My report on common illicit drugs in Australia

Common illicit drugs in Australia, there physical and psychological effects on the body and mind, signs of overdose, withdrawal, and emergency and follow up treatments in a rural and remote setting.

Table of contents

Executive summary:                                                                                               4                                                                                

Introduction:                                                                                                           5

Definitions:                                                                                                              7

Cannabis:                                                                                                                  9

Ecstasy:                                                                                                                     11

Amphetamines, (Speed, Ice and free base methamphetamine):             15

Cocaine:                                                                                                                    20

GHB:                                                                                                                          24

Heroin:                                                                                                                      27

Hallucinogens:                                                                                                        30

Inhalants:                                                                                                                 33

Follow up and psychosocial interventions:                                                     36

Reference List:                                                                                                        38

Appendix one – Learning Contract:                                                                  40

Executive summary

According to the Australian Crime commission illicit Drug Data report 2009-10 (www.aic.gov.au) cannabis continues to dominate the Australian illicit drug market, illicit drug arrests are the highest reported in the last 10 years and a massive 694 clandestine laboratories were discovered.  As the use of illicit drugs increase so do the presentations to hospital emergency departments, General Practice offices, and clinics. (National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).  Nurses and Doctors can be on the frontline and do the most to detect and treat drug overdose and withdrawal as well as, perhaps most importantly provide appropriate follow up treatment (Hulse, white & Cape, 2002).  Nurses and Doctors are ideally placed to provide relevant information about drugs, identify drug related problems, provide interventions and aid in the referral process for specialist assessment and treatment as well as help provide follow up care (National Centre for Education and Training on Adduction (NCETA) Consortium, 2004; Hulse, et al, 2002).   Patients presenting to emergency departments and general wards, who use illicit drugs, can face barriers to health care (Ford, 2011).  The drug and alcohol knowledge of nurses is known to be inadequate (Ford, 2011).  Nurses have limited support in policy and practice standards as well as poor resources when dealing with the clinical aspect of these patients (Ford, 2011).  This report is designed to aid nurses in rural and remote settings in dealing with illicit drug users.

Introduction

This report will look at common illicit drugs in Australia; it will define illicit drugs, overdose, and withdrawal and drug abuse.  The report will identify physical and psychological effects on the brain and body, how to diagnose and what emergency treatments are available. This report will look at follow up and psychosocial interventions.  Please note: emergency treatments and interventions are limited to those that may be able to be accessed in a rural and remote setting. It is often the case that even basic blood tests have to be sent via courier to be tested at a larger facility. If further investigation, treatment and interventions are needed, then evacuation via the Royal Flying doctors Service (RFDS) is recommended.  It is a mandatory requirement if the person is suffering from any psychological effects they must be sedated and intubated for the flight.  The common illicit drugs in Australia include cannabis, ecstasy, amphetamines (speed, ice, and free base methamphetamine), cocaine, GHB, Heroin, hallucinogens, and inhalants.  This report will be a learning tool for nurses in rural and remote settings to help them identify, diagnose and treat the effects of illicit drugs.  Inhalants have been included, because although not illegal to buy, have many serious side effects and are commonly used to get high particularly by adolescents (Krivonet, 2000). Inhalants include but are not limited to, general household products such as solvents, aerosols and glues as well as petrol, (National Drug Campaign, 2012; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).  In the Northern Territory many remote and rural towns and communities have replaced petrol with Avgas or opal unleaded petrol which doesn’t produce the same effect as unleaded and have made other products harder to obtain by placing them behind the counter at shops and stores.   

Illegal drugs generally fall into three categories – depressants – such as heroin and cannabis, these drugs slow down the activity in the central nervous system including the messages sent from the brain to the body. (www.afp.gov.au, 2012).  Stimulants – such as amphetamines and cocaine, these drugs will speed up the activity in the central nervous system. (www.afp.gov.au, 2012).  Hallucinogens – such as lysergic acid diethylamide (LSD) and magic mushrooms, these drugs alter the sense of reality which may result in hallucinations (www.afp.gov.au, 2012).  

There are a number of reasons people use illicit drugs in the first place.  Many people use drugs to change the way the feel, they want to feel better, or to block either physical or psychological pain (Act now, 2012). Drug taking can be used as a form of escapism – as a means to avoid problems with family life, school or work, friendships and relationships as well as low self esteem and depression (www.druginfo.adf.org.au, 2012).   Curiosity and peer pressure or to relax, have fun or to be part of the group are also reasons. The use of stimulants at social settings such as clubs, pub, parties and raves is well known (Frei, 2010).  People may continue to take drugs because they enjoy the feelings felt when using drugs (www.druginfo.adf.org.au, 2012).  People use the drugs for their perceived benefits e.g. euphoric feelings, heightened sexual experiences, increased energy, appreciation of music, sense of well being, disinhibition rather than their potential harm (ACT now, 200; Frei, 2010).  The availability of the drug and the price will effect or influence the type and amount of drug taken (Greenstein & Gould 2004).

Definitions

Accidental overdose- can occur regardless of whether the user is experienced or not.  Illicit drugs often vary in content and strength.  If a user comes in contact with a new batch of drug or obtains it from a different source, they may not realise that it is more potent than what they are used too (Novak, Ritchie, Murphy, Bartu, Holmes, Capus, 1997).

Central nervous system – integrates information that it receives from the brain and coordinates the activity of all parts of the body, it consists of the brain and spinal cord and it uses both electrical and chemical means to send and receive messages (Tintinalli, Stapczynski, Cydulka, Ma, cline, Meckler, 2011).

Contaminants – Drug manufactures or dealers will often cut their product with a substance in order to increase their profits.  Potential contaminants include caffeine, talcum powder, cornstarch, sugars and cellulose (Hulse et al, 2002).

Cravings- a strong desire to use the drug. This can become stronger during withdrawal and can often be triggered by a memory or activity where a drug was used (Better Health Channel, 2012).

Illicit drugs – are those whose production, sale or possession is prohibited (National Centre for Education and Training on Addiction (NCETA) Consortium, 2004)

Overdose – An overdose occurs when a toxic or poisonous amount of a drug or a medicine is taken (Better Health Channel, 2012).  When the amount of drug ingested exceeds that persons tolerance, the results can include acute psychosis or other potentially life threatening effects such as respiratory depression (National Centre for Education and Training on Addiction (NCETA) Consortium, 2004)

Recreational overdose- this can occur with experimentation of a previous untried drug.  Whereas an experienced user may be able to tolerate a dose of an illicit drug, that same dose given to a novice may cause an overdose (Novak, et al, 1997).

Paranoia – “Paranoia is the irrational and persistent feeling that people are ‘out to get you’ or that you are the subject of persistent, intrusive attention by others. This unfounded mistrust of others can make it difficult for a person with paranoia to function socially or have close relationships.” (Better Health Channel, 2012).

Party drugs – refers to a group of drugs that are usually taken in pubs, clubs, parties or raves. The drugs usually include stimulants such as amphetamines, ecstasy and GHB (Better Health Channel, 2012).

Psychosis – “Psychosis is associated with illnesses that affect the brain In psychosis, the everyday thoughts that enable us to lead our daily lives become confused. People with psychosis may believe: Their thoughts are being interfered with, they can influence the thoughts of others, and other people can read their thoughts.  These disturbances in thinking can impair a person’s ability to concentrate, remember things and to make plans. These effects can persist, even after the psychotic episode has subsided”. (Better Health Channel, 2012).

Psychological dependence – a person exhibits compulsive drug seeking behaviour. The drug gives them pleasant feelings and causes mental anguish when withdrawn (Greenstein & Gould, 2004).

Physical dependence - long term abuse produces biochemical changes, if the drug is then withdrawn the user will begin to experience unpleasant physical signs and symptoms (Greenstein & Gould 2004).

Tolerance- when continued use of a drug no longer has the same effect, the user has a decreased response to the drug dose and has to increase the dose to achieve the same level of effect previously experienced (Better Health Channel, 2012).

Withdrawal syndrome- is a wide range of physical and psychological symptoms that can occur when a drug user suddenly stops or even just reduces the amount of substance used. Signs and symptoms of withdrawal can be the opposite of the acute effects of the drug.  However withdrawal symptoms can depend on the person, the drug, level of tolerance, overall health and well being as well as the psychosocial environment (National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).

Cannabis

Cannabis is the most commonly used drug in Australia, it is usually smoked. It can also be ingested.  Cannabis has been used by humans for centuries. In some cultures it has been used for its therapeutic properties such as analgesia, to decrease nausea, help broncodialation and it has the capacity to reduce intraocular pressure (Hulse, et al, 2002; National Drugs campaign, 2012; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004). According to the National Drug Strategy Household Survey in 2010 over 35.4 % of Australians over the age of 12 have used or use Cannabis (Australian Drug Foundation, 2012).

Common names:

pot, weed, grass, rope, mull, dope, skunk, bhang, ganja, hash, refer, joint, cone, spiff

(National Drugs Campaign, 2012; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).

Physical and psychological effects on the brain and body:

Physical	psychological
Sleep problems	Anxiety
Lowered sex drive	Depression
Respitory illness –chronic cough	Learning difficulties
Reduced coordination	Memory problems
Dilated pupils	Paranoia
Bloodshot or glassy eyes	Problems concentrating- general difficulty and a tendency to focus on a particular activity
Dryness of mouth	Slow thinking
Increased appetite	Reduced motivation
Tachycardia and  supraventicular arrhythmias	Mood swings
Hypotension	Panic attacks
Reduced intraocular pressure	Psychosis
Broncodilation	Hallucinations
Relaxation	Delusions
Dependence	Euphoria
Slow reflexes	Disinhibition
	Altered sense of time
	Impaired cognition

(National drug campaign, 2012; Tintnalli, et al, 2011; Greenstein & Gould, 2004; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).

Signs and symptoms of  withdrawal

·         Irritability

·         Anxiety

·         Nervousness

·         Anger

·         Aggression

·         Loss of appetite

·         Excessive sweating particularly at night

·         Disturbed and restless sleep

·         Nightmares

(Hulse, et al, 2002)

Signs and symptoms of overdose

·         Feelings of paranoia or fear

·         Nausea and vomiting

·         Increase heart rate

·         Hallucinations and disorientation

(www.allaboutcounselling.com, 2012)

Emergency treatments

It is recommended for all overdoses and suspected overdoses that universal precautions be used at all times (Tintinalli, et al 2011; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004)

Significant medical complications such as panic attacks, toxic psychoses and pneumothorax are rare

Cannabis effects are short term and seldom require treatments, however medical treatments may include medications, such as benzodiazepines or relaxation techniques to reduce the heart rate and to relieve some of the symptoms of overdose and withdrawal.  Anti-psychotic drugs such as risperodone or haloperidol may be needed to treat psychotic states (Husle et al, 2002).

Chronic users may need treatments to help with respiratory disease, chronic cough and chronic bronchitis.

 Medications such as antiemetic for vomiting and nausea

Monitor vital signs

(Boderick, 2003; Greene, Ker & Braitberg, 2008; Tintnalli et al, 2011; Schuckit, 2000).

Ecstasy

Ecstasy or methylenedioxymethampetaine (MDMA) is commonly taken by ingesting a tablet form orally however it can be snorted in powder form and taken rectally (Australian Drug Foundation, 2012; Broderick, 2003). Ecstasy is a stimulant it causes a person using ecstasy to feel more alert, awake, confident or energetic (Australian Drug Foundation, 2012; Broderick, 2003).

  In 2010 the National Drug Strategy Household survey stated that 10.3% of all Australians aged over 14 years had used Ecstasy at some point in their life’s (Australian Drug Foundation, 2012).

The effects of Ecstasy on a person can depend on the individual, their health, other drugs taken and even the contaminants in the preparation of the dug (Australian Drug Foundation, 2012; Broderick, 2003).  Ecstasy users can develop a tolerance to and a dependence on ecstasy.  The dependence is psychological and the user may feel the need to take the drug in certain social settings (National Centre for Education and Training on Addiction (NCETA) Consortium, 2004)

Common names:

E, pills, Ex, pingers, EnC, eccy, MDMA, xtc, eggs and disco biscuits, the love drug

(National Drugs Campaign, 2012; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).

Physical and psychological effects on the brain and body

Physical	Psychological
Pupil dilation	Nervousness
Increased jaw tension	Confusion
Loss of appetite	Hallucinations
Insomnia	Memory impairment
Depression	Panic
Headaches	Decreased emotional control
Dry mouth	Lethargy
Tachycardia
Increased blood pressure
Nausea
Vomiting
Hot and cold flushes
Sweaty palms
Hyperthermia
Hyponatremia
Muscle stiffness
Visual distortions
Cracked teeth through grinding
Dehydration
Tremors
Nerve cell damage
Serotonin syndrome
Death from heart failure
Rhabdomyolysis
Seizures
Disseminated intravascular coagulation
Renal impairment
Liver impairment

(National drug campaign, 2012; Tintnalli, et al, 2011; Greenstein & Gould, 2004; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004)

Withdrawal

A person withdrawing from ecstasy may experience more psychological problems than physical (Australian Drug Foundation, 2012).

·         Cravings

·         Sleepiness

·         Anxiety

·         Depression

·         Loss of concentration

·         Insomnia

·         Restlessness

·         Agitation

·         General aches and pains

(Australian Drug Foundation, 2012).

A person withdrawing from ecstasy should be watched closely in a subdued setting for several hours or until the symptoms subside (National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).

Signs and symptoms of overdose

Ecstasy overdose can cause death through heart attacks and brain haemorrhage, other symptoms of overdose include

·         Floating sensations

·         Vomiting

·         Increased temperature

·         Increase blood pressure

·         Increase heart rate

·         Hallucinations

·         irrational behaviour

·         bizarre behaviour

·         convulsions

(National drug campaign, 2012; Tintnalli, et al, 2011; Greenstein & Gould , 2004; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004)

Emergency treatments

It is recommended for all overdoses and suspected overdoses that universal precautions be used at all times (Tintinalli et al, 2011; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).

Monitor vital signs

Activated charcoal can be helpful if given within an hour of ingestion

Hypertension and tachycardia can be treated with benzodiazepines

Severe hypertension can be treated with a propanolol infusion

Hyperthermia – cooling measures and fluid resuscitation

An extensive assessment should be undertaken, look for signs and symptoms of overdose

Investigations may include. 

·         pathology tests – electrolytes, renal function, creatinine, coagulation, liver function, arterial blood gas, serial cardiac enzymes,

·         electrocardiograph (ECG)

Intravenous cannula (IV) access

Arterial line

Sedation and intubation may be required

Benzodiazepines are first line agents for agitation and seizures

Antispasmodic agents for the cramps

NSAIS for muscle and joint pains

Medications such as antiemetic for vomiting and nausea

Phenobarbatone is a second line agent for seizures

If available a chest x-ray looking for evidence of aortic dissection, pneumothorax, pulmonary aspiration or other traumas

Abdominal x-ray looking for trauma or evidence of ingestion of large quantities of packaged drugs

Signs of rhabdomyolysis – aggressive fluid resuscitation, monitor kidney function and urine output

(Boderick,2003; Greene, Ker & Braitberg, 2008; Tintnalli et al, 2011; Schuckit, 2000).

Amphetamines, (Speed, Ice, and free base methamphetamine)

Amphetamine was first synthesized in Germany in 1887 (Greene, Kerr, & Braitberg, 2008).  It is the second most common illicit drug used in Australia after cannabis (Greene, et al, 2008). It was not used clinically until the 1920’s where it was marketed in nasal sprays and asthma treatments.  Amphetamines were widely used in World War Two, for a variety of conditions.  It became regulated in the 1970s decreasing the abuse rates, Amphetamines began to be illegally produced in the 1980s and the 1990s rave scene increased use and production including the development of ‘ICE’ a more pure and potent form of amphetamine (Green et al, 2008).

Amphetamines are taken in the form of powder, tablets, capsules or crystals either orally or intravenously.  There is no safe level of use (Australian Drug Foundation, 2012).

According to the National Drug Household Survey in 2010, 7% of Australians aged over 14 had used amphetamines at some stage in their life (Australian Drug Foundation, 2012).

Common names:

Ice: crystal meth, meth, crystal, shabu, batu, d-meth, tina and glass

Base: speed Dexedrine, dexies, dex, shad, go-ee, glass, tina, paste, oxblood, shabu, yabba, and crank

Speed: wiz go-ee, snow, zip, point, eve, gogo, pure, gas

(Australian Drug Foundation, 2012; National Drugs Campaign, 2012; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).

Physical and psychological effects on the brain and body

Ice and Base methamphetamine

Physical	Psychological
Increased heart rate	Irritability
Increased respitiory rate	Hostility
Tremors of hands and fingers	Hallucinations
High blood pressure	Paranoia
Increased  or irregular temperature	Psychosis
Excessive sweating	Panic attacks
Stomach cramps	Aggression
Blurred vision	Memory loss
Headaches	Depression
Dizziness	Inability to make decisions
Insomnia, other sleep problems
Decreased appetite
Itching, picking and scratching at the skin
Increased risk of stroke
Anorexia
Malnutrition
Increased risk of kidney problems
Constricted blood vessels
Heart problems
Aged appearance
Damaged teeth
Lesions on skin
Decreased lung function

(National drug campaign, 2012; Tintnalli, et al, 2011; Greenstein, Gould, 2004; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004)

There is also a high risk of the user contracting an infectious disease, such as hepatitis, and HIV.  This can occur through needle sharing.  The affected person could also exhibit signs and symptoms of an infectious disease.   The symptoms of methamphetamine use could mask those of an infectious disease (National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).

Speed

Physical	Psychological
Increased heart rate	Nervousness
Irregular heart beat	Insomnia
Increased respitory rate	Aggression
Teeth grinding	Mood swings
Cracked teeth through grinding	Chronic sleep problems
Increased temperature or over heating	Hallucinations
Sweating	Paranoia
Headaches	Anxiety
Blurred vision	Decreased emotional control
Dry mouth	Severe depression
Dilated pupils	Violent behaviour
Nausea and vomiting	Speed psychosis – heightened awareness of the environment, paranoia, anxiety and tension
Chronic	Tension
Nerve cell damage
Death from heart failure
Stroke
High risk of dependence

(National drug campaign, 2012; Tintnalli, et al, 2011;Greenstein & Gould , 2004; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004)

There is also a high risk of the user contracting an infectious disease, such as hepatitis, and HIV.  This can occur through needle sharing.  The affected person could also exhibit signs and symptoms of an infectious disease.   The symptoms amphetamine use could mask those of an infectious disease (National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).

Withdrawal

·         Cravings for amphetamines

·         Disorientation and poor concentration

·         Lack of energy

·         Apathy

·         Limited ability to experience pleasure

·         Irritability

·         Depression

·         Anxiety

·         Panic attacks

·         Paranoia

·         Fatigue and exhaustion

·         Headaches

·         General aches and pains

·         Hunger and an increased appetite

·         Disturbed and restless sleep

·         Nightmares

·         Suicidal ideas

·         Relapse to drug use

·         Bizarre thoughts

·         Poor social functioning

·         Restlessness

(National drug campaign, 2012; Tintnalli, et al, 2011; Greenstein & Gould , 2004; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004)

Signs and symptoms of overdose

·         Stereotypic or unpredictable behaviour

·         Violent behaviour

·         Irrational behaviour

·         Mood swings, hostility and aggression

·         Pressured or slurred speech

·         Paranoid thinking

·         Confusion

·         Headaches

·         Blurred vision

·         Dizziness

·         Psychosis

·         Cerebrovascular accident

·         Seizures

·         Coma

·         Teeth grinding

·         Gross body image distortions

(National drug campaign, 2012; Tintnalli, et al, 2011; Trounces, 2004; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).

Amphetamine Toxicity

·         Seizure

·         Focal neurological deficit

·         Reduced level of consciousness

·         Abnormal motor movements

·         Hyperthermia

·         Dysrhythmias

·         Hypotension/hypertension

·         Coronary artery spasm

·         Automanomic instability

(Greene, et al 2008)

Emergency treatments

It is recommended for all overdoses and suspected overdoses that universal precautions be used at all times (Tintinalli, et al, 2011; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).

Airway, breathing and circulation are immediate priorities. 

Monitor vital signs

Patients showing signs of significant agitation, hyperthermia, cardiovascular, neurological or respiratory compromise should be triaged to the resuscitation area. 

Patients with an altered level of conscious must have blood sugar level taken

An extensive assessment should be undertaken, look for signs and symptoms of amphetamine toxicity

Investigations may include. 

·         pathology tests – electrolytes, renal function, creatinine, coagulation, liver function, arterial blood gas, serial cardiac enzymes,

·         electrocardiograph (ECG)

Intravenous cannula (IV) access

Arterial line

Sedation and intubation may be required

Benzodiazepines are first line agents for agitation and seizures

Phenobarbatone is a second line agent for seizures

If available – a chest and abdominal x-ray

 Avoid antipsychotics

Monitor temperature for hyperthermia – use cool mist sprays and fans

(Boderick,2003; Greene, Ker & Braitberg, 2008; Tintnalli et al, 2011; Schuckit, 2000).

Cocaine

Cocaine is a stimulant it comes from a South American coca bush (erythroxylum coca).  The coca leaf extract is processed to produce cocaine, freebase, and crack. It has long been used by the people indigenous to South America for its stimulant and appetite suppressant properties (Australian Drug Foundation, 2012).  Cocaine is usually ‘snorted’ but can be injected, freebase and crack cocaine are usually injected (National Drug Campaign, 2012). According to the National Household survey 2010 7.3% of Australians aged over 14 have taken cocaine at some stage in their life (Australian Drug Foundation).

Common names

Cocaine - Coke, charlie, blow, C, pepsi, nose candy, snow, white lady, toot, white dust, stardust

Freebase- Base

Crack – Rock, wash

(Australian Drug Foundation, 2012; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004)

Physical and psychological effects on the brain and body

Physical	Psychological
Increased heart rate	Anxiety
Aggression	Depression
Dilated pupils	Paranoia
Chest pain	Agitation
Overheating and sweating	hallucinations
Nose bleeds	High risk of dependence
lethargy	Cocaine psychosis
Reduced appetite	Violent or erratic behaviour
Muscle twitches	Sleeping disorders
Tremors	Impaired sexual performance
Nausea and vomiting	Impaired thinking
Nasal and sinus congestion Damage to the nasal septum
Ulceration of the mucous membrane of the nose
Cardiomyopathy
Eating disorders
Cardiac arrest
Convulsions
Kidney failure
Stroke
Seizures
Cerabal atrophy

(National drug campaign, 2012; Tintnallis, et al, 2011; Greenstein & Gould, 2004; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004)

There is also a high risk of the user contracting an infectious disease, such as hepatitis, and HIV.  This can occur through needle sharing.  The affected person could also exhibit signs and symptoms of an infectious disease.   The symptoms cocaine use could mask those of an infectious disease (National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).

Intravenous drug users can also have sores and infections along the injections sites due to poor sanitisation and hygiene while injecting National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).

Withdrawal

·         Tension

·         Anxiety

·         Depression

·         Radical mood swings

·         Total exhaustion

(Australian Drug foundation, 2012).

Signs and symptoms of overdose

·         Exhaustion Depression Anxiety, paranoia and psychosis Eating disorders and weight loss Sexual dysfunction Hypertension Hallucinations Cerebral atrophy Impaired thinking Radical mood swings Coma Death Increased heart rate Heart attack Chest pain Kidney failure Hypothermia Seizures Brain Haemorrhage Stroke Nausea Vomiting

(National Drug campaign, 2012).

Emergency treatments

Monitor vital signs

Airway, breathing and circulation are immediate priorities. 

Patients with an altered level of conscious must have blood sugar level taken

An extensive assessment should be undertaken, look for signs and symptoms of cocaine use

Investigations may include. 

·         pathology tests – electrolytes, renal function, creatinine, coagulation, liver function, arterial blood gas, serial cardiac enzymes,

·         electrocardiograph (ECG)

Intravenous cannula (IV) access

Arterial line

Sedation and intubation may be required

Benzodiazepines are first line agents for agitation and seizures

Phenobarbatone is a second line agent for seizures

If available a chest x-ray looking for evidence of aortic dissection, pneumothorax, pulmonary aspiration or other traumas

Abdominal x-ray looking for trauma or evidence of ingestion of large quantities of packaged drugs

Medications such as antiemetic for vomiting and nausea

Antispasmodic agents for the cramps

NSAIS for muscle and joint pains

(Boderick,2003; Greene, Ker & Braitberg, 2008; Tintnalli et al, 2011; Schuckit, 2000).

GHB

Gamma-hydroxybutyrate

GHB is commonly found on the ‘party scene’ it can induce a euphoric feeling. It is absorbed rapidly and is also used as a date rate drug as when mixed with alcohol can be quite effective a sedating and producing anaesthetic properties. It is usually swallowed but can be injected.  GHB was originally marketed in the 1980’s as a dietary supplement for body builders. According to the National Household Survey 2010, 0.8 % of all Australians over 14 have used GHB at some stage in their life (Australian Drug Foundation, 2012).

Common names

Fantasy, grievous bodily harm (GHB), liquid ecstasy, liquid E, G, liquid x, salty water, homeboy, gerorgia, soap, scoop, cherry meth, blue nitro (National Drug Campaign, 2012)

Physical and psychological effects on the brain and body

Physical	Psychological
Placidity	Confusion
Mild euphoria	Agitation
Pleasant dis inhabitation	hallucinations
Drowsiness – can be extreme	Reduced muscle tone
Nausea	Disorientation
vomiting	Amnesia
Induced sleep	Addictive with prolonged use
headache	Memory lapse
Difficulty focusing eyes	Blackouts
Impaired movement	Increased sex drive
Impaired speech
Reduced muscle tone
Seizures
Coma
Respitory distress
Reduced heart rate
Decreased blood pressure
Death
Urinary incontinence
Decreased body temperature

(National drug campaign, 2012; Tintnalli, et al, 2011; Greenstein & Gould, 2004; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).

Withdrawal

·         Confusion

·         Agitation

·         Anxiety

·         Panic

·         Blackouts

·         Feelings of doom

·         Paranoia

·         Insomnia

·         Tremors

·         Muscle cramps

·         Perspiration

·         Delirium

·         Hallucinations

·         Tachycardia

·         Bowel and bladder incontinence

(National Drug Campaign, 2012; Australian Drug Foundation, 2012).

Overdose

The risk of overdose with GHB is extremely high, it is hard regulate, there is no way of knowing the strength and there is a fine line between becoming intoxicated and overdosing, it is also used as a date rape drug because of the anaesthetic, and sedative effects as well as the amnesia it can cause( National Drug Campaign, 2012; Australian Drug Foundation, 2012)

Emergency treatments

It is recommended for all overdoses and suspected overdoses that universal precautions be used at all times (Tintinalli et al 2011; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004)

Monitor vital signs

Airway, breathing and circulation are immediate priorities. 

An extensive assessment should be undertaken, look for signs and symptoms of GHB

Investigations may include. 

·         pathology tests – electrolytes, renal function, creatinine, coagulation, liver function, arterial blood gas, serial cardiac enzymes,

·         electrocardiograph (ECG)

Intravenous cannula (IV) access

Arterial line

Sedation and intubation may be required

Short acting benzodiazepines such as diazepam to help with symptom relief

Medications such as antiemetic for vomiting and nausea

Antispasmodic agents for the cramps

NSAIS for muscle and joint pains

(Boderick,2003; Greene, Ker & Braitberg, 2008; Tintnalli et al, 2011; Schuckit, 2000).

Heroin

Heroin is a depressant and is an opioid that includes other drugs such as morphine, codeine and pethidine. It is made from the Opium Poppy (Australian Drug Foundation, 2012). It is usually injected although it can be smoked or snorted (National Drug Campaign, 2012; National Centre for Education and Training on Addiction (NCETA) consortium).  According to the National Household Survey 2010, 1.4 % of all Australians over the age of 14 have used Heroin (Australian Drug Foundation, 2012).

Common names

Horse, hammer, H, dope, Smack, junk, gear, boy, skag, harry, big harry, black tar, china white, Chinese H, white dynamite, dragon, elephant, home bake, poison

(Australian Drug Foundation, 2012; National Drugs Campaign, 2012; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).

Physical and psychological effects on the brain and body

Physical	Psychological
Decreased blood pressure and heart rate	Confusion
Dry mouth	High risk of dependence
Slurred speech	Mood swings
Reduced coordination	Depression
Nausea and vomiting	Anxiety disorders
Suppressed cough reflex	Suicidal ideation
Reduced sexual drives	Memory impairment
Loss of sex drive in men	Euphoria
Menstrual irregularity and infertility in women
lethargy
Drowsiness
Constipation / chronic constipation
Constricted pupils
Reduced respitory rate
Infection at injection sites
Skin, heart and lung infections
Death
Difficulty passing urine

(National Centre for Education and Training on Addiction (NCETA) Consortium, 2004)

There is also a high risk of the user contracting an infectious disease, such as hepatitis, and HIV.  This can occur through needle sharing.  The affected person could also exhibit signs and symptoms of an infectious disease.   The symptoms of heroin use could mask those of an infectious disease. Disease (National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).

Intravenous drug users can also have sores and infections along the injections sites due to poor sanitisation and hygiene while injecting National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).

People who become psychologically dependant on heroin often crave it to the point that other activities in their life become less important, and obtaining and using the drug is all that matters (National Drug Campaign, 2012)

Withdrawal

·         Craving

·         Restlessness

·         Low blood pressure

·         Increased heart rate

·         Stomach and leg cramps

·         Muscle spasms

·         Loss of appetite

·         Vomiting and diarrhoea

·         Runny nose

·         Watery eyes

·         Increased irritability

·         Insomnia

·         Depression

Withdrawal symptoms can start a few hours after the last dose and can last up to several days depending on the level of dependence.  A continued craving, chronic depression, anxiety, insomnia and loss of appetite can continue for months and even years (Australian Drug Foundation, 2012).

Signs and symptoms of overdose

Accidental overdose is common, it is impossible to know the purity of heroin, and contaminates.  Taken in conjunction with other drugs and alcohol can prove fatal (Fatouvich, Bartu, Davis, Atrie,& Daly, 2010)

·         Comma

·         Respitor  depression

·         Decrease in body temperature

·         Irregular heartbeat

·         Unconsciousness

·         Death

·         Nausea

·         Vomiting

·         Increase in sweating and itching

(Fatouvich et al, 2010)

Emergency treatments

It is recommended for all overdoses and suspected overdoses that universal precautions be used at all times (Tintinalli,et al 2011; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004)

Naloxone can be used to reverse the effects of Heroin

Withdrawal symptoms can manifest within hours of the last dose, if the patient is still conscious they may begin to experience some of the symptoms listed above.

Medications such as antiemetic for vomiting and nausea

Anti diarrhoeal agents for diarrhoea

Antispasmodic agents for the cramps

NSAIS for muscle and joint pains

Airway, breathing and circulation are immediate priorities. 

An extensive assessment should be undertaken, look for signs and symptoms of Heroin use

Investigations may include. 

·         pathology tests – electrolytes, renal function, creatinine, coagulation, liver function, arterial blood gas, serial cardiac enzymes,

·         electrocardiograph (ECG)

Intravenous cannula (IV) access

Arterial line

Sedation and intubation may be required

(Boderick,2003; Greene, Ker & Braitberg, 2008; Tintnalli et al, 2011; Schuckit, 2000).

Hallucinogens

There are two types of hallucinogens discussed here

·         Lysergic acid diethylamide (LSD) discovered in 1938 it is one of the most potent mood and perception altering drugs available. It is found in ergot – a fungus that affects rye.  LSD comes in the form of gelatine squares or blotting paper that has been dipped in LSD, it is usually swallowed however it can be sniffed or injected

·         Psilocybin is a chemical with hallucinogenic properties found in certain types of mushrooms, In Australia there are around 20 species of mushrooms containing psilocybin found in Victoria, new South Wales and Queensland, the mushrooms are mostly commonly referred to as magic mushrooms.  It can be in the form of powder, dried mushrooms or fresh mushrooms, either eaten fresh or brewed into a ‘tea’

There is no safe level of a hallucinogenic drug. According to the National Household Survey 2010, 6.7% of Australians over the age of 14 have tried a hallucinogenic drug other than cannabis or ecstasy (Australian Drug Foundation, 2012; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004)

Common names

LSD – acid, trips, wedges, windowpanes, blotter, microdot,

Psilocybin – mushies, blue meanies, magic mushrooms, gold tops Airway

(Australian Drug Foundation, 2012; National Drugs Campaign, 2012; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).

Physical and psychological effects on the brain and body

Physical	Psychological
Tachycardia	Agitation
Tremor	Panic
Hyperreflexia	Loss of control
Lack of coordination	Trance like state
Dizziness	Excitation
Increased respitory rate	Euphoria
Blurred vision	Hallucinations
Unstable body temperature	Paranoia
Increased blood pressure	Confusion
	Visual hallucinations can cause anxiety, fear, confusion, paranoia, depression, anxiety and unpredictable flashbacks
	Sense of relaxation and well being

National drug campaign, 2012; Tintnallis, et al, 2011; Greenstein & Gould, 2004; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004

Withdrawal

·         Depression

·         Anxiety

·         Panic attacks

·         Psychosis

·         Cravings

·         Fatigue

·         Irritability

·         Reduced ability to experience pleasure

(Australian Drug Foundation, 2012).

Signs and symptoms of overdose

LSD

·         Coma

·         Hyperthermia

·         Tachycardia

·         Anxiety

·         Coagulopathy

·         Muscle tension

·         Panic attacks

·         Persistent acute psychosis

·         Extreme paranoia

·         Suicides can occur

Psilocybin

·         Tachycardia

·         Muscle tension

·         Nausea

·         Vomiting

·         Rarely – seizures

·         Rarely – Hyperthermia

Emergency treatments

It is recommended for all overdoses and suspected overdoses that universal precautions be used at all times (Tintinalli et al, 2011; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).

Reassurance and emotional support

Benzodiazepines for agitation

Haloperidol – an additional sedative

Supportive treatments

Airway, breathing and circulation are immediate priorities. 

An extensive assessment should be undertaken, look for signs and symptoms of Hallucinogenic drug use

Investigations may include. 

·         pathology tests – electrolytes, renal function, creatinine, coagulation, liver function, arterial blood gas, serial cardiac enzymes,

·         electrocardiograph (ECG)

Intravenous cannula (IV) access

Arterial line

Sedation and intubation may be required

NSAIS for muscle and joint pains

Medications such as antiemetic for vomiting and nausea

(Boderick,2003; Greene, Ker & Braitberg, 2008; Tintnalli et al, 2011; Schuckit, 2000).

Inhalants

Inhalants include a variety of products, generally household or office products such as aerosol spray cans, chrome based paint, cleaning fluid, liquid paper, paint or paint thinner, felt tipped pens and glue, as well as petrol (Australian Drug Foundation, 2012).

Although not illegal to buy these products,

Common names

Nitrous oxide-laughing gas, whippits, nitrous,

Amyl nitrate- snappers, poppers, pearlers, rushamines

Butyl nitrate- locker room, bolt, rush, climax, red gold

 (Australian Drug Foundation, 2012; National Drugs Campaign, 2012; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).

Physical and psychological effects on the brain and body

Physical	Psychological
Brain damage	Severe depression
Paralysis	Bizarre or reckless behaviour
Chest pain	Lowered inhibitions
Muscle and joint pain	Agitated
Heart problems	Uneasy
Loss of appetite	Reckless behaviour
Bronchial spasm	Confusion
Sores on nose or mouth	disorientation
Nose bleeds	blackouts
Diarrhoea
Fatigue
Suffocation
Sudden death
Runny nose, sneezing
Visual distortions
Decreased coordination
Kidney and liver damage
Weight loss
Excessive thirst

(National drug campaign, 2012; Tintnalli, et al, 2011; Trounces, 2004; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004)

Withdrawal

·         Headache

·         Nausea

·         Dizziness

·         Hangover symptoms

·         Stomach pain

·         Tremors

·         Shakiness

·         Cramps

·         Hallucinations

·         Seeing spots

Signs and symptoms of overdose

·         Sudden sniffing death

·         Liver damage

·         Kidney damage

·         Irritability

·         Chest pain

·         Angina

·         Loss of sense of smell and hearing

·         Tremors

·         Irregular Heartbeat

(Australian Drug Foundation, 2012).

Emergency treatments

It is recommended for all overdoses and suspected overdoses that universal precautions be used at all times (Tintinalli et al, 2011; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004)

Treatments for inhalant use and overdose, are aimed at air way management and oxygen administration (Broderick, 2003)

Medications such as antiemetic for vomiting and nausea

Reassurance and emotional support

Benzodiazepines for agitation

Haloperidol – an additional sedative

An extensive assessment should be undertaken, look for signs and symptoms of inhalant use

Investigations may include. 

·         pathology tests – electrolytes, renal function, creatinine, coagulation, liver function, arterial blood gas, serial cardiac enzymes,

·         electrocardiograph (ECG)

Intravenous cannula (IV) access

Arterial line

(Boderick,2003; Greene, Ker & Braitberg, 2008; Tintnalli et al, 2011; Schuckit, 2000).

Follow up and psychosocial interventions

The follow up and interventions for cannabis use are limited; it was thought that cannabis dependence was limited.  Most interventions for cannabis addiction are based on those used for alcohol addiction and treatments.

Most hospitals provide beds to help people through the acute withdrawal stage.

For long term support there are several national groups:

·         Counselling online

·         Cannabis information and helpline

1800304050

·         Family Drug Support

1300 368 186

·         Kids help line

1800551800

·         Lifeline

131114

Each state and local area will also have support agencies

There are different forms of counselling available

·         Psychotherapy – helps people to discuss personal situations and work through problems and issues.

·         Cognitive behavioural therapy – can help teach and correct problems in the way a person thinks or behaves

·         Brief intervention – a short term treatment which can help people at certain stages of their treatment

·         Relapse prevention -  helps people to recognise warning signs of relapse, how to deal with and prevent a relapse

·         Motivational interviewing – helps people work out personal reasons for getting involved in treating and stopping drug use

·         Anger and anxiety management – uses cognitive behavioural methods to help people better manage

·         Family therapy – this involves all the members of the family in the treatment process, as well as people in the individuals social network.  Family Therapy looks at dysfunctional relationships and interactions.

There are rehabilitation programs available – these are often in patient programs that help with a long term approach to a drug free life

Complementary therapies such as massage, relaxation techniques and support from a naturopath can help with symptom management.

If available to a person peer, social and family support can be a great benefit

Self help options may be beneficial; however they do involve the individual being responsible for their own treatment.  The individual can use books, videos, self help groups and online support.  Often other forms of treatment are needed as well.

Pharmacotherapy’s can be used to help with symptom management as well as co excisisting depression and anxiety

Refer to a Social worker if possible

Aspects that also need considering are

·         Housing services

·         Financial support services

·         Legal advise

·         Employment

·         Education and training

 (National Centre for Education and Training on Addiction (NCETA) Consortium, 2004; Schuckit, 2000; Krivanek, 2000).

Reference List

Actnow.com.au. Illicit drugs.  What are illicit drugs? How are users of illicit drugs being affected? Why do people use illicit drugs? Viewed 30^th March 2012 www.actnow.com.au

Australian Government Department of Health and Aging. National Drugs Campaign. Viewed 04 April 2012 www.drugs.health.gov.au

Australian Institute of criminology Viewed 04 April 2012www.aic.gov.au/crime_types/drugs_alcohol/illicit_drugs

Australian Federal Police Viewed 10 April 2012. www.afp.gov.au

Australian Drug Foundation, 2012 Viewed 02 April 2012

Better Health Channel.Viewed 28 March 2012  www.betterhealth.vic.gov.au

Broderick, M 2003 Spotting Drug Use. www.rnweb.com.au Vol 66 No9

Department of Health aging – illicit drugs.  Viewed 01 April 2012 www.health.gov.au

Fatovich, D, Bartu, A Davis, G, Atrie, J, Daly, F. 2010 Morbidity associated with heroin overdose presentations to an emergency department: A 10 year record linkage study. Emergency Medicine Australasia. Vol 22 no 3240-245.

Frei, M. 2010 Party Drugs and Harm Reduction. Australian Family Physician Vol 39, No 8

Ford, R. 2011 Interpersonal Challenges as a constraint on care: The experience of nurses care of patients who use illicit drugs.  School of nursing and midwifery Australian Catholic University Fitzroy Vic Australia vol 37 no 2. 20-28

Greene Kerr & Braitberg, 2008, Review Article: Amphetamines and related drugs of abuse Emergency Medicine Australasia vol 20, no 1 391-402

Greenstein, B, Gould, D. 2004, Tronce’s Clinical Pharmacology for nurses, seventeenth edition. Churchill Livingstone London.

Holt, M, 2005,Young people and illicit drug use in Australia. Social Research Issues Paper. NSW Department of health National Centre in HIV social Research.

Hulse,G. White, J.& Cape, G. 2002, Management of Alcohol and Drug problems. Oxford University Press, Victoria Australia.

Krivanek, J. 2000, Understanding drug use: The key issues.  National library of Australia

National Centre for education and training on Addiction Consortium (NCETA)2004 Alcohol and other drugs: A handbook for health professionals.  Australian Government Department of Health and Aging

Novack, Ritchie, Murphy, Bartu, Holmes & Carpus, 1997, Drug overdose. Oxford University Press, Victoria Australia.

Schuckit, M. 2000, Drug and alcohol abuse: A clinical guide to diagnostics and treatment Kluwer Academic/ Plenum Publisher: New York

The Facts about young people and drugs.  www.druginfo.adf.org.au Drug prevention and Alcohol Facts.

Tintinalli, J. Stapczynski, S. Cydulka, R. Ma, J. Cline.D, & Meckler. 2011 Tintinalli’s Emergency Medicine: A Comprehensive study guide. 7^th Edition. McGraw Hill Medical. America

www.allaboutcounselling.com 2012 Viewed 01 May 2012

Appendix One

Learning Contract

NUR8550 Professional Studies 1

Student:  Rochelle Lindsay                                                                           Course examiner: Marie Cleary

Due date: 19^th March                                                                                             Course advisor: Geoff Wilson

Introduction:  As a nurse working in a rural and remote setting I have not had a lot of exposure to the effects of illicit drugs on users.  In 2008 I worked in a large emergency department, despite having worked in a rural and remote setting for many years prior to this, I still felt quite confident and competent in dealing with my workload, with the exception of drug overdose.  During my time working there I found myself nursing many patients suffering from the effects of various illicit drugs including overdose.  The patients that didn’t end up in the Intensive Care Unit were either admitted to the Mental Health unit or discharged home for community follow up.  There were many presentations, while I was there.  I found that I didn’t know many of the street names, I couldn’t match those street names with the actual drug and I had no understanding of how it was affecting the person mentally and physically. Nor did I know what the potential effects of the drug may have on a user.  Since then I have been interested in expanding my knowledge in this area.  My goal in this subject is to reduce the gap in my knowledge. 

It has come to my attention while developing this learning contract that illicit drug use and abuse cause problems that touch on all areas of medicine and health care (National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).  With drugs such as cannabis which is the most widely used illicit drug in Australia (Australian government Department of Health and Ageing, 2012; National Centre for Education and Training on Addiction (NCETA) Consortium, 2004), the problems caused are well known and highly visible where as other drugs cause subtle problems that are often missed by health professionals (Australian Government Department of Health and Aging, 2004).  Nurse and medical practitioners such as those that work in small rural clinics or hospitals have a critical role to play in the identification of drug use and provision of treatment (National Centre for Education and Training on Addiction (NCETA) Consortium, 2004).  Nurses in these areas are ideally placed to provide relevant information about drugs, identify drug related problems, provide interventions and aid in the referral process for specialist assessment and treatment as well as help provide follow up care (National Centre for Education and Training on Adduction (NCETA) Consortium, 2004; Hulse, White & Cape, 2002).This new knowledge further confirms my knowledge gap and compels me to reduce this gap.  To do this I am going to research illicit drug use, to find out the common illicit drugs in Australia, to identify their street names, there effects, what an overdose is, what drug withdrawal is and how to recognise them, as well as how to treat drug overdose and withdrawal.  I will also look at the psychosocial effects and treatments and emergency treatments.

The purpose of this learning contract is to identify learning objectives, strategies and resources, and an appropriate time frame these are to be achieved by. The objective is to produce a written Report on common illicit drugs in Australia, there physical and psychological effects on the body, identify, diagnose and treat withdrawal and overdoses, as well as community follow up.  The report will be used as a learning tool to help nursing staff, in rural and remote settings quickly identify and treat drug overdose and withdrawal.   The final report submitted by the 4^th of June will also be the required proof that my learning objectives have been met.

Learning Objectives	Strategies and Resources	Time Frame	Verification/proof learning objectives have been met
·         Define illicit drugs ·         Identify common illicit drugs used in Australia ·         Define overdose	·         Text books ·         Contact the Alcohol and drug community nurse in Tennant Creek ·         websites –such as www.drugs.health.gov.au www.nationaldrugstrategy.gov.au www.aic.gov.au www.aihw.gov.au www.health.gov.au www.health.insite.gov.au	·         19th-24th march Week 4	·         A report will be produced covering all the learning objectives mentioned in this contract.
For each drug ·         Identify physical and psychological effects on the brain/body	·         Text books ·         Contact the Alcohol and drug community nurse in Tennant Creek	·          2nd-5th April Week 6	·          A report will be produced covering all the learning objectives mentioned in this contract.
For each drug ·         Diagnosis ·          Emergency Treatments available ·         Identify available pharmacological treatment that may be available for the patient	·         Textbooks ·         Websites- such as www.drugs.health.gov.au www.nationaldrugstrategy.gov.au www.aic.gov.au www.aihw.gov.au www.health.gov.au www.health.insite.gov.au ·         Primary Clinical Care Manual 2011 ·         Journal articles- the Cochrane Library	·         16th-20th May Week 8	·         A report will be produced covering all the learning objectives mentioned in this contract.
·         Withdrawal symptoms that a user may experience	·         Textbooks ·         Websites –such as www.drugs.health.gov.au www.nationaldrugstrategy.gov.au www.aic.gov.au www.aihw.gov.au www.health.gov.au www.health.insite.gov.au ·         Primary clinical Care Manual 2011	·         30th Apr-4th May       Week 10	A report will be produced covering all the learning objectives mentioned in this contract.
·         Overdose symptoms that a user may experience	·         Textbooks ·         Websites- such as www.drugs.health.gov.au www.nationaldrugstrategy.gov.au www.aic.gov.au www.aihw.gov.au www.health.gov.au www.health.insite.gov.au	·         14th-18th May Week 11	·         A report will be produced covering all the learning objectives mentioned in this contract.
Identify ·         Psychosocial interventions for patients ·         Community follow up for patients	·         Textbooks ·         Contact the Alcohol and drug community nurse in Tennant Creek ·         Journal articles –The Cochrane Library	·         21st-25th May Week 12	·         A report will be produced covering all the learning objectives mentioned in this contract.

Reference List

 National Centre for Education and Training on Addiction (NCETA) Consortium.  2004. Alcohol and Other Drugs: A Handbook for Health Professionals. Australian Government Department of Health and Aging, Canberra

Australian Government Department of Health and Aging.  2012 National Drugs Campaign.  www.drugs.health.gov.au viewed 01/03/2012

Hulse, G,  White,J  & Cape,G (eds) 2002. Management of Alcohol and drug problems.  Oxford university press. South Melbourne, Victoria Australia.