Substance abuse: clinical identification and management

Newborn renal tubular acidosis associated with prenatal maternal toluene sniffing

Sniffing of volatile organic solvents containing toluene, such as acrylic paints, glues, adhesives, paint thinners, varnishes and shoe polishes, has become increasingly frequent in recent years. Renal tubular acidosis is one of a number of human complications reported in the offspring of mothers inhaling toluene during pregnancy. This article reports a case of a premature newborn with renal tubular acidosis probably due to maternal sniffing of paint containing toluene. Characteristics of this condition are described as well as its medical management. With increasing frequency of maternal glue and paint sniffing, more cases of newborn renal tubular acidosis will likely appear. Physicians should be prepared to manage neonatal tubular acidosis that may accompany maternal toluene sniffing in order to lessen newborn morbidity and/or mortality.

Cocaine hepatotoxicity in mice: histologic and enzymatic studies

The severity of hepatotoxicity in CF-1 mice given 5 daily doses of 5, 10, and 20 mg cocaine/kg body weight and sacrificed 24 hr after the last injection appeared to be dose-dependent. Using light microscopy, the hallmark of cocaine early toxicity was manifested by pallor and ballooning of the hepatocytes in the midzonal and then in the centrilobular areas. Degeneration and necrosis of the liver cells in the same zones were encountered while the hepatocytes in the periportal areas remained intact. When examined under the electron microscope, such pallor and ballooning of the hepatocytes appeared to to be due to dilation of the rough endoplasmic reticulum (RER) profiles which often revealed a significant loss of their ribosomes. Dilation of the smooth endoplasmic reticulum (SER) was also common and moderate proliferation of peroxisomes was frequently seen. In the degenerating hepatocytes, the 2 forms of endoplasmic reticulum were difficult to recognize and the peroxisomes appeared sparse. Cocaine treatment elevated the level of glutamic pyruvic transaminase and glutamic oxaloacetic transaminase in a dose-dependent manner. Although hepatic cytochrome P450 was slightly increased in the low dose groups, a reduction in the enzyme activity was noticed in the group treated with 20 mg cocaine/kg. However, hepatic reduced glutathione content manifested a significant increase in the group which received 20 mg cocaine/kg.

Teratogenic effect of cocaine and diazepam in CF1 mice

This study was conducted to determine the teratogenic effect of cocaine hydrochloride, alone or in combination with diazepam. Pregnant mice were administered cocaine hydrochloride at 10 and 20 mg/kg body weight intravenously (tail), and/or diazepam at 20 or 40 mg/kg b.w. by gavage. Combinations of diazepam and cocaine (20/10 and 40/20, respectively) were used. Significant reductions of fetal weight and length were found in the group treated with diazepam and cocaine (40/20). The incidences of incomplete ossification of sternebrae and skull bones, as well as delayed ossification of the paws, were significantly increased in the combination groups. Hydronephrosis and cryptorchidism were observed in the cocaine-treated groups, with the incidence of these malformations increasing significantly when diazepam was co-administered.

Clinical features and management of intoxication due to hallucinogenic drugs

Hallucinogenic drugs are unique in that they produce the desired hallucinogenic effects at what are considered non-toxic doses. The hallucinogenic drugs can be categorised into 4 basic groups: indole alkaloid derivatives, piperidine derivatives, phenylethylamines and the cannabinols. The drugs reviewed include lysergic acid diethylamide (LSD), phencyclidine (PCP), cocaine, amphetamines, opiates, marijuana, psilocybin, mescaline, and 'designer drugs.' Particularly noteworthy is that each hallucinogen produces characteristic behavioural effects which are related to its serotonergic, dopaminergic or adrenergic activity. Cocaine produces simple hallucinations, PCP can produce complex hallucinations analogous to a paranoid psychosis, while LSD produces a combination of hallucinations, pseudohallucinations and illusions. Dose relationships with changes in the quality of the hallucinatory experience have been described with amphetamines and, to some extent, LSD. Flashbacks have been described with LSD and alcohol. Management of the intoxicated patient is dependent on the specific behavioural manifestation elicited by the drug. The principles involve differentiating the patient's symptoms from organic (medical or toxicological) and psychiatric aetiologies and identifying the symptom complex associated with the particular drug. Panic reactions may require treatment with a benzodiazepine or haloperidol. Patients with LSD psychosis may require an antipsychotic. Patients exhibiting prolonged drug-induced psychosis may require a variety of treatments including ECT, lithium and l-5-hydroxytryptophan.

The abuse of volatile substances

Volatile substances have been used to alter consciousness since ancient times. Societal trends have brought forth one inhalant fad after another. It would be reasonable to expect this pattern to change as certain of the inhalants come under greater control or become less available (e.g., leaded gasoline). Experimentation with these agents among younger adolescents probably will continue, and for this reason, pediatric practitioners should be aware of the use of these agents and their potential toxicities.