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Dextroamphetamine

DEXTROAMPHETAMINE

This is the d -isomer of Amphetamine. It is classified as a Psy-Chomotor Stimulant drug and is three to four times as potent as the l -isomer in eliciting central nervous system (CNS) excitatory effects. It is also more potent than the l -isomer in its Anorectic (appetite suppressant) activity, but slightly less potent in its cardiovascular actions. It is prescribed in the treatment of narcolepsy and Obesity, although care must be taken in such prescribing because of the substantial Abuse Liability.

High-dose chronic use of dextroamphetamine can lead to the development of a toxic psychosis as well as to other physiological and behavioral problems. This toxicity became a problem in the United States in the 1960s, when substantial amounts of the drug were being taken for nonmedical reasons. Although still abused by some, dextroamphetamine is no longer the stimulant of choice for most psychomotor stimulant abusers.

(See also: Amphetamine Epidemics ; Cocaine )

Marian W. Fischman

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dexamfetamine

dexamfetamine (dexamphetamine) (deks-am-fet-ămin) n. see amphetamines.

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Dextroamphetamine

DEXTROAMPHETAMINE

OFFICIAL NAMES: Dextroamphetamine, D-amphetamine, dextroamphetamine sulfate (Dexedrine)

STREET NAMES: Speed, uppers, bennies, beans, dexies, black beauties, go pills, L.A. turnarounds, West Coast turnarounds, pep pills

DRUG CLASSIFICATIONS: Schedule II, stimulant


OVERVIEW

Dextroamphetamines are a part of the amphetamine class of drugs, central nervous system (CNS) stimulants that are used in the treatment of certain brain-based disorders. Because of their long-lasting and potent stimulant effects, they are also highly physically and psychologically addictive and have a high rate of abuse.

Amphetamines were first synthesized in 1887 by the German chemist L. Edeleano. However, they were not generally used until 1932, when pharmaceutical manufacturer Smith, Kline and French introduced Benzedrine, an over-the-counter inhaler for relieving nasal congestion. By the late '30s, the drug was available in tablet form for the treatment of several neurological disorders, including narcolepsy (a sleeping disorder), Parkinson's disease, and minimal brain dysfunction (now called attention deficit hyperactivity disorder, or ADHD).

During World War II, dextroamphetamines and methamphetamines were widely distributed among Allied, German, and Japanese soldiers to keep them awake and alert on the battlefield. Beyond the front, civilians who worked in factories manufacturing goods for the war effort were also using the drug to boost productivity. After the war, use escalated abroad. Abuse of amphetamines became a widespread problem in Japan, until legislation known as the "Amphetamine Control Law" was passed in 1951.

In 1952, Smith, Kline and French introduced the stimulant Dexedrine (dextroamphetamine sulfate) for narcolepsy in the United States. It was manufactured as a Spansule, the first time-release capsule, which gradually released the drug over a period of time.

In the United States, amphetamines were prescribed for many reasons, from the treatment of depression to weight loss. The drug was being used by long-distance truckers, who dubbed the drug "West Coast turnaround" because of its ability to help them stay awake during long-haul and coast-to-coast runs. Athletes used the stimulant to enhance performance, and the military continued its use through the Korean conflict and into Vietnam.

In the 1960s the abuse of the drug became more widespread. A new method of using—injecting liquid methampetamine—gained popularity after doctors in San Francisco began prescribing the treatment for heroin addicts. As massive prescription fraud and drug abuse mounted, calls for stricter legislation of amphetamines were becoming louder.

Senate testimony given in the late 60s in support of passage of the Controlled Substances Act (CSA) reported that 50% of the amphetamines being produced annually in the U.S. were ending up in the illegal drug market. In order to stop rising abuse, the amphetamines were changed to a Schedule II drug with passage of the CSA in 1970. According to the U.S. Drug Enforcement Administration (DEA), over two billion units of amphetamine and methamphetamine were legally manufactured in the United States in 1970, enough for ten doses for every person in the United States at the time. Stricter limits would be established to slow production of the drug.

Stimulants like amphetamines may look attractive to athletes for their ability to slow appetite and raise energy levels and mood. They may be attracted to amphetamine use by the belief that a lower weight will improve athletic performance. However, the negative side effects experienced from long-term abuse of amphetamines are greater than any temporary gains in ability. Amphetamines are considered a banned substance by the International Olympic Committee (IOC), the United States Anti-Doping Agency (USADA), the World Anti-Doping Agency (WADA), and a number of other national and international sporting authorities. Amphetamines are also banned by the National Collegiate Athletic Association (NCAA); however, the NCAA does make exceptions for players with a documented medical need for stimulant drugs (i.e., ADHD).

CHEMICAL/ORGANIC COMPOSITION

The molecular formula for dextroamphetamine is C9H13N. The full chemical name for dextroamphetamine sulfate, the formulation used in the medication Dexedrine, is d-alpha-methylphenethylamine.

INGESTION METHODS

Dextroamphetamines come in capsule and tablet form. For the treatment of narcolepsy, patients are typically prescribed 5–60 mg per day. Patients with ADHD usually take anywhere from 3 to 60 mg depending on age and response to the drug.

Illicit methods of taking amphetamines include smoking (in combination with marijuana or tobacco) or injecting it alone or with other drugs. The tablet form of the drug is sometimes crushed and snorted. Dextroamphetamine pills and capsules may also be taken orally by individuals who have no clinical need for the drug.

THERAPEUTIC USE

Amphetamines such as dextroamphetamine sulfate (Dexedrine), amphetamine and dextroamphetamine sulfate combinations (Adderall), and methamphetamine hydrochloride (Desoxyl) are standard therapies in the treatment of ADHD. Although it's not completely understood how it works, when used as part of a comprehensive treatment program, the stimulant can help improve symptoms of poor concentration, hyperactivity, and distractibility for many children with ADHD. Other components of an effective treatment program for ADHD include family counseling, behavioral therapy, and a customized educational curriculum.

One of the oldest uses for dextroamphetamines is in the treatment of narcolepsy, a sleep disorder characterized by constant daytime fatigue and sleepiness, with a disturbance in nighttime REM sleep (the period of sleep when dreams occur). During the day or other periods of time when they would normaly be awake, people with narcolepsy often experience sudden episodes of REM sleep. They may also suffer from sleep paralysis and/or cataplexy, an abrupt, total loss of muscle control. Central nervous system stimulants like dextroamphetamine help to relieve these symptoms.

In the 1970s, both Dexedrine and another dextroamphetamine sulfate formula called Obetrol were approved for use as anti-obesity drugs. However, the manufacturer (Rexar) was bought by a new company (Richwood pharmaceuticals) who resubmitted the drug to the Food and Drug Administration (FDA). It was relabeled as a treatment for ADHD only and reintroduced in 1996 as Adderall. As of 2002, none of the dextroamphetamine drugs on the U.S. market were labeled for use as an appetite suppressant or weight loss aid (although Desoxyl, or methamphetamine hydrochloride, is approved for the treatment of obesity).

USAGE TRENDS

The National Institute on Drug Abuse (NIDA) estimates that there were approximately 900,000 Americans age 12 and older misusing prescription stimulants in1999. Because of its popularity as a treatment for ADHD, adolescents are at a special risk for misusing dextroamphetamine drugs.

According to the U.S. Centers for Disease Control (CDC) the number of prescriptions written for ADHD medications quadrupled between 1989 and 1998. And in 1999, both Adderall and Dexedrine were ranked among the top 200 for number of new drug prescriptions, ranking 59 (4,140 new prescriptions) and 169 (1,735 new prescriptions), respectively. Adderall accounted for $155.7 million in U.S. pharmaceutical sales in 1999.

Scope and severity

Amphetamine abuse is one of the most significant global drug problems. According to the United Nations Office for Drug Control and Crime Prevention (UNDCCP), by the late 1990s, an estimated 29 million people worldwide were taking amphetamines—a larger group than cocaine and all opiate drugs combined.

In 2000, 922 emergency room visits related to dextroamphetamine use were reported to the Drug Abuse Warning Network (DAWN). Amphetamines in general (excluding methamphetamines) were the seventh most reported drug for emergency room visits among children aged 6 to 17, and eighth most reported among patients aged 18 to 34. Amphetamines were also among the top 15 most-reported drugs for emergency department visits among women, accounting for 2.43% of the total female admissions.

Age, ethnic, and gender trends

There have been a number of anecdotal reports of illicit use of Dexedrine, Adderall, Ritalin (methylphenidate), and other ADHD stimulants among college students in recent years. In 2000, University of Wisconsin health officials estimated that one in five of their students were using ADHD stimulant medications without a doctor's prescription.

Although a slight rise in the popularity of amphetamines occured in the 1990s in the United States, amphetamine use (excluding methamphetamines) in the United States seems to have leveled off in recent years. The 2001 "Monitoring the Future" study, an annual survey of drug use among adolescents and young adults performed by the University of Michigan and the NIDA, reports that between 1991 and 2000, overall amphetamine use among high school students, college students, and young adults has declined.

Stimulant "sharing" of prescription dextroamphetamines and other ADHD medications is also a problem among adolescents. A Canadian study published in 2001 found that 15% of children who used stimulants for medical purposes reported giving these drugs to peers, while 7% had sold their stimulants at some point. Theft of medication was also a problem, with 4.3% having ADHD drugs stolen, and another 3% reporting being coerced out of medication at some point.

In the United States, a 1998 study of Wisconsin children who were prescribed Ritalin for the treatment of ADHD reported that 16% of the children in the study had been asked to sell or share their medication. Security was also an issue, with 37% of schools reporting that stimulants were stored in an unlocked space and 10% of children being allowed to carry and administer their own medication.

The 2000 "Monitoring the Future" report found that 10% of eighth graders have tried prescription amphetamines, with 3.4% reporting use of the drugs in the prior month. Amphetamine use was highest among white high school students in comparison to African-American and Hispanic high school students. Adolescent girls were also more likely to abuse amphetamines than boys. This trend reversed in the older subjects surveyed, with males aged 19 to 32 reporting slightly higher use of amphetamines than females of the same age group.

Among 40-year-olds included in a follow-up of the study, 53% had tried amphetamines at some point in their lifetime. However, only 1% reported use of the drugs in the past year.

MENTAL EFFECTS

Dextroamphetamine stimulates the production of the neurotransmitters dopamine and norepinephrine. Neurotransmitters are the brain chemicals responsible for transporting electrical impulses from nerve cell to nerve cell. Dopamine, the neurotransmitter associated with feelings of pleasure, triggers the euphoria that is related to dextroamphetamine use. Norepinephrine is a neurotransmitter thought to be responsible for the adrenaline-like effects of the drug.

Because it stimulates the central nervous system, dextroamphetamine fights mental fatigue. The drug can also improve mood and give users a sense of power, euphoria, and well-being. With chronic use, however, it may cause obsessive thoughts and feelings of paranoia, anxiety, hypersensitivity—and, in extreme cases, psychosis.

Amphetamine psychosis causes feelings of severe paranoia and auditory and visual hallucinations. The amphetamine addict who is psychotic typically experiences delusions of persecution, believing someone, or everyone, is "out to get" them. Because of these paranoid delusions, violence can frequently occur during amphetamine psychosis. Once the amphetamine abuser is free of the drug, psychosis fades quickly. However, symptoms such as mental confusion, memory problems, and delusional thoughts may last up to several months or longer.

PHYSIOLOGICAL EFFECTS

In addition to their trademark effects on mood and mental status, dextroamphetamines significantly influence the cardiovascular system. They increase the heart rate and boost blood pressure. They are also weak bronchodilators—meaning they open the bronchial tubes (air passages) of the lungs. In fact, one of the early uses for dextroamphetamines was asthma treatment.

Dextroamphetamine also acts as an anoretic agent, suppressing appetite. Formulas popular in the 1970s, such as Obetrol, were marketed as weight loss drugs.

Harmful side effects

Common side effects of dextroamphetamine include, but are not limited to:

  • difficulty sleeping
  • dry mouth
  • unintentional weight loss
  • headache
  • nausea
  • nervousness
  • rash
  • picking at the skin
  • rise in blood pressure and pulse
  • diarrhea or constipation

When used for medical purposes, dextroamphetamines are prescribed at the lowest possible dosage. The dosage is then raised gradually until the desired therapeutic effect is achieved. All amphetamines are highly addictive. Tolerance to the drug builds slowly but steadily. Tolerance occurs when it takes more and more of the drug to produce the same physiological effects. With amphetamines, it may also develop unevenly, with some effects of the drug weakening before others.

Symptoms of overdose may include panic or anxiety attacks, hallucinations, confusion, tremor or shaking, arrhythmia (irregular heartbeat), vomiting, collapse of the circulatory system, stomach cramps, convulsions, and coma. Overdose can be fatal.

Dextroamphetamine can make tics worse, so its use may not be recommended for someone with Tourette's syndome or another tic disorder. Anyone who suffers from hypertension, arteriosclerosis, hyperthyroidism, or glaucoma should also not take dextroamphetamines.

Animal studies show that amphetamine abuse may cause birth defects. There are no controlled studies of this effect in humans; however it is known that pregnant women who are amphetamine-dependent may give birth prematurely and are more likely to have infants with a low birth weight. Amphetamines cross the placenta, so a baby born to an amphetamine abuser may experience withdrawal symptoms once the drug begins to leave the infant's system.

Amphetamines also pass into a nursing mother's milk. For this reason, women taking amphetamines should avoid breastfeeding. Dextroamphetamines are not recommended for the treatment of ADHD in children under the age of 3, as the drugs have not been sufficiently tested in this age group. In addition, there are few long-term follow-up studies on the long-term effects of extended dextroamphetamine use by pediatric ADHD patients.

Long-term health effects

Chronic dextroamphetamine use and abuse can cause sexual dysfunction (impotence). Because of the stress amphetamines place on the cardiovascular system, heart attack, cardiovascular shock, and cerebral hemorrhage may also occur with chronic use.

Symptoms of dextroamphetamine abuse include insomnia, irritability, hyperactivity, and psychosis. Psychosis is characterized by radical changes in personality, impaired functioning, and a distorted sense of reality. Hallucinations, delusions, and feelings of paranoia are also common features of psychosis.

Withdrawal from chronic amphetamine abuse can be long and difficult. Also, it results in depression and at least two of the following symptoms: fatigue, vivid dreams, irregular sleep patterns, increased appetite, and psychomotor problems.

REACTIONS WITH OTHER DRUGS OR SUBSTANCES

Dextroamphetamines interact with a number of drugs and other substances. These include:

  • Hypertension drugs. Because amphetamines stimulate the circulatory system and raise blood pressure, they can inhibit the effect of drugs used to lower blood pressure.
  • MAOIs. MAO inhibitors, a class of antidepressant drugs, can slow the metabolism of amphetamines. This mix of drugs may result in skyrocketing blood pressure, severe headaches, and potentially fatal neurological damage.
  • Tricyclic antidepressants. When taken with dextroamphetamine, the effects of tricyclic antidepressants (such as desipramine) may increase.
  • Meperidine (Demerol). Amphetamines can increase the analgesic (pain killing) effect of meperidine.
  • Ethosuximide (Zerontin). The intestinal absorption of this anti-epileptic drug is effected by dextroamphetamine, which may delay or decrease its effectiveness.

The drug chlorpromazine (Thorazine) blocks the effects amphetamines have on the central nervous system, and is sometimes used to treat cases of amphetamine overdose or intoxication. Additional drugs, foods, and substances that may also counteract dextroamphetamines and make them less effective include antihistamines, lithium carbonate, haloperidol, and any acidic agent such as fruit juice or ascorbic acid.

Other drugs may increase the effects of dextroamphetamine. For example, bicarbonate and other alkalinizing agents increase the amount of amphetamines absorbed in the digestive system. Thiazides (potassiumdepleting diuretics) decrease the amount of amphetamines that leave the body in urine. Also, other central nervous system stimulants, such as cocaine and nicotine, can amplify the stimulating effects of dextroamphetamines.

TREATMENT AND REHABILITATION

Treatment for amphetamine dependence may be either "inpatient" or "outpatient." Inpatient, or residential, drug programs require a patient to live at the hospital or rehab facility for a period of several weeks to several months. Outpatient programs allow patients to spend part of their day at the treatment facility, and return home at night.

For amphetamine addicts and drug abusers, the controlled, therapeutic environment of residential rehab provides a safe place to learn new behaviors and explore the emotional issues behind their drug use. And for patients experiencing amphetamine or other drug withdrawal symptoms, an inpatient facility is the best option for a safe and gradual detoxification from the drug.

Once an amphetamine abuser stops taking the drug, withdrawal symptoms begin as the body tries to adjust to the absence of the stimulant. This results in very uncomfortable and potentially life-threatening physical symptoms, called withdrawal syndrome. According to the World Health Organization (WHO), withdrawal is experienced by 87% of amphetamine users who stop the drug.

Frequent symptoms of amphetamine withdrawal include excessive fatigue and depression. These may also occur: nausea, vomiting, chills, cramps, headaches, and arrhythmia (a change in the rhythm of the heartbeat). A physician may prescribe antidepressants to help alleviate depression during amphetamine withdrawal. Also during withdrawal, if psychosis and/or hallucinations are experienced, treatment with chlorpromazine (Thorazine) or haloperidol (Haldol) may be necessary. Finally, ammonium chloride may be prescribed to more quickly remove amphetamines through the urine.

Once detoxification is complete, the drug abuser can start the rehabilitation and long-term recovery process with a clear head. Research shows that detoxification alone is not an effective treatment. Addicts who leave rehab immediately after detox with no further counseling or interventions will likely soon be abusing stimulants or another mind-altering substance again.

Recovery refers to the life-long process of avoiding drug use, as well as the mental and physical rehabilitation of the damage done by drug abuse. An individual in recovery from drug addiction must avoid all psychoactive drugs, including alcohol. Amphetamine cravings can be extremely powerful, and may last indefinitely. Anything can "trigger" a relapse.

An effective drug rehabilitation program changes patterns of behavior and deals with the underlying emotional issues surrounding drug use. Education about the long-term physical and psychological effects of substance abuse is also typically part of a rehab program.

Therapy and/or counseling is also very important. Different therapy approaches used in substance abuse treatment include: individual psychotherapy, behavioral therapy, cognitive-behavioral therapy, group therapy, and family therapy. Often, more than one therapeutic approach is used during drug rehabilitation.

Individual psychotherapy

One-on-one counseling explores the emotional issues underlying a patient's drug dependence and abuse. Individual psychotherapy is particularly useful when there is also some type of mental disorder, such as depression or an anxiety disorder, along with the drug abuse.

Behavioral therapy

Behavioral therapy focuses on replacing unhealthy behaviors with healthier ones. It uses tools such as rewards (positive reinforcement for healthy behavior) and rehearsal (practicing the new behavior) to achieve a drug-free life.

Cognitive-behavioral therapy

Like behavioral therapy, cognitive-behavioral therapy (CBT) also tries teaching new behavioral patterns. However, the primary difference is CBT assumes that thinking is behind behavior and emotions. Therefore, CBT also focuses on—and tries to change—the thoughts that led to the drug abuse.

Family therapy

Family members often develop habits and ways of coping (called "enabling") that accidentally help the addict continue their substance abuse. Group counseling sessions with a licensed counselor or therapist can help family members build healthy relationships and relearn old behaviors. This is particularly important for adolescents in drug treatment, who should be able to rely on the support of family.

Group therapy

Group therapy offers recovering drug abusers a safe and comfortable place to work out problems with peers and a group leader (typically a therapist or counselor). It also provides drug abusers insight into their thoughts and behaviors through the eyes and experiences of others. Substance abusers who have difficulty building healthy relationships can benefit from the interactions in group therapy. Offering suggestions and emotional support to other members of the group can help improve their self-esteem and social skills.

Self-help and 12-step groups

Self-help organizations offer recovering drug abusers and addicts important support groups to replace their former drug-using social circle. They also help create an important sense of identity and belonging to a new, recovery-focused group.

Twelve-step groups, one of the most popular types of self-help organizations, have been active in the United States since the founding of Alcoholics Anonymous (AA) in 1935. Narcotics Anonymous (NA), a group that serves recovering drug addicts, was founded in 1953. Like AA and other 12-step programs, NA is based on the spiritual philosophy that turning one's will and life over to "a higher power" (i.e., God, another spiritual entity, or the group itself) for guidance and self-evaluation is the key to lasting recovery.

The accessibility of self-help groups is one of their most attractive features. No dues or fees are required for AA and NA, so they're a good option for the uninsured and underinsured. Meetings are held in public places like local hospitals, healthcare centers, churches, and other community organizations, and frequent and regular attendance is encouraged.

In addition, 12-step groups work to empower members and promote self-esteem and self-reliance. NA meetings are not run by a counselor or therapist, but by the group or a member of the group. And the organization encourages sponsorship (mentoring another member), speaking at meetings, and other positive peer-to-peer interactions that can help reinforce healthy social behaviors. Today, the internet and on-line support communities has added a further degree of accessibility to those who live in rural or remote areas.

PERSONAL AND SOCIAL CONSEQUENCES

Criminal drug charges may harm future employment, career advancement, and educational opportunities. Amendments made to the Higher Education Act in 1998 make anyone convicted of a drug offense ineligible for federal student loans for anywhere from one year to indefinitely. They may also be ineligible for state aid. An individual convicted of a drug offense may also be denied employment based on his or her criminal history.

Amphetamine abusers and addicts become preoccupied with when and where they will be able to get their next dose. Relationships with family and friends frequently deteriorate as the drug takes center stage in the addict's life. Money problems may began to surface as the addict funds his growing habit. Substance abuse also contributes to crime, domestic violence, sexual assault, drop-out rates, unemployment, and homelessness. It is also a factor in the spread of sexually transmitted diseases (STDs) and unwanted pregnancy.

The financial toll is enormous as well. The Office of National Drug Control Policy estimated an economic loss due to illicit drugs of over $160 billion from the U.S. economy for the year 2000. This figure represented an increase of 5.8% annually between 1998 and 2000, and included $14.8 billion in healthcare costs and $110.4 billion in lost productivity from drug-related illness, incarceration, and death.

LEGAL CONSEQUENCES

Abuse of any amphetamine can have serious legal consequences. A conviction of illegal possession of amphetamines in the United States carries fines of up to $10,000 and possible jail time. A felony may also result in the loss of one's driver's license and right to vote, depending on the state where the conviction occurred.

Under the Controlled Substances Act of 1988, being arrested for use or possession of a small amount of dextroamphetamine in the United States is classified by the U.S. Drug Enforcement Administration (DEA) as a "personal use amount." Anyone charged with an offense of possessing a personal use amount faces a civil fine of up to $10,000. The fine amount is based on the offender's income and assets, as well as the circumstances surrounding the case. With first offenses, jail time is typically not involved, and the proceedings are civil rather than criminal. This means that if the offender pays the fine, stays out of trouble for three years, and passes a subsequent drug test, the case is dismissed and no criminal or civil record of it is made.

Olympic athletes who test positive for amphetamines are suspended from participation in the Games. They may also be stripped of any medals they have won in competition.

Legal history

The Drug Abuse Control Amendments of 1965—the legislation that formed the FDA Bureau of Drug Abuse Control—gave the FDA tighter regulatory control over amphetamines, barbiturates, and other prescription drugs with high abuse potential. By 1970, legal control of amphetamines was even stricter, with the drug being placed in Schedule II of the new Controlled Substances Act (CSA).

Schedule II drugs are prescription medications that have a legitimate medical use, but are recognized as having a high potential for abuse that may lead to severe psychological and/or physical dependence. To prevent abuse and diversion, schedule II drugs (like dextroamphetamine) require a written doctor's prescription, do not allow automatic refills, and require special security precautions. Pharmacies and hospitals that dispense schedule II drugs must register with the DEA. In addition, limits are placed on the amount of dextroamphetamine produced by manufacturers for the U.S. each year.

Federal guidelines, regulations, and penalties

While dextroamphetamine's more potent cousin, methamphetamine, is frequently made in secret labs with potentially dangerous substances, the majority of illicit dextroamphetamine drug supply comes actual prescription drugs obtained illegally, either through fraud or theft.

Anyone convicted of transporting or dealing dextroamphetamine faces stiff penalties. Federal guidelines mandate that a first-time trafficking offender face up to 20 years in prison and a $1 million fine. If death or serious injury is involved with the trafficking charge, the sentence must be at least 20 years with a maximum sentence of life in prison.

Amphetamines are designated a class B drug in the United Kingdom under the Misuse of Drugs Act 1971. Possession carries a penalty of imprisonment for three months to five years, and trafficking carries a sentence of six months to 14 years. A fine may also be imposed.

See also Amphetamines; Methamphetamine; Methylphenidate

RESOURCES

Books

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Press, Inc., 1994.

Physicians' Desk Reference. 56th ed. Montvale, NJ: Medical Economics, 2002.

Periodicals

Emonson, D., and R. Vanderbeek. "The Use of Amphetamines in U.S. Air Force Tactical Operations during Desert Shield and Storm." Aviation Space and Environmental Medicine 66, 3 (1995): 802.

Johnston, Lloyd D., et al. Monitoring the Future: National Sur

vey Results on Drug Use, 1975-2000. Vols. I and II. Bethesda, MD: National Institute on Drug Abuse, 2001.

Other

Drugs of Abuse. U.S. Drug Enforcement Administration. March 20, 2002 (April 1, 2002). <http://www.usdoj.gov/dea/concern/abuse/contents.htm>.

U.S. Anti-Doping Agency. 2001 (April 1, 2002). <http://www.usantidoping.org/>.

Organizations

National Institute on Drug Abuse (NIDA); part of the National Institutes of Health (NIH), 6001 Executive Boulevard, Room 5213, Bethesda, MD, USA, 20892-9561, (301) 443-1124, (888) 644-6432, [email protected]ists.nida.nih.gov, <http://www.nida.nih.gov/>.

Paula Anne Ford-Martin

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Dextroamphetamine

Dextroamphetamine


What Kind of Drug Is It?

Dextroamphetamines are stimulants—substances that increase the activity of a living organism or one of its parts. Stimulants create a temporary "high" that elevates users' moods, but these effects do not last long. A "low," which can sometimes be overwhelming, follows once the drug's effects wear off.

Like other amphetamines, dextroamphetamines also give people more energy, allowing them to do more and stay awake longer without getting tired. This effect of "speeding up" people's actions explains how the drugs came to be known by the street names "go-pills," "pep pills," "speed," and "uppers."

Overview

Dextroamphetamines are addictive drugs that have a high rate of abuse. The prefix "dextro" in the drug name dextroamphetamine refers to dextrose, a type of sugar. Dextroamphetamines are simply amphetamines that contain sugar molecules. (An entry on amphetamines is also available in this encyclopedia.)

The history of amphetamines stretches back to the late nineteenth century. The drug was first synthesized, or made in a laboratory, in 1887. However, it was not used until 1932 when the drug manufacturer Smith, Kline and French introduced Benzedrine. Packaged as an over-the-counter inhaler, the amphetamine drug Benzedrine helped relieve nasal congestion.

Official Drug Name: Dextroamphetamine (DEKS-troh-am-FETT-uh-meen), D-amphetamine, dextroamphetamine sulfate (Dexedrine [DEKS-uh-dreen], DextroStat [DEKS-troh-statt])

Also Known As: Copilots, dexies, go-pills, pep pills, speed, uppers

Drug Classifications: Schedule II, stimulant

Dextroamphetamine: The Drug with Multiple Uses

Throughout the 1930s, doctors in Europe prescribed amphetamines to treat colds, hay fever, and asthma. That same decade, amphetamines became available in tablet form for the treatment of the daytime sleeping disorder known as narcolepsy, a fairly rare condition that causes people to fall asleep quickly and unexpectedly. Later, many Americans became hooked on amphetamines—specifically the dextroamphetamine sulfate Dexedrine—after finding that users could lose weight quickly and effortlessly. Only then did researchers begin to realize that these drugs could be dangerous and addictive.


During World War II (1939–1945), amphetamines were distributed among soldiers from the United States, the United Kingdom, Germany, and Japan to keep them awake and alert on the battlefield. Back on the home front, people who worked in factories manufacturing goods for the war effort were also using the drug to boost their productivity. After the war, use of the drug continued, both in the United States and abroad.

Access to Amphetamines Is Restricted

Amphetamines and dextroamphetamines became the drug of choice for people who needed a lift or who needed to stay alert. Night-shift workers, students cramming for exams, and truck drivers on long hauls were among the most common users. The addictive nature of the drugs contributed to the growing demand for them. In 1970, drug companies in the United States produced about 12 million amphetamine tablets. A large percentage of these drugs fell into the wrong hands and made their way to the black market. That year, the U.S. Congress passed the Controlled Substances Act (CSA) in an effort to stop the huge increase in drug use. The new law restricted the use of amphetamines and classified them as Schedule II drugs—drugs with genuine medical uses that nevertheless possess a high potential for abuse and dependency.

What Is It Made Of?

All amphetamines are synthetic, or manufactured, substances. They cannot be grown in a garden or dug up from the ground. The composition of amphetamine pills or capsules is actually a combination of various types of crystalline compounds called amphetamine salts. The difference between amphetamine and dextroamphetamine is a few molecules of dextrose, which is a type of sugar.

The chemical formula for dextroamphetamine is (C9H13N)2. The chemical formula for dextroamphetamine sulfate is C18H28N2O4S.

How Is It Taken?

Dextroamphetamine sulfate is manufactured in capsule and tablet form and is usually swallowed. Dexedrine capsules have one brown end and one clear end and are filled with two types of tiny drug pellets. One type of pellet dissolves shortly after the capsule is ingested. The other type is time-released, allowing for a gradual release of the rest of the medication throughout the day. The capsules are available in 5-milligram, 10-milligram, and 15-milligram doses. Dexedrine also comes in tablet form. The 5-milligram pills are triangular and orange. DextroStat, another dextroamphetamine sulfate, is only available in 5-milligram and 10-milligram tablets. The pills are yellow and round.

For the treatment of narcolepsy, patients are typically prescribed 5 milligrams to 60 milligrams of dextroamphetamine per day. Patients age six or older with attention-deficit/hyperactivity disorder (adhd) usually take 5 milligrams to 40 milligrams per day, depending on their age and response to the drug. The youngest ADHD patients—ages three to five—may be given half of a 5-milligram tablet.


Are There Any Medical Reasons for Taking This Substance?

Amphetamines such as Dexedrine and DextroStat (dextroamphetamine sulfate) and Adderall (a combination of amphetamine and dextroamphetamine sulfate referred to as a "mixed amphetamine") are used to treat ADHD and narcolepsy. (An entry on Adderall is also available in this encyclopedia.) Dextroamphetamines are useful in the treatment of ADHD because they improve the user's ability to concentrate. The drug helps patients with narcolepsy by speeding up bodily functions and increasing alertness.

In the 1970s, dextroamphetamines were approved for use as antiobesity drugs. Because they decrease feelings of hunger in people who


take them, dextroamphetamines and other amphetamines have often been abused by dieters. This is exactly what happened with Dexedrine. By the start of the twenty-first century, research was underway on a variety of different diet pills. Dextroamphetamines like Dexedrine, however, were no longer being prescribed for weight loss in the United States.

Usage Trends

Problems undoubtedly develop when dextroamphetamine pills and capsules are taken by individuals who have no medical need for the drug. All amphetamines are psychostimulants, meaning that they act primarily on the brain. Amphetamines are extremely addictive, and high doses can affect the brain in negative ways. Regardless of the dangers, their power to increase concentration and decrease the need for sleep has led to a new trend known as stimulant "sharing." (See separate entries in this encyclopedia on "Adderall" and "Ritalin and Other Methylphenidates.")

Reports from the United States, Canada, and the United Kingdom in the first five years of the twenty-first century indicate that prescription dextroamphetamines are being shared—or sold—among adolescents and college students. illicit drug users claim they receive the stimulants from other young people who use them for medical purposes. In some cases, the drugs are stolen or simply lifted from the family medicine cabinet.

The reasons for the abuse of dextroamphetamines at the high school and college levels vary. Nicholas Zamiska commented in the Wall Street Journal that the "unapproved use" of drugs like Adderall seem to stem from increased pressure on students to perform well on standardized tests. Illicit recreational drug use occurs as well.

Major Studies on Amphetamine Use and Abuse

DAWN and NSDUH:

The Drug Abuse Warning Network (DAWN) operates through the Substance Abuse and Mental Health Services Administration (SAMHSA), a division of the U.S. Department of Health and Human Services. DAWN monitors drug-related visits to hospital emergency departments (EDs). In the last two quarters of 2003, the DAWN report estimated that the use of stimulants resulted in 42,538 emergency department visits in 260 hospitals across the United States. Of those visits, 18,129 of them were attributed directly to amphetamines and dextroamphetamines.

SAMHSA's own annual study, known as the National Survey on Drug Use and Health (NSDUH), tracks nonmedical drug use among Americans of all ages. The latest statistics available from SAMHSA as of mid-2005 were from 2003. That year, 4 percent of all youths age twelve to seventeen reported using prescription-type drugs, including stimulants. The percentage was higher among eighteen- to twenty-five-year-olds. Six percent of this age group admitted to using prescription drugs for nonmedical reasons. About 1.9 percent of adults age twenty-six and older reported illicit prescription drug use.

Generation Rx?:

On April 21, 2005, the Partnership for a Drug-Free America (PDFA) released the findings of its 2004 study on the abuse of drugs among U.S. teenagers. The PDFA's Partnership Attitude Tracking Study, better known as PATS, indicated that the trend in teen drug use in the early part of the twenty-first century involves prescription (Rx) and over-the-counter (OTC) medications. The authors of the study see this as a sign that "Rx and OTC medicine abuse has penetrated teen culture."

Millions of teens are using prescription drugs without a doctor's order, prompting the media to dub these young adults "Generation Rx." According to PATS, 10 percent of American teenagers, or 2.3 million young people, have tried prescription stimulants like Adderall without a doctor's prescription. The teens in the study reported that they obtained the stimulants from fellow classmates or from their own home medicine cabinets.

Monitoring the Future … and Beyond:

The PATS statistics mirror the results of the 2004 Monitoring the Future (MTF) study. An annual survey of drug use among eighth, tenth, and twelfth-grade students, the MTF is performed by the University of Michigan and funded by the National Institute on Drug Abuse (NIDA). Although amphetamine use was down slightly among eighth and tenth graders, about 10 percent of high school seniors reported recreational use of the drug in 2004.

A study conducted by University of Michigan Substance Abuse Research Center scientists, detailed in the journal Addiction in 2005, tracked the usage of amphetamines beyond high school. Of nearly 11,000 randomly selected college students, 6.9 percent of them reported nonmedical prescription stimulant use at least once in their lives. About 4.1 percent admitted using prescription stimulants in the past year, and 2.1 percent used them in the past month. The authors of the study concluded that "high-risk behavior" such as this "should be monitored further." They added, "intervention efforts are needed to curb this form of drug abuse."


Effects on the Body

Common side effects of dextroamphetamine use include dry mouth, headache, nausea, dizziness, restlessness, increased blood pressure and pulse rate, loss of appetite, difficulty sleeping, and either diarrhea or constipation. Higher doses can result in fever, an unusually fast heartbeat, chest pain, blurred vision, tics, tremors, moodiness, and even aggression.

Amphetamine Psychosis

High-dose dextroamphetamine abusers can develop "amphetamine psychosis" after a week or so of continuous use. Amphetamine psychosis affects the way the mind functions, causing feelings of severe paranoia, and all kinds of hallucinations—visual, auditory, and tactile. Tactile hallucinations make the user feel as if bugs, worms, or snakes are crawling on their skin. Such sensations are very real, and therefore extremely frightening, to the individual who is experiencing them. As a result, violent reactions sometimes occur during amphetamine psychosis. Once the amphetamine abuser is free of the drug, however, the psychosis goes away. Symptoms such as mental confusion and memory problems may linger, however.

Monitoring Dosage

When used for medical purposes, dextroamphetamines are prescribed at the lowest possible dosage. The dosage is then raised gradually by a doctor until the desired action is achieved. All amphetamines are highly addictive. According to the 59th edition of the Physicians' Desk Reference: "There are reports of patients who have increased the dosage to many times that recommended," leading to "tolerance, extreme psychological dependence, and severe social disability."

Tolerance occurs when it takes more and more of the drug to achieve the effect or high originally produced by smaller doses. Tolerance to amphetamines can occur quickly and often leads to overdose. Symptoms of dextroamphetamine overdose include extreme confusion and anxiety, hallucinations, severe tics or shaking, an irregular heartbeat, extremely high blood pressure, vomiting, stomach cramps, convulsions, and coma. An overdose of dextroamphetamine—or any other amphetamine, for that matter—can be fatal.

Finding the Right Treatment


Dextroamphetamines such as Dexedrine and amphetamine/dextroamphetamine mixtures such as Adderall are commonly prescribed by physicians to treat ADHD. Finding the right drug to treat a child or an adult with ADHD is often a process of "trial and error." Doctors try one drug, observe the effects, and decide whether an alternate form of treatment is advisable.

Establishing a safe and effective drug treatment can be especially difficult when it comes to children. Some evidence indicates that children experiencing ADHD-like symptoms may actually be suffering from severe anxiety, or a severe state of fear or worry, which is worsened by the use of stimulants. In these very rare cases, amphetamines and dextroamphetamines can cause overstimulation in the child.

In one case reported in the May 2004, issue of Pediatrics, doctors raised the question about whether dextroamphetamines may have contributed to psychotic behavior in a seven-year-old ADHD patient. His symptoms, including extreme agitation, an elevated temperature, ranting and raving, and hallucinations, all disappeared when the stimulant prescription was discontinued and an anti-anxiety drug was administered. Results such as these suggest that the child was suffering from severe anxiety rather than ADHD, even though his symptoms mirrored those of a typical ADHD patient.

Dextroamphetamine as a Treatment for ADHD

Amphetamines and dextroamphetamines typically give the user a boost of energy. In people with attention-deficit/hyperactivity disorder (ADHD), however, these very same drugs help to calm them down, allowing them to better focus their energy. Individuals with ADHD typically have a short attention span, and they tend to get distracted quite easily. They may also show signs of hyperactivity, impulsive behavior, and emotional instability. It can be a challenge for people with untreated ADHD to concentrate their attention and control their behavior. Drugs like Dexedrine, a dextroamphetamine sulfate, and Adderall, a combination of amphetamine and dextroamphetamine salts, help manage the symptoms of ADHD by acting on the part of the brain that decides when and how to act.

According to an article in Phi Delta Kappan, it is essential that parents or caregivers of children and teens with ADHD: 1) be informed about the effects of the drugs that have been prescribed for treatment; 2) know the consequences that might arise if these drugs are discontinued; and 3) accept the responsibility to stay in close touch with the child's doctor and therapist. In most cases, drug treatment for ADHD must be combined with some sort of counseling or therapy to achieve the highest success rates. One of the most popular and successful therapeutic methods as of 2005 was cognitive behavioral therapy (cbt), or "talk" therapy. Cognitive behavioral therapy helps patients develop better coping skills and change their negative patterns of thinking and behavior into positive ones.

Reactions with Other Drugs or Substances

The stimulating effects of dextroamphetamine can be intensified when the drug is combined with other stimulants such as cocaine or nicotine. (Entries on cocaine and nicotine are also available in this encyclopedia.) Dextroamphetamines should never be mixed with alcohol or other depressants.

Some medications can cause severe reactions in the user when mixed with stimulants. In addition, people with certain medical conditions should stay away from these drugs. Specifically, dextroamphetamines should not be taken by pregnant women, nursing mothers, or individuals with any of the following conditions:

  • heart disease
  • high blood pressure
  • thyroid disease
  • tourette's syndrome, or any other tic disorder
  • a history of drug abuse
  • depression that is being treated with prescription drugs
  • severe pain that is being treated with the prescription drug meperidine. (A separate entry on meperidine is available in this encyclopedia.)

Treatment for Habitual Users

withdrawal from amphetamines can be a long and difficult process for many users. Psychological dependence is made even worse by the intense cravings for the drug that users experience. Unpleasant and sometimes frightening symptoms develop as the body tries to adjust to the absence of the stimulant. The withdrawal process causes depression and may also bring on fatigue, vivid dreams, irregular sleep patterns, and increased appetite.

Experts in the treatment of substance abuse and addiction report that behavioral therapy and emotional support are essential for the successful rehabilitation of amphetamine abusers. An individual recovering from drug addiction must avoid all psychoactive drugs, including alcohol. Amphetamine and dextroamphetamine cravings can be extremely powerful and may last for years after a former user has kicked the habit.

Patti Davis, daughter of former U.S. President Ronald Reagan and his wife, Nancy, talked about her past drug addiction in the article "Dope: A Love Story" in Time magazine. In the article, Davis wrote that she often wondered "why the world is so hard for some people" that they "run for the refuge of drugs." This observation shows why an effective drug rehabilitation program must help patients identify and deal with the underlying emotional issues surrounding their drug use.

The reasons for drug use are numerous. The Merck Manual of Medical Information noted that "some amphetamine abusers are depressed and seek the mood-elevating effects of these stimulants to temporarily relieve the depression." Davis pointed out that some people are afraid of the world. Drugs "take you away—far away; they let you hide, which is what frightened people do," she commented. Recovering drug abusers need a solid support system to remain drug free.

Consequences

Amphetamine addicts frequently allow their need for the drug to take over their lives. Users can become so obsessed with satisfying their drug habit that they ignore the most important people in their lives. Relationships with family and friends frequently deteriorate, and money problems may begin to develop as the addiction grows. In general, substance abuse is associated with increased rates of school failure, theft (usually to fund the drug habit), domestic violence, sexual assault, unemployment, and homelessness. People who are high on amphetamines are more likely to engage in risky behavior than people who do not take drugs. This can contribute to the spread of sexually transmitted diseases, including HIV (the human immunodeficiency virus, which can lead to acquired immunodeficiency syndrome [AIDS]).

The Law

Abuse of any amphetamine can have serious legal consequences. Amphetamines are controlled substances, meaning their use is regulated by certain federal laws. Under the terms of the Controlled Substances Act (CSA) of 1970, amphetamines are classified as Schedule II drugs. Schedule II drugs are prescription medications that have genuine medical uses but also pose a high risk for abuse and addiction. Schedule II drugs like dextroamphetamines require a doctor's prescription and carry a warning that states they "should be prescribed or dispensed sparingly." Pharmacies and hospitals that dispense Schedule II drugs must register with the U.S. Drug Enforcement Administration. In addition, limits are placed on the amount of dextroamphetamine produced by manufacturers for the United States each year.

Since the passage of the CSA, according to Andrew Weil and Winifred Rosen in From Chocolate to Morphine, "most cases of amphetamine abuse have involved legally manufactured and prescribed drugs." Most of the illicit dextroamphetamine supply, then, comes from actual prescriptions that are obtained, used, and sold illegally.

"Go-Pills" and the Military


Dextroamphetamines have a long history of use by the military and were even given to astronauts to fight motion sickness and fatigue during space flights. The drug's routine use by air force pilots has given new meaning to the term "copilot," one of several street names for dextroamphetamine.

The U.S. Air Force has used Dexedrine, known in military circles as "go-pills," since 1960. A 1995 report from Langley Air Force Base revealed widespread amphetamine use in Operation Desert Storm. Gene Collier, writing in the Post-Gazette, reported that 60 percent of U.S. pilots in the Gulf War said they took Dexedrine during their missions. In a study performed by the U.S. Army Aeromedical Research Laboratory in 2000, one pilot was able to stay awake for sixty-four hours straight by taking Dexedrine.

Dextroamphetamine reportedly improves alertness and flight performance by fighting fatigue, confusion, and air sickness in the cockpit. It has been shown to increase accuracy, improve short-term memory, and speed up reaction time. But Dexedrine, like all amphetamines, is a habit-forming drug with potentially serious side effects. A tragic incident occurred in 2002 involving two American pilots who were taking the drug. This incident called the use of Dexedrine by the military into serious question.

Deadly Consequences

The two pilots, Major Harry Schmidt and Major William Umbach, were flying separate F-16s back from a mission in Afghanistan. On the night of April 17, 2002, twelve Canadian soldiers in Afghanistan were hit by a quarter-ton bomb dropped by Major Schmidt from his F-16. Four of the soldiers were killed, the other eight were wounded. The Canadians had been conducting a live-fire exercise with anti-tank guns that night—an exercise that U.S. Air Force officials apparently had been told about earlier. According to the Canadian inquiry report on the case, as reported by CBC News, "Until the moment the bombs struck, Canadian forces had no knowledge of impending danger."

Both U.S. pilots stated that they believed they were under attack when they saw the flashes of gunfire on the ground below. Schmidt wanted


to return fire, but, according to the Post-Gazette, was told by Umbach, "Let's just make sure that it's not friendlies, that's all." By "friendlies," Umbach was referring to soldiers fighting on the same side as the Americans. Cockpit voice recordings indicate that Major Schmidt was instructed to hold his fire, but he remained convinced that he was under attack and responded, "I am rolling in in self-defense."

The American pilot who dropped the 500-pound bomb had taken a 20-milligram dose of Dexedrine about an hour before the incident. Some observers felt that the drug "may have been a factor in the decision to drop a bomb on allied soldiers," noted CBC News. American Air Force officials argued that hundreds of earlier patrols had been flown safely and successfully over Afghanistan by pilots on Dexedrine.

The outcome of the so-called "friendly fire" case was decided on July 6, 2004. According to CBC News, the text of the U.S. Air Force verdict stated that Schmidt exhibited "arrogance and a lack of flight discipline" for not taking "a series of evasive actions and remain[ing] at a safe distance to await further instructions." Instead, he "closed on the target and blatantly disobeyed the direction to 'hold fire."' Schmidt's actions were deemed "inexcusable," and he was found guilty of dereliction of duty—abandoning duty or showing negligence—for his actions.

The use of Dexedrine by the military remains a hot topic of debate.

Anyone convicted of transporting or dealing in dextroamphetamine in the United States faces up to twenty years in prison and a hefty fine for a first offense. Repeat offenders face even stiffer penalties. In the United Kingdom, amphetamines are designated a class B drug under the 1971 Misuse of Drugs Act. Possession carries a penalty of imprisonment for three months to five years, and dealing carries a sentence of six months to fourteen years, along with a possible fine.

For More Information

Books

Beers, Mark H., and others. The Merck Manual of Medical Information, 2nd home ed. New York: Pocket Books, 2003.

Brecher, Edward M., and others. The Consumers Union Report on Licit and Illicit Drugs. Boston: Little Brown & Co., 1972.

Clayton, Lawrence. Amphetamines and Other Stimulants. New York: Rosen Publishing Group, 1994.

Gahlinger, Paul M. Illegal Drugs: A Complete Guide to Their History, Chemistry, Use, and Abuse. Las Vegas, NV: Sagebrush Press, 2001.

Kuhn, Cynthia, Scott Swartzwelder, Wilkie Wilson, and others. Buzzed: The Straight Facts about the Most Used and Abused Drugs from Alcohol to Ecstasy, 2nd ed. New York: W.W. Norton, 2003.

Physicians' Desk Reference, 59th ed. Montvale, NJ: Thomson PDR, 2004.

Weil, Andrew, and Winifred Rosen. From Chocolate to Morphine. New York: Houghton Mifflin, 1993, rev. 2004.

Periodicals

"Attention Deficit Disorder: Generic Dexedrine Spansule Capsules Approved." Medical Letter on the CDC & FDA (February 17, 2002): p. 6.

Calello, Diane P., and Kevin C. Osterhoudt. "Acute Psychosis Associated with Therapeutic Use of Dextroamphetamine." Pediatrics (May, 2004): p. 1466.

Collier, Gene. "Pilots on the Go Might Not Know When to Stop." Post-Gazette (January 19, 2003).

Davis, Patti. "Dope: A Love Story." Time (May 7, 2001): p. 55.

Emonson, D., and R. Vanderbeek. "The Use of Amphetamines in U.S. Air Force Tactical Operations during Desert Shield and Storm." Aviation Space and Environmental Medicine, volume 66, number 3 (1995): p. 802.

Grady, Denise. "History Counsels Caution on Diet Pills." New York Times (May 25, 1999).

Hewitt, Bill. "Clipped Wings." People (February 3, 2003): pp. 103-104.

Jurgensen, John. "Military Researchers Focus on Pilot Fatigue." Detroit News (January 25, 2003).

McCabe, S. E., and others. "Non-medical Use of Prescription Stimulants among U.S. College Students." Addiction (January, 2005): pp. 96-106.

"Negligence Is a Two-Way Street." Phi Delta Kappan (November, 1995): pp. 259-260.

"Sex, Drugs, and Rock 'n' Roll." Independent (January 28, 1996): p. 8.

Shute, Nancy, and others. "The Perils of Pills: The Psychiatric Medication of Children Is Dangerously Haphazard." U.S. News & World Report (March 6, 2000): p. 44.

Zamiska, Nicholas. "Pressed to Do Well on Admissions Tests, Students Take Drugs; Stimulants Prescribed for Attention Disorders Find New Unapproved Use." Wall Street Journal (November 8, 2004): p. A1.

Web Sites

"2003 National Survey on Drug Use and Health (NSDUH)." U.S. Department of Health and Human Services, Substance Abuse and MentalHealth Services Administration.http://www.oas.samhsa.gov/nhsda.htm (accessed June 30, 2005).

"Drug Abuse Warning Network, 2003: Interim National Estimates of Drug-Related Emergency Department Visits." DAWN, 2003: Office of Applied Studies, Substance Abuse and Mental Health Services Administration. http://DAWNinfo.samhsa.gov/ (accessed June 30, 2005).

"Generation Rx: National Study Reveals New Category of Substance Abuse Emerging: Teens Abusing Rx and OTC Medications Intentionally to Get High." Partnership for a Drug-Free America.http://www.drugfree.org/ (accessed June 30, 2005).

"Grieving Canadians Stunned U.S. Pilots Took Drugs." CBC News, December 21, 2002. http://www.cbc.ca/stories/2002/12/21/clooney_021221 (accessed June 30, 2005).

"Indepth: Go-Pills, Bombs & Friendly Fire." CBC News, November 17, 2004. http://www.cbc.ca/news/background/friendlyfire/gopills.html (accessed June 30, 2005).

"Indepth: The 'Friendly Fire' Reports." CBC News, October 22, 2003. http://www.cbc.ca/news/background/friendlyfire/reports.html (accessed June 30, 2005).

"Indepth: U.S. Air Force Verdict." CBC News, July 6, 2004. http://www.cbc.ca/news/background/friendlyfire/verdict.html (accessed June 30, 2005).

Monitoring the Future.http://www.monitoringthefuture.org/ and http://www.nida.nih.gov/Newsroom/04/2004MTFDrug.pdf (both accessed June 30, 2005).

National Institute on Drug Abuse.http://www.nida.nih.gov/ and http://www.drugabuse.gov (both accessed June 30, 2005).

"Shepperd: 'Go-Pills' Common for Pilots." CNN.com, January 3, 2003. http://www.cnn.com/2003/US/01/03/cnna.shepperd/index.html (accessed June 30, 2005).

"Teens Becoming 'Generation Rx'." CNN.com. http://www.cnn.com/2005/HEALTH/parenting/04/21/drug.survey.ap/index.html (accessed June 30, 2005).

"U.S. Pilots Took Amphetamines before 'Friendly Fire' Incident." CBC News, December 21, 2002. http://www.cbc.ca/story/world/national/2002/12/20/friendlyfire021220.html (accessed June 30, 2005).

See also: Adderall; Amphetamines; Methamphetamine; Ritalin and Other Methylphenidates

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