Table Of ContentS
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Psychiatry R
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The misuse of both legally prescribed and illegally supplied drugs is now so widespread that it PA
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affects, either directly or indirectly, a high proportion of the population, impacting many areas N
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of daily life. There are few countries that are not touched by some aspect of substance misuse, -
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and the consequences for individuals, families and the wider community can be devastating. A
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The third edition of Symptoms and Signs of Substance Misuse has been completely E
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updated and revised, continuing to provide trusted information from leading experts. /
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• Basic principles of treatment for the most commonly encountered substances—from O
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tobacco and alcohol to cocaine and heroin, as well as 'designer' drugs T-
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• The legal aspects of substance misuse highlighted throughout A
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• Convenient A-Z format helps you find information at a glance
• References and further reading direct you to more authoritative
information about each substance
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With specialist information clearly explained along with a full glossary, this handy pocket-sized Y
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book is essential for all health professionals needing a concise and up-to-date overview of the
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signs and symptoms of substance misuse as well as the management and treatment options T
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available. Junior hospital doctors, emergency department staff, primary care teams, communi-
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ty workers and counsellors will find this text invaluable. The book is also an excellent resource S T H I R D E D I T I O N
for police officers as well as a quick reference guide for professionals involved in setting up A
and managing drug and alcohol policies in organisations and businesses. N
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Margaret Stark LLM MSc (Med Ed), FFFLM, FACBS, FHEA, FACLM, S
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FRCP, DGM, DMJ, DAB G
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Adjunct Professor, Central Clinical School, Discipline of Medicine and Sydney Forensic
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Medicine and Science Network, University of Sydney; Director, Clinical Forensic Medicine
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Unit, NSW Police Force, Sydney, Australia; Founding Academic Dean, Faculty of Forensic F
and Legal Medicine, Royal College of Physicians of London, UK S
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Jason Payne-James LLM, MSc, FFFLM, FFSSoc, FRCS(Ed & Eng), DFM Mediator B
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Specialist in Forensic and Legal Medicine; Honorary Senior Lecturer, Cameron Forensic T
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Medical Sciences, Barts and the London Medical and Dental School, London; Director, N
Forensic Healthcare Services Ltd, Leigh-on-Sea, UK C
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Michael Scott-Ham BSc, MFSSoc M
Committee member of United Kingdom and Ireland Association of Forensic Toxicologists; IS
Member of Society of Forensic Toxicologists; Member of The International Association of U
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Forensic Toxicologists; Senior Associate Member Royal Society of Medicine; Forensic E
Toxicology Consultant; Director of Principal Forensic Toxicology and Drugs Consultancy Ltd,
London; Director of Principal Forensic Services Ltd, London, UK
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D Margaret Stark • Jason Payne-James
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symptoms
and signs
of
Substance Misuse
THIRD EDITION
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symptoms
and signs
of
Substance Misuse
THIRD EDITION
Margaret Stark LLM MSc (Med Ed), FFFLM, FACBS, FHEA, FACLM, FRCP, DGM, DMJ, DAB
Adjunct Professor, Central Clinical School, Discipline of Medicine and Sydney Forensic
Medicine and Science Network, University of Sydney; Director, Clinical Forensic Medicine
Unit, NSW Police Force, Sydney, Australia; Founding Academic Dean, Faculty of Forensic
and Legal Medicine, Royal College of Physicians of London, UK
Jason Payne-James LLM, MSc, FFFLM, FFSSoc, FRCS(Ed & Eng), DFM, Mediator
Specialist in Forensic and Legal Medicine; Honorary Senior Lecturer, Cameron Forensic
Medical Sciences, Barts and the London Medical and Dental School, London; Director,
Forensic Healthcare Services Ltd, Leigh-on-Sea, UK
Michael Scott-Ham BSc, MFSSoc
Committee member of United Kingdom and Ireland Association of Forensic Toxicologists;
Member of Society of Forensic Toxicologists; Member of The International Association
of Forensic Toxicologists; Senior Associate Member Royal Society of Medicine; Forensic
Toxicology Consultant; Director of Principal Forensic Toxicology and Drugs Consultancy
Ltd, London; Director of Principal Forensic Services Ltd, London, UK
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CRC Press
Taylor & Francis Group
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© 2015 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business
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Version Date: 20140331
International Standard Book Number-13: 978-1-4441-8175-3 (eBook - PDF)
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knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid
advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly
urge to consult the relevant national drug formulary and the drug companies’ printed instructions, and their websites, before administering any of
the drugs recommended in this book. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual.
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CONTENTS
Preface vii
Author biographies ix
PART I Introduction 1
1 Routes of administration 3
2 Harm reduction and minimisation 7
3 Drugs, statutes and legal requirements 9
4 The medical and health complications of substance misuse 15
5 Suspected internal drug traffickers: drug stuffers and mules 25
6 Substance detection 27
PART II Specific drugs 31
A Alcohol 33
Aminoindanes, indoles and benzofurans 37
Amphetamine-type stimulants 39
Anabolic steroids 43
B Barbiturates 45
Benzodiazepines 47
C Cannabis 51
Cocaine 57
E Ecstasy 63
H g-Hydroxybutyrate and related compounds 67
K Ketamine 71
Khat 75
L LSD 79
N Nitrites 83
O Opiates/opioids 85
P Phencyclidine 93
Phenethylamines 97
Piperazines 101
Pipradrols 103
S Synthetic cannabinoids 105
Synthetic cathinones 109
T Tobacco 113
Tryptamines 115
V Volatile substances 119
Z ‘Z’ drugs 123
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Symptoms and Signs of Substance Misuse
PART III Appendices 125
A Glossary 127
B Clinical Institute Withdrawal Assessment of Alcohol Scale, revised
(CIWA-Ar) 133
C Alcohol assessment questionnaires: Brief MAST, CAGE and AUDIT 135
D Clinical Opiate Withdrawal Scale 139
E Further reading and resources 141
Index 143
vi
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PREFACE
Misuse of both illicit and licit drugs is widespread on a global and massive scale. The
term ‘substance misuse’ is a general term to describe the misuse of drugs.
All drugs (those legally obtained or prescribed and those illegally supplied), including
alcohol and tobacco, have the potential to be misused. Individuals may use drugs
occasionally (so-called ‘recreational’ use), e.g. at weekends, or may become addicted
to, and dependent upon, certain drugs. Drugs can affect all aspects of life including
home, relationships, school, college, university, employment, sport and personal life.
The effects of drugs on individuals or institutions are frequently highlighted in news
stories, often coated with a veneer of excitement, daring or glamour. This can be very
misleading.
Unfortunately, whether drug use is recreational, or results in dependence or addiction,
each drug will have physical or psychological effects, or a combination of both. Some
of these effects may appear positive, e.g. a temporary feeling of wellbeing, and some
individuals may be lucky enough to use drugs without any adverse consequences.
However, for many drug users, adverse consequences are frequently seen, and such
effects may be prolonged or fatal, affect the ability to maintain or seek employment or
travel, and result in a criminal record.
The undesirable and unwanted effects differ from drug to drug. Individuals may
describe physical or psychological effects that they feel or experience – ‘symptoms’ – or
others may see or observe physical effects – ‘signs’. The widespread availability and
enormous variety of drugs – many used in combination (polydrug use) – with many
different effects can make it difficult to recognise: (1) if drugs are being used or
(2), if a drug is being used, what type it is. Increasingly organised crime syndicates are
producing new drugs – often inappropriately termed ‘legal highs’ – to try to outwit the
legal systems and drug laws. This in itself creates further problems, in that the nature
of drugs bought and consumed on the street may be completely unknown to the
buyer and vendor, although they may be believed to represent a particular drug group.
Medical and scientific knowledge are increasing exponentially but will always remain
behind the curve when attempting to identify and categorise adverse effects.
This book is aimed at providing concise and readily accessible facts about the known
possible symptoms and signs associated with the most commonly misused and available
drug groups to help healthcare professionals, employers, police, parents, teachers,
partners or friends to identify whether drugs are being misused. The book also
summarises the different types of drugs, how they produce their effect, and methods of
treatment or management.
The range and mix of drugs mean that few signs and symptoms are diagnostic of a
particular drug, and if drug use is suspected further specialist help should be sought
from those experienced in the assessment and management of substance misuse. Perhaps
the most important guidance is that if a friend or relative’s behaviour and demeanour
appear to have undergone a change, it is important to at least question whether use
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Symptoms and Signs of Substance Misuse
of drugs, of some type and in some form or other, may be a contributory factor. As a
general rule doctors and other healthcare professionals should consider it appropriate to
always ask direct questions about possible drug usage of anyone they are assessing, in the
same way as the use of alcohol or cigarettes would be explored.
The legal issues in this book are placed primarily in the context of current law
in England and Wales. The medical and clinical principles referred to are similar
throughout the world.
As many new drugs are being encountered on a very frequent basis, legislators are
reviewing controls regularly and the status of drugs in the book may have changed
since publication. Consequently a link to the UK’s Home Office website, which details
changes to legislation, is included.
For those wishing to explore some of these issues further, this edition includes further
reading that the authors believe are key publications and links to sources of information
and specific interest.
viii
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AUTHOR BIOGRAPHIES
Margaret Stark
Margaret Stark is the Director of the Clinical Forensic Medicine Unit for the NSW
Police Force (since May 2011). In June 2012 she was made an adjunct professor in the
Faculty of Medicine of the University of Sydney. Margaret qualified as a doctor in 1981
and is a vocationally trained general practitioner. She completed a Master of Law at the
University of Wales in 1996.
Previously, she worked with the Metropolitan Police Service for 22 years as a forensic
physician and was the first medical director of the Forensic Healthcare Service from
2010 to 2011. As a forensic physician she has expertise in the assessment of detainees in
police custody, including providing primary and emergency care, the management and
treatment of substance misuse and mental health problems, and the forensic assessment
of detainees, where appropriate. She has extensive experience in writing reports for
court and giving evidence as an expert witness.
She was President of the Association of Forensic Physicians from 2002 to 2004 and
instrumental in the establishment of the Faculty of Forensic and Legal Medicine of
the Royal College of Physicians of London. She was the Founding Academic Dean
from 2006 to 2011, leading the team responsible for the establishment of the faculty
membership examination. She was awarded the David Jenkins Professorship in Forensic
and Legal Medicine from 2011 to 2012.
Margaret has been involved in training professionals in the field of clinical forensic
medicine as an information provider, on-the-job educator, facilitator, assessor, and
planner, and completed a Master of Science in Medical Education at University College
London in 2010. She has written extensively in the field and edited the textbook
Clinical Forensic Medicine – A physician’s guide as well as contributing 20 chapters to a
variety of publications including Clinical Forensic Medicine, Encyclopedia of Forensic and
Legal Medicine and Legal and Forensic Medicine. Over the years she has been involved in a
number of qualitative and quantitative research projects resulting in articles published in
peer-reviewed journals and research reports.
Jason Payne-James
Jason Payne-James is a forensic physician and specialist in forensic and legal medicine.
He qualified in medicine in 1980 at the University of London and undertook additional
postgraduate education to higher degree level at Cardiff Law School, the Department
of Forensic Medicine and Science at the University of Glasgow and the University of
Ulster, Northern Ireland. He is a mediator accredited by the Civil Mediation Council.
Jason is Honorary Senior Lecturer at Cameron Forensic Medical Sciences, Barts and the
London Medical and Dental School, UK. He is external consultant to the UK National
Crime Agency and National Injuries Database. He has been a forensic medical examiner
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