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General Practice, Chapter 18

Chapter 18 - Drug problems


A custome loathsome to the e e, hateful to the nose, harmeful to the braine, dangerous to the lungs and the
black e stink ing fume thereof, neerest resembling the horrible Stigian smok e of the bottomless pit.
Ja e I (1566-1625)
On smok ing
D g- e a ed
be
ae e a
e ade i fa i
ac ice. Thi i c de
e c ibed d g , e he
c
e d g a d cia
i ega
ee d g . I i i
a he ef e ha a
e c ibi g d c
ai ai a
high i de f
ici
ha a c i ica
be
a be a
cia ed i h hei ea e
f he a ie .

Adverse drug reactions


A ad e e d g effec i defi ed a 'a
a ed effec f ea e f
he edica
e f d g ha
cc
a a
a he a e ic d e'. A
e e d g ca ca e a ad e e eac i , hich
be e ici ed
i he hi
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b a ce ha
d ce be eficia he a e ic effec
a a
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a ed,
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f he eac i
a a ge f
a id i a h
a ea
dde
dea h f
a a h a i .A
d ha h
ha he i cide ce f ad e e eac i
i c ea e f
ab
3%
i a ie
10-20 ea
f age ab
20% i a ie
80-89 ea
f age. 1
Reac i
ca be c a ified i e e a a , e.g. ide effec , e d age, i
e a ce, h e e i i i a d
idi
c a . H e e , a ef c a ifica i
f
a ed effec i di ided i
eAa d
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e Augmented pharmacolog , i.e. he a e ca ed b
a ed, a bei edic ab e, effec
f he d g.
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c
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a e d e-de e de .
T e B eac i
a e b defi i i Bi arre. The eac i
ae
E a
e i c de he a
ici a d b d d c a ia .

edic ab e f

e ie

f he d g.

Golden rules for prevention of adverse effects


Bef e
1.
2.
3.
4.

e c ibi g a

d g he

e c ibe

I he d g ea
ece a ?
Wha i ha e if i i
ed?
Wha g d d I h e achie e?
Wha ha
a e
f
hi ea

dc

ide he f

i g

e :

e ?

Common adverse effects


The e i a e e i e i
f c i ica
high igh ed h gh
hi b
.C
CNS

a ai e, d

CVS

a iai

GIT

S i

a h,

chia ic/E

be

a i

ca ed b d g a
ide effec i c de:

i e

, fa ig e/ i ed e

, e i he a

ea,

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i

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, headache, di

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e

ide effec

i e ac i

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ia, cha ge i b

e habi (dia h ea, c

i ai

hi g

ia, i i abi i , a

ie , de e

, agi a i

Drugs that commonl produce adverse effects


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A i ic bia
e ici
h
e ac
e
e c
A ic

i /ce ha
a ide
ci e
ci
a e

a
ca ba a e i e
he ba bi e
he
i
di
a
ae

A ide e

ic c ic
MAO i hibi
A i-i f a

ie a d a a ge ic

a i i / a ic a e
c dei e/
hi e, e c.
NSAID
g d a
A ih

e e

i e age

( e e a)
Ca diac age
dig i
i idi e
a i da e
he a ia h h ic
Di e ic
hia ide
f e ide
Ta

i i e
he hia i e
be
dia e i e
ba bi a e
ch dia e
ide

O he d g i c de
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h
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ic
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Nico ine
'S
i gi g df
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ae
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d A ab
e b. 'The d g
i
bi e
e
c gh i
ee a d
i
ea i e
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e ab e ca e f dea h a d di ea e i A

beca e
e
ffe he i dig i ie

a ia. I ha bee
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estimated to have caused approximately 20 000 deaths in 1991, over six times the number of deaths from
road accidents. 2 Diseases attributed to smoking are summarised in Figure 18.1 .

Fig. 18.1 Possible serious adverse effects of nicotine smok ing

Ge ing pa ien

oq i

Several studies have highlighted the value of opportunistic intervention by the family doctor. It is important not
only to encourage people to quit but also to organise a quitting program and follow-up. In Australia 80% of
smokers (representing about 30% of the adult population) have indicated that they wish to stop smoking.
Point out that it is not easy and requires strong will power. As Mark Twain said, 'Quitting is easy I've done it
a thousand times.'

Me hod
Educate patients about the risks to their health and the many advantages of giving up smoking, and
emphasise the improvement in health, longevit , mone savings, look s and se ualit .
The extent of nicotine dependence can be assessed using a questionnaire (based on the Fagerstrom
Test) and scoring system. 3
Fac

o poin o
Advantages
Food tastes better.
Sense of smell improves.
Exercise tolerance is better.
Sexual pleasure is improved.
Bad breath improves.
Risk of lung cancer drops: after 10-15 years of quitting it is as low as someone who has never
smoked.
Early COAD can be reversed.
Decreases URTIs and bronchitis.
Chance of premature skin wrinkling and stained teeth is less.
Removes effects of passive smoking on family and friends.
Removes problem of effects on pregnancy.

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Ask them to keep a smoker's diary.


If they say no to quitting, give them motivational literature and ask them to reconsider.
If they say yes, make a contract (example below).

A contract to quit
'I ...................... agree to stop smok ing on .................... I understand that stopping smok ing is the single
best thing I can do for m health and that m doctor has strongl encouraged me to quit.'
........................................ (Patient's signature)
........................................ (Doctor's signature)

These motivated patients will require educational and behavioural strategies to help them cope with
quitting. Ongoing support by their GP is very important.
Organise joining a support group.
Arrange follow-up (very important), at least monthly, especially during first 3 months.
Going 'cold turk e ' (stopping completely) is preferable but before making the final break it can be made
easier by changing to a lighter brand, inhaling less, stubbing out earlier and reducing the number.
Changing to cigars or pipes is best avoided.

Q i ing ip (ad ice o pa ien )


Make a definite date to stop (e.g. during a holiday).
After quitting
Eat more fruit and vegetables (e.g. munch carrots, celery and dried fruit).
Foods such as citrus fruit can reduce cravings.
Chew low-calorie gum and suck lozenges.
Increase your activity (e.g. take regular walks instead of watching TV).
Avoid smoking situations and seek the company of non-smokers.
Drink more water and avoid substituting alcohol for cigarettes.
Be single-minded about not smoking be determined and strong.
Take up hobbies that make you forget smoking (e.g. water sports).
Put aside the money you save and have a special treat. You deserve it!!

Wi hd a al effec
The initial symptoms are restlessness, cravings, hunger, irritability, poor concentration, headache,
tachycardia, insomnia, increased cough, tension, depression, tiredness and sweating. After about 10 days
most of these effects subside but it takes about three months for a smoker to feel relatively comfortable with
not smoking any more. Nicotine replacement therapy certainly helps patients cope.

Pha macological ea men


Nicotine replacement therapy, which should be used in conjunction with an educational support program, has
been proved to be effective and is available as chewing gum or transdermal patches (the preferred method).
Ideally the nicotine should not be used longer than 3 months.
Nico ine g m 3
This is available as 2 mg and 4 mg.
Low dependence (less than 10 cigarettes per day): use non-pharmacological methods rather than
replacement
Moderate dependence (10-14 cigarettes per day): 2 mg
High dependence (> 15 per day): 4 mg initially, changing to 2 mg after 4-6 weeks.
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Useful points
Chew each piece slowly for about 30 minutes.
Ensure all the nicotine is utilised.
Chew at least 6 pieces per day, replacing at regular intervals (not more than 1 piece per hour)
Use for 3 months, weaning off before the end of this period.
Transdermal nicotine 3
This is available as 16-hour or 24-hour nicotine patches in three different strengths. The patients should stop
smoking immediately on use.
Recommendations
Moderate dependence: 14 mg patch; change to 7 mg patch after 4-6 weeks
High dependence: 21 mg patch; change to 14 mg patch after 4-6 weeks
Apply to non-hairy, clean, dry section of skin on upper outer arm or upper chest and leave in place for 24
hours. Rotate sites with a 7-day gap for reuse of a specific site.
Contraindications
These are pregnancy and breast-feeding, children, severe myocardial ischaemia, arrhythmias or recent CVA.
Adverse reactions
Gum: hiccoughs, orodental problems, jaw pain, gastrointestinal including exacerbation of peptic ulcer
Patches: local reaction, sleep disturbances (use 16-hour patch for this)
Both: nervousness, sweating, dry mouth, dyspepsia, abdominal cramps, angina and arrhythmias

Alcohol
Excessive drinking of alcohol can cause several clinical manifestations. Identification of the alcohol-affected
person is complicated by the tendency of some to hide, underestimate or understate the extent of their
intake.
In order to diagnose and classify alcohol-dependent people, the family doctor has to rely on a combination of
parameters that include clinical symptoms and signs, available data on quantity consumed, clinical intuition,
personal knowledge of the social habits of patients, and information (usually unsolicited) from relatives, friends
or other health workers.
A checklist of pointers to the adverse effects of chronic alcohol abuse is presented in Table 18.1 . In a study
by the author the outstanding clinical problems are the psychogenic disorders (anxiety, depression and
insomnia) and hypertension. 4 Susceptibility to work and domestic accidents were also significant findings.
The challenge to the family doctor is early recognition of the alcohol problem. This is achieved by developing a
special interest in the problem and a knowledge of the early clinical and social pointers, and being ever alert
to the tell-tale signs of alcohol dependence (refer to Chapter 106 ).
Table 18.1 Checklist of pointers of alcohol abuse

Ps chosocial features

concern about drinking by self, family or others


heavy drinking more than six glasses per day
early morning drinking
reaching for the bottle when stressed
regular hotel patron
skipping meals/poor diet
cancelling appointments
increased tolerance to alcohol
alcohol-related accidents
frequent drinking during working day
marital problems
behavioural problems in children
driving offences
criminal offences
financial problems

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absenteeism from work/loss of job


heavy smoking
Clinical features

characteristic facies
hand tremor
alcohol foetor by day
morning nausea and vomiting
traumatic episodes
dyspepsia gastritis/ulcer
obesity
palpitations
impotence
insomnia/nightmares
anxiety/depression
hypertension
hepatomegaly
gout
pancreatitis
personal neglect, 'vagabond' look

Hard addictive street drugs


There are several psychotropic substances that are used for their effects on mood and other mental functions.
Many of the severe problems are due to withdrawal of the drug. Symptomatic behaviour common to the hard
addictive drugs includes:
rapid disappearance of clothing, personal belongings from home
signs of unusual activity around hang-outs and other buildings
loitering in hallways or in areas frequented by addicts
spending unusual amounts of time in locked bathrooms
inability to hold a job or stay in school
rejection of old friends
using the jargon of addicts
Newer drugs include 'crack', which is a cocaine base where the hydrochloride has mostly been removed,
usually in a microwave oven. Crack can be inhaled or smoked. It is the crude form of methamphetamine, a
derivative of amphetamine.
A summary of the effects of 'hard' street drugs is presented in Table 18.2 .
Table 18.2 Illicit substance abuse: A summar of hallmarks
Drug

LSD

Ph sical s mptoms

Look for

Dangers

Severe hallucinations. Feelings of


detachment. Incoherent speech.
Cold hands and feet. Vomiting.
Laughing and crying.

Cube sugar with


discolouration in centre.
Strong body odour. Small
tube of liquid.

Suicidal tendencies.
Unpredictable behaviour.
Chronic exposure causes
brain damage. LSD causes
chromosomal breakdown.

Jars of pills of varying


colours. Chain smoking.

Death from overdose.


Hallucinations.
Methamphetamines
sometimes cause
temporary psychosis.

Amphetamines Aggressive or overactive


behaviour. Giggling. Silliness.
Euphoria. Rapid speech.
Confused thinking. No appetite.
Extreme fatigue. Dry mouth.
Shakiness.
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Barbiturates

Drowsiness. Stupor. Dullness.


Slurred speech. Drunk
appearance. Vomiting.
Stupor/drowsiness. Marks on
body. Watery eyes. Loss of
appetite. Bloodstain on shirt
sleeve. Running nose.

Pills of various colours.

(b) cocaine

Similar effects to amphetamines


muscle pains, irritability,
paranoia, hyperactive, jerky
movements.

Powder: in microwave
ovens

Death from overdose


sudden death from
arrhythmias. Seizures,
mental disorders. Severe
respiratory problems.

Phencyclidine
(angel dust)

Lack of co-ordination. Feeling of


increased physical strength.
Hallucinations. Mood disorders.

White powder. Tablets


unbranded. Syringes.
Smoked in conjunction
with marijuana.

Suicidal tendencies. Death


from overdose. Mental
disorder. Self-injury.

Marijuana

Initial euphoria. Floating feeling.


Sleepiness. Wandering mind.
Enlarged eye pupils. Lack of coordination. Craving for sweets.
Changes of appetite.

Strong odour of burnt


leaves. Small seeds in
pocket lining. Cigarette
paper. Discoloured
fingers.

Inducement to take
stronger narcotics. Recent
medical findings reveal that
prolonged usage causes
cerebral lesions.

Glue sniffing

Aggression and violence. Drunk


appearance, slurred speech.
Dreamy or blank expression.

Tubes of glue, glue


smears. Large paper or
plastic bags or
handkerchiefs.

Lung/brain/liver damage.
Death through suffocation
or choking.

Narcotics
(a) opiates,
e.g. heroin

Needle or hypodermic
syringe. Cotton.
Tourniquet string. Rope,
belt, burnt bottle, caps or
spoons. Glassine
envelopes.

Death from overdose or as


a result of withdrawal.
Addictions. Convulsions.
Death from overdose.
Mental deterioration.
Destruction of brain and
liver. Hepatitis. Embolisms.

Narcotic dependence
This section will focus on heroin dependence.

T pical profile of a heroin-dependent person 5


Male or female: 16-30 years.
Family history: often severely disrupted, e.g. parental problems, early death, separation, divorce,
alcohol or drug abuse, sexual abuse, mental illness, lack of affection.
Personal history: low threshold for toleration, unpleasant emotions, poor academic record, failure to
fulfil aims, poor self-esteem.
First experiments with drugs are out of curiosity, and then regular use follows with loss of job,
alienation from family, finally moving into a 'drug scene' type of lifestyle.

Methods of intake
Oral ingestion
Inhalation
intranasal
smoking
Parenteral
subcutaneous
intramuscular
intravenous

Withdrawal effects
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These develop within 12 hours of ceasing regular usage. Maximum withdrawal symptoms usually occur
between 36 and 72 hours.
anxiety and panic
irritability
chills and shivering
excessive sweating
'gooseflesh' (cold turkey)
loss of appetite, nausea (possibly vomiting)
lacrimation/rhinorrhoea
tiredness/insomnia
muscle aches and cramps
abdominal colic
diarrhoea
A secondary abstinence syndrome is identified 5 at 2 to 3 months and includes irritability, depression and
insomnia.

Complications
Medical
Acute heroin reaction: respiratory depression may include fatal cardiopulmonary collapse. There is
an alarming increase in opioid deaths (including methadone).
Injection site: scarring, pigmentation, thrombosis, abscesses, ulceration (especially with barbiturates).
Distal septic complications: septicaemia, infective endocarditis, lung abscess, osteomyelitis,
ophthalmitis.
Viral infections: hepatitis B, hepatitis C, HIV infection.
Neurological complications: transverse myelitis, nerve trauma.
Physical disability: malnutrition.
Table 18.3 A street drug dictionar

Amphetamines or uppers

Benzedrine:
Dexedrine:
Methedrine:
Drinamyl:

roses, beanies, peaches


dexies, speed, hearts
meth, crystals, white light
purple hearts, goof balls

Hallucinogens
LSD: acid, blue cheer, strawberry fields, barrels, sunshine, pentagons, purple haze, peace pills, blue
light.
Cannabis (Indian hemp)
1. Hashish (the
resin):

hash, resin

2. Marijuana (from pot, tea, grass, hay, weed, locoweed, Mary Jane, rope, bong, jive, Acapulco gold.
leaves):
Cigarettes:

reefers, sticks, muggles, joints

Smoking pot:

blow a stick, blast a joint, blow, get high, get stoned

Narcotics
Morphine:

Morph, Miss Emma

Heroin:

H, Big H, Big Harry, GOM (God's own medicine), crap, junk, dynamite (high-grade
heroin), lemonade (low-grade heroin)
Injection of dissolved powder: mainlining, blast, smack
Inhalation of powder: sniffing

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Cocaine:

coke, snow, lady of the streets, nose candy, toot, snort, crack

H & C:

speed balls

Mi cellaneo
Barbiturates:

devils, barbies, goof balls

Social
Alienation from family, loss of employment, loss of assets, criminal activity (theft, burglary, prostitution, drug
trafficking).

Managemen
Management is complex because it includes the medical management not only of physical dependence and
withdrawal but also of the individual complex social and emotional factors. The issue of HIV prevention also
has to be addressed. Patients should be referred to a treatment clinic and then a shared care approach can
be used. The treatments include cold turkey with pharmacological support, acupuncture, megadoses of
vitamin C, methadone substitution and drug-free community education programs.
Methadone maintenance programs that include counselling techniques are widely used for heroin
dependence. Acute toxicity requires injections of naloxone.
The natural history of the opiate dependence indicates that many patients do grow through their period of
dependence and, irrespective of treatments provided, a high percentage become rehabilitated by their midthirties.

Cannabi (ma ij ana)


Cannabis is a drug that comes from a plant called Cannabis sati a or the Indian hemp plant. It contains a
chemical called tetrahydrocannabinol, which makes people get 'high'. It is commonly called marijuana, grass,
pot, dope, hash or hashish. Other slang terms are Acapulco Gold, ganga, herb, J, jay, hay, joint, reefer,
weed, locoweed, smoke, tea, stick, Mary Jane and Panama Red. Marijuana comes from the leaves, while
hashish is the concentrated form of the resinous substances from the head of the female plant and can be
very strong (it comes as a resin or oil). The drug is usually smoked as a leaf (marijuana) or a powder
(hashish), or hashish oil is added to a cigarette and then smoked. The effects of taking cannabis depend on
how much is taken, how it is taken, how often, whether it is used with other drugs and on the particular
person. The effects vary from person to person. The effects of a small to moderate amount include:
feeling of well-being and relaxation
decreased inhibitions
woozy, floating feeling
lethargy and sleepiness
talkativeness and laughing a lot
red nose, gritty eyes and dry mouth
unusual perception of sounds and colour
nausea and dizziness
loss of concentration
looking 'spaced out' or drunk
lack of co-ordination
a new form called 'skunk' or 'mad weed' causes paranoia
The effects of smoking marijuana take up to 20 minutes to appear and usually last 2 to 3 hours and then
drowsiness follows. The main problem is habitual use with the development of dependence, although
dependence (addiction) is worse than originally believed.

Long- e m

e and addic ion

The influence of 'pot' has a severe effect on the personality and drive of the users. They lose their energy,
initiative and enterprise. They become bored, inert, apathetic and careless. A serious effect of smoking pot is
loss of memory. Some serious problems include:
crime
lack of morality

scant respect for others and their property

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respiratory disease (more potent than nicotine for lung disease): causes COAD, laryngitis and rhinitis
often prelude to taking hard drugs
becoming psychotic (resembling schizophrenia): the drug appears to unmask an underlying psychosis

Withdra al
Sudden withdrawal produces insomnia, night sweats, nausea, depression, myalgia, irritability and maybe
anger and aggression.

Management
The best treatment is prevention. People should either not use it or limit it to experimentation. If it is used,
people should be prepared to 'sleep it off' and not drive.

Anabolic steroids
The apparent positive effects of anabolic steroids include gains in muscular strength (in conjunction with diet
and exercise) and quicker healing of muscle injuries. However the adverse effects, which are dependent on
the dose and duration, are numerous.
Adverse effects in women are:
masculinationmale pattern beard growth
suppression of ovarian function
changes in mood and libido
hair loss
In adult men, adverse effects are:
feminisation: enlarged breasts, high-pitched voice
acne
testicular atrophy and azoospermia
libido changes
hair loss
Severe effects with prolonged use include:
liver function abnormalities including hepatoma
tumours of kidneys, prostate
heart disease
In prepubescent children there can be premature epiphyseal closure with short stature.

Drugs in sport
It is important for general practitioners to have a basic understanding of drugs that are banned and those that
are permissible for elite sporting use. The guidelines formulated by the International Olympic Committee (IOC)
Medical Commission are generally adopted by most major sporting organisations. 7 Tables 18.4 and 18.5
provide useful guidelines. The IOC's list of prohibited drugs is regularly revised. Banned classes of drugs
include stimulants, narcotics, anabolic agents, diuretics and various hormones. Banned methods include
blood doping (the administration of blood, red blood cells and related blood products) and pharmaceutical,
chemical and physical manipulation (substances or methods that alter the integrity and validity of the urine
testing).
Restricted drugs include alcohol, marijuana, local anaesthetics, corticosteroids and betablockers.
Practitioners can check the guidelines and provide written notification to the relevant authority.
Table 18.4 Prohibited classes of substances ith e amples International Ol mpic Committee
Medical Commission 1998
Classes

A. Stimulants

E amples

Amiphenazole, amphetamines, caffeine (above 12 g/mL in urine), cocaine,

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ephed ine, me oca b, e b aline,* alme e ol,* alb amol,* p e doephed ine,
phen lp opanolamine
B. Na co ic **

Diamo phine (he oin), me hadone, mo phine, pe hidine, pen a ocine

C. Anabolic agen

Me handienone, nand olone,

D. Di e ic

Ace a olamide, f emide, h d ochlo o hia ide, iam e ene, indapamide,


pi onolac one (and ela ed b ance )

E. Pep ide and


gl cop o ein ho mone
and analog e

G o h ho mone, co ico ophin, cho ionic gonado ophin, e


No e: ma king agen
ch a p obenecid a e banned

ano olol, e o e one, o and olone, DHEA

h opoie in

Classes subject to certain restrictions


A. Alcohol

Re

ic ed in ce ain po

( efe o eg la ion )

B. Ma ij ana

Re

ic ed in ce ain po

( efe o eg la ion )

C. Local anae he ic

Mo agen
injec ion

D. Co ico e oid

Ro e of admini
injec ion

E. Be a-blocke

Re

ible e cep cocaine: o e e

a ion e

ic ed o local o in a-a ic la

ic ed o opical inhala ion, local o in a-a ic la

ic ed in ce ain po

* pe mi ed b inhale onl b
** codeine, de
pe mi ed

pe mi

i h pe mi

ome ho phan, de

op opo

ion
phene, dih d ocodeine, dipheno

la e and pholcodeine a e

Table 18.5 Guidelines for treatment of specific conditions International Ol mpic Committee Medical
Code 1996

A hma

Allo ed Salb amol inhale , alme e ol inhale , e b aline inhale


Banned S mpa homime ic p od c , e.g. ephed ine, p e doephed ine, i op enaline,
be a-2 agoni

Co gh

emic

Allo ed All an ibio ic , eam and men hol inhala ion , co gh mi


e con aining
an ihi amine , pholcodine, de ome ho phan, dih d ocodeine
Banned S mpa homime ic p od c , e.g. ephed ine, phen lp opanolamine

Dia hoea Allo ed Dipheno


Banned P od c
Ha fe e

con aining elec ol e , e.g. Ga

ol e

con aining opioid , e.g. mo phine

Allo ed An ihi amine , na al p a


c omogl ca e p epa a ion
Banned P od c

Pain

la e, lope amide, p od c

con aining a co ico e oid o an ihi amine, odi m

con aining ephed ine, p e doephed ine

Allo ed A pi in, codeine, dih d ocodeine, ib p ofen, pa ace amol, all NSAID
Banned P od c

con aining opioid , e.g. mo phine, o caffeine

Vomi ing Allo ed Dompe idone, me oclop amide

References
1. K me PJ, Cla k ML. Clinical medicine (2nd edn). London: Baillie e Tindall, 1990, 733-740.
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2. Holman CDJ. The quantification of drugcaused morbidit and mortalit in Australia. Canberra:
Commonwealth Department of Communit Services and Health, 1988.
3. Mashford ML (chairman). Cardiovascular drug guidelines (2nd edn). VMPF Therapeutics Committee,
1995/6, 53-58.
4. Murtagh JE. Alcohol abuse in an Australian communit . Aust Fam Ph sician, 1987; 16:20-25.
5. Jagoda J. Drug dependence and narcotic abuse: Clinical consequences. Course Handbook:
Melbourne: Monash Universit of Communit Medicine, 1987, 66-71.
6. Goldman L. Handbook on alcohol and other drug problems for medical practitioners. Canberra:
Australian Government Publishing Service, 1991, 35.
7. International Ol mpic Committee. List of prohibited classes of substances and prohibited methods.
Lausanne; IOC, 1996.

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