Bangkok Hypnosis

Cocaine Abuse

Posted by Sun on August 1, 2011

Cocaine Abuse Overview

Cocaine is presently the most abused major stimulant in America. It has recently become the drug most frequently involved in emergency department visits. It is not a new drug of abuse but is now considered the caviar of recreational drugs. Thus, this distinction is reflected in its description-champagne of drugs, gold dust, Cadillac of drugs, status stimulant, yuppie drug, and others. Street names for cocaine also reflect its appearance or method of use (such as flake, snow, toot, blow, nose candy, her, she, lady flake, liquid lady [a mixture of cocaine and alcohol], speedball [cocaine and heroin], crack, rock). And it can also express its method of preparation, such as freebase. It is more popularly known simply as coke.

A common myth is that cocaine is not addictive because it lacks the physicalwithdrawal symptoms seen in alcohol or heroin addiction. Cocaine has powerful psychological addictive properties. As more than one user has reflected, “If it is not addictive, then why can’t I stop?” The trend in drug abuse in the United States is presently multiple or polydrug abuse, and cocaine is no exception. Cocaine is often used with alcohol, sedatives such as Valium, Ativan, or heroin, as an upper/downer combination. The other drug is also used to moderate the side effects of the primary addiction. A common polydrug abuse problem, seen especially in adolescents, is cocaine, alcohol, and marijuana.

Drug abuse, chemical dependency, and addictive behavior spare no one and are spread throughout society. They do not respect age, profession, race, religion, or physical attributes.

  • History: Cocaine is a naturally occurring alkaloid usually extracted from the leaves of the coca shrub, which was originally found in the Andes Mountains of Peru and Bolivia. With its appreciation as a lucrative cash crop, it is now cultivated in Colombia, Argentina, Brazil, Mexico, the West Indies, Ecuador, and Java. Coca leaves were mixed with lime and chewed by the Peruvian Indians as early as the sixth century to allay the effects of cold, hunger, and fatigue. It is still used as such as a gift from the Sun God. In this sense, coca is an important sociocultural tradition for Peruvian and Bolivian Indians and should not to be confused with the cocaine snorting, smoking, and injecting of the Western abuser. Coca was later introduced to Europe, where the alkaloid cocaine was isolated. Its medicinal effects on depression, alcohol andmorphine addiction, fatigue, and as a local anesthetic were discovered. However, these discoveries were not without cost to those who experimented with it. The result was addiction and dependency on the drug.
  • A brain tonic: In 1886, an elixir containing cocaine from the coca leaf andcaffeine from the African kola nut was marketed in Atlanta. It was sold as a brain tonic recommended for headaches, alcoholism, morphine addiction,abdominal pain, and menstrual cramps. This elixir, appropriately named Coca-Cola, rapidly became one of the most popular elixirs in the country. But because of the adverse effects of cocaine, appreciated even then, the Coca-Cola Company agreed to use decocainized coca leaves in 1903. Cocaine came under strict control in the United States in 1914 with the Harrison Narcotic Act. It is listed as a narcotic and dangerous. Though its use is dangerous, it is not a narcotic, but its use is subject to the same penalties as those for opium, morphine, and heroin.
  • Limited medical use: Cocaine has little medical use. Because of its anesthetic effect, it was used for eye surgery. But because of its profound ability to vasoconstrict blood vessels (that is, make veins and arteries narrow, thus stopping bleeding), it can lead to scarring and delayed healing of the cornea. It is still available for use in the nose for surgery, stopping nosebleeds, and as a local anesthetic for cuts in children.
  • Street use: The cocaine destined for street use in the United States is generally isolated and converted to cocaine hydrochloride in South American labs. This cocaine salt, which can be as pure as 95%, is then smuggled into the country. As it passes through many hands from the importer to the user, it is usually diluted (“cut” or “stepped on”) at each stage of distribution to increase each dealer’s profit. The final product can be from 1% to 95% pure. Common additives are sugars, such as mannitol, lactose, or glucose, or even sugar substitutes, and local anesthetics such as tetracaine, procaine, and lidocaine. Quinine, talc, and cornstarch have also been used. Other illicit drugs, such as heroin, codeine, amphetamine, phencyclidine (PCP), LSD, and hashish, can be mixed in as well. Some consumers may unknowingly purchase a supply without any cocaine, but just a cocaine substitute such as caffeine, amphetamine, PCP, procaine, and lidocaine.
    • Population surveys released by the National Institute on Drug Abuseindicate that most cocaine users are older, inner-city crack addicts.
    • However, field reports are identifying new groups of users: teenagers smoking crack with marijuana in some cities, Hispanic crack users in Texas, middle-class suburban users of cocaine hydrochloride, and female crack users in their 30s with no prior drug use history.
  • Methods of abuse: Coke in this hydrochloride salt form may be injected; swallowed; applied to oral, vaginal, or even rectal mucous membranes; or mixed with liquor. Coke is most commonly used by snorting or sniffing.
    • With snorting, the usual ritual is to place a line of coke, about 0.3 cm wide by 2.5 cm long, on a smooth surface. The finely divided powder is then snorted (inhaled quickly) into a nostril through a plastic or glass straw or a rolled currency bill. This ritual is usually repeated within a few minutes using the other nostril.Special spoons and other paraphernalia are available for snorting cocaine.
    • Cocaine is generally not taken by mouth for recreational purposes. Toxic reactions, including death, have occurred in people who swallow the drug to avoid police detection or border authorities. This smuggling attempt is known as body packing. This crystalline white powder can be dissolved in water and used intravenously (“slammed”). In this form, it has a high melting point, so it cannot be smoked and is the most widely used form of the drug.
    • Freebasing involves the conversion of cocaine hydrochloride into cocaine sulfate that is “free” of the additives and nearly 100% pure. It is not water soluble and has a low melting point, so it can be smoked. The freebaser runs the risk of being burned by the conversion process because a highly volatile solvent, such as ether, is being used.
    • Crack is extracted from coke using baking soda and heat-a relatively safe method compared with the ether technique. The waxy base becomes rocks of cocaine, ready to be sold in vials. This rock cocaine is also easy to smoke, the most common form of use in the streets. Cocaine sulfate is also available as coca paste known as basuco, bazooka, piticin, pistol, pitillos, or tocos and is widely smoked in South America. Because the freebase is resistant to destruction by heat, it can be smoked either in cigarettes, including marijuana cigarettes, or in “coke pipes.” Smoking the freebase produces a more powerful effect more rapidly, but it is also more dangerous because the safe dose can easily be exceeded. A user describes the comparison: “Snorting coke is like driving 50 miles per hour. Smoking crack is like driving 150 miles per hour without brakes!”
  • Why cocaine becomes addictive: Research with cocaine has shown that all laboratory animals can become compulsive cocaine users. Animals will work more persistently at pressing a bar for cocaine than for any drug, including opiates. An addicted monkey pressed the bar 12,800 times until it got a single dose of cocaine. If the animal survives, it will return to the task of obtaining more cocaine.
    • The human response is similar to that of the laboratory animal. The cocaine-dependent human prefers it to all other activities and will use the drug until the user or the supply is exhausted. These persons will exhibit behavior entirely different from their previous lifestyle.
    • Cocaine-driven humans will compel themselves to perform unusual acts compared with theirformer standards of conduct. For example, a cocaine user may sell her child to obtain more cocaine. There are many stories of professionals, such as lawyers, physicians, bankers, and athletes, with daily habitscosting hundreds to thousands of dollars, with binges in the $20,000-$50,000 range. The result may be loss of job and profession, loss of family, bankruptcy, and death.
  • Lethal dose: Although this drug has been in use for more than 5000 years, the toxic dose or the amount of cocaine that will cause death or some significant medical consequence is unknown. The average lethal dose by the IV route or by inhalation is about 750-800 mg. This is subject to significant individual variation because deaths have occurred in doctors’ offices with as little as 25 mg applied to the mucous membrane or the snorting of a single line in recreational use where the average dose of 1 line is 20 mg.
  • Effects: The method of use dictates the onset of activity and duration of its effects. If snorted, the effects will peak within 30 minutes with its duration of effect lasting 1-3 hours. If swallowed with alcohol, effects peak in 30 minutes and last about 3 hours. If used intravenously or inhaled/smoked, the effects peak in seconds to 2 minutes but last only 15-30 minutes. The breakdown products of the drug will be excreted and can be detected in the urine for 24-72 hours. For chronic users, it can be detected for up to 2 weeks.

Cocaine Abuse Causes

Addictive disease is believed to be caused by genetic background and environment. Those from high-risk family environments are particularly susceptible to the development of addictive disease, and they need to know this in their pre-adolescent period. However, the presence of an addict in the family does not mean that a person will become an addict.

  • Researchers supported by the National Institute on Drug Abuse have identified a process in the brain that may help explain addiction to cocaine and other drugs of abuse. Their research indicates that repeated exposure to cocaine causes a change in genes that leads to altered levels of a specific brain protein. This protein regulates the action of a normally occurring brain chemical called dopamine. It is a chemical messenger in the brain associated with the cocaine’s pleasurable “rush”-the mechanism of addiction. Certainly, more research is needed to unlock the mysteries of addiction, but this information adds one more link in explaining how the brain adapts in the addiction process.

Cocaine Abuse Symptoms

The effects of cocaine can be divided into what goes on in the central nervous system, in the brain, and in the rest of the body. The effects of the drug vary greatly, depending on the route of administration, amount, purity, and effects of the added ingredients. The effect also varies with the user’s emotional state while taking the drug. This is based on the user’s attitude toward the drug, the physical setting in which the drug is being used, his or her physical condition, and whether or not the person is a regular user. Because cocaine affects every organ system, from the brain to the skin, the following discussion will cover signs (what doctors find by physical examination) and symptoms (what you feel) for major organ systems.

  • Central nervous system and psychiatric effects: Users who have pleasurable experiences report varying degrees of euphoria; increased energy, excitement, and sociability; less hunger and fatigue; a marked feeling of increased physical and mental strength; and decreased sensation of pain. Some will feel a great sense of power and competence that may be associated with the delusion or false sense of grandeur, known as cocainomania. There can be talkativeness, good humor, and laughing. Dilated pupils, nausea, vomiting, headache, or vertigo (the sensation of your surroundings or yourself moving or spinning). With or even without increased amounts of coke, these can progress to excitement, flightiness, emotional instability, restlessness, irritability, apprehension, inability to sit still, teeth grinding, cold sweats, tremors, twitching of small muscles (especially of face, fingers, feet), muscle jerks, hallucinations (cocaine bugs, snow lights, voices and sounds, smells), and cocainepsychosis. Cocaine psychosis resembles paranoid schizophrenia and can bring on paranoia, mania, and psychosis.

Major effects that usually cause a cocaine abuser to go to an emergency department are severe headache, seizures, loss of consciousness that can be caused by not breathing or bleeding in the brain, stroke, hyperthermia(increased body temperature), coma, loss of vital support functions (such aslow blood pressure, slow heart rate, slow respirations, and death).

  • Brain effects: The use of cocaine causes the alteration of responsiveness of the brain to various chemicals. These chemicals or neurotransmitters, such asnorepinephrine, dopamine, serotonin, acetylcholine, and gamma-aminobutyric acid, are responsible for most of the complications of cocaine. Infants of cocaine-smoking parents have been brought to an emergency department because of seizures induced by secondhand cocaine smoking. One study of people who sought care in an emergency department reported that 22% complained of anxiety, 13% dizziness, 10% headache, 9% nausea, 9% psychosis, and 9% confusion.
  • Ear, nose, and throat effects: Because the majority of users sniff or snort cocaine through their nose, there are a variety of nasal and sinus diseases. Many users complain of nasal irritation, nasal crusting, recurrent nosebleeds, nasal stuffiness, facial pain caused by sinusitis, and hoarseness.
    • The mucous membrane of both sides of the septum (the cartilage that separates the nostrils) can be damaged by decreased blood supply, along with drying, crusting, and nose picking. This results in a perforation or hole in the septum with more crusting, foul secretions, nosebleeds, and whistling with nasal breathing, the so-called coke nose.
    • Because nasal obstruction is a common complaint, many users self-treat with over-the-counter nasal decongestants, such as Afrin, which adds to the problem because it also closes or narrows the blood vessels. Many users have also realized that this easily recognized and accepted form of self-medication with a nasal spray is a way to administer cocaine in public. After all, who is going to check that it is not a common nasal spray in the dispenser?
  • Lung effects: The direct effects of smoking cocaine are responsible for most lung and breathing complications. The large surface area of the lungs and its great blood supply cause rapid and profound brain stimulation known as the head rush.
    • Smoking the freebase, crack, or paste is done using a glass pipe, waterpipes, or cigarettes, which are heated by butane lighters or matches. The residue from the tars, matches, cocaine contaminants, and additives, such as marijuana, often cause chronic bronchitis, chronic coughing, and coughing up black, nonbloody phlegm. These conditions can cause shortness of breath and chest pain.
    • Utilizing the technique of deep inhalation and breath holding to maximize the amount of cocaine inhaled and absorbed can cause the lung to collapse. These cocaine users will complain of sharp chest pain, often worse with deep breathing, neck pain, difficult or painful swallowing, and air under the skin in the neck that feels like Rice Krispies under the skin when touched (subcutaneous emphysema). Though unusual, the user’s lungs can fill with fluid (pulmonary edema) causing extreme shortness of breath, sometimes respiratory failure, and death.
    • In one study of the cocaine abusers who came to an emergency department, 40% complained of chest pain-the most common complaint-and 22% complained of shortness of breath or were unable to breathe.
  • Cardiovascular (heart, blood vessels): The major effect of cocaine is to stimulate the sympathetic nervous system. This system is responsible for the “fight or flight response” and is controlled primarily by adrenaline orepinephrine. The effects include increased heart rate, blood vessel narrowing, and high blood pressure. Angina or the chest pain that is felt with decreased blood supply to the heart and heart attack have accounted for more reports in medical journals than any other complication of cocaine intoxication. Chest pain associated with cocaine use is now a common problem in urban emergency departments.
    • Other cardiovascular complications include abnormal heart rhythms or rapid heart rate, cardiomyopathy or disease of the heart muscle, or aortic rupture or dissection where there is weakening of the walls of the aorta. The acute use, despite the amount or route, causes narrowing of the arteries to the heart and vasospasm resulting in decreased blood flow to the heart. This causes angina, which can lead to a heart attack that means death of heart tissue. Chronic use of cocaine, again regardless of the route, leads to accelerated hardening and subsequent narrowing of the coronary arteries. Therefore, angina and heart attacks and cardiac deaths have been found in young users from ages 19-44 years.
    • The overstimulation of the sympathetic system with the rapid heart rate, high blood pressure, and vasospasm also cause the abnormal rhythms. Those rhythms may be ventricular tachycardia and ventricular fibrillationand may cause sudden death. Chest pain has been the most common complaint to the emergency department, up to 40% of people, 21% complain of palpitations or the sensation that their hearts are racing or going fast.
  • Pregnancy effects: Cocaine use during pregnancy can increase the complications of pregnancy and affect the fetus directly. These abusers may also use other drugs, alcohol, and nicotine, which adversely affect the pregnancy. They have an increased rate of miscarriages, placenta abruption in which the placenta separates from the wall of the uterus and results instillbirth. There is increasing information that cocaine may cause birth defects with increased rates of malformation, low birth weights, and behavioral abnormalities.
  • Infections: The infectious complications related to IV use of cocaine are not unique to cocaine. All IV drug users are at risk for infections such as cellulitis(soft tissue infection at the injection site), abscesses at the injection sites,tetanus or lockjaw, lung or brain abscesses, or infection of the heart valves. These are due to nonsterile techniques of IV injections. Contagious viruses such as hepatitis B, hepatitis C, and HIV (AIDS virus) are transmitted by sharing IV needles. The abuser may complain of pain and swelling and redness at the injection site or fever. Abusers may also complain of jaundiceor turning yellow, abdominal pain, nausea, vomiting, loss of appetite, or the multitude of complaints that accompany hepatitis and AIDS.
  • Body packers or stuffers: People smuggle the processed cocaine across international borders. They often swallow drug-filled packets or stuff them into body openings such as the vagina or rectum. The “body packer” or “mule” can carry 50 to 200 tightly wrapped condoms or latex bags filled with high-grade cocaine hydrochloride. If the containers break or leak, the cocaine can be absorbed by the person’s body. Most mules have no symptoms and may be apprehended by an astute official who notices some suspicious behavior. Some will become acutely ill when the packets leak or rupture resulting in massive intoxication, seizures, and death. A similar problem may occur with “body stuffers.” These are cocaine users or traffickers who swallow bags of cocaine when arrested so there is no evidence.

When to Seek Medical Care

If you have a psychiatrist who knows of your drug use, and if your symptoms are psychiatric in nature (such as mania, paranoia, violence,suicidal, major depression, homicidal, or hallucinations), call or have someone call your doctor.

  • Call your doctor if the following conditions develop:
    • If you have foul, itchy, or bloody discharge, or facial pain that seems like sinusitis
    • If your chronic cough is associated with a mild fever, more phlegm production, or foul phlegm
    • If you are pregnant and have premature labor pain, vaginal bleeding, or ankle swelling with high blood pressure.
    • If you notice redness with mild swelling and mild pain at an injection site

Severe headache, generalized seizures, loss of consciousness, signs of a stroke (loss of vision, seeing double, inability to speak or slurred speech, weakness of extremities), or coma are all symptoms that demand emergency care. Call 911 for an ambulance as opposed to bringing someone by car to a hospital emergency department.

Someone with severe depression, violent behavior, paranoia, suicidal, or homicidal behavior should certainly be brought to the hospital, especially if a psychiatrist is easily reached. Police may be needed to subdue the violent, paranoid, suicidal, or homicidal person.

  • Go to an emergency department if the following conditions develop:
    • A brisk nosebleed that cannot be stopped by direct pressure for 10 minutes
    • Facial pain or headache with a fever
    • Severe chest pain, difficulty breathing, shortness of breath, or foul or bloody phlegm with fever
    • High blood pressure, especially with symptoms of headache, chest pain, or shortness of breath
    • Chest pain, usually described as pressure or squeezing in nature, which may be accompanied by difficulty breathing, nausea, vomiting, and sweatiness
    • Vaginal bleeding, premature labor pains, and suspicion of miscarriage
    • Significant swelling, pain, redness, red lines leading from the injection site, and accompanied by fever
    • Severe abdominal pain, persistent vomiting, vomiting blood
    • If you think that one of your packets you have swallowed or stuffed in a body orifice (vagina, rectum) is leaking or has broken

Exams and Tests

Often, the final diagnosis of someone who is abusing cocaine is not made by emergency department evaluation and may require admission to the hospital, further testing, and results of tests, which take time or are not done in a hospital emergency department.

Overall, the doctor will conduct whatever tests are necessary to evaluate the symptoms of someone with cocaine-induced conditions. In addition to a physical exam and medical history, tests may include blood and urine analysis, chest x-ray, CT scans, MRI scans, and spinal tap.

  • Cocaine-induced headache diagnosescan include such conditions as tension headache, stroke (bleed in head), sinusitis,meningitis, or brain abscess.
  • Cocaine-induced seizures might indicate more serious problems such as bleeding in the brain, meningitis, very high blood pressure with organ injury, or low blood pressure, respiratory failure, and heart problems. Infants may experience seizures caused by parents’ smoking cocaine in their presence. It is important to note that this is a form of child abuse.
  • Psychiatric problems caused by cocaine abuse may include cocainomania, anxiety, hallucinations, paranoia, psychoses, violence, major depression, suicidal or homicidal tendencies, or attempted suicide.
  • Nasal and throat complications of cocaine abuse will include diagnoses of nasal itching, post-nasal drip, nosebleed, sinusitis, laryngitis, and perforatednasal septum.
  • Pulmonary diagnoses may include pneumonia, bronchitis, COPD (chronic obstructive pulmonary disease or emphysema), asthma or reactive airway disease, or a collapsed lung.
  • Cardiovascular diagnoses include heart problems such as chest pain, heart attack, abnormal heart rhythms, and various heart conditions that can lead to sudden death.
  • Pregnancy diagnoses may include vaginal bleeding, threatened abortion, incomplete abortion, or spontaneous abortion, or miscarriage. Ultrasound may be used in this diagnosis.
  • Infectious diagnoses may include cellulitis, shooter’s abscess, lung abscess, brain abscess, septic shock, hepatitis, and any of the opportunistic infections associated with AIDS if you are HIV infected.
  • Body packers and stuffers may have various diagnoses depending on whether the packets leak or remain intact. If they leak, the diagnoses may be massive cocaine intoxication with seizures, high temperatures, hypertension, muscle breakdown, kidney failure, and death. If the abuser has no symptoms with normal vital signs and refuses medical care, invasive procedures may not be done until proper legal documentation has been provided.

Cocaine Abuse Treatment

Self-Care at Home

First and foremost, the cocaine abuser must stop using the drug and other drugs that accompany its use. Not many complications of cocaine use can be treated at home. The most common complications are psychiatric in nature.

  • Anxiety, mild agitation, loss of appetite,insomnia, irritability, mild panic attacks, mild depression, and mild headaches could probably be treated at home by stopping the use of the drug and observing the user.
  • Runny noses, nasal congestion, and brief nosebleeds can be also be cared for at home by stopping the drug, increasing the humidity of the air breathed in with vaporizers and humidifiers, and direct nasal pressure for 10 minutes to stop the nosebleed. Apply topical antibiotic such asbacitracin or petroleum jelly to help with the drying and crusting. Avoiding nose picking.
  • The chronic cough or coughing up of black, nonbloody phlegm can be treated again by cessation of cocaine smoking and other drugs such as nicotine or marijuana. Over-the-counter cough medicines containing the ingredientguaifenesin, the active compound in Robitussin, plus increased water drinking may help.
  • IV drug users who do not stop using cocaine may lower their exposure to communicable diseases and infection by not reusing or sharing needles. Cleansing the skin properly prior to the injection also decreases risk of infection.

Medical Treatment

Emergency treatment includes emergency procedures to get the person breathing and stable. These measures will take time-sometimes longer than waiting family and friends expect. The initial contact in a hospital emergency department may be the police, the receptionist/secretary, the social worker, or a nurse. If you accompany a person to the emergency department, give these medical staff as much information as possible that will help in the medical care of the drug user because he or she may not be capable of giving any history at all.

  • After the person is stabilized, the doctor can take a medical history, perform a more detailed physical exam, and begin diagnostic testing.
  • Despite the best of medical efforts, certain medical complications of cocaine use can lead to sudden death. The person may never regain consciousness and die in the emergency department or the intensive care unit from these complications: high body temperature, massive bleeding into the brain usually due to high blood pressure, heart attack, or seizures.
  • The great majority of people who come to the emergency department are alive, awake, and have normal vital signs or vital signs that rapidly become normal. They will usually be sent home in relatively good health after their immediate medical and physical conditions are treated.
    • Certain medical conditions will require hospitalization and referral to specialists. Chest pain is a common problem, and people with this condition will be referred to heart specialists. Other less life-threatening conditions may require antibiotics, IV medications, or prescription medications. Abscesses are often drained in the emergency department.
    • Complications with pregnancy will be monitored and referred to specialists.
    • People with mental conditions will be referred to psychiatrists and drug abuse counselors for follow-up counseling after initial health issues are resolved.
  • The treatment of body packers and body stuffers is rapid removal of the packets before they leak. If access is relatively easy, such as in the vagina and rectum, the packets are carefully removed manually. If the packets are swallowed and the person has no symptoms and the vital signs are normal, whole bowel irrigation may be done. A tube is placed into the stomach, then a nonabsorbable fluid (typically polyethylene glycol) is put in continuously until the packets are recovered or the fluid from the rectum is clear. Activated charcoal may also be used initially to adsorb any drug that may leak during the process. If the person has any symptoms or shows signs the drug is leaking into the body, treatment is immediate removal by surgery plus control of the blood pressure, heart rate, temperature, and seizures. Retrieval of the packets using a fiberoptic scope (endoscopy) is not recommended.

Next Steps


Follow-up should be as planned in the emergency department or as discussed when discharged from the hospital. Because any addiction involves the entire family, the treatment plan should include family. It may consist of follow-ups with a drug counselor, psychiatrist, family doctor, internist, infectious disease specialist, obstetrician, general surgeon, or heart surgeon.


Prevention should start early in the preadolescent years for those who are at risk. This would include children in families with a history of any addiction such as alcoholism and drug use. However simplistic the concept, teaching youngsters to say “no” to smoking, alcohol, and drugs is an excellent prevention tool. If we can keep the children and our future generations from the gateway drugs of nicotine, alcohol, and marijuana, then we may be able to prevent the escalation to harder drugs such as cocaine.


The prognosis for minor complications of cocaine use is good if further drug use can be stopped completely. This will be a significant challenge to the addicted person and may require professional and support group interaction. The majority of the cocaine abusers who come to the hospital for medical care will usually do well and are often sent home. They may be seen or referred to chemical dependency counselors for follow-up as outpatients.


I am medical doctor and hypnotherapist with more than 17 years experience. Feel free to send me email ( to discuss your situation.

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