ACCIDENTS AND INJURIES FROM DRUGS

Throughout history, humans have taken substances other than food into their bodies in ways that usually were socially accepted. The most common form has been as medicine, in attempts to change some feeling of ill-being or disease, such as Pain, fatigue, or tension. Some cultures distinguish between socially approved and disapproved uses of substances by labeling those approved as "medicine" and those disapproved as "drugs." Although the word medicine derives from a Latin word meaning "of a physician," throughout much of recorded history and even today, "folk" medicine and "home remedies" are widely practiced. Early medicines were taken exclusively from nature, and Plants are still an important source of medicinal products (e.g., foxglove for heart problems, bread mold for penicillin).

Organic Hallucinogenic substances (plants with perception-altering properties, such as peyote and mescaline, and fungi, such as psilocybin mushrooms) have been used in various cultures in the context of religious rituals, with the dramatic visual and aural hallucinations induced being interpreted in spiritual terms. Intoxicating beverages (with alcohol and/or other drugs) also have a long history of use, usually recreationally (i.e., for their relaxing and disinhibiting effects in social situations), but sometimes also for supposed medicinal purposes, as in elixirs and tonics that were marketed as patent medicines in the United States in the late 1800s and early 1900s.

With the development of modern chemistry and scientific growing methods, there has been an increase in the number, types, and strength of both organically derived (principally Marijuana) and chemically synthesized (laboratory-created) substances, which has prompted the implementation of measures to regulate their processing or manufacture, distribution, and dispensing (by pharmacists and physicians). In the United States, this regulatory scheme is called the Federal Controlled Sub-Stances Act (Public Law 91-513, H.R. 18583, October 27, 1970). This act, which is regularly updated, classifies substances into five categories according to the potential for abuse, accepted medical effectiveness and use, and potential for creating physiological or psychological dependence. The Controlled Substances Act is the basis for federal and state drug laws that specify the conditions making specific substances illicit (illegal) drugs and define differential criminal penalties for their manufacture, distribution, sale, and possession. Substance abuse, for the purposes of this discussion, is defined as the use of illicit drugs, the misuse of medicines (particularly those which must be prescribed by physicians but also those which are available Over the Counter). Accidents and injuries from the excessive or prohibited (e.g., underage) use of other legal drugs, such as alcoholic beverages, are not included here.

There have been increases since the mid-1960s in both substance abuse and public awareness of it. Here the emphasis will be on an aspect of substance abuse—the unintended, negative consequences—that is relatively well known to researchers but less familiar to the general public and their representatives in government.

UNINTENDED AND NEGATIVE CONSEQUENCES

Data do not exist to document in a comprehensive or detailed manner the extent to which the negative consequences of substance abuse exist worldwide, for specific nations (including theUnited States), or for given states or cities. Consequently, I have chosen to present mainly summary information that is based on the best evidence available rather than partial statistical data of questionable accuracy, which would soon be out of date.

The following discussion is divided into four categories of drug problems; acute, chronic, drug-caused, and drug-related. Acute problems are defined as those which usually occur suddenly and often can be remedied in a relatively short time. Chronic problems typically have a relatively gradual onset and tend to persist, sometimes indefinitely. Drug-caused problems, for the purposes of this discussion, are defined as those which have an obvious and/or demonstrated direct causal connection between the use of a substance and a negative effect. In drug-related problems, negative outcomes result from drug-diminished capacities and their effects on user behaviors.

Acute Drug-Caused Problems.

The National Institute on Drug Abuse's Drug Abuse Warning Network (DAWN) estimates that alcohol-in-combination (alcohol used with another drug, the criterion for reporting this substance to DAWN) represents the most frequently reported category in drug-related hospital emergency department visits.

"Other drugs" (illicit drugs, accidentally misused, and intentionally abused legal medications) collectively represent an acute drug-caused problem that may equal or surpass Alcohol in this category. The DAWN system is the best source of documentation of these problems, capturing data on substance abusers who come or are brought to hospital emergency departments, particularly for negative and/or unexpected reactions. These cases are usually thought of as overdoses, attributable to (a) tolerance effects (the need to use increasingly larger doses to achieve the same Psychoactive effects). (b) inexperienced users with panic reactions, or (c) the use of a substance of greater strength than intended or expected. There also is increasing evidence that users of some drugs, such as Cocaine, can experience medical emergencies and deaths from seizure disorders and allergic reactions. This is true not only for first-time users but also experienced users at their regular (and sometimes low) dosage levels. Other frequently noted hospital emergency department (and medical examiner) cases involve Suicide Attempts (and successes) where medications and/or drugs are the means chosen.

Chronic Drug-Caused Problems.

Intravenous drug users can suffer from chronic cardiovascular problems that may be primarily attributable to infections and damage from "fillers"—talcum powder, cornstarch, or baking soda added to drugs to increase volume, unit sales, and profits—that have been injected. Some drugs—especially the Designer Drugs, where an easily added molecule can produce a deadly variant of the intended substance—are neurotropic/neuropathic (have an affinity for and do damage to nerve endings and tissue). Researchers and clinicians are studying and treating individuals who are afflicted with Parkinson's disease caused by such "party" drugs.

One chronic drug-caused problem is particularly tragic because the individuals most damaged are totally innocent and defenseless against the substances that can cause them permanent disabilities or even death. I refer here to teratogenic drug use (use by pregnant women that causes abnormal fetal development).

When the use of Crack-cocaine exploded in the mid-1980s, fetal developmental damage resembling Fetal Alcohol Syndrome began to be noted among infants born to women who had used this drug during the pregnancy. Although accurate counts are difficult to obtain, estimates cited in a 1990 government report—which are not based on representative national samples—range from 100,000 infants annually exposed to cocaine alone to as many as 375,000 annually exposed to drugs in general; more recent research, however, produced much lower estimates.

Acute Drug-Related Problems.

Acute drug-related problems are typified by physical trauma; because of inebriation- or intoxication-impaired judgment or motor control/coordination, substance-abusing individuals can and do accidentally injure themselves.

Common examples in this category are accidental weapon discharges and motor vehicle and boating accidents; drownings, falls, and electrocutions are less common but not rare.

Even more unfortunate are instances where others—clean and sober—are injured or killed by the impaired substance abuser. (These cases often go unnoted; for example, DAWN records only cases where the injured or deceased had drugs "on board.") In addition to the types of accidental injuries noted immediately above, there are anecdotal (verbally reported but not documented) accounts which suggest that spouses, children, other relatives, and friends often are the victims of drug-impaired individuals. With diminished emotional control, inhibitions, and judgment, substance abusers often inflict physical trauma (e.g., gunshot, blunt force, or penetrating injuries) in chance encounters with strangers (other drivers, business-people), in disputes with coworkers or friends, in domestic disputes, or in physical abuse of their children. Moreover, analysis by Brookoff and his colleagues (1993) conclude that DAWN reporting procedures seriously underreport drug-involved emergency department cases, especially those with serious trauma.

Chronic Drug-Related Problems.

Some of the most common chronic drug-related problems are similar to those resulting from in utero exposure of fetuses to cocaine and other development-impairing substances, in that severe illness and death are frequently involved and individuals other than the users themselves are victims. This class of drug-related problems is most closely associated with injecting drug use because the category is defined by infectious diseases that can be transmitted via sharing of unsanitized hypodermic needles. The most deadly infectious agent spread in this manner is the Human Immunodeficiency Virus (HIV), which causes Acquired Immunodeficiency Syn-Drome (AIDS). Another potentially deadly infection spread in this manner is the liver disease hepatitis B. Various sexually transmitted diseases (including AIDS, syphilis, and gonorrhea), as well as tuberculosis, are among the other debilitating and often fatal diseases that are chronic problems related to substance abuse.

DRUG-SPECIFIC NEGATIVE CONSEQUENCES

Discussion in this section is limited to the specific negative consequences of a few of the most prevalent illicit drugs: marijuana, cocaine, and heroin. Other illicit substances that could have been discussed here include Lysergic Acid Diethylamide (LSD), Phencyclidine (PCP), and other "alphabet" or "designer" drugs ("ecstacy," etc.), Amphetamine, and Methamphetamine (and its smokable form, "ice"). This discussion also could well include legal substances that are abused by inhalation, such as gasoline, airplane glue, and various solvents, which are mundane but widely used—especially in economically depressed areas of the United States and in developing nations. These are very harmful to lungs and brain cells, and are often deadly.

Marijuana.

The smoking of marijuana, probably the most widely used illicit drug, may well have more serious acute and chronic consequences than once thought. Recent and continuing research is casting new light on the chronic health risks posed by marijuana smoking, contradicting the conventional wisdom that it is less harmful than either drinking alcoholic beverages or smoking tobacco. For example, it is reported that three times the tar is delivered (and four times more is deposited) to the mouth and lungs per puff from a marijuana joint than from a filter-tipped cigarette. Smoking marijuana also produces up to five times more carbon monoxide in the user's blood than does tobacco. Knowledge is also being accumulated regarding the specific health-damaging mechanisms from the 426 known chemicals contained in Cannabis sativa (which are transformed into over 2,000 when ignited).

Among the pertinent facts already established is that 70 of these chemicals are fat-soluble and accumulate in fatty body tissue, notably the brain, lungs, liver, and reproductive organs. This represents a persistence-of-residue effect in which portions of THC (delta-9-Tetrahydrocannabinol), the most potent psychoactive chemical in marijuana, not only remain in the body (and are thus detectable) for several weeks following use, but also accumulate with repeated use. This THC buildup is particularly noteworthy when one considers that the potency (THC content) of marijuana has increased dramatically since the 1960s, when the average potency was about 0.2 percent.

Regular marijuana smoking can contribute to emotional and other behaviorally defined mental-health problems through degraded interpersonal relationships and arrested development. The mechanism for this seems to be a drug-induced perception of well-being and problem abatement that may not reflect reality and contributes to avoidance rather than coping with life situations.

Research findings from the 1980s and 1990s highlight a marijuana health risk that is largely unmeasured but may be much greater than generally considered. Researchers examined blood samples from over 1,000 individuals brought to a hospital trauma unit with severe injuries. Two-thirds of these individuals had accidental injuries associated with the operation of motor vehicles (drivers, passengers, and pedestrians injured by cars, trucks, or motorcycles). Using a bloodtest that normally ceases to detect THC around 4 hours after use, the researchers found about 34 percent of these accident victims had psychoactive levels of THC in their blood when they arrived at the hospital. A more recent study found that 45 percent stopped for reckless driving tested positive for marijuana. Given that there currently are no simple, legally recognized tests to detect marijuana use, the extent of marijuana-related vehicular injuries and deaths is an unknown but potentially sizable statistic.

Cocaine.

Many readers undoubtedly have heard that Sigmund Freud, the famous Viennese psychoanalyst, was an avid user and proponent of cocaine. The initial account of his observations of the drug's effects for himself and some of his patients indeed was glowing. It was translated from German and reprinted in an American medical journal in the mid-1880s, thus popularizing the drug in the United States and prompting its incorporation into products from patent medicines to soft drinks. Less well reported is the fact that Freud and his colleagues had discovered the significant negative effects of cocaine by the end of that same decade and had withdrawn their support for its applications in medical therapy.

Cocaine has had several periods of popularity in the United States as a drug of abuse, with the most recent beginning in the early 1980s. Touted as a safe, nonaddicting, recreational drug, cocaine hydrochloride (in powder form) was "snorted" (inhaled) by millions who liked the absence of hypodermic needles, the lack of lung-cancer risk, and the rapid high, with its feelings of alertness, wittiness, and sexual prowess.

Unfortunately, cocaine users often progress from casual to compulsive patterns of use. The grandiose perceptions of heightened mental and physical abilities inevitably wane (typically within 20 minutes following use), and the resulting dysphoria (opposite of euphoria) is so marked in contrast that it resembles depression. Trying to relieve the depression and regain the euphoria, cocaine abusers repeat this cycle over long periods (called binges) until their supplies, resources, and/or stamina are exhausted. In the study of reckless drivers noted earlier, 25 percent tested positive for cocaine.

The risk of infection with HIV and other sexually transmitted diseases is high among compulsive cocaine users, particularly female crack users. Often forsaking socially acceptable means of earning income, they live an existence that revolves around crack use. Many maintain their crack supply by repeatedly selling or trading their sexual services, with each unprotected sexual contact increasing the chance that they will have an HIV-infected partner.

Other manifestations of negative effects of cocaine abuse include hyperstimulation; digestive disorders, nausea, loss of appetite and weight; tooth erosion; nasal mucous membrane erosion, including perforations of the nasal septum (holes in the membrane separating the nostrils); cardiac irregularities; stroke (from vascular constriction); convulsions (especially among individuals prone to seizure disorders); and paranoid psychoses and delusions of persecution. Cocaine is a notoriously fickle drug—some experts say it behaves as though it belongs in other pharmacological categories besides stimulant. A highly publicized case was the 1986 cocaine-induced death of the athlete Len Bias, who reportedly was a first-time user of a small amount. In addition, research indicates that the concurrent use of cocaine and alcohol (a common practice) produces a new, liver- and brain-accumulating and-damaging drug (Coca-Ethylene) within the user's body. It is implicated in puzzling low-dosage "excited delirium" fatalities and increased mortality risks for individuals with existing heart problems.

Some of the fetal damage from maternal cocaine use occurs because cocaine is a vasoconstrictor, a useful characteristic for topical application in delicate medical procedures, such as eye surgery, but a decided negative as it concerns the placenta of a pregnant woman. The restriction of blood flow through the placenta limits nutrients and oxygen to the fetus, leading to retarded growth and development of vital organs. Heavy cocaine use during pregnancy also can cause spontaneous abortion, and anecdotal reports of cocaine being used intentionally for this purpose are not uncommon. Premature separation of the placenta from the uterus, another common medical complication among cocaine-using pregnant women, results in either a premature birth or a stillbirth. Surviving infants usually have low (sometimes very low) birthweights, and low birthweight itself increases risk for a variety of problems. Cocaine-exposed under-weight newborns have been documented to be at greater risk for stroke and respiratory ailments, and at much greater risk for sudden infant death syndrome (SIDS or crib death). Research studies are being conducted to confirm anecdotal and preliminary studies that indicate higher rates of retarded emotional, motor, and cognitive development, including Attention Deficit Disorders, among such children entering school.

Heroin.

Paradoxically, the negative direct physiological consequences to the user that are attributable to heroin itself are less than from the use of tobacco, alcohol, cocaine, or many prescription drugs. This does not mean that heroin is a drug whose use is without negative consequences, however. Heroin is highly addictive, and once its central nervous system depressive effects wear off, (typically in 4 to 6 hours), users tend compulsively to seek sources and means for another "hit." This often leads to socially unproductive, self-neglectful lifestyles, not uncommonly involved with income-producing crime committed to maintain the addiction. Fetuses exposed to heroin from their mothers' use during pregnancy suffer many of the same negative effects as those exposed to cocaine.

In addition, heroin users frequently experience negative reactions and overdoses because of Tolerance effects, since the drug purity and type of filler may vary widely among dealers. Often, they are unknown with certainty by the user. However, the greatest threat to current heroin users' health and lives undoubtedly stems from the risks of hepatitis and HIV infection from sharing contaminated hypodermic syringes and needles. Their risks of infection with HIV and other diseases through sexual activity are elevated in ways similar to those described for cocaine users. The risks of fetal HIV infection among pregnant heroin-using women is also increased because of their own needle use and the likelihood that they have had at least one intravenous-drug-using sexual partner.

ECONOMIC COSTS OF SUBSTANCE ABUSE

Numerous studies designed to estimate the cost or burden of drug abuse were conducted in recent years. This presentation will focus on two of the most recent and authoritative reports.

Gerstein and Harwood (1990) produced a set of estimated societal Economic Costs of the illicit drug problem in the United States totaling 71.9 billion dollars. This total is broken down into categories; almost half ($33.3 billion) of the total estimated costs was attributed to productivity losses resulting from substance-abuse-impaired workers. More than half of the total estimated cost was attributed to the criminal aspects of drug abuse ($5.5 billion to tangible losses to crime victims; $12.8 billion to law enforcement; $17.6 billion to lost economic productivity because of time spent in crime or in prison). A minor portion of the estimated costs was assigned to drug prevention and treatment ($1.7 billion) and drug-related AIDS ($1.0).

The Gerstein and Harwood estimate is an update incorporating "a number of statistical updates and revisions" of a similar estimate for 1980 (Harwood et al., 1984), which totaled $46.9 billion dollars.

Rice et al. (1990) produced what is probably the most authoritative work currently available on this topic: The Economic Costs of Alcohol and Drug Abuse and Mental Illness: 1985. Among the multiple objectives of the study were the following: to estimate as precisely as possible the economic costs to society of alcohol abuse, drug abuse, and mental illness (ADM) for 1985, the most recent year for which reliable data were available; to update previous cost estimates, using new data sources and a revised methodology; and to develop an improved approach to deal with the issues of Comorbidity (the tendency for cases to overlap, that is, for individuals to have problems in more than one ADM category). Briefly, Rice et al. produced ADM cost estimates for 1980, 1985, and 1988. Estimated costs for illicit drug problems (in billions of dollars) were 1980, 46.9; 1985, 44.1; 1988, 58.3.

Their cost estimates are considered to be the best available, but even the analysts who produced them will readily agree that they are probably not very precise. It is probable, in my opinion, that the health and social care costs for AIDS-infected drug abusers is underestimated even for the years addressed, and are undoubtedly significantly higher in the new millenium. Similarly, health and social service costs for infants and children who have suffered prenatal exposure to drugs undoubtedly have mushroomed since 1985, the approximate beginning of the crack-cocaine epidemic (these costs could become astronomical if the worst fears regarding permanent learning disabilities are confirmed).

(See also: Accidents and Injuries from Alcohol ; Alcohol: History of Drinking ; Dover's Powder ; Driving, Alcohol, and Drugs ; Fetus: Effects of Drugs on ; Social Costs of Alcohol and Drug Abuse )

BIBLIOGRAPHY

Brookoff, D., Campbell, E. A., & Shaw, L. M. (1993). The underreporting of cocaine-related trauma: Drug Abuse Warning Network reports vs. hospital toxicology tests. American Journal of Public Health, 83 (March), 369.

Brookoff, D., Cook, C. S., Williams, C., & Mann, C.S. (1994). Testing reckless drivers for cocaine and marijuana. New England Journal of Medicine, 331 (August), 518.

Gerstein, D. R., & Harwood, H.J. (Eds.). (1990). Treating drug problems, vol. 1. Washington, DC: National Academy Press.

Harwood, H. J., Napolitano, D. M., Kristiansen, P., & Collins, J. J. (1984). Economic costs to society of alcohol and drug abuse and mental illness: 1980. Research Triangle Park, NC: Research Triangle Institute.

Rice, D. P., Kelman, S., Miller, L. S., & Dunmeyer, S. (Eds.). (1990). The economic costs of alcohol and drug abuse and mental illness: 1985. San Francisco: Institute for Health and Aging.

James E. Rivers