• Initiation of cocaine use is most likely to occur during high school, particularly in 12th grade.
• 8.7% of U.S. teenagers have used cocaine at least once.
  
• Cocaine is extremely addictive, both physically and psychologically.
  
• Cocaine is a stimulant that increases levels of dopamine, serotonin, and norepinephrine neurotransmitters in the brain.
• Cocaine initially causes hyperalertness and a sense of euphoria. As the drug effect wanes and neurotransmitters are depleted, there is a rebound dysphoria and depression, leading to more drug craving. The more frequent the cocaine use, the more severe the rebound depression.
• Cocaine is usually inhaled. It can also be smoked, as crack ("freebasing").
• Cocaine is a potent vasoconstrictor (i.e., arteries constrict), leading to decreased blood flow to all organs.
• Decreased blood flow to the heart resulting in myocardial infarction (a heart attack) is the leading cause of death from cocaine use. It can occur with the first use of cocaine, the 10th time, or the nth time.
• One study reports that 25% of heart attacks presenting to emergency rooms may be related to cocaine use.
• Other medical problems associated with cocaine use include heart rhythm disturbances (also a cause of sudden death), high blood pressure, headaches, seizures, strokes, hallucinations and delirium, bronchoconstriction (asthma), damage to lungs, muscle cell death, liver injury, erosion of the nasal septum, fetal demise in pregnancy, kidney failure, and progressive cognitive impairment.
• The source of cocaine is always suspect - cocaine can be laced with other potentially dangerous chemicals or impurities.
• Withdrawal symptoms from chronic cocaine use are mostly due to depressed dopamine levels in the brain. These symptoms can be difficult to treat.

Greene JP, Ahrendt D, Stafford EM. Adolescent Abuse of Other Drugs. Adolescent Medicine Clinics 2006; 17(2):283-318.

INFORMATION ABOUT INFLUENZA

1. Influenza (“Flu”) is a contagious respiratory illness caused by Influenza Type A and Type B viruses. It usually peaks between November and February, and on average affects 5%-20% of the population in the United States each year.
   
   
2. Symptoms of the flu include fever, headaches and body aches, sore throat, nasal congestion, a dry cough, and fatigue. These symptoms often last 5-7 days. The vast majority of flu infections are self-limited, but occasionally medical complications or secondary bacterial infections can arise.
   
   
3. The flu is spread by direct exposure to respiratory droplets from coughing or sneezing, or by direct contact with an infected person or infected surfaces. A person is potentially contagious from one day prior to the development of symptoms  to five to seven days after the illness begins. The typical incubation period for the flu is one to four days.
   
4. The flu vaccine can prevent the flu or lessen its severity. Because of continual viral mutations, a flu vaccine is only effective for a given year. The usual vaccine involves an injection with inactivated flu virus. Because the virus is dead in this vaccine, one cannot develop the flu from the vaccine itself.
   
   
5. People who should get yearly flu vaccines include people aged 65 years or older; individuals with chronic heart, kidney, or lung diseases (e.g., asthma); individuals with a weakened immune system; children between 6 and 24 months; pregnant women; and healthcare providers.
   
   
6. Specific to Phillips Academy, boarding students are strongly encouraged to receive the flu vaccine each year. The flu tends to be quite contagious in enclosed spaces such as dorms, and a potential week of missed classes and school work can be difficult to make up.
   
   
7. Aside from the flu vaccine, the best protection against the flu (and other viruses) is frequent hand washing, particularly before eating. It is also prudent to avoid sharing beverages and eating utensils. Adequate sleep (8-9 hours for adolescents), proper nutrition, regular exercise, and stress management are all important for a healthy immune system to fight off viral infections.
   
   
8. There are medications that can be used to treat the flu, but they must be taken early on in the infection (within one to two days after the start of the illness). Studies have shown that these medications shorten the duration of flu symptoms on average by only one day.

THE AVIAN FLU

1. There has been much coverage in the press recently about the H5N1 avian (bird) flu virus, and its potential to cause a worldwide outbreak of this potentially dangerous strain of flu. Nearly all cases of avian flu in humans have been traced to contact with infected poultry or contaminated surfaces. Reported cases of possible human to human transmission of avian flu are extremely rare, and it has never been observed to spread beyond one person. There is concern in the medical community that the H5N1 avian flu virus might mutate at some point in the future, and allow easy transmission from person to person. There is current work underway to develop a vaccine against the H5N1 virus.
   
   
2. In the event of a developing worldwide outbreak of avian flu, the Isham medical staff would consult with the Centers for Disease Control and Prevention, the Massachusetts Department of Public Health, and/or infectious disease authorities at Boston Children's Hospital for specific guidance. We would also discuss the situation with our peer schools to develop a unified response. It is important to remember that any epidemic (including avian flu) develops over time. There will be ample opportunity to develop an appropriate, thoughtful response specific to the emerging situation.

• The primary psychoactive molecule in marijuana, which is derived from the plant Cannabis sativa, is delta-9-tetrahydrocannabinol (THC). It stimulates dopamine-producing neurons in parts of the brain. Hashish, a more potent form of marijuana, is derived from resins in the leaves or flowers of the plant.
• THC is stored in fat cells, from which it is eliminated very slowly. With even modestly regular use, THC leaks out of fat cells, resulting in a constant presence of THC in the brain.
• Of all adolescents who try marijuana at least once, 10 percent will develop dependence. Of adolescents who try marijuana more than five times, 20 percent become daily users.
• About one third of adolescents who use marijuana daily or nearly daily will develop a true dependence (addiction). The higher potency of today’s marijuana may be leading to higher rates of dependence. Symptoms of withdrawal from marijuana dependence include irritability, anxiety, physical tension, depression and decreased appetite. These symptoms can last up to 7 to 10 days.
• Similar to alcohol, there are genetic factors in marijuana dependence.
• Adolescent marijuana use has been shown to be associated with other risky behaviors and their effects: tobacco use, alcohol use, use of other illicit drugs, teenage pregnancy, sexually transmitted diseases and drunk driving.
• Many studies report an association between psychiatric illnesses and marijuana use, although cause and effect have not been established. Marijuana may precipitate mood problems or schizophrenia in susceptible individuals.
• The “high” of marijuana is accompanied by distortions of time and space, and enhancement of various sensations. Adverse psychological experiences include anxiety, panic reactions, paranoia, depersonalization and depressed mood.
• Marijuana use diminishes lung function and athletic endurance. Like tobacco, it has many carcinogens (molecules that cause cancer). Chronic use can lead to decreased immune function with increased susceptibility to infections, and breast development in males. Acute effects of marijuana use include increased heart rate and blood pressure, dry mouth, inflamed eyes, bronchoconstriction (asthma), and increased appetite.
• Cognitive side-effects of marijuana use include impairments of memory, attention, complex decision making and reaction time. These impairments can persist for a week or more beyond the period of acute intoxication. Regular marijuana use often leads to “amotivational syndrome,” whereby adolescents lose interest in academics and personal pursuits, with loss of goals and ambitions.
• Another concern about marijuana use is that when purchased, it may be laced with other, more dangerous illicit drugs (e.g., Angel dust, or phencyclidine [PCP]) or other harmful chemicals.
• The only conceivable medicinal use of marijuana is to treat the nausea and loss of appetite associated with AIDS or the use of chemotherapy for cancer, when other treatments fail.

1/26/05
Reference
Gruber AJ, Pope HG. Marijuana use among adolescents. The Pediatric Clinics of North America 2002; 49(2): 389-413

• There are 1,000 bicycle-related deaths and 17,000 hospitalizations/year.
  
  
• Head injuries are the biggest cause of bicycle-related deaths.
  
  
• Bicycle injuries account for the largest number of sports injuries treated in emergency rooms.
  
  
• Bicycle helmets reduce the risk of head injury by 85%.
  
  
• Bicyclists admitted to hospitals with head injuries are 20 times more likely to die than those without head injuries. In addition, bicycle-related head injuries can cause permanent brain damage.
  
  
• 98% of bicyclists who are killed were not wearing helmets.
  
  
• Helmet use prevents >75% of cycling deaths.
  
  
• In states that have youth bicycle helmet laws, there has been a dramatic reduction in bicycle-related injuries and deaths.

November 13, 2002

All animals, including PA students, need adequate sleep. Studies have demonstrated that the average adolescent needs 8.5 to 9.5 hours of sleep per night in order to achieve maximal cognitive function the next day. With progressively less sleep, cognitive function also progressively declines, first with simple, repetitive tasks, and then with more complex thought processes. There is much evidence that memory of tasks and skills learned during the day becomes consolidated and permanent during sleep that night.

Besides causing impaired cognitive function, sleep deprivation has significant adverse health consequences. Sleep deprivation leads to the secretion of stress hormones in the body, such as cortisol and epinephrine. The immune system becomes compromised, leading to increased susceptibility to infections. Stress related symptoms can develop, including headaches, back pain, malaise, nausea, diarrhea, abdominal pain, and rashes. Almost all chronic illnesses and medical conditions are aggravated by stress and sleep deprivation, including migraines, ulcers, irritable bowel syndrome, various inflammatory conditions, asthma, diabetes, and heart diseases. Sleep deprivation also makes one more vulnerable to depression, anxiety, and mood changes, as one's coping skills can be significantly impaired. When someone states, "I only need 6 hours of sleep a night," the reality is that he/she has merely grown accustomed to a state of chronic sleep deprivation; the sleep deprivation still has a negative impact on the mind and body.

Caffeine does not compensate for sleep deprivation; it merely temporarily masks it. As the caffeine wears off, there is profound rebound exhaustion. Caffeine acts as a stimulant that promotes the secretion of epinephrine and increases levels of cyclic AMP, which can have adverse effects on many organs. A typical caffeine pill has the same amount of caffeine as two to four cups of coffee. Side effects, which worsen with increasing doses, include nervousness, anxiety, restlessness, stomach cramps, a racing heart, chest pain, elevated blood pressure, headache, agitation, dangerous heart rhythm disturbances and seizures. Caffeine is quite addictive - one builds a tolerance to its stimulatory effects, and withdrawal symptoms can be rather unpleasant.

Some may say it can be a little difficult getting 8-9 hours of sleep every night as a PA student.

If you do need to stay up late one night, it is important to try to get a full night's sleep the next night. Consecutive nights of sleep deprivation are far worse than sporadic ones. Some other tips for good sleep: avoid all caffeinated beverages and heavy exercise 3-4 hours before bedtime, and avoid waking up very late on Sunday because it will throw off your sleep cycle for the start of the week.

Pleasant dreams.

- Dr. Richard Keller

- Binge drinking is the consumption of large amounts (5 or more drinks) of alcohol in a short period of time (20-60 minutes).

- Alcohol is a poison to the body, especially to the central nervous system. As blood alcohol levels rise, the cerebral cortex and cerebellum become impaired, leading to loss of inhibitions, problems with speech and poor coordination. As levels rise into the lethal range, the brain stem, which controls swallowing, breathing and heart rate, becomes impaired.

- Death from an alcohol overdose usually results from a cardiopulmonary arrest. Aspiration of stomach contents into the lungs, a fall in blood sugar, or a fall in body temperature can also lead to death.

- The danger of binge drinking is that blood alcohol levels rise very quickly as the alcohol is absorbed from the stomach. With non-binge drinking over a longer period of time, alcohol levels rise more slowly, and the drinker will experience symptoms that will usually discourage him/her from drinking further amounts which could be life threatening. The drinker may start to vomit, he/she may fall asleep or pass out, or his/her friends may notice how intoxicated he/she is becoming, and they will prevent further drinking. With binge drinking, there are no warning signs that a lethal dose may have been consumed.

- Non-binge drinking has its own dangers associated with the loss of social inhibitions, including unwanted sexual advances, date rape, and other risky or violent behavior. Most deaths from acute alcohol use are a result of drunk driving.

- How rapidly your blood alcohol level rises with drinking depends on several factors. Heavier body weights, previous chronic usage of alcohol with stimulation of hepatic enzymes, and food intake are all associated with lower rates of rise in blood levels.

- Blood alcohol levels:

0.08 (80 mg/dl) - legal definition of intoxication
0.2 (200 mg/dl) - severely intoxicated
0.3 (300 mg/dl) - risk of serious adverse effects or death
0.4 - 0.5 (400-500 mg/dl) - lethal level for most people

- Average lethal doses of binge alcohol (1 drink = 1 oz hard liquor = 3-4 oz. wine = 12 oz. beer):

100 lb. Person - 8 to 12 drinks

150 lb. Person - 12 to 16 drinks

I urge all students not to drink at your age. Please remember to seek medical help through the sanctuary policy if you or your friends are in any danger from alcohol or illicit drugs. If any of you has any specific concerns or questions, please see me in Isham for a confidential conversation. - Dr. Richard Keller

Over the last few weeks, as we have entered the cold and flu season, many people have asked us about the difference between viral and bacterial respiratory infections. The vast majority (more than 95 percent) of upper respiratory infections (URIs, or typically the common cold) are caused by a wide range of viruses. They are not airborne, but are spread through contaminated surfaces or by aerosolized droplets. Typically, these infections begin with a sore throat, progress to nasal and sinus congestion and end with a phase of coughing, which may last for days to weeks. Fevers, headaches, fatigue and malaise are other symptoms that may occur. These infections are almost always self-limited. Antibiotics, which only treat bacterial infections, will do nothing for colds. In fact, the indiscriminate use of antibiotics for viral infections—prescribed by physicians often under pressure from their patients—is largely responsible for the worldwide crisis in the emergence of antibiotic-resistant strains of bacteria.

Rarely, bacteria can be the cause of URIs. Bacterial infections can be the result of direct infection, as in the case of streptococcal pharyngitis ("strep throat"). More commonly, they are the result of a secondary infection developing during the course of the initial viral infection. Basically, the virus sets up an area of inflammation, which can become a fertile environment for bacteria to later seed and grow. Thus, fluid in a middle ear can become infected and turn into otitis media, or an ear infection. Secretions in one's sinuses can become infected and turn into sinusitis. Bacteria can also seed the large airways or small airways in the lungs, resulting in bronchitis or pneumonia, respectively. All of these bacterial infections usual don't take root and cause symptoms until late in the course of a cold virus, often a week or more after the cold starts. Typically, patients will notice their viral symptoms improving, then suddenly worsen. Alternatively, the viral-type symptoms may linger on without improvement. In either case, the patient should be reassessed by a clinician to determine if a bacterial infection has taken over where the virus left off.

Parents often ask, why not take an antibiotic early in the course of a viral cold to prevent these bacterial complications? There are many reasons why people who have healthy immune systems shouldn't. The vast majority of these infections remain self-limited viral infections. As mentioned, the overuse of antibiotics leads to the development of drug-resistant strains of bacteria—there are now some bacteria for which there is no effective treatment! Furthermore, in normal people, the early use of antibiotics will not prevent secondary bacterial infections; if anything, one will be selecting for more unusual, antibiotic-resistant strains of bacteria to begin an infection, which can be much more difficult to treat.

So, how does one stay healthy in the winter? Besides heading off to Florida, wash your hands frequently, especially prior to eating. Get adequate sleep. Eat properly. Manage your stress, as excessive stress can weaken your immune system. Unfortunately, there is NO scientific evidence that Vitamin C, zinc, garlic, antioxidants or herbal concoctions will do anything to prevent or ameliorate the cold.

It's 1 a.m., and you still have three hours of homework left. Think twice before using those caffeine pills purchased downtown.

Caffeine is a stimulant that promotes the secretion of adrenaline and increases levels of cyclic AMP, which can have adverse effects on many organs. A typical caffeine pill has the same amount of caffeine as two to four cups of coffee. Side effects, which worsen with increasing doses, include nervousness, anxiety, restlessness, stomach cramps, a racing heart, chest pain, elevated blood pressure, headache, agitation, dangerous heart rhythm disturbances and seizures. Instead of cheating yourself of a few hours of sleep in order to work, you may end up spending many more hours in an emergency room.

Ritalin, Dexedrine and Adderall are potent stimulants used specifically to treat attention deficit disorder. Possible side effects are similar to overdoses of caffeine. These drugs can be very dangerous if not taken as prescribed or if they are mixed with certain prescription or non-prescription drugs, alcohol or illicit drugs. The likely disciplinary response to the sale or distribution of these medications is dismissal for both parties involved. The United States Drug Enforcement Administration, which controls the distribution of all prescription medications, labels Ritalin and similar drugs as Class II medications, which means it's a felony to illegally acquire or dispense them.

Please consider better time management skills instead of stimulants. The body you help may be your own. If you have any questions about these or other drugs, feel free to see Dr. Keller or one of the nurses at Isham for a confidential conversation.