SUBSTANCE ABUSE DRUGS
Sultana Poonja
University of the Sciences in Philadelphia,
Philadelphia College of Pharmacy
Doctor of Pharmacy Candidate
February 2005
PP495 Project in Pharmacy
Instructor: Grace Earl, Pharm.D.
1
Use of this Presentation
• This presentation may be used for
educational purposes.
• Please obtain permission by using contact
information on the next page
2
Acknowledgement
• Contact Grace Earl, Pharm.D. at
g.earl@usip.edu
• Instructor: Grace Earl, Pharm.D.,
Assistant Professor, University of the
Sciences in Philadelphia, Philadelphia
College of Pharmacy, Box 8, 600 South
43rd Street, Philadelphia, PA 19104
3
Reviewed by
•
•
•
•
Laura Mandos, Pharm.D.
Associate Professor
University of the Sciences in Philadelphia
Philadelphia College of Pharmacy and
Science
4
Purpose of this Presentation
• This presentation was designed to be used for
educational purposes.
• The information describes general information
on drugs and substances that are abused.
• Each section gives information on
pharmacology, explanation of methods used to
administer substances, symptoms, statististics.
5
DEA DEFINITIONS
• I
•
•
•
•
highest potential abuse, unpredictable,
psychological & physical dependence, death, NO
medical use
II high potential abuse, severe psychological/physical
dependence, medical use accepted with restrictions
III medium potential abuse, moderate or low physical,
high psychological dependence, accepted medical
use
IV low potential abuse, limited physical/psychological
dependence, accepted medical use
V lowest potential abuse, limited physical /
psychological dependence, accepted medical use
6
Featured Illicit Drugs
•
•
•
•
•
•
•
•
•
•
•
Gamma Hydroxybutyrate (GHB)
Flunitrazepam (Rohypnol)
Amphetamines (Ecstasy)
Cocaine
Marijuana
Lysergic Acid Diethyl-amide (LSD)
Volatile Inhalants
Heroin
Oxycodone
Ketamine
Dextromethorphan
7
Gamma Hydroxybutyrate (GHB)
Definition
• Central Nervous System depressant.
• A sedative-hypnotic, was originally
developed as a sleep-aid.
• A similar drug, “GBL,” turns into GHB
in the body, having the same effect.
• DEA SCHEDULE I
• No known medical use.
8
GHB STREET NAMES
 GBH
 Grievous Bodily
Harm
 “G”
 Liquid Ecstasy
 Easy Lay
 Energy Drink
 Liquid E
9
GHB DOSAGE FORMS
• A teaspoon or capful → normal dose.
• Proper dose is unknown. A teaspoon
could also be an overdose.
10
GHB POSSIBLE EFFECTS
• LOW DOSES
– Euphoric
effect~ (alcohol)
– Relax
– Happy
– Sociable
• HIGH DOSES
– Dizziness
– Sleepiness
– Vomiting
– Muscle spasms
– Loss of
consciousness
11
GHB OVERDOSE EFFECTS
• Cause loss of consciousness (temporary
coma)
• Slow breathing.
• With alcohol, slows breathing to a
dangerously low rate, which causes
deaths.
• Overdose occurs because the onset is
delayed for up to two hours.
12
GHB APPEARANCE
• Powder and capsule form.
• A clear liquid form that is colorless and
odorless. (most common)
• Produced as a white crystalline powder.
• Slightly salty to the taste, and sold in
small bottles.
13
GHB 2002 STATISTICS1
•
•
•
•
5 fatal cases reported
Ages: 19-36 years of age
2 of the 5 cases were single ingestions.
3 cases were multiple ingestions (GHB
with other substance abuse drugs.
• Acute type ingestions
14
FLUNITRAZEPAM
(ROHYPNOL)
•
•
•
•
•
Definition
Brand for flunitrazepam, a benzodiazepine
drug, family of Valium & Xanax.
“Date rape” drug
DEA SCHEDULE IV
Not approved in the U.S. , used in the rest of
the world as a tranquilizer, insomnia treatment
& a sedative prior to surgery.
No statistical data reported.
15
ROHYPNOL STREET NAMES
• Roofies
• Rophies
• Lunch Money
(referring to the
drug's low price
on the street)
• Pappas or
Potatoes (refers to
mental capacity of
someone under the
influence of the
drug)
• Mind-Erasers
• Mexican Valium
16
ROHYPNOL DOSAGE FORMS
• Orally in pill form, crushed and snorted.
• Ingested orally, usually with alcohol or
other drugs, including heroin.
• 1 and 2 milligram dose
17
ROHYPNOL POSSIBLE EFFECTS
WITHOUT ALCOHOL
•
•
•
•
•
•
•
Disorientation and confusion
Drowsiness
Dizziness
Slurred speech
Impaired judgement
Lack of coordination (difficulty walking)
Amnesia (impairs memory of events)
18
ROHYPNOL POSSIBLE EFFECTS
WITH ALCOHOL
•
•
•
•
Low blood pressure
Difficulty breathing
Death
Coma
19
ROHYPNOL EFFECTS OF
OVERDOSE
• Rapid mood swings
• Violent outbursts of temper
• Can be life-threatening when mixed with
alcohol
• Development of physical and
psychological dependence
20
ROHYPNOL APPEARANCE
• White & round pill, smaller than a dime.
• Pills may be ground up or crushed into a
powder.
• Liquid form.
• Dropped into a drink, it may dissolve &
become "invisible."
• Currently supplied with a 1-milligram
dose in an olive green, oblong tablet,
imprinted with the number 542.
21
AMPHETAMINES (ECSTASY)
DEFINITION
• A MDMA/3,4Methylenedioxymethamphetamine.
Belongs to “entactogens,” drug family,
meaning “touching within.”
• Other drugs: MDA,MDE and MBDB.
• DEA SCHEDULE I
• Appearance : N/A
• No Medical Use
http://www.usdoj.gov/dea/photo_library.html accessed May 6, 2005
22
AMPHETAMINES (ECSTASY)
http://www.usdoj.gov/dea/photo_library.html accessed May 6, 2005
23
ECSTASY STREET NAMES
• E
• X
• XTC
• Adam
• Clarity
• Lover’s Speed
24
ECSTASY DOSAGE FORMS
• Tablet or capsule.
• Usual dose is 100-125 mg
• Black market "ecstasy" tablets vary
widely in strength, and often contain
other drugs.
25
ECSTASY POSSIBLE EFFECTS
•
•
•
•
MDMA is a "mood elevator"
Relax, euphoric state.
It does NOT produce hallucinations.
Increased chances of dehydration,
hypertension, & heart or kidney failure
• Increased body temperature leads to
death.
26
ECSTASY EFFECTS OF
OVERDOSE
• Linked to neurotoxic damage in
laboratory animals.
• It is still unknown whether such damage
occurs in humans or, if it does, whether
this has any long-term, negative
consequences.
27
ECSTASY 2002 STATISTICS 1
• 9 fatal cases
• 1 of the 9 cases was by inhalation.
• The 8 cases were by ingestion with
multiple means such as cocaine, LSD,
marijuana, ethanol, propranolol,
benzodiazepine, etc.
• Acute type ingestions/inhalations.
• 3 of the cases were suicides.
28
LYSERGIC ACID DIETHYL
AMIDE (LSD)
DEFINITION
• A hallucinogenic or psychedelic drug.
• Found absorbed into tiny pieces of paper
called “blotter”.
• Found as a pure liquid or absorbed into a
sugar cube.
• LSD costs about $5 for a "hit."
• DEA SCHEDULE I
29
LSD
http://www.usdoj.gov/dea/photo_library.html accessed May 6, 2005
30
LSD STREET NAMES
• Acid- (battery,
black, blotter,
blue, lime, paper,
vodka)
• Electric Kool-Aid
• Mind detergent
• Caps (blue,
brown, green,
pink, purple,
yellow)
• Sunshine (black,
California,
Hawaiian, Yellow)
• Crystal tea
31
LSD DOSAGE FORMS
• The form or derivative found in the seeds
of the morning glory family plant.
• Four to eight of these seeds are equal to
10,000 micrograms of LSD
• Believed to be the ingredient in the
parasitic fungus Claviceps purpurea and
in the Convolvulaceae plant family, both
of which were used in religious rites
32
LSD POSSIBLE EFFECTS
DESCRIBED AS A TRIP WITH 4 PHASES:
1. THE ONSET
2. THE PLATEAU
3. THE PEAK
4. THE COMEDOWN
33
ONSET
Approximately 30 minutes after ingestion,
colors appear sharper, moving objects
leave "trails" behind them, and flat
surfaces may appear to "breathe."
34
THE PLATEAU
Over the second hour, the effects become
more intense. Imaginary visions can
appear from nowhere--from shapes in
smoke, to lines on the palms of the hand.
35
PEAK
Time is slowed almost to a standstill. Users
may feel like they are in a different world,
or a movie. For some this is profound and
mystical, but it can be very frightening for
others.
36
COMEDOWN
Five or 6 hours after taking the drug the
sensations begin to subside, then after 8
hours the trip is usually over. The residual
effects may last until after sleep
37
LSD OVERDOSE EFFECTS
• Longer, more intense “trip” episodes
• Psychosis
• Possible death
38
LSD APPEARANCE
• Powder, tablet, capsule
• Sugar cube
• Drop of LSD solution evaporated on filter
or blotting paper.
• Incorporated into a square of gelatin
("windowpane")
39
LSD MEDICAL USES
• Once proposed as an analgesic in
terminal patients.
• An aid in psychotherapy
• An adjunct to the treatment of
alcoholism, opioid addiction, sexual
abnormalities, autism, and sociopathy.
40
LSD 2002 STATISTICS 1
•
•
•
•
•
Only one fatal case was reported.
Age of the person was 16 years old
Acute type
Usage way was unknown
Used in abuse
41
MARIJUANA
DEFINITION
• Cannabis, an ancient hallucinogenic drug
derived from hemp plant
• Can grow wild almost everywhere
• Consists of dried, chopped, plant parts.
• THC: active ingredient to cause damage.
• Other types: Hashish, Bhang, Ganja, &
Sinsemilla
42
• Dea Schedule I
MARIJUANA
http://www.usdoj.gov/dea/photo_library.html accessed May 6, 2005
43
MARIJUANA STREET NAMES
•
•
•
•
Pot
Grass
Weed
Mary Jane
•
•
•
•
Dope
Reefer
Skunk
Boom
44
MARIJUANA DOSAGE FORMS
• Smoked as a cigarette or joint, or in a
pipe or bong.
• Appeared in "blunts" =>cigars that have
been emptied of tobacco and re-filled
with marijuana, sometimes in
combination with another drug, such as
crack
45
MARIJUANA POSSIBLE EFFECTS
•
•
•
•
•
•
•
•
•
Affects learning & social behavior
Affects memory & concentration
Drowsiness
Some experience insomnia
Feeling unmotivated
Feeling giddy
Uneasiness & anxiety
Thirst & hunger
Smoke can affect breathing
46
MARIJUANA OVERDOSE
EFFECTS
• Impairs memory and may cause
delusions, hallucinations and
disorientation.
• There is NO documented case worldwide
of a fatal overdose from taking
marijuana.
47
MARIJUANA APPEARANCE &
MEDICAL USES
• It is a plant that is crushed into powder form to
be able to sniff.
• Legally there are no medical uses in America
for marijuana. However, it has been used for
patients who have AIDS & cancer because it
helps them to control pain & nausea & other
symptoms. Further research is needed for this
drug to be legalized as a medicinal use.
• No statistics reported
48
COCAINE
DEFINTION
• A powerful addictive stimulant directly
affecting the brain.
• The pure chemical, cocaine HCL, has
been an abused substance for more than
100 years, & coca leaves, the source of
cocaine, have been ingested for 1000
years.
49
• DEA SCHEDULE II
COCAINE
http://www.usdoj.gov/dea/photo_library.html accessed May 6, 2005
50
COCAINE STREET NAMES
• Coke
• “C”
• Snow
• Flake
• Blow
• Speedball (when
linked with
Heroin)
51
COCAINE DOSAGE FORMS
• 2 chemical forms of cocaine: the
hydrochloride salt & the "freebase.“
• Hydrochloride salt, or powdered form of
cocaine, dissolves in water &, if abused,
can be taken intravenously (by vein) or
intranasal (in the nose).
• Freebase refers to a compound that has
not been neutralized by an acid to make
the hydrochloride salt. The freebase form
of cocaine can be smoked.
52
COCAINE POSSIBLE EFFECTS
Hypertension
Hyperthermia
Chest pain
Tachycardia
Endocarditis
Euphoria
Restlessness
Tremor
Hyperflexia
Difficulty breathing
Asthma
Pulmonary edema
Pulmonary
hemorrhage
Pneumothorax
53
COCAINE OVERDOSE
EFFECTS & COMMENTARY
• DEATH IF ANY OF THE EFFECTS
CROSS THEIR LIMITS
• Pure cocaine first extracted from leaf of
the Erythroxylon coca bush, grows in
Peru & Bolivia, in the mid-19th century.
In the early 1900s, it was the main
stimulant drug used in most of the
tonics/elixirs developed to treat a variety
of illnesses.
54
COCAINE APPEARANCE
• Sold on the street as a fine, white,
crystalline powder.
• Diluted with such inert substances as
cornstarch, talcum powder, and/or sugar,
or with such active drugs as procaine (a
chemically-related local anesthetic) or
with such other stimulants as
amphetamines.
55
COCAINE MEDICAL USES
• High potential for abuse (CII), can be
administered by a doctor for legitimate
medical uses, such as a local anesthetic
for some eye, ear, and throat surgeries.
• Local vasoconstriction, ophthalmologic
impurity signature profiles analysis
(CISPA).
56
COCAINE 2002 STATISTICS 1
•
•
•
•
45 fatal reported cases involving Cocaine.
Age ranges: 19 to 51 years old
26 single types reported
19 multiple types reported which included marijuana,
opium, heroin, diazepam, amphetamines, salsalate, and
codeine.
• Majority of the 45 cases were acute type of death.
• Majority of the cases were due to inhalation and
ingestion. Some were unknown and 1 case was due to
rectal cause.
• Most of the cases were from misuse and abuse reason.
Couple of the reasons were suicide.
57
HEROIN
• Highly addictive drug
• Opiate
• Processed from morphine, a
naturally occurring substance
extracted from the seed pod of
certain varieties of poppy plants.
http://www.usdoj.gov/dea/photo_library.html accessed May 6, 2005
58
HEROIN STREET NAMES
•
•
•
•
•
•
•
Aunt Hazel
Black Tar
Big H
Bozo
Dead President
Crown Crap
Diesel
59
HEROIN DOSAGE FORMS
• Injected
• Sniffed/snorted/smoked
60
HEROIN POSSIBLE
CONSEQUENCES
• “Rush”
• Depressed
respiration
• Clouded mental
functioning
• Nausea &
vomiting
• Suppression of
pain
• Spontaneous
abortion
• Addiction
61
HEROIN POSSIBLE
CONSEQUENCES OF IV USE
• Infectious diseases
• Viral
– HIV/AIDS
– Hepatitis B & C
• Bacterial Infections
• Abscesses
62
HEROIN OVERDOSE EFFECTS
•
•
•
•
Muscle spasticity
Pinpoint pupils
Bluish colored fingernails and lips
Tongue discoloration
63
HEROIN APPEARANCE
• White or brownish powder
• Black sticky substance known on the
streets as "black tar heroin."
• Purer heroin is becoming more common,
most street heroin is "cut" with other
drugs or with substances such as sugar,
starch, powdered milk, or quinine.
• Street heroin can also be cut with
64
strychnine or other poisons.
HEROIN 2002 STATISTICS 1
• Total of 40 cases were reported.
• 15 of the cases were by the drug itself.
• 25 of the cases were with other drugs,
such as cocaine, marijuana, ethanol,
alprazolam, & acetaminophen.
• 27 cases were with inhalation or
ingestions, 13 cases were unknown.
• 5 were suicidal cases, 35 were cases of
abuse.
65
VOLATILE INHALANTS
• Volatile substances that produce chemical
vapors, which can be inhaled to induce a
psychoactive, or mind-altering effect.
• Mind-altering (inhaled into lungs)
– fumes
– vapors
– gases
66
VOLATILE INHALANTS STREET
NAMES
•
•
•
•
•
•
•
Huff
Poor man’s pot
Satan’s Secret
Texas shoe shine
Spray
Toilet water
Bullet Bolt
67
VOLATILE INHALANTS DOSAGE
FORMS
•
•
•
•
Volatile solvents
Aerosols
Gases
Nitrites
68
VOLATILE INHALANTS POSSIBLE
EFFECTS
• Blurred vision
• Stupor or coma
• “Fetal solvent syndrome” if inhalant used
during pregnancy
69
VOLATILE INHALANTS
OVERDOSE EFFECTS
•
•
•
•
•
“Sudden sniffing death syndrome”
Accidental suffocation
Red, glassy or watery eyes; nosebleeds
Some products are carcinogens
Asphyxiation (displacing of available
oxygen in lungs.)
70
VOLATILE INHALANTS
MEDICAL USE
• Mild anesthetic used in medicine and
dentistry
• Nitrites used to enhance orgasm
• Nitrites also used to dilate blood vessels
and relax muscles.
71
VOLATILE INHALANTS 2002
STATISTICS 1
• In general, many cases were reported
with selective inhalants.
• Carbon monoxide caused 31 deaths.
• Hydrogen sulfide caused 6 deaths.
72
OXYCODONE
 Narcotic pain medication.
 Raises your pain threshold and
blunts your brain’s perception of
pain.
 Analgesic
73
OXYCODONE STREET NAMES
& BRAND NAMES
 M-Oxy
 Oxycontin (Brand Name)
 Oxyir
 Percolone
 Roxicodone
74
OXYCODONE DOSAGE
FORMS & MEDICAL USES
 Tablets: 10, 20, 40, 80, or 160 mg
 Higher doses ( 80 & 160 mg) only for
use in opioid-tolerant patients only for
pain relief
 Relief of moderate to severe pain.
75
OXYCODONE POSSIBLE
EFFECTS
• Upset stomach
• constipation
• dry mouth,
• hives
• skin rash
• yellowing of the skin or eyes
76
OXYCODONE OVERDOSE
EFFECTS
• Skeletal muscle flaccidity, cold and
clammy skin, constricted pupils,
bradycardia, hypotension, and death.
77
OXYCODONE 2002 STATISTICS 1
•
•
•
•
27 cases were reported.
Age range was 14-75 years old.
3 cases were with oxycodone.
24 cases were oxycodone with other drugs
such as marijuana, cocaine, heroin, &
methadone.
• 12 cases were suicidal, 8 cases were
abuse, 2 cases were misuse, 5 cases were
78
unknown.
KETAMINE
• Also known as ketamine hydrochloride.
• A non-barbiturate
• Rapid-acting disassociative anesthetic used on
both animals and humans; used primarily for
veterinary anaesthesiology.
• It is being abused by an increasing number of
young people as a "club drug," and is often
distributed at "raves" and parties
• Schedule III
79
KETAMINE STREET NAMES
•
•
•
•
•
•
K
Special K
Vitamin K
Kit Kat
Blind squid
Cat valium
80
KETAMINE DOSAGE FORMS
• A liquid and the most potent ways of using it
are by injecting it intramuscularly or
intravenously.
• tablet or a powder by evaporating the liquid
and reducing it to a fine white powder that can
be smoked or snorted.
• Recreational doses = 30-300mg
• Snorted dose = 15-200 mg
• IM = 25 – 125 mg
• Oral dose = 75- 300 mg
81
KETAMINE POSSIBLE EFFECTS
• Loss of motor control before injection is
completed.
• lower doses= hallucinogenic effect, clumsy, or
'robotic' movement, decrease in sensations,
vertigo.
• At higher doses= difficulty moving, nausea,
dissociated from environment, Near Death
Experiences (NDEs), loss of visions, black outs.
• Psychologically addictive
82
MEDICAL USE OF KETAMINE
• Used in human medicine for pediatric
burn cases and dentistry
• Used in experimental psychotherapy.
83
DEXTROMETHORPHAN
• An antitussive
• Used to relieve a nonproductive cough
caused by a cold, the flu, or other
conditions.
84
DEXTROMETHORPHAN
STREET NAMES
•
•
•
•
•
•
•
•
DXM
DM
CCC
Triple C
Candy
Robo
Velvet
Rojo
85
DEXTROMETHORPHAN
DOSAGE FORMS
• Adult
– Oral dose of either 10 to 20 mg every four
hours or 30 mg every 6 to 8 hours not to
exceed 120 mg daily.
• Children
– Oral dose of either 5 to 10 mg every 4 hours
or 15 mg every six to eight hours, not to
exceed 60 mg daily.
86
DEXTROMETHORPHAN
OVERDOSE EFFECTS
•
•
•
•
•
Slurred speech
Restlessness
A feeling of poor coordination
Difficulty breathing
Seizures
87
DEXTROMETHORPHAN
APPEARANCE
•
•
•
•
•
Liquid
Lozenges
Powder
Syrup
Tablets
88
Summary
• Respiratory failure: GHB, Rohypnol,
Marijuana, Cocaine, Heroin & Volatile
Inhalants
• Hallucinations: Rohypnol, LSD &
Marijuana
• Suicide: Ecstasy, Cocaine, Heroin &
Oxycodone
89
REFERENCES
• 1. 2001 Annual Report of the American Association of Poison
Control Centers Toxic Exposure Surveillance System. Am J
Emerg Med 2002; 20(5): 391-452.
• 2. Ellenhorn, Matthews. J. New York. Ellenhorn’s Medical
Toxicology Diagnosis & Treatment of Human Poisoning. 2nd
edition. 1998.
• 3. National Institute on Drug Abuse Home Page [Resource on
World Wide Web]. URL: http://www.drugabuse.gov
• 4. United States Department of Justice Home Page [Resource on
World Wide Web]. URL: http://www.usdoj.gov
• 5. Micromedex
90
Substance-Abuse Headlines
91
ISSUES RELATED TO DRUG
ABUSE
• Affects on pregnancy
• Young teenagers being punished with
penalty
• Money becomes a factor
• General places for drug exchange lead to
problems
• Some drugs…good or bad for medical
use
92
DRUG & LAUNDRY BUST WITH
NEW TECHNIQUES
• Drugs and cash found hidden in clothes
dryer.
• Trail lead to a van which had a secret
code with more cocaine.
• Decoding resulted in electronic sequence
where a car had to be running, all doors
locked, defroster on & rear vents in
certain positions simultaneously.
Philadelphia Inquirer, The (PA): Raid nets 5 arrests, 24
kilos.Http://doc.newsbank.com
December 11 2003. By: Thomas J Gibbons Jr.
93
PIZZA WITH A SIDE ORDER OF
DRUGS WITH HANDCUFFS
• Pizza shop as a front to sell cocaine.
• Called the ringmasters of a distribution
network that sold, packaged, or stored
cocaine at the pizza shop.
• Detected through tapped cell phones &
walkie talkies.
Philadelphia Inquirer, The (PA): Police: Trooper pizza shop was front for a drug ring
http://docs.newsbank.com February 5, 2004. By: Keith Herbert
94
MONEY IS GOOD BUT NOT THE
JAIL TIME
• 11 year-old arrested for dealing crack
and heroin.
• 14 & 15 year-old arrested in dragnet and
charged for distributing crack and
heroin.
• Money made from dealing versus money
used if possible for bail.
•
Philadelphia Inquirer, The (PA):3 boys among 19 arrested in drug sting.
http://docs.newsbank.com March 13, 2004. By: Sam Wood
95
DRUGS AND PREGNANCY
• Women taking cocaine while pregnant
lead to a dead baby and accused for
murdering child.
• Women tested positive for cocaine when
delivered dead baby.
• Lead to conviction and case still in court.
Philadelphia Inquirer, The (PA): High court declines to hear appeal of murder
conviction in stillbirth. http://docs.newsbank.com October 7, 2003 By: Anne Gearan.
96
MEDICAL USE FOR MARIJUANA?
• Marijuana used for pain for sick and
dying patients
• Some states agree, Federal law recognizes
no medical purpose for it.
• Questioning for specific cases such as
cancer & AIDS patients.
• Court investigating physicians who agree
to the treatment.
•
Philadelphia Inquirer, The (PA): Medical marijuana fight draws civil rights
analagy. http://docs.newsbank.com August 11, 2003 By: Anne Gearan
97
DEBATE FOR & AGAINST
PEYOTE
• Historical background of peyote resulting in
pain relief and positive attitude amongst
families.
• Considered a hallucinogenic & leading to
spiritual experiences.
• May lead to brain damage vs. healing agent.
• Found toxins that cane lead to a risky
undertaking.
Philadelphia Inquirer, The (PA): Envisioning uses for hallucinogens.
http://docs.newsbank.com November 17, 2003. By: Faye Flam
98
ISSUES WITH DRUG ABUSE
• PEOPLE OF ALL
AGES AND ALL
CONDITIONS
• ABUSE IN USE
• ABUSE IN
QUESTION
• EVERY PART OF
THE WORLD
•
•
•
•
•
•
SUICIDAL
POLICE
LAW
JUDGES
COURT
HEALTH CARE
99