Trends in Drug AbuseUpdate for School Nurses

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Trends in Drug AbuseUpdate for School Nurses

• Jane C. Maxwell, Ph.D.
• Center for Excellence in Drug Epidemiology
• Gulf Coast Addiction Technology Transfer Center
• www.gcattc.net

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Data Sources

• Treatment admission records (TEDS-DSHS)
• Overdose death certificates (DSHS)
• Poison Control Center cases (DSHS)
• Emergency room data (DAWN)
• Price, purity, supply, trafficking data (DEA)
• Surveys (National DSHS)
• Forensic laboratory tests by DEA and DPS
• Maxwell, J. C et al. (2006). Drug use and risk of
  HIV/AIDS on the Mexico-U.S. Border A comparison
  of treatment admissions in both countries. Drug
  and Alcohol Dependence.

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Percentage of Texas Secondary Students Who Had
Ever Used Substances, Border vs. Non-Border 2006
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Percentage of Texas Secondary Students Who Had
Ever Used Substances, Border vs. Non-Border 2006
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Percentage of Texas Elementary Students Who Had
Ever Used Substances, Border vs. Non-Border 2006
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Percentage of Texas Sixth Grade Students Who Had
Used Alcohol or Tobacco This School Year, Border
vs. Non-Border 2006
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Percentage of Border and Non-Border Drug-Using
Secondary Students Who Had Used One or More
Illicit Drugs in the Past Year 2006
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Percentage of Border and Non-Border Secondary
Students Who Had Ever Used Rohypnol, by Grade
2006
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Percentage of Border and Non-Border Secondary
Students Who Said Selected Substances Were Very
Easy to Obtain 2006
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Percentage of Past-Month Alcohol Users Who
Always/Most of the Time Get Alcohol From Various
Sources, Border and Non-Border Secondary
Students 2006
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Percentage of Border and Non-Border Secondary
Students Who Thought Selected Substances Were
Very Dangerous to Use 2006
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Parental Attendance at School Events for
Past-Month Alcohol and Marijuana Users Compared
to Non-Users, Border and Non-Border Secondary
Students
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Alcohol
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Percentage of Texas Secondary Students Who
Reported They Normally Consumed Five or More
Drinks at One Time, by Gender 20002004
Liu, L. Texas School Survey of Substance Use
Among Students in Grades 7-12, DSHS.
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Percentage of Texas Secondary Students Who
Reported They Normally Consumed Five or More
Drinks at One Time, by Gender 2004
Liu, L. Texas School Survey of Substance Use
Among Students in Grades 7-12, DSHS.
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Percentage of Texas Seniors Who Had Driven While
Drunk or High from Drugs 19902004
Liu, L. Texas School Survey of Substance Use
Among Students in Grades 7-12, DSHS.
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Primary Problem Substance of DUI Admissions to
Treatment
2005
1996
2
1
7
75
66
4
Maxwell, Impaired Drivers at Admission to
Substance Abuse Treatment, RSA Poster, 2006.
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Texas Treatment Admissions by Primary Substance
of Abuse 1987-2005
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Admissions to Treatment in Texas-Mexico Border
Programs1996-2004
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Reefer Sadness
Marijuana
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MARIJUANA IN TEXAS

• Fairly stable.
• CJ v. Non-CJ treatment admissions
• Use with Fry, PCP, DANK, crack, cough syrup,
  honey, etc., continues.
• Continuing references to pot and PCP and
  embalming fluid. Effects of smoking joint dipped
  just in embalming fluid?

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Marijuana Indicators in Texas 1997-2006
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• Primos--marijuana joint and crack.
• Fry, Amp--joint and embalming fluid (PCP?)
• Fry Sticks Fry Squares--10 each.
• Fry Sweets--blunts in embalming fluid.
• Sweet Houses--sell ready-mades.
• Candy Blunts--cigarillos in codeine cough syrup.
• Sherms--menthol cigarettes in embalming fluid.

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Texas Secondary Students Who Had Used Any
Illicit Drug in the Past Month, by Ethnicity
1988-2006
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Addiction Severity Index Problems of Texans
Treated with Primary Marijuana Problem 2006
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Heroin

• 1998 Miami DMP Samples
• Southwest Asian 2.1 Pure
• Southeast Asian 2.3 Pure
• South American 19.2 Pure

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Heroin Indicators in Texas1998-2006
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Cheese Heroin

• Cheese is heroin Tylenol PM, but now mentions
  of Advil, Nytol, and other PM products, as well
  as Xanax combination.
• Young Hispanic youths in Dallas, but may spread.
  Culturally relevant education intervention
  needed. Couple of mentions elsewhere in the
  state.
• Death data varies ME v. newspaper.
• Emphasize HEROIN, not Cheese.

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CHEESE HEROIN
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Route of Heroin Administration for Texas
Treatment Admissions 1989-May 2007
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Percent of Heroin Inhalers at Admission to Texas
Treatment Who are Hispanic 1989-May 2007
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Age of Heroin Inhalers at Admission to Texas
Treatment 1989-May 2007
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27
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DRAFT
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DRAFT
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COCAINEStill Aroundwith New Users
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Cocaine Indicators in Texas
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Cocaine

• Different routes of administration. Injecting
  cocaine and heroin either together or
  sequentially (Speedball)
• Risky sexual behaviors while smoking crack and
  trading drugs for sex in crack houses.
• Danger of disease transmission through burned
  lips from crack pipes. Harm minimization
  kitsspark plug covers, new brillo pieces,
  vitamins, etc.
• Methamphetamine outselling cocaine and crack in
  some areas coke dealers now fronting cocaine to
  competeor shifting to selling Ice.
• Increasing cocaine use among Hispanics. Will
  Hispanics be the next victims of the crack and
  HIV epidemic?

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Race-Ethnicity of Texas Cocaine Admissions 1993
v. 2005
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Texas Secondary Students Who Had Ever Used
Powdered Cocaine and Crack, by Grade 2006
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Route of Administration of Cocaine Admissions to
Treatment in US-Mexico Border Programs
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COCAINE
California Cocaine 12
Arizona Cocaine 9
New Mexico Cocaine 9
Texas Cocaine 26
Baja California Cocaine 3
Sonora Cocaine 35
Tamaulipas Cocaine 35
Chihuahua Cocaine 19
Coahuila Cocaine 25
Nuevo Leon Cocaine 28
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Methamphetamine
They used to say Speed Kills?
They used to say Speed Kills?
It still does
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Methamphetamine Amphetamine Indicators in
Texas 1997-2006
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Methamphetamine

• Prescribed for attention deficit disorders,
  narcolepsy, occasionally for obesity, alertness.
• Abusers use to feel alert, be sociable, euphoric,
  cope with mental illness, feel normal, stay
  awake longer, strength and energy, lose weight,
  sexual performance.
• Risk of HIV due to IDU and high-risk sex. Both
  heterosexuals and homosexuals report sex on
  methamphetamine as compulsive and obsessive,
  with loss of control over their sexual
  expression.
• Use on the job? Long bomber runs, truckies, day
  laborers, people working long hours in boring
  jobs or working multiple jobs?
• Increase in the purer Ice. La Tina?

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Sources of Amphetamine-Type Substances
Sources of ephedrine
Major producers of methamphetamine
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EPHEDRINE
H
H
H
C
C
N
CH
CH
OH
3
3
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Methamphetamine Forms Australia
Methamphetamine Powder IDU Description
Beige/yellowy/off-white powder
Base / Paste Methamphetamine IDU Description
Oily, gunky, gluggy gel, moist, waxy
Crystalline Methamphetamine IDU Description
White/clear crystals/rocks crushed glass /
rock salt
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METHAMPHETAMINE
California Methamphetamine 31
Arizona Methamphetamine 27
New Mexico Methamphetamine 4
Texas Methamphetamine 8
Baja California Methamphetamine 44
Sonora Methamphetamine 18
Tamaulipas Methamphetamine 0
Chihuahua Methamphetamine 0
Coahuila Methamphetamine 0
Nuevo Leon Methamphetamine 1
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Route of Administration of Methamphetamine
Admissions to Treatment in US-Mexico Border
Programs
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Stages of Meth Epidemic?

• Early StagesIce in gay and party scene powder
  meth via overnight express from California crack
  in urban areas.
• Middle StagesMom Pop cookers and large problem
  in rural areas but number of labs declining with
  restrictions on sales of cold medicines crack
  still strong in urban areas Mexican meth starts
  being trucked in to urban areas.
• Late Stagesprimary problem for treatment
  admissions spreads across racial/ethnic groups
  Ice is dominant form and powder supply decreases
  increasing types of traffickers (criminal groups,
  ethnic gangs, outlaw bikers).
• Now in a lull? Supply down and cost up.

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Primary Amphetamine/MethamphetamineTEDS
Admission Rates 1997(per 100,000 aged 12 and
over)
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35 - 58
12 - 35
No data
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Primary Amphetamine/MethamphetamineTEDS
Admission Rates 2003(per 100,000 aged 12 and
over)
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35 - 58
12 - 35
No data
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Primary Amphetamine/MethamphetamineTEDS
Admission Rates 2005(per 100,000 aged 12 and
over)
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35 - 58
12 - 35
No data
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Routes of Administration of Methamphetamine of
Clients in Texas Programs 1988-2006
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Changes in Price of a Pound of Ice in Houston
from 1st Half 2004 to 2nd Half of 2005
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Changes in Price of a Pound of Meth in Dallas
from 2nd Half 2006 to 1st Half of 2007
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• Meth abusers have trouble organizing information
  from more than one sourcecant switch points of
  view.
• Paradoxicalconcentration better when on
  methworse as become abstinentlearning memory.
• Comprehension deficits. Make sure they understand
  what counts as compliance (drug courts, CPS
  workers reuniting families, taking meds as
  scheduled). Cant remember. Need concrete and
  specific information.

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Treatment

• Withdrawal can last 2-10 days with depression,
  fatigue, anxiety, paranoia, cognitive impairment,
  agitation, confusion.
• Meth clients dont do well in traditional tmt.
  Poor engagement rates, high dropout rates, severe
  paranoia, high relapse rates, ongoing episodes of
  psychosis.
• Counselors may not like to treat meth patients
  due to cognitive problems and concerns about
  violence.

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Matrix Model

• Manualized 16 week non-residential, psychosocial
  approach used for the treatment of drug
  dependence.
• Designed to integrate several interventions into
  a comprehensive approach. Elements include
• Individual counseling
• Cognitive behavioral therapy
• Motivational interviewing
• Family education groups
• Urine testing
• Participation in 12-Step programs.

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Urinalysis Results

• Results of Ua Tests at Discharge, 6 months and 12
  Months post admission
• Matrix Group TAU Group
• D/C 66 MA-free 65 MA-free
• 6 Ms 69 MA-free 67 MA-free
• 12 Ms 59 MA-free 55 MA-free
• Over 80 follow up rate in both groups at all
  points
• Rawson, R et al Addiction vol 99, 2004

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Self-Reported Reasons for Starting
Methamphetamine Use
R. Willis, M. Hillhouse (2003). Findings from
the Methamphetamine Treatment Project Weight
concerns and depression in females. Poster
presented at CPDD.
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Gender Differences and Implications for Treatment

• Body image and nutrition need to be addressed.
• Co-occurring mental health problems complicate
  treatment and require longer duration for
  treatment.
• Violence linked to meth use is related to trauma
  and safety needs which must be addressed in
  treatment.

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Histories of Violence among Clients Treated for
Meth

• Persons in tx for meth reported high rates of
  violence
• 85 women
• 69 men
• The most common source of violence
• For women, partner (80)
• For men, stranger (43)
• History of sexual abuse and violence
• 57 women
• 16 men

Cohen, J., 2003.
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DOWNERS

• Barbiturates (phenobarbital), benzos
  (diazepam-Valium, alprazolam-Xanax,
  clonazepam-Klonopin, lorazepam-Ativan,
  chlordiazepoxide-Librium).
• Potentiate low-quality heroin (and seen in heroin
  overdoses)
• Come down from speed or cocaine trips
• Dependence among females
• Kids like Xanax (Four Bars).

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Benzodiazepines Identified by DPS Labs in Texas
19982006
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Club Drugs in Texas

• Club drugs can be a ticket to treatmentoften
  with poor outcomes.
• Ecstasy treatment numbers are up and it is moving
  out of the club scene.
• GHB centered in DFW metroplex.
• Rohypnolblue punch to get around dye.
• Ketamine numbers low.
• PCP indicators risingBuck Naked.
• Coricidin HPB (Skittles) used by kids .
• Lack of evidence-based treatment for the
  dependent.

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Admissions to DSHS-Funded Treatment Programs With
a 1st, 2nd, or 3rd Problem With a Club Drug 2006
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ECSTASY--The Ugachaka Phenomena

• Epidemic Outbreak
• Compulsive
• I cant stop...
• Youthful

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Adverse Effects of Ecstasy

• Agitation, anxiety, tachycardia and hypertension.
• MDMA affects depression, other mood disorders,
  impulsiveness, hostility, psychotic symptoms,
  anxiety and panic.
• However, ecstasy use might be associated with use
  of multiple substances and onset of mental
  disorder may precede ecstasy use.
• Memory problems reported by 29 of novice users,
  53 of moderate users 73 of heavy users.
• Equal doses of MDMA per kgm body weight produced
  stronger responses in women as well as more
  hallucinogen-like perceptions and more mid-week
  low mood. But self-rated aggression same for
  women and men.
• Users take selective serotonin reuptake
  inhibitors such as fluoxetine, sertraline or
  antioxidens such as vitamin C or E. This
  information does not appear to have been
  medically evaluated.

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Ecstasy Indicators in Texas 1998-2006
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Texas Treatment Admissions with a Primary,
Secondary or Tertiary Problem with Ecstasy
1998-2006
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NDARC Study of Ecstasy Users

• N329 young, well educated, employed or
  students oversample of heavy users.
• Polydrug users with high IDU rates.
• Young female polydrug users those who binged on
  ecstasy for 48 hours reported physical,
  psychological, other problems which they
  attributed to ecstasy use.
• Users may benefit from credible information to
  modify use and reduce problems.
• Need treatment options to meet demand indicated.
• Topp, Hando, Dillon et al., Ecstasy Use in
  Australia, Drug and Alcohol Dependence 55 (1999)
  105-115.

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GHB, GBL, 1-4 BD,Fantasy

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GHB Adverse Effects

• Central Nervous System depressant-- intoxication,
  then deep sedation.
• GBL and 1-4BD turn into GHB when swallowed.
• Role of web re inaccurate information and
  availability.
• Threat of drink spiking.
• Tolerance dependence build rapidly.
• Intervention treatment may be delayed because
  providers lack knowledge about GHB dependence.
  Little information on treatment.

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LSD

• Slang terms--Acid, Blotter, or name of picture on
  tab.
• Is a small paper square with picture or
  jello-like square tab.
• More prevalent than we think?
• What about mushrooms?

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DISSOCIATIVE DRUGS PCP, Ketamine, DXM

• Distort perceptions of sight and sound and
  produce feelings of detachment, but not
  hallucinations (Zombie effect)

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Phencyclidine

• PCP, Angel Dust, Killer Weed
• Dissolved in embalming fluid (Fry, Amp,
  Water, Water).
• Swallowed, sniffed, smoked on joints dipped in
  Fry.
• Out-of-body strength.

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PCP Indicators in Texas 1998-2006
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KETAMINE

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SPECIAL K (Ketamine)

• Anesthesia doses 2-10 mg/km recreational doses
  50-100 mg.
• Unsafe sexual behavior associated with frequent
  use of Ketamine. Use at gay circuit parties of
  concern.
• Taken in cyclical binges similar to cocaine or
  methamphetamine.
• Available as powder to snort or as liquid to
  inject used with puffers to get exact dosing.
• Users can become psychologically dependent but no
  evidence of physiologic withdrawal syndrome.

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NDARC Study of Ketamine Users

• N100 well-educated older group of party drug
  users.
• Some had access because in medical field.
• Used with MDMA, MDA amphetamines.
• Many had regular negative side effects such as
  inability to speak, blurred vision, lack of
  coordination.
• Issue for warnings Usually unpleasant side
  effects seen by some as positive and encouraged
  experimentation.
• Dillon, Copeland, Jansen, Patterns of Use and
  Harms Associated with Non-Medical Ketamine Use,
  Drug and Alcohol Dependence 69 2003) 23-28.

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What is DxM? Dextromethorphan is a psychoactive
drug found in common over the counter cough
medicines.
Source www.httpthird-plateau.lycaeum.org/beginn
er/index.html
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DxM

• Robotrip high dosages can produce
  hallucinogenic effects
• Part of family of psychoactive compounds called
  dissociative anesthetics.
• Some effects have been described as similar to
  those of ketamine (Special K) and PCP.
• The DxM experience is described as occurring on
  levels, or plateaus depending on the amount of
  the dose taken.
• Each plateau is different from another. There
  are 4 major plateaus a fifth one that is
  generally unpleasant and involves a possible trip
  to the hospital

Source www.httpthird-plateau.lycaeum.org/beginn
er/index.html
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DXM Calculator
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Texas Carisoprodol (Soma) Data

• Ds, Dance, Las Vegas Cocktail (with Vicodin),
  Soma Coma (with codeine)
• Soma is a muscle relaxant.
• PCC abuse calls from 1998 to 200339 involved
  only carisoprodol. More likely males,
  adolescents, happened at other residences,
  schools, public areas serious medical outcomes
• 2005 deaths with mention of carisoprodol 49
  male, 87 white, av. age 40. Only 4 of 99 were
  just Soma the rest also involved other
  substances, especially hydrocodone (Vicodin) and
  alprazolam (Xanax)

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Inhalants
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Texas Secondary Students Who Had Used Inhalants
Ever or in the Past Month, by Grade 2006
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Percentage of Texas Students Who Had Ever Used
Inhalants, by Grade and Number of Different Types
Used 2006
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Texas Reform Secondary School Students Who
Had Ever Used Specific Inhalants 2000-2001
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Occupation by Type of Inhalant Mention, Texas
Deaths 1988-1998
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• IN SUMMARY
• Methamphetamine is major problem on western end
  of US and Mexico border Ice use is up. Need
  research on use while working long hard
  jobsmigrant farm workers, truckers,
  maquilladoras?
• Smoking crack is increasing on the border. Will
  the HIV increases seen among Blacks due to crack
  spread to Hispanics?
• Injection risks continue tradition of
  needle-sharing for antibiotics vitamins,
  injecting heroin.

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Risk Factors for HIV on the Border

• Risk of HIV/AIDS heightened by high rates of
  border crossings and migration into U.S.
  Immigrants becoming younger from more urban
  areas.
• In 2000, 12.7 of all AIDS cases in Mexico
  involved people who had lived in the US.
• Migrants change their sexual practices because of
  transient lifestyles and exposure to US culture
  partners increases as they travel from place to
  place loneliness isolation lack of women
  more permissive society sex workers who inject.

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