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CE Course 3
Do You Know if Your Patients, Co-workers, Friends, Family, or You Have an Addiction?
Credit: Continuing Education Hours: 2
If you have specific questions about the CE requirements in your state, or if you're not sure if the course will be accepted, please consult your state dental board.
After reading this CE course, click this link to pay and take the test. Pay and take the CE test.
Table of Contents
- Course Goals
- Learning Outcomes
- Abstract
- Introduction
- Background
- Terminology
- Physiologic Effects
- Signs of Substance Abuse
- Oral Effects
- Techiques for Acquiring Drugs
- Screening for Addiction
- Conclusion
- Self Assessment Questions
- Resources
- About the Author
- Supplemental Activities
- Additional Readings
- Definition of Terms
- References
Course Goals
The purpose of this course is to increase dental hygienists' knowledge of substance abuse and to articulate their role and responsibilities in the identification and treatment of individuals who are chemically dependent.
Learning Outcomes
Upon completion of this continuing education course, the learner will be able to:
- Explain evolving attitudes towards chemical dependency
- Identify three causes and three ways to prevent substance abuse
- Describe the types and effects of abused substances
- Identify intraoral and extraoral manifestations of substance abuse
- Explain the dental hygienist's role in managing clients who are substance abusers
Assessment Method: Post-test only
Substance abuse (chemical dependence) is often a silent, but pervasive problem in today's society. Chemically dependent people come from all components of society, regardless of financial status, ethnicity, or age. They are masters at disguising their addictions.
A variety of chemicals, including over-the-counter, prescription, and street drugs are used and abused. Dopamine, a neurotransmitter in the brain, appears to be the major determinant in whether or not a person progresses from casual substance use to substance abuse. This course will discuss commonly abused types of substances, signs of substance use (psychological, physiological, oral manifestations), and the role of dopamine in the addiction process. An outline of successful interventions and preventive strategies will be included. Because health care professionals should be aware of the many aspects of substance abuse, this course is designed to increase understanding of the clinical and social aspects of the problem. It will provide information to help a patient, co-worker, or family member manage this debilitating and complicated problem.
"Although substance abuse is a major concern throughout the world, this course will only include the use and abuse of drugs in the United States.
Attitudes of people in the United States towards drug abuse changed rapidly in the beginning of the 19th century when patented medicines containing morphine and opium were often used to treat coughs, diarrhea, dysentery, and "women's pains." These opiates were the most effective methods available to physicians to relieve the pain of virtually any ailment.1
Opiates were rarely used as recreational drugs until the Civil War, when soldiers were treated with injected morphine and experienced the same euphoric effects as dancing, smoking, and gambling. People were viewed not as drug abusers but "spiritually weak."2
By the end of the 19th century, it became easier to isolate and produce morphine, cocaine, and opium. Since there were no legislative controls over these drugs, they were readily available from pharmacists and physicians and were heavily promoted by pharmaceutical firms.3
Parke-Davis offered coca and cocaine in forms that could be smoked, sniffed and injected, and Coca-Cola even created a soft drink with it. Despite questions about cocaine's safety, most medical experts considered it a harmless stimulant. Therefore, its use spread quickly across the United States and stories of overdoses, addictions, reactions, and the antisocial behavior of users began to rise. At the same time, another opioid, morphine, was made a prescription drug, and its use declined, due largely in part to the public's awareness and apprehension about addiction and the casual-use of habit forming drugs.4
The federal government passed laws early in the 20th century to control substance abuse. The Harrison Narcotic Act of 1914 limited the sale of opium, morphine, heroin, cocaine, and other drugs to small quantities, except when prescribed by a physician. Thereafter, abuse of opiates declined, except among people of middle to higher classes.4
The popularity of cocaine also dropped, except for among Hollywood celebrities and those involved in the criminal world. In the 1920s and 1930s, marijuana was brought to the United States by Mexican immigrant workers, and its use spread to jazz musicians.4
The picture began to change following World War II. New medications, such as tranquilizers and other mind-altering prescription drugs, became the substances of choice--especially since they were used for relieving anxiety and depression. At the same time, organized crime began smuggling narcotics into the United States on a larger scale.4
Between the 1960s and 1970s, drug addiction was being discussed as a symptom of psychological problems, requiring hospitalization for treatment. Marijuana was "rediscovered" by teenagers and was widely use\ by this age group and continued through the '90s. Hallucinogenic drugs, termed the "psychedelic" or "conscious-expanding" drugs such as lysergic acid diethlamide (LSD) and mescaline also became popular, as did designer drugs such as methylene dioxymethamphetamine (MDMA--an appetite suppressant), and phencyclidine (PCP--an anesthetic). Heroin, barbiturates, amphetamines, and cocaine became readily available to athletes and the wealthy.4
The 1980s and 1990s brought extensive use of crack cocaine and a subsequent increase in crime and violence. The term designer drugs was first used to describe synthetic or laboratory-produced derivatives of prescription drugs controlled by the U.S. Food and Drug Administration (FDA). Until late in 1986, as long as such drugs were not identical to controlled drugs, their producers could not be prosecuted or fined for making them. "Designer drug" also refers to a known, abused drug that has been repackaged or redesigned for easier use or increased appeal to consumers. Crack cocaine is such an example.
In addition to these newer drugs, alcohol abuse continues to be a major health risk in the United States. A recent report to the U.S. Congress estimates that 18 million adults 18 years and older are currently having problems resulting from alcohol use, many of them are actually addicted to it.5 A National Institute of Mental Health survey of more than 20,000 U.S. adults found that 13.7% had experienced problems with alcohol dependence, and that one half of those who were alcoholics had at least one additional problem, such as abuse or addiction to another drug.5 The inefficacy of intervention programs, complicating social and cultural factors, and controversies over the causes and treatments for substance abuse make this a complex issue. Therefore, health care professionals should be able to identify substance abusers, as well as be armed with adequate information to attempt to help them.5
Participants in this course may ask themselves am I aware of the silent, pervasive addictions infiltrating the United States? Could these addictions be affecting people in my office, my community, and my home? The answers may be yes because substance abusers are masters at disguising their condition. They come from all segments of society regardless of their financial status, ethnic background, or age. The following case histories may sound familiar:
Joan, a 30-year-old divorced mother of two, owned her own business. As the stress of her job increased and the demands of raising her two children alone became more difficult, she began using alcohol to cope. It started with one drink after work a couple of nights a week, but eventually, she was consuming two and three drinks after work every night. After six months of this pattern, her performance at work was declining. A co-worker noticed the changes in Joan's behavior and suggested she get help. Joan denied her addiction to alcohol until she was charged with DUI at the scene of an accident in which she hit a child on a bicycle.
Jim, a popular high school senior, was actively involved in athletics and clubs and did not appear to have any stress in his life. Unknown to others, Jim had smoked since he was 10 years old, and during his senior year of high school had started experimenting with marijuana "just for fun." Since he enjoyed marijuana, he thought some other drugs might make him feel even better, so he tried cocaine. His experience with cocaine was different, but he felt he was still in control. However, his cocaine experience led to addiction. He lost his athletic scholarship and found himself struggling to maintain his once high grades. Meanwhile, his self-esteem and popularity plummeted. Jim's parents admitted him to a substance abuse treatment facility, and he was finally able to get his addictions under control. Although it was not in time to save his athletic scholarship, it did give him a better chance at life.
This third case did not end as well. Cindy, a bright, cheerful college student, wanted to be a Certified Public Accountant (CPA) and was well on her way to a successful life. She was fun to be around, well adjusted, articulate and focused, as her parents had taught her to enjoy life. However, her life ended abruptly when, Mark, a fellow student with whom she was riding, crashed his car into another vehicle, killing both Cindy and the driver of the other car. Unknown to Cindy, Mark was under the influence of alcohol and also had been free-basing.
Defining the terms drug, substance abuse, and chemical dependence is a logical beginning. Taber's Cyclopedic Medical Dictionary defines a drug as any substance that when taken into a living organism, may modify one or more of its functions.6 Drugs are classified according to their biochemical action, physiologic effect, or the organ system(s) they affect. According to Inaba, et al., drug abuse is the continued use of a drug despite negative consequences. Chemical dependence refers to the interaction between a drug and the individual when there is a compulsion to take the drug to obtain its effects and/or to avoid the discomforts of withdrawal.7 Simply stated, if a substance is intentionally taken to alter one's mood or perception, it can be considered an "abused substance."
Regardless of their legal use status, drugs are classified in specific categories as: cannabinoids; central nervous system (CNS) stimulants (sypathomimetics); CNS depressants (anxiolytics); opiates (opioids); hallucinogens (psychedelics; inhalants; anabolic-androgenic steroids (hormones); prescription drugs; and over-the-counter (OTC) drugs. Categories of drugs with their effects, street names, signs, symptoms, and treatments for the abuse of each are shown in Figure 1.
Dopamine is the neurotransmitter of reward active in alcohol, opiate, and cocaine dependence.
Release of dopamine affects the part of the brain that regulates motor behavior. The destruction of the neurons that produce dopamine by substance abuse produces symptoms of Parkinson's disease, such as rigidity and tremor. Blockage of the actions of dopamine in other brain regions accounts for the therapeutic activities of anti-psychotic drugs. This neurotransmitter has been linked to addiction through its role as a pleasure chemical and enhancing learning and appears to be the common neurotransmitter affected by all addictive substances.
Other neurotransmitters involved in the brain reward system are:
Serotonin--Changes in the activity of serotonin producing neurons results in changes in mood, appetite, sleep, and sexual function. Medications to treat depression focus on increasing serotonin levels in the brain.
Enkephalins--These neurotransmitters are normally occurring substances that bind to localized opiate receptors, sites involved in pain perception. They mimic the effects of opiates.
Adapted from Snyder, S.H. Drugs and the Brain, Scientific American Library, New York, 1996.
Physiologic Effects
So what happens in the brain of people when they take a drug into their body? A simple review of basic brain anatomy and physiology will assist in understanding substance abuse and addiction. Although a comprehensive review of this topic is beyond the scope of this course, a list of resources is provided for those interested in further study of this aspect of addiction.
The organized layers of the brain can be thought of like floors in the house. Vital functions such as heart rate, breathing, and blood pressure are controlled by the brain stem, hind-brain, and mid-brain--the first floor.8
The central core of the brain--the second floor--is divided into two sections: the hypothalamus and the limbic system. The hypothalamus controls important biological functions such as sex drive, thirst, hunger, sleep cycle, energy level, the immune system, and "pleasure centers." The limbic system is called the "emotional brain" and plays an important role in regulating emotional behavior.8
The cortex, the third floor, is the highest level of the brain and is responsible for perception, information processing, thinking, reasoning, and higher cognitive functions. The frontal lobes of the cortex can be thought of as the penthouse. The front halves of these lobes are especially critical because they are active in inhibiting emotional reactions, maintaining attention and concentration, and enabling complex thinking and problem solving.8
The inside in the brain at the molecular level can be compared to the wooden structure of the house in that wood is made up of millions of grains. The grain in the wood is like the millions of nerve cells (neurons) that make up the brain. Normal brain function is dependent on the appropriate action of neurons. Each neuron functions by producing and releasing a particular chemical substance called a neurotransmitter. These neurotransmitters are called messenger molecules because they influence other neurons and assist in the transmission of messages from neuron to neuron. Neurotransmitters can impact the function of the nerve cell by activating and inactivating the cell and causing adjacent cells to produce and release hormones or to grow or to die.8
The neurotransmitters that have been associated with addiction include serotonin, dopamine, norepinephrine, gamma-amino-butyric acid (GABA), and glutamate. Medications, recreational drugs such as alcohol and cocaine, stress, genetic factors, and hormonal factors have been found to interfere with nerve cell function. This discussion will focus on the interaction between alcohol, drugs, neurotransmitters, the brain's pleasure center, and addiction.8
The pleasure centers of the brain are areas that are part of an internal biological reward system. They are activated by the release of particular neurotransmitters that are triggered by certain life experiences. Under normal circumstances, experiences such as watching a funny movie, enjoying a meal or making love can produce a range of feelings from joy to euphoria. Pleasure centers can also be activated artificially.8 For example, a person can temporarily feel on top of the world by drinking a glass of wine because of the release of dopamine, a neurotransmitter discovered in 1958.
The cell membrane, which directs the flow of chemicals in and out of the cells, can be altered by drugs, making it less stable and allowing more chemicals to enter. Therefore, certain chemicals, such as alcohol and cocaine can damage cell function.8
Addiction occurs when the body responds to repeated substance use by increasing its level of resistance to the immediate drug effects and tolerance is developed. While trying to maintain a normal state, the cell membrane is changing, as the receptors and brain chemicals try to help the brain function normally. Eventually, the body is unable to function in the altered state without the drug.
Research has also shown that dopamine plays a role in learning by drawing a person's attention to a particular event associated with past pleasure or reward. Dopamine is now also thought to be a stimulus for behavior…anticipating that pleasure or reward might follow.9 So as a person experiments with a chemical substance and finds it makes him feel good, they are creating a memory of pleasure. So the next time they think about drinking alcohol or using a drug, if the memory of pleasure is now present, they may continue its use. This cycle is described in Figure 2.
Research has shown that the progression to addiction usually occurs in three stages--experimental, tolerance, and dependency. In the initial stage, an individual tries a substance and it feels good. In the second stage, tolerance, an individual may progress to using the substance often, eventually needing more to achieve the original effect. Many people feel embarrassed or guilty at this point. In the third stage, dependency, an individual requires the substance daily. Physical side effects, such as loss of appetite, nutritional deficiencies, infections such as hepatitis, AIDS, and sexually transmitted diseases (since sex is often traded for drugs) are noticeable.
Signs of Substance Abuse
Because substance abusers come from all socioeconomic and cultural groups, health care professionals often encounter people who are skilled at masking their addiction and enlisting the aid of others to obtain drugs.2 Some of the more obvious physical and behavioral signs of substance abuse are:
- Careless in appearance, dress, and personal hygiene (especially in someone who is usually neat and well-groomed)
- Wearing long sleeves to cover needle marks
- Dramatic weight loss
- Wearing sunglasses to mask dilated or constricted pupils or eye redness
- Unusual behavior such as gazing or slurred speech
Psychological and social signs include:
- Anxiety, insomnia, depression, and suicide attempts
- Social isolation
- Mood changes
- Severe marital problems and status changes
- Social problems at work or school
- Frequent job changes and moves to new areas
- Changes of friends or associates
- Child or spouse abuse
Oral Effects
Oral manifestations of substance abuse vary, but abusers tend to have a higher incidence of dental caries and periodontal disease than the general population.10 This may result from neglect more than drugs, but cocaine addicts may apply the drug to gingival tissues, and it may be directly responsible for the oral disease. Cocaine abusers may also exhibit angular cheilitis, oral candidiasis, glossodynia, cervical abrasion, gingival laceration, and severe bruxism. Patients with combined cocaine and alcohol addiction tend to exhibit the most severe oral disease conditions and symptoms, such as severe xerostomia, advanced periodontitis, many decayed teeth, many missing teeth, and severe tooth attrition from bruxism. Oral manifestations of cocaine use include reduced salivary secretions, increased dental caries, abnormal tooth-wear patterns, and acute gingival inflammatory effects.10
Individuals who are opiate-dependent may exhibit dental caries on the labial and buccal cervical one-third of the teeth rather than on the occlusal or interproximal surfaces. These lesions are usually darker, larger, and less painful than routine caries. Allergic thrombocytopenia caused by the quinine in adulterated heroin may appear as ecchymosis (an irregular formed hemorrhagic area) of the oral mucous membranes. Marijuana users tend to have a greater incidence of decayed, missing, and filled teeth, stain, and greater microbial plaque with resulting gingivitis. People who abuse alcohol also exhibit extra oral signs including breath and body odor of alcohol, hand, tongue and eyelid tremors, redness of the forehead, cheeks and nose, and jaundice of the face.10
Techniques for Aquiring Drugs
It is also important for oral health care professionals to be aware of the techniques addicts often used to obtain substances. Some of the more common are:
- Telephone requests for analgesics
- Complaints of anxiety, fatigue, insomnia, or depression, followed by requests for stimulants or depressants
- Requests for premature refills for "stolen" or "lost" medication, or medication left at home while on vacation
- Consistent failure to keep appointments, or refusal of treatment or lab work despite drug requests
- Pressure, including the use of guilt, sympathy, or the threat of harm
- Requests for specific controlled substances or drugs that are inappropriate for the individual's problem or procedure
- Claims of being allergic to all drugs except certain controlled substances
- Requests from elderly patients who, through confusion or deliberate effort, obtain multiple prescriptions for the same drug, or who are taking conflicting medications
- Requests for extra medication from patients claiming to be going on vacation or a business trip
- Visits to several different physicians for the same reasons
- Theft of prescription pads
Screening for Addiction
When screening a patient for drug abuse, the oral health care professional should take a nonjudgmental approach and:
Ask specific, factual questions that do not permit yes and no answers.
Be persistent: if answers are vague, reword the question or say "I don't understand."
When patients are antagonistic or evasive, recognize this behavior as part of their denial mechanism.
Be sympathetic, letting the patient talk about the reactions of their family and friends to their use of drugs.
Don't accept qualified answers. If the response is "hardly at all," ask how often that means.
If users seem to be holding back information, contact family members for additional information about the extent of drug use.
End the interview on a less threatening topic so the patient will be comfortable in future discussions.
Drug abuse is a complex problem thought to result from a combination of hereditary, psychological, and environmental factors. It affects people from the neonatal stage to old age. Infants of abusers may suffer from neglect or the effects of parental drug use. As they grow into childhood, they may demonstrate antisocial behavior, and signs of malnutrition, poor self-esteem, depression, or attention deficit disorder. This may lead an adolescent to use drugs, have unwanted pregnancies, and drop out of school. Identification of drug abuse is a difficult first step on the road to recovery because of the methods many abuses use to hide their addiction, the inability of family members to recognize or accept the problem, and the relatives' enabling behavior.
Oral health care professionals, have an ethical responsibility to inform patients of how drug abuse can damage their health. With increased knowledge of chemical dependency, one may be able to identify and encourage a patient, co-worker, or family member to seek the support needed to change substance abuse habits. The self-assessment checklist and list of resource may provide insight and information helpful to someone who must take that difficult first step to recovery.
Self-Assessment Questions
Following are some self-assessment questions aimed at helping you decide where you are in relation to an addiction. Answer these as honestly as you can. You may wish to discuss the results with a professional experienced in dealing with addiction, an addict in a recovery program, or someone else you trust.
- What are the substance(s) or behavior(s) that you are concerned about possibly being addicted to? When did you start these, and how long have you been involved with them? How much, and how often, do you use the substance(s) or participate in the behavior?
- What is your usual pattern of engaging in this behavior (for example: every day, several times each week, several times per month), and how has it changed over the past several years (that is, is it getting worse)?
- How has this substance or behavior affected your physical health?
- How has this substance or behavior affected your thinking patterns, concentration, or attitudes?
- How has this substance or behavior affected your moods or feelings?
- How has this substance or addiction affected your behavior?
- How has this substance or behavior affected your personality?
- How has this substance or behavior affected your self-esteem?
- How has this substance or behavior affected your motivation and your job or school performance?
- How has this substance or behavior affected your financial condition?
- How has this substance or behavior affected your relationships with your family, including your children?
- How has this substance or behavior affected your relationships with friends or other people?
- How has this substance or behavior affected your ability to conform to the laws of society?
- How has this substance or behavior affected your religious beliefs and/or your spirituality?
- What other ways has this substance or behavior affected you?
- Who in your life has expressed concern over your possible addictive use of a substance or involvement in an addictive behavior? What exactly was the nature of this concern?
- How would your life be different if you did not use this substance or engage in this behavior?
- After reviewing your answers to these questions, what conclusions do you reach about yourself in terms of addiction(s)?
Adapted from: Daley, DC. Kicking Addictive Habits Once and for All. San Francisco: Jossey-Bass Publishers; 1998: 5.
Alcoholics Anonymous World Services, Inc.
PO Box 459, New York, NY 10163, (212) 870-3400,
Al-Anon Family Group Headquarters, Inc
1600 Corporate Landing Parkway, Virginia Beach, VA 23454-5617. (800) 356-9996 or (800) 356-2666
Cocaine Anonymous
6125 Washington Boule-vard, Suite 202 Los Angeles, CA 90230
Columbia Addiction and Substance Abuse Center (CASA)
PO Box 435 Ann Arbor, MI 48106,
(800) 222-5145
Marijuana Anonymous
PO Box 2912, Van Nuys, CA 91404
Moderation Management
(612) 512-1484
Narcotics Anonymous
PO Box 9999, Van Nuys, CA 91409, (818) 773-9999
National Center on Addiction and Substance Abuse
152 West 57th Street, New York, NY 10019
National Clearinghouse for Alcohol and Drug Information
PO Box 2345, Rockville, MD 20847-2345 (800) 729-6686
About the Author
Patty Bonasso Byrd, RDH, is a Professional Educator for Philips Oral Healthcare, makers of sonicare, and a Clinical Instructor in Dental Hygiene at the University of Louisville. As a graduate from the University of Louisville (1978) with 22 years in dental hygiene , she has done extensive consulting and lecturing nationwide on numerous topics in the dental industry. She has been actively involved in her Kentucky State Dental Hygienists' Association as vice-president, president-elect and president (1998-1999). She has also been a delegate for four years to the American Dental Hygienists' Association.
Supplemental Activities
- Visit Procter & Gamble's Web site: www.dentalcare.com for additional information. Click on Research Resources, then click on Internal Medicine. At least the following are available: Hypertension, Effects of Hypertension, Congestive Heart Failure, Diabetes, and Epilepsy.
- Visit Procter & Gamble's Web site: www.dentalcare.com for additional continuing education courses. At least the following are available under Courses for Dental Hygienists: Seizure Disorders, and Asthma (under Courses for Dentists).
- Participate in courses offered by the American Red Cross, such as Responding to Emergencies, 'Til Help Arrives, Emergency Response, Community First Aid and Safety.
- Order and complete: Medical History Evaluation and Management of Medical Emergencies package from Jill Stoltenberg at the University of Minnesota, Department of Preventive Sciences, Division of Dental Hygiene, Clinic Director: 612/625-5651.
- Visit www.centerwatch.com/drugs for the most recent information about prescription drugs.
Additional Readings
- Blum K, et al.: Reward deficiency syndrome. Amer Scientist 1996;84(2):132-145.
- Board of Trustee Report. Drug abuse in the United States. Strategies for prevention. JAMA 1991:265(160):2102.
- Cochran J: Substance Abuse: Drugs. Miami, Health Studies Institute, 1995, p.108-109.
- Inaba DS, Cohen WE, Holstein ME: Uppers, Downers, All Arounders. Ashland, OR: CNS Publications, Inc. 1997.
- Lowinson JH, Ruiz P, Millman RB, Langrod JC, eds: Substance Abuse. A Comprehensive Textbook. Baltimore, Williams & Wilkins, 1992.
- Rees TD: Oral effects of drug abuse. Critical Reviews in Oral Biology and Medicine 1992;3(3):163-184.
Definition of Terms
Abuse—pattern of abnormal drug use that occurs despite negative consequences or the threat of physical damage; not the same as addiction.
Addiction—physical and psy-chological dependence, includ-ing tolerance of a drug, withdrawal symptoms when use is stopped, and persistent relapses following reversal of physical dependence.
Chemical dependence—a primary chronic disease with genetic, psychosocial, and environmental factors influencing its development and it manifesta-tions.
Codependency—suffering and/or dysfunction that is associ-ated with or results from focusing on the needs and behavior of others. A constellation of responses by significant others, particularly family, to being involved with the dependent.
Designer drugs—a term first used in the 1980s to describe synthetic or lab-produced derivatives of prescription drugs con-trolled by the U.S. Food and drug (FDA). Until late 1986, so long as drug imitations were only similar, but not identical, to controlled drugs, individuals could not be prosecuted or fined for making them. Designer drug can also refer to a known, abused drug that has been repackaged or redesigned for easier use or increased appeal to consumers. Crack cocaine is a designer form of cocaine.
Dependence—a condition marked by use of a substance in excessive dosages or for a longer period than directed by a physician; use despite persistent social, psychological, and physical problems; expenditure of considerable effort to obtain,use, and recover from a sub-stance; withdrawal symptoms or repeated failure to reduce or control use; and continued use to relieve or avoid withdrawal symptoms.
Drug abuse—regular use of a drug other than for its accepted medical purpose or in doses greater than those considered appropriate.
Ecchymosis—a small hemorrhagic spot, larger than a petechia, in the skin or mucous membrane forming a non-ele-vated, rounded or irregular, blue or purplish patch.
Experimental—the stage during which individuals become aware that a substance makes them feel good.
Gateway drugs—substances such as, alcohol, tobacco and marijuana, thought to lead to use of more addictive sub-stances.
Glossodynia—pain in the tongue.
Neurotransmitters—chemicals that stimulate adjacent neurons.
Physical dependence—physical adaptation to chronic use of a specific psychoactive substance. Withdrawal symptoms develop when use ceases, and may be relieved when use is resumed.
Psychological dependence— a subjective sense of need for a specific psychoactive substance, to experience its posi-tive effects or to avoid the negative effects associated with stopping its use.
Substance abuse—regular use of a drug other than for its accepted medical purpose or in doses greater than those con-sidered appropriate.
Thrombocytopenia—a decrease in the number of blood platelets.
Tolerance—the need for higher and higher doses of a drug to achieve the same effects. This occurs because of alternations in drug metabolism, so that the liver destroys the drug more quickly, and because of changes in the target cells (usually those of the nervous system).


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Fox will to be giving away copies of the Death Sentence poster EXCLUSIVELY at the San Diego Comic-Con next week and will also going to have Kevin Bacon, James Wan, and Garrett Hedlund signing them at the Fox Atomic booth on Saturday, 7/28 at 3:00 PM!
Death Sentence will be a part of Fox's presentation at this year's Comic Con.
Anyone planning to go?
- Haley
- Kayla
- holly
- Flops
- Maddawg
- Greta
- Renee84
- ohhwow
- Corinne
- dri12
This entry was posted on Tuesday, July 17th, 2007 at 3:15 pm and is filed under Appearances, Events, Garrett Update. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.

subset: commoncrawl


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Miss Mary's K-12 June Newsletter: School Specials & More!
As we close the book on another school year and the "Class of 2012" has "left the building", one can't help but think what an impact the school cafeterias have on the students they serve daily. For many it truly is the best meal they have all day; and all students, many years later, will recall their favorite school meal with fond memories. There is no better time than now to pay tribute to the men and women that are responsible for the millions of school breakfast and lunches that are served daily. You are not just support personnel, but play a very vital role in a child's total education. We at KaTom congratulate and thank you for the outstanding job you do daily. We are committed to offering quality products; service and assistance in helping you fulfill your important role in the lives of our students.
Preventative Maintenance & Predictive Maintenance
Preventative maintenance is of utmost importance to the life of your equipment throughout the year, but the summer break provides an opportune time to do that extra cleaning, checking and replacing of filters, gaskets, hoses that time may not permit during the regular school year. Just a few thoughts in relation to preventative maintenance vs. predictive maintenance:
- Preventative maintenance occurs on a set schedule, such as once a month, while predictive maintenance is done based on the condition of the equipment and what appears to need the work the most.
- Preventative maintenance done correctly and regularly will result in less need for predictive maintenance.
- In other words, if you are not doing preventative maintenance you certainly can predict that you will have problems with equipment and will ultimately be required to fix a problem that is more involved.
Preventative maintenance ensures equipment remains in excellent operating condition and identifies and resolves potential problems before they happen. Some preventative maintenance such as cleaning, should be done on a daily basis, others should be done weekly, such as vacuuming refrigeration coils. All manufactures will recommend preventative maintenance on their equipment so be sure and refer to the service manual for the type and frequency recommended for each piece of equipment. During the summer break, a general inspection of the equipment should be performed and include but is not limited to: lubrication, cleaning of air filters, inspection and adjustments of belts, checking and servicing refrigerants, checking controls, checking and tightening electrical connections, and ensuring light bulbs, hinges, and knobs are installed and working properly.
Tour of True Manufacturing Facilities
The best way to be able to judge and know what quality standards one wants in the equipment they purchase is to see firsthand the quality of materials and workmanship that go into the different brands available. It also makes one more aware of the specifications that are important to them when they are ready to purchase equipment. This is the philosophy behind True Manufacturing's decision to not advertise through magazines, billboards, etc., but rather have opted to bring customers in for a tour of the factory whereby they can actually see the equipment being manufactured.
School Nutrition Directors considering purchasing refrigeration equipment are invited to participate in a tour of the True facilities. Several of you have taken the tour and have found it to be very informative and valuable. Recently Karen Dalton, Putnam County School Nutrition Director and Brenda Hawkins, School Nutrition Director for Jackson County, joined Bill Roberts (True Representative) and me to tour the facilities.
Carter-Hoffmann Heated Cabinet School Special
If you are looking for a way to keep all your food warm, then try a Heated Cabinet by Carter-Hoffmann. These cabinets allow you to prepare large quantities in advance and keep everything at the appropriate temperatures for hours, saving time and effort. Special pricing for schools is available now. Call Dawn for more school pricing and more details at 800-541-8683 ext. 140.
Recipes of the Month
As the season brings tasty fresh melons our way, I wanted to share a couple quick and delicious recipes to enjoy over the summer months.
Melon With Raspberry SauceYield 6 Servings
- 2-2/3 cups unsweetened raspberries
- 3 tablespoons honey
- 1 teaspoon lemon juice
- 1/8 teaspoon ground ginger
- 1 large cantaloupe
- 1 medium honeydew melon
- Set aside a few raspberries for garnish. Place the remaining berries in a blender or food processor; cover and process until pureed. Add the honey, lemon juice and ginger; cover and process. Strain and discard seeds; set sauce aside.
- Cut the cantaloupe and honeydew into three wedges; cut each wedge widthwise in half. Remove seeds and rind. With a knife, slice each piece of melon lengthwise toward narrow end without cutting completely to the end. Open into a fan shape.
- On each dessert plate, place 2 tablespoons of raspberry sauce and a cantaloupe fan and honeydew fan. Garnish with reserved raspberries.
Strawberry-Melon SaladYield 6 servings
- 1 cup lemon yogurt
- 1 tablespoon honey
- 1 teaspoon lemon juice
- 2 cups watermelon balls
- 2 cups cantaloupe balls
- 2 cups halved fresh strawberries
In a salad bowl, whisk together the lemon yogurt, honey, and lemon juice until smooth, and gently fold in the watermelon balls, cantaloupe balls, and strawberries. Toss to coat, and serve.
Anyone building or renovating schools that involve kitchens, serving areas or dining areas; please contact me at email@example.com or 865-223-1150; or KaTom direct at (800-541-8683 or 423-586-5839). We would be grateful for the opportunity to provide quotes or respond to bids or RFP's on any and all items needed.
Thank You,
Mary Lou Henry


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Subaru celebrates the 40th anniversary of its signature Symmetrical All Wheel Drive system this year and will mark the occasion with a showcase at next month's Geneva International Motor Show.
All Wheel Drive was introduced in 1972 on the Leone wagon in Japan. In the ensuing years, Fuji Heavy Industries (FHI), the maker of Subaru vehicles, has refined the technology.
Before the end of the decade Subaru was entering international rallies with its AWD Leone models – most notably the Kenyan Safari. A long period of development culminated in World Manufacturer's Championships with the Impreza in a variety of models in the 1990s and driver's titles for Colin McRae, Richard Burns and Petter Solberg.
Closer to home Subaru has been the most successful marque in rallying on both sides of the Tasman with multiple drivers and manufacturers awards as well as winning national and international series around the world over the last 25 years, thanks to the mechanical correctness of Symmetrical All Wheel Drive.
Total production* of Subaru AWD vehicles reached 11,782,812 at the end of January 31, 2012 making up nearly 56% of Subaru's total vehicle sales.
The AWD system provides optimum traction by distributing engine power to all four wheels in a balanced manner.
AWD combines with Subaru's flat horizontally opposed Boxer engine to produce a perfectly symmetrical power-train and low centre of gravity – the lack of major components sitting either side of the powertrain results in great balance, stability, response – and the driving dynamics for which Subarus are famed.
Continuous research and development over 40 years has refined the AWD technology, making the system ideal for a wide variety of conditions, from rough roads to rain, gravel mud, sand, snow and ice.
The latest technology includes four-wheel traction management, giving accurate grip to all four wheels, all the time.
Variable Torque Distribution (VTD)-AWD: Electronically controlled sporty AWD for enhanced turning performance
A compact AWD system that combines the centre differential with an electronically controlled hydraulic multiple-disc clutch and Limited Slip Differential (LSD) using the planetary gear. The 45:55 front: rear torque distribution is continuously variable, using a multiple disc clutch LSD. Torque distribution is controlled automatically up to an equal 50:50 front: rear ratio to suit road surface conditions, for superb stability. By distributing torque with an emphasis on the rear wheels, turning performance is enhanced, providing aggressive and sporty driving.
Active torque split AWD: Electronically controlled AWD for enhanced fuel efficiency and stability
Subaru's original electronically controlled Multi Plate Transfer (MPT) adjusts torque distribution to the front and rear wheels in real-time, to suit driving conditions. The system usually distributes torque 60:40 front: rear. It maximizes the benefits of AWD by providing stability and safety, regardless of the driver's skill in any driving situation.
Viscous centre differential AWD: Mechanical AWD for manual transmissions
The system is a combination of the bevel-gear-type centre differential and the viscous LSD. A 50:50 front: rear torque distribution is set under normal conditions. It delivers stable and sporty driving that always maximizes available traction.
Multi-mode Driver Control Centre Differential AWD: Performance-directed AWD
The electronically controlled DCCD AWD system employs a combination of torque sensing mechanical LSD and electronically controlled LSD. It provides a performance-oriented 41:59 front: rear torque distribution for optimum vehicle dynamics control. The mechanical LSD has a quicker response and activates just before the electronic LSD. While managing large torque, the system demonstrates the highest balance between agility and stability. There is the choice of automatic LSD control modes and manual mode, which the driver can select according to conditions.
*Including the productions of part-time 4WD vehicles


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Sharon J. Green-Hennessy, Ph.D.
Access to mental health care, attachment theory, child maltreatment, child and adolescent psychopathology, child and adolescent assessment.
Beth A. Kotchick, Ph.D.
Moderator, Active Minds
Parenting and family processes, child and adolescent psychopathology, adolescent sexual and health behavior, cognitive-behavioral theory and therapy with children and adolescents.
Heather Z. Lyons, Ph.D.
Director, Clinical Training
Culture, discrimination and person-organization fit in the workplace; social cognitive and cultural influences on career expectations; and training issues in multicultural psychology.


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Memory Clinic
Senior Primary Care Practice – Parkridge
190 Parkridge Drive, Suite G-100
Columbia, SC 29212
(803) 434-4700
The Memory Care Clinic seeks to thoroughly assess and diagnose dementia, facilitate and enhance medical and behavioral interventions, maintain or improve current functioning, and involve caregivers and family in planning for patient care through educational services.
The Memory Care Clinic will be the leading, comprehensive care management program for people with memory related disorders and their caregivers/family, while providing educational services to the community.
The Memory Care Clinic will assist you to find direction in the care of memory loss and/or related problems for yourself or a loved one.
The comprehensive plan for memory care includes:
- Initial Social Work Evaluation, including cognitive testing
- Initial Medical Consultation
- Follow-ups, as necessary
- Connection to community resources
- Team of committed professionals, who are willing to help all involved in the patient's care
- Collaboration with the Alzheimer's Association Palmetto Chapter, University of South Carolina School of Medicine, and the University of South Carolina School of Social Work
Prior to scheduling an appointment for a memory evaluation, a referral is needed from a primary care physician.
Consultations are scheduled by calling the Senior Primary Care Practice at (803) 434-4700. Please request a Memory Care Clinic appointment.


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Role, Scope, and Mission Statement: Louisiana State University at Shreveport (LSUS), the comprehensive urban university serving the Shreveport/Bossier metropolitan area, is committed to the freedom of inquiry and to the pursuit of excellence for out students, faculty, and staff. LSUS provides a stimulating learning environment for the students and faculty to participate in the discovery, understanding, and dissemination of knowledge. LSUS serves the Shreveport/Bossier metropolitan area with programs that aid the economic, social, and cultural development through excellence in teaching, research, and public service.
Peer Institutions: Auburn University at Montgomery, The University of West Florida, Georgia College, Bowie State University, Delta State University, Western Carolina University, Southeastern Oklahoma State University, Citadel Military College of South Carolina, Midwestern State University, and Christopher Newport University.
This agency's recommended appropriation does not include any funds for short-term debt.
In addition to the above recommended appropriation, $725,581 will be paid in Fiscal Year 1999-2000 for long-term debt incurred on behalf of this agency from the previous sale of bonds. Total long-term debt service payments for the state for Fiscal Year 1999-2000 are reflected in the Governor's Executive Budget Supporting Document in Non-Appropriated Requirements, Schedule 22-922.
This agency's recommended appropriation also includes the following amount by means of financing for payments on the unfunded accrued liability of the Louisiana State Employees' Retirement System and the Teachers' Retirement System in accordance with the provisions of Article X, Section 29 of the Constitution of Louisiana:
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Rev. Irene Monroe: The Stonewall Riot started on the backs of working class African American and Latino queers who have been bleached from its written history.
A Pride Event Not to Be Proud of
Rev. Irene Monroe: Because of the bleaching of the Stonewall Riots, the beginnings of LGBTQ movement post-Stonewall is an appropriation of a black, brown, trans, and queer liberation narrative. And it is the deliberate visible absence of these black, brown, and yellow LGBTQ people that makes it harder, if not nearly impossible, for LGBTQ communities to build trusted coalitions with white LGBTQ communities.