http://www.addictionsearch.com Addiction Research and Resources]
* [http://www.drugalcohol-rehab.com Drug Alcohol Rehab Resource]
* [http://www.interventionguide.com Drug Intervention Information.]
* [http://www.dual-diagnosis.net Dual Diagnosis]
* [http://www.quihn.org.au Fact sheets on harm reduction strategies, detox and effects of illicit drugs]
* [http://narconon.ca/drug_addiction.htm Drug addiction explained in a simple and interesting way - Narconon]

==Literature==
* Sainsbury, ''Drug and the Drug Habit'' (New York, 1909)
* C. A. McBride, ''Modern Treatment of Alcoholism and Drug Narcotism'' (New York, 1910)
* G. E. Pettey, ''Narcotic Drug Diseases and Allied Ailments'' (Philadelphia, 1913)
* [[Fitz Hugh Ludlow]] wrote ''The Hasheesh Eater'' (1857) and ''The Opium Habit'' (1868), designed as a warning.

==References==
* Nestler, Eric and Malenka, Robert (Mar. 2004). "The Addicted Brain". ''Scientific American'', pg. 78-83.
* Leavitt, Fred (2003) The REAL Drug Abusers. Rowman & Littlefield.

[[Category:Addiction]]
[[Category:Drugs]]
[[Category:Substance-related disorders]]
[[Category:Social stigma]]

[[da:Narkoman]]
[[es:Toxicomanía]]
[[fr:Toxicomanie]]
[[it:Tossicodipendenza]]
[[pl:Narkomania]]
[[ru:Наркомания]]
[[uk:Наркоманія]]

Psychoactive drug

2006-06-19T23:38:38Z

Quihn:

A '''psychoactive drug''' or '''psychotropic substance''' is a [[chemical]] that alters [[brain]] function, resulting in temporary changes in [[perception]], [[mood (psychology)|mood]], [[consciousness]], or [[behavior]]. Such drugs are often used in [[recreational drug use]] and as [[entheogen]]s for spiritual purposes, as well as in [[medication]], especially for treating neurological and psychiatric illnesses.

Many of these substances (especially the [[stimulants]] and [[depressants]]) can be habit-forming, causing [[chemical dependency]] and often leading to [[substance abuse]]. Conversely, others (namely the [[psychedelic drug|psychedelics]]) can help to treat and even cure such [[addiction]]s.
[[Image:Pyschoactive_Drugs.jpg|thumb|right|250px|An assortment of [[psychoactive drug]]s]]

==Psychoactive drug chart==
The following [[Venn diagram]] attempts to organize and provide a basic overview of the most common psychoactive drugs into intersecting groups and subgroups based upon pharmacological classification and method of action.<ref name="mckim">{{cite book | author=William A. McKim | title=Drugs and Behavior: An Introduction to Behavioral Pharmacology (5th Edition)| publisher=Prentice Hall| year=2002| pages=400| id=ISBN 0130481181 }}</ref><ref name="nida">{{cite web | title=Information on Drugs of Abuse | work=Commonly Abused Drug Chart | url=http://www.nida.nih.gov/DrugPages/DrugsofAbuse.html | accessdate=December 27th| accessyear=2005}}</ref>
Items within each subgroup are close to those of most similar action, and also follow a general placement in accordance with the legend below the diagram. Primary intersections are represented via color mixing.
''(Note: this is a work in progress. Please discuss errors, changes and suggestions on the talk page).''

<br style="clear:both;">

<div style="position: relative">[[Image:BlankDrugChart.png]]

<div style="position: absolute; left: 10px; top: 80px; font-size: 12pt">'''[[Stimulants|STIMULANTS]]'''</div>

<div style="position: absolute; left: 41px; top: 154px; font-size: 8pt">'''''[[Sympathomimetic amine|Sympathomimetic Amines]]'''''</div>
<div style="position: absolute; left: 31px; top: 185px; font-size: 8pt">'''''[[Dopamine reuptake inhibitors|Psychomotor Stimulants]]'''''</div>
<div style="position: absolute; left: 55px; top: 205px; font-size: 9pt">[[Amphetamines]]</div>
<div style="position: absolute; left: 53px; top: 224px; font-size: 9pt">[[Cathinone]] [[Khat|(Khat)]]</div>
<div style="position: absolute; left: 53px; top: 243px; font-size: 9pt">[[Methylphenidate]]</div>
<div style="position: absolute; left: 69px; top: 262px; font-size: 9pt">[[Cocaine]]</div>

<div style="position: absolute; left: 185px; top: 107px; font-size: 8pt">'''''[[Ketones|Amino ketones]]'''''</div>
<div style="position: absolute; left: 195px; top: 123px; font-size: 9pt">[[Bupropion]]</div>
<div style="position: absolute; left: 185px; top: 141px; font-size: 9pt">[[Diethylpropion]]</div>

<div style="position: absolute; left: 143px; top: 265px; font-size: 9pt">[[Ephedrine]]</div>
<div style="position: absolute; left: 102px; top: 284px; font-size: 9pt">[[Pseudoephedrine]]</div>

<div style="position: absolute; left: 37px; top: 320px; font-size: 8pt">'''''[[Methylxanthine]]s'''''</div>
<div style="position: absolute; left: 55px; top: 340px; font-size: 9pt">[[Caffeine]]</div>
<div style="position: absolute; left: 45px; top: 355px; font-size: 9pt">[[Theophylline]]</div>
<div style="position: absolute; left: 43px; top: 370px; font-size: 9pt">[[Theobromine]]</div>

<div style="position: absolute; left: 250px; top: -20px; font-size: 10pt">'''[[Antipsychotics|ANTIPSYCHOTICS]]'''</div>
<div style="position: absolute; left: 164px; top: 35px; font-size: 8pt">'''''[[Atypical antipsychotics]]'''''</div>
<div style="position: absolute; left: 160px; top: 55px; font-size: 8pt">[[Clozapine]]</div>
<div style="position: absolute; left: 220px; top: 55px; font-size: 8pt">[[Risperidone]]</div>
<div style="position: absolute; left: 153px; top: 70px; font-size: 8pt">[[Olanzapine]]</div>
<div style="position: absolute; left: 220px; top: 70px; font-size: 8pt">[[Quetiapine]]</div>

<div style="position: absolute; left: 318px; top: 35px; font-size: 8pt">'''''[[Typical antipsychotics]]'''''</div>
<div style="position: absolute; left: 325px; top: 55px; font-size: 8pt">[[Haloperidol]]</div>
<div style="position: absolute; left: 390px; top: 55px; font-size: 8pt">[[Fluphenazine]]</div>
<div style="position: absolute; left: 325px; top: 70px; font-size: 8pt">[[Thioridazine]]</div>
<div style="position: absolute; left: 390px; top: 70px; font-size: 8pt">[[Chlorpromazine]]</div>

<div style="position: absolute; left: 288px; top: 95px; font-size: 9pt">[[Cannabidiol|CBD]]</div>

<div style="position: absolute; left: 287px; top: 137px; font-size: 8pt">'''''[[Selective serotonin reuptake inhibitor|SSRIs]]'''''</div>
<div style="position: absolute; left: 276px; top: 151px; font-size: 8pt">[[Paroxetine]]</div>
<div style="position: absolute; left: 277px; top: 163px; font-size: 8pt">[[Fluoxetine]]</div>
<div style="position: absolute; left: 279px; top: 175px; font-size: 8pt">[[Sertraline]]</div>

<div style="position: absolute; left: 265px; top: 198px; font-size: 8pt">'''''[[Acetylcholine|Cholinergics]]'''''</div>
<div style="position: absolute; left: 276px; top: 214px; font-size: 9pt">[[Nicotine]]</div>
<div style="position: absolute; left: 275px; top: 230px; font-size: 9pt">[[Betel nut]]</div>
<div style="position: absolute; left: 272px; top: 246px; font-size: 9pt">[[Muscarine]]</div>

<div style="position: absolute; left: 480px; top: 80px; font-size: 12pt">'''[[Depressants|DEPRESSANTS]]'''</div>

<div style="position: absolute; left: 385px; top: 100px; font-size: 8pt">'''''[[Sedative]] [[Hypnotics]]'''''</div>
<div style="position: absolute; left: 475px; top: 130px; font-size: 9pt">[[Alcoholic beverage|Alcohol]]</div>
<div style="position: absolute; left: 485px; top: 150px; font-size: 9pt">[[diethyl ether|Ether]]</div>
<div style="position: absolute; left: 460px; top: 170px; font-size: 9pt">[[Barbiturate]]s</div>
<div style="position: absolute; left: 455px; top: 190px; font-size: 9pt">[[Chloroform]]</div>
<div style="position: absolute; left: 375px; top: 217px; font-size: 9pt">[[Chloral hydrate]]</div>
<div style="position: absolute; left: 395px; top: 235px; font-size: 9pt">[[Methaqualone]]</div>
<div style="position: absolute; left: 480px; top: 220px; font-size: 9pt">[[Gamma-hydroxybutyrate|GHB]]</div>

<div style="position: absolute; left: 360px; top: 130px; font-size: 8pt">'''''[[Benzodiazepines]]'''''</div>
<div style="position: absolute; left: 385px; top: 145px; font-size: 7.5pt">[[Lorazepam]]</div>
<div style="position: absolute; left: 385px; top: 157px; font-size: 7.5pt">[[Alprazolam]]</div>
<div style="position: absolute; left: 375px; top: 170px; font-size: 7.5pt">[[Flunitrazepam]]</div>
<div style="position: absolute; left: 385px; top: 183px; font-size: 7.5pt">[[Diazepam]]</div>

<div style="position: absolute; left: 450px; top: 275px; font-size: 8pt">'''''[[Opioids|Narcotic Analgesics]]'''''</div>
<div style="position: absolute; left: 475px; top: 295px; font-size: 9pt">[[Opium]]</div>
<div style="position: absolute; left: 480px; top: 315px; font-size: 9pt">[[Codeine]]</div>
<div style="position: absolute; left: 485px; top: 335px; font-size: 9pt">[[Morphine]]</div>
<div style="position: absolute; left: 490px; top: 355px; font-size: 9pt">[[Heroin]]</div>
<div style="position: absolute; left: 495px; top: 375px; font-size: 9pt">[[Fentanyl]]</div>

<div style="position: absolute; left: 273px; top: 290px; font-size: 10pt">[[Cannabis (drug)|Cannabis]]</div>
<div style="position: absolute; left: 285px; top: 309px; font-size: 10pt">[[Tetrahydrocannabinol|(THC)]]</div>
<div style="position: absolute; left: 176px; top: 306px; font-size: 10pt">'''''[[Psychedelic drug|Psychedelics]]'''''</div>
<div style="position: absolute; left: 157px; top: 328px; font-size: 9pt">[[MDMA]]   [[3,4-Methylenedioxyamphetamine|MDA]]</div>
<div style="position: absolute; left: 174px; top: 344px; font-size: 9pt">[[MDEA]]</div>
<div style="position: absolute; left: 160px; top: 366px; font-size: 9pt">[[Mescaline]]</div>
<div style="position: absolute; left: 170px; top: 384px; font-size: 9pt">[[2,5-dimethoxy-4-methylamphetamine|DOM]]</div>
<div style="position: absolute; left: 180px; top: 402px; font-size: 9pt">[[LSD]]</div>
<div style="position: absolute; left: 190px; top: 420px; font-size: 9pt">[[Psilocybin]]</div>
<div style="position: absolute; left: 225px; top: 439px; font-size: 9pt">[[Alphamethyltryptamine|AMT]]</div>
<div style="position: absolute; left: 255px; top: 450px; font-size: 9pt">[[Dimethyltryptamine|DMT]]</div>
<div style="position: absolute; left: 289px; top: 465px; font-size: 9pt">[[Ibogaine]]</div>

<div style="position: absolute; left: 380px; top: 366px; font-size: 10pt">'''''[[Dissociative drug|Dissociatives]]'''''</div>
<div style="position: absolute; left: 370px; top: 390px; font-size: 9pt">[[Ketamine]]</div>
<div style="position: absolute; left: 452px; top: 390px; font-size: 9pt">[[Dextromethorphan|DXM]]</div>
<div style="position: absolute; left: 370px; top: 410px; font-size: 9pt">[[Phencyclidine|PCP]]</div>
<div style="position: absolute; left: 370px; top: 430px; font-size: 9pt">[[Nitrous Oxide]]</div>
<div style="position: absolute; left: 379px; top: 465px; font-size: 9pt">[[Salvinorin A]]</div>
<div style="position: absolute; left: 345px; top: 489px; font-size: 9pt">[[Ibotenic acid]]   [[Muscimol]]</div>

<div style="position: absolute; left: 360px; top: 519px; font-size: 8pt">'''''[[Deliriant]]s'''''</div>
<div style="position: absolute; left: 350px; top: 538px; font-size: 7.5pt">[[Dimenhydrinate]]</div>
<div style="position: absolute; left: 345px; top: 553px; font-size: 7.5pt">[[Diphenhydramine]]</div>
<div style="position: absolute; left: 355px; top: 568px; font-size: 7.5pt">[[Scopolamine]]</div>
<div style="position: absolute; left: 368px; top: 583px; font-size: 7.5pt">[[Atropine]]</div>
</div>
<div style="position: absolute; left: 245px; font-size: 12pt">'''[[Psychedelics, dissociatives and deliriants|HALLUCINOGENS]]'''</div>
<br>

=== Legend ===
* <font color="#0000FF">Blue</font>: Stimulants generally increase in potency to the upper left.
* <font color="#AF0000">Red</font>: Depressants generally increase in potency to the lower right.
* <font color="#008000">Green</font>: "Hallucinogens" are psychedelic to the left, dissociative to the right, generally less predictable down and to the right, and generally more potent towards the bottom.
* <font color="#FF4060">Pink hue</font>: The so called "antipsychotics". ''A new and controversial addition to the chart.''
==== Sub-sections ====
* White: Overlap of all three main sections (Stimulants, Depressants and Hallucinogens) — ''Example: cannabis exhibits effects of all three sections.''
* <font color="#900090">Magenta</font> (''purple''): Overlap of Stimulants (''Blue'') and Depressants (''Red'') — ''Example: nicotine and SSRIs exhibit effects of both.''
* <font color="#008080">Cyan</font> (''light blue''): Overlap of Stimulants (''Blue'') and Psychedelic hallucinogens (''Green'') — ''Primary psychedelics exhibit a stimulant effect''
* <font color="#906000">Yellow</font> : Overlap of Depressants (''Red'') and Dissociative hallucinogens (''Green'') — ''Primary dissociatives exhibit a depressant effect''

== A brief history of drug use ==
Drug use is not a new phenomenon by any means. There is archaeological evidence of the use of psychoactive substances dating back at least 10,000 years, and historical evidence of cultural use over the past 5,000 years.<ref name="merlin">{{cite journal | author=M.D. Merlin | title=Archaeological Evidence for the Tradition of Psychoactive Plant Use in the Old World | journal=Economic Botany | volume=57 | issue=3 | pages= 295–323 }}</ref>

While medicinal use plays a very large role, it has been suggested that the urge to alter one's consciousness is as primary as the drive to satiate thirst, hunger or sexual desire.<ref name="weil">{{cite book | first=Dr. Andrew | last=Weil | year=2004 | title=The Natural Mind : A Revolutionary Approach to the Drug Problem (Revised edition) | pages=15 | publisher=Houghton Mifflin | id=ISBN 0618465138}}</ref>

Some may point a finger to marketing, availability or the pressures of modern life as to why humans use so many psychoactives in their daily lives, but one only has to look back at history, or even to children with their desire for spinning, swinging, sliding amongst other activities to see that the drive to alter one's state of mind is universal.<ref name="weil"/>

This relationship is not limited to humans. A surprising number of animals consume different psychoactive plants and animals, berries and even fermented fruit, clearly becoming intoxicated. Traditional legends of sacred plants often contain references to animals that introduced man to their use.<ref name="samorini">{{cite book | first=Giorgio | last=Samorini | year=2002 | title=Animals And Psychedelics: The Natural World & The Instinct To Alter Consciousness | publisher=Park Street Press | id=ISBN 0892819863 }}</ref>

Biology suggests an evolutionary connection between psychoactive plants and animals, as to why these chemicals and their receptors exist within the nervous system.<ref name="albert">{{cite web | author=Albert, David Bruce, Jr. (1993) | title=Event Horizons of the Psyche | url=http://www.csp.org/chrestomathy/event_horizons.html | accessdate=February 2nd| accessyear=2006}}</ref>

== Other psychoactive drugs ==
* [[Aphrodisiac]]s
** [[Bremelanotide]]

* In a broader sense also:
** [[Antiemetic]]s
** [[Analgesic]]s
** [[Antiepileptic]]s

== Ways psychoactive drugs affect the brain ==
There are many ways in which psychoactive drugs can affect the brain (''see [[neuropsychopharmacology]]''). While some drugs affect neurons presynaptically, others act postsynaptically and some drugs don't even attack the synapse, working on neural axons instead.{{fact}} Here is a general breakdown of the ways psychoactive drugs can work.

# Prevent The Action Potential From Starting
#*Lidocaine, TTX (they bind to voltage-gated sodium channels, so no action potential begins even when a generator potential passes threshold)
# Neurotransmitter Synthesis
#* Increase - L-Dopa, tryptophan, choline (precursors)
#* Decrease - PCPA (inhibits synthesis of 5HT)
#* Causes increased sensitivity to the five senses, due to an increasing number of signals being sent to the brain.
# Neurotransmitter Packaging
#* Increase - MAO Inhibitors
#* Decreasing - Resperine (pokes holes in the synaptic vesicles of catecholamines)
# Neurotransmitter Release
#* Increase - Black Widow Spider (Ach)
#* Decrease - Botulinum Toxin (Ach), Tetanus (GABA)
# Agonists - Mimic the original NTs and activate the receptors
#* Muscuraine, Nicotine (Ach)
#* AMDA, NMDA (Glu)
#* Alcohol, Benzodiazepines (GABA)
# Antagonists - Bind to the receptor sites and block activation
#* Atropine, Curare (Ach)
#* PCP (Glu)
# Prevent Ach Breakdown -
#*Insecticides, Nerve Gas
# Prevent Reuptake
#* Cocaine (DA), Amphetamines (E)
#* Tricyclics, SSRIs

''- based on information taught in NSC 201, Vanderbilt University'' {{fact}} ''

==Philosophy and Morality of psychoactive drugs==

For thousands of years, people have studied psychoactive drugs, both by observation and ingestion. However, humanity remains bitterly divided regarding psychoactive drugs, and their value and use has long been an issue of major philosophical and moral contention, even to the point of war (the [[Opium Wars]] being a prime example of a war being fought over psychoactives). A majority of youths and adults consume one or more psychoactive drugs{{Citation needed}}. In the West, the most common by numbers of users are caffeine, alcohol, and nicotine, in that order. Most people accept restrictions on some and the prohibition of others, especially the "hard" drugs, which are generally illegal in most countries.

Because so many consumers want to reduce or eliminate their own use, many professionals, self-help groups, and businesses specialize in that field, with varying degrees of success. Many parents attempt to influence the actions and choices of their children.

Debate continues over whether each psychoactive drug being considered is or is not spiritual, sinful, therapeutic, poisonous, ethical, immoral, effective, risky, responsible, recreational, a weapon to use against enemies, a boost to the economy, etc. These attitudes can often be deeply rooted in philosophical and/or religious beliefs, making it difficult to reach consensus or agreement on the proper moral and philosophical stance regarding psychoactive drugs. A major point of contention regards the role of government, whether it should, in respect to each drug, remain neutral, make use safer, educate for abstention, educate for moderation, regulate trade, require a prescription, restrict promotion, prohibit altogether, alter penalties, change enforcement, and so on.

==See also==
*[[Antipsychotics]]
*[[Stimulants]]
*[[Depressants]]
*[[Psychedelics, dissociatives and deliriants|Hallucinogens]]
*[[Entheogens]]
*[[Medication]]
*[[Recreational drug use]]
*[[Drug addiction]]
*[[Demand reduction]]
*[[Freedom of thought]]
*[[Substance abuse]]
*[[Poly drug use]]
*[[List of street names of drugs]]
*[[Arguments for and against drug prohibition]]
*[[Neuropsychopharmacology]]
*[[Psychedelics, dissociatives and deliriants]]

==References==
<references />
*{{cite book | author=Siegel, Ronald K| title=Intoxication: The Universal Drive for Mind-Altering Substances| publisher=Park Street Press, Rochester, Vermont | year=2005 | editor= | id=ISBN 1-59477-069-7}}(paperback edition) Note: new ISBN comes in 1 January 2007 and is 978-1-59477-069-2

==External links==
*[http://www.erowid.org/ Erowid] – Extensive portal primarily relating to psychoactive drugs (''Wikipedia article about the website –'' [[Erowid]])
*[http://lycaeum.org/ The Lycæum] – Lycaeum Synaesthesia (similar website)
*[http://www.tccwiki.com/wiki/index.php?title=Main_Page TCCWiki] A free collaborative drug information project that anyone can edit
* [http://www.quihn.org.au Fact sheets and harm reduction strategies about psychoactive drugs]

[[Category:Psychoactive drugs| Psychoactive drug]]

[[bg:Наркотично вещество]]
[[de:Psychoaktive Substanz]]
[[es:Psicotrópico]]
[[fr:Psychotrope]]
[[hr:Psihoaktivne droge]]
[[it:Sostanza psicoattiva]]
[[lt:Narkotikai]]
[[ja:向精神薬]]
[[no:Psykoaktivt stoff]]
[[pt:Drogas psicotrópicas]]
[[ru:Наркотик]]
[[fi:Päihde]]