The Opiod Epidemic Medical Nursing Counseling

Behavioral Treatment 1st Edition by Albert

Anthony Rundio, Stephanie Brooks ISBN
9781536183696 1536183695 download
https://ebookball.com/product/the-opiod-epidemic-medical-nursing-
counseling-behavioral-treatment-1st-edition-by-albert-anthony-
rundio-stephanie-brooks-isbn-9781536183696-1536183695-6512/

Instantly Access and Download Textbook at https://ebookball.com

 Get Your Digital Files Instantly: PDF, ePub, MOBI and More
Quick Digital Downloads: PDF, ePub, MOBI and Other Formats

Counseling the Nursing Mother 5th edition by Judith Lauwers, Anna

Swisher ISBN B007KRXXH8 978-0763780524

https://ebookball.com/product/counseling-the-nursing-mother-5th-
edition-by-judith-lauwers-anna-swisher-
isbn-b007krxxh8-978-0763780524-1050/

Counseling in Speech Language Pathology and Audiology Reconstructing

Personal Narratives 2nd Edition by Anthony DiLollo, Robert Neimeyer
1635502985 9781635502985

https://ebookball.com/product/counseling-in-speech-language-
pathology-and-audiology-reconstructing-personal-narratives-2nd-
edition-by-anthony-dilollo-robert-
neimeyer-1635502985-9781635502985-21248/

Behavioral Neurobiology of Anxiety and Its Treatment 2010th Edition by

Murray Stein, Thomas Steckler ISBN 3642029110 9783642029110

https://ebookball.com/product/behavioral-neurobiology-of-anxiety-
and-its-treatment-2010th-edition-by-murray-stein-thomas-steckler-
isbn-3642029110-9783642029110-2288/

Lange Medical Microbiology 24th edition by Geo Brooks, Karen Carroll,

Janet Butel, Stephen Morse ISBN 0071476660 9780071476669

https://ebookball.com/product/lange-medical-microbiology-24th-
edition-by-geo-brooks-karen-carroll-janet-butel-stephen-morse-
isbn-0071476660-9780071476669-2260/
Ganong's Review of Medical Physiology 26th Edition by Kim Barrett,
Susan Barman, Jason Yuan, Heddwen Brooks ISBN 1260122417 97812601224

https://ebookball.com/product/ganong-s-review-of-medical-
physiology-26th-edition-by-kim-barrett-susan-barman-jason-yuan-
heddwen-brooks-isbn-1260122417-9781260122411-3362/

Ganong Review of Medical Physiology 26th Edition by Kim Barrett, Susan

Barman, Jason Yuan, Heddwen Brooks ISBN 9781260122411 1260122417

https://ebookball.com/product/ganong-review-of-medical-
physiology-26th-edition-by-kim-barrett-susan-barman-jason-yuan-
heddwen-brooks-isbn-9781260122411-1260122417-236/

Ganong's Review of Medical Physiology 24th Edition by Kim Barrett,

Susan Barman, Scott Boitano, Heddwen Brooks ISBN 0071780033
9780071780032

https://ebookball.com/product/ganong-s-review-of-medical-
physiology-24th-edition-by-kim-barrett-susan-barman-scott-
boitano-heddwen-brooks-isbn-0071780033-9780071780032-2650/

Johns Hopkins Nursing Evidence based Practice Implementation and

Translation 1st Edition by Stephanie Poe, Kathleen White ISBN
193053891X 9781930538917

https://ebookball.com/product/johns-hopkins-nursing-evidence-
based-practice-implementation-and-translation-1st-edition-by-
stephanie-poe-kathleen-white-isbn-193053891x-9781930538917-714/

Jawetz Melnick and Adelbergs Medical Microbiology 26th Edition by Geo

Brooks, Karen Carroll, Janet Butel, Stephen Morse ISBN 0071790314
9780071790314

https://ebookball.com/product/jawetz-melnick-and-adelbergs-
medical-microbiology-26th-edition-by-geo-brooks-karen-carroll-
janet-butel-stephen-morse-isbn-0071790314-9780071790314-1996/
 SUBSTANCE ABUSE ASSESSMENT, INTERVENTIONS AND TREATMENT

THE OPIOID EPIDEMIC

MEDICAL, NURSING, COUNSELING

BEHAVIORAL TREATMENT

No part of this digital document may be reproduced, stored in a retrieval system or transmitted in any form or
by any means. The publisher has taken reasonable care in the preparation of this digital document, but makes no
expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No
liability is assumed for incidental or consequential damages in connection with or arising out of information
contained herein. This digital document is sold with the clear understanding that the publisher is not engaged in
rendering legal, medical or any other professional services.
 SUBSTANCE ABUSE ASSESSMENT,
INTERVENTIONS AND TREATMENT

Additional books and e-books in this series can be found on Nova’s

website under the Series tab.
SUBSTANCE ABUSE ASSESSMENT, INTERVENTIONS AND TREATMENT

THE OPIOID EPIDEMIC

MEDICAL, NURSING, COUNSELING

BEHAVIORAL TREATMENT

ALBERT ANTHONY RUNDIO, JR.

AND
STEPHANIE BROOKS
EDITORS
Copyright © 2020 by Nova Science Publishers, Inc.
All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or
by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the
written permission of the Publisher.

We have partnered with Copyright Clearance Center to make it easy for you to obtain permissions to reuse content from
this publication. Simply navigate to this publication’s page on Nova’s website and locate the “Get Permission” button
below the title description. This button is linked directly to the title’s permission page on copyright.com. Alternatively,
you can visit copyright.com and search by title, ISBN, or ISSN.

For further questions about using the service on copyright.com, please contact:
Copyright Clearance Center
Phone: +1-(978) 750-8400 Fax: +1-(978) 750-4470 E-mail: [email protected].

NOTICE TO THE READER

The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of
any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or
consequential damages in connection with or arising out of information contained in this book. The Publisher shall not
be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of,
or reliance upon, this material. Any parts of this book based on government reports are so indicated and copyright is
claimed for those parts to the extent applicable to compilations of such works.

Independent verification should be sought for any data, advice or recommendations contained in this book. In addition,
no responsibility is assumed by the Publisher for any injury and/or damage to persons or property arising from any
methods, products, instructions, ideas or otherwise contained in this publication.

This publication is designed to provide accurate and authoritative information with regard to the subject matter covered
herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other
professional services. If legal or any other expert assistance is required, the services of a competent person should be
sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE
AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS.

Additional color graphics may be available in the e-book version of this book.

Library of Congress Cataloging-in-Publication Data

Names: Rundio Jr., Albert Anthony, editor.
Title: The Opioid Epidemic: : medical, nursing and counseling
behavioral treatment / Albert Anthony Rundio Jr., Drexel University,
Philadelphia, PA, US, Stephanie Brooks, Associate Dean Division of
Health Professions, College of Nursing and Health Professions, Drexel
University, Philadelphia, PA, US, editors.
Description: New York : Nova Science Publishers, [2020] | Series: Substance
abuse assessment, interventions and treatment | Includes bibliographical
references and index. |
Identifiers: LCCN 2020030183 (print) | LCCN 2020030184 (ebook) | ISBN
9781536182170 (hardcover) | ISBN 9781536183696 (adobe pdf)
Subjects: LCSH: Opioid abuse--United States. | Medication abuse--United
States. | Substance abuse--United States. | Substance abuse--United
States--Treatment. | Substance abuse--United States--Alternative
treatment. | Substance abuse--United States--Psychological aspects.
Classification: LCC RM146.7 .S83 2020 (print) | LCC RM146.7 (ebook) | DDC
362.29--dc23
LC record available at https://lccn.loc.gov/2020030183
LC ebook record available at https://lccn.loc.gov/2020030184

Published by Nova Science Publishers, Inc. † New York

This book is dedicated to those who suffer from Substance Use Disorders
and for the many who maintain long term sobriety and recovery.
Throughout my career in this field I have learned so much
from each patient.
This book is also dedicated to the all of the interprofessional health care
team members that are on the front-line in this epidemic.
They are the true heroes!

Albert Rundio

Thank you to the countless families including my own who taught me what
they really need from a couple and family therapist.

Stephanie Brooks
 CONTENTS

Preface ix
Chapter 1 The Opioid Epidemic/SUD:
Facts, Figures and Assessment Tools 1
Albert Anthony Rundio, Jr.
Chapter 2 The Neurobiology of Opioid Drug Addiction 33
William J. Lorman
Chapter 3 Pharmacologic Concepts in Opioid Addiction
Treatment Through the Continuum 45
William J. Lorman
Chapter 4 Maternal Substance Use: Systemically
Understanding Treatment and Recovery 67
Jessica Chou and Rikki Patton
Chapter 5 Opiate/Heroin Use in Pregnancy 103
Kathleen Bradbury-Golas
Chapter 6 Complementary and Integrative Therapies for the
Treatment of Opioid Abuse Disorder 117
Rita Cola Carroll
viii Contents

Chapter 7 Adolescent Substance Use 149

DeAnna Harris-McKoy and Ebony Okafor
Chapter 8 Couple and Family Therapy Best Practices in
Substance Use Disorders 171
Stephanie Brooks and Shiricka Fair
Chapter 9 Understanding the Intersection between Trauma
and Substance Use: Treatment Recommendations 201
Heather Katafiasz and Trish Caldwell
Chapter 10 Drug Treatment Courts 217
Adriatik Likcani and F. Ryan Peterson
Conclusion 241
Editor Contact Information 243
Index 245
 PREFACE

The Opioid Epidemic is one of the major events that has occurred in the
United States during the past few years. Several factors have contributed to
this epidemic. Accrediting bodies identifying pain as the 5th Vital Sign
certainly addressed patient’s pain but also accelerated the use of prescription
narcotic pain medications as first line therapy rather than utilizing other
types of pharmacologic agents that are not narcotics as well as trying other
non-pharmacologic interventions such as holistic health modalities.
Dependent upon the type of narcotic pain medication prescribed,
patients can develop a dependence upon the medication which then leads to
addiction. Purchasing such medications can be rather expensive. Many
patients then turn to purchasing less expensive drugs, such as Heroin, off of
the street. Compounding the problem today is that much of the heroin is
tainted with other drugs, such as Benzodiazepines and Fentanyl. Fentanyl is
far more potent than heroin. The end result is that many young people as
well as older people are dying from overdoses. If someone is not available
to administer Naloxone immediately the end result is death.
There have been many strategies implemented by both the federal
government and individual states governments to combat the opioid
epidemic. Many states have implemented Prescription Drug Monitoring
Programs (PDMP) that report the prescriptions for controlled substances that
a patient purchases. Legislation has been passed to promote addiction
x Albert Anthony Rundio, Jr. and Stephanie Brooks

treatment centers and medicated assisted treatment programs. Although

there has been a noted decreased in opioid related deaths, there is still a long
way to go to combat this epidemic.
Care rendered to the patient with opioid substance use disorders needs
to be interprofessional and inclusive of Medicine, Nursing, Counseling and
other behavioral modalities. Such interprofessional care will yield the best
treatment outcomes.
Chapter 1 - This chapter discusses the history and also provides facts
and figures on the opioid epidemic currently affecting the USA. In addition
to various graphs that tracks and trends the epidemiology of the epidemic
the second part of the chapter displays the various assessment tools for
substance use disorders. As many individuals have co-dependencies these
assessment tools are not only tools for assessing opioids but also other
substances.
Chapter 2 - interactions between biologic and environmental factors.
The risk for addiction in individuals with mental illness is significantly
higher than for the general population. Although there are psychological
elements involved in the addictive process, the pleasure-seeking behaviors
leading to euphoria are the result of a physiological process in the brain.
Ultimately, active addiction is maintained because of the physiologic
process of cravings. The more common models of addiction are presented.
Chapter 3 - To understand addiction treatment, one must understand the
pharmacokinetics and pharmacodynamics of the opioid drugs: what the
drugs do to the body (especially the brain) and how the body initially reacts
and ultimately tolerates those drugs. When drugs are taken in at a rate in
excess of how the body can cope, there is an overdose condition and unless
intervened, death may occur. When the intake of drugs ceases, the
body/brain is in a state of instability and physiologic withdrawal occurs. This
can be treated medically to reduce the severity of symptoms. In order to
control cravings and the persistent anxiety associated with drug abstinence,
protocols for medication-assisted treatment have been developed to prevent
relapse.
Chapter 4 - The impacts of the substance use epidemic on the United
States population are well-known and widely documented. Women are
 Preface xi

uniquely impacted by substance use initiation, addiction severity, treatment,

and recovery. As such, it is critical to consider the intersection of substance
use among women’s lives in an effort to determine best practices in
prevention, treatment, and recovery. To address this need, this chapter
provides an overview of key concepts in maternal substance use and best
practices for assessing and treating maternal substance use. A case
application is included to contextualize the factors that impact maternal
substance use and related treatment and recovery. Further, future directions
are considered within the context of current knowledge and best practices.
Chapter 5 - Opioid Use disorder has become a major health issue in the
United States. The pregnant woman has not been exempted from this
disorder, with numbers increasing significantly in recent years. However,
management of the pregnant patient requires comprehensive
interprofessional collaboration among obstetric care, addiction medicine,
social/behavioral health, and pediatric care providers. This chapter addresses
assessment/screening recommendations, management strategies to reduce
pain and medication assisted treatment (MAT) during and after pregnancy.
Neonatal Opioid Withdrawal Syndrome is also reviewed.
Chapter 6 - With high levels of morbidity and mortality, opioid abuse
disorder is a public health emergency that shows little sign of abating.
Generally, Medication Assisted Therapies (MAT), such as methadone,
buprenorphine and naltrexone, combined with psychological support, are
considered to be the most effective, but with high relapse rates, there is a call
for innovative and comprehensive approaches to treatment. Complementary
and integrative therapies (CITs) offer non-pharmaceutical options that may
be integrated into conventional treatment to boost the effectiveness, with
limited or no side effects. A complementary and integrative approach
promotes an individualized, holistic plan of treatment. These therapies can
also be used long-term as foundational practices for a healthy lifestyle that
supports well-being of the mind, body and spirit, as well as sustainable
recovery. In this chapter the authors will explore several complementary and
integrative health practices, each with a proven track record in the area of
addictions treatment, particularly treatment for opioid dependency.
xii Albert Anthony Rundio, Jr. and Stephanie Brooks

Chapter 7 - Adolescence is a developmental time period where a myriad

of problematic behaviors could rise such as substance abuse. Over time,
adolescents have decreased their use of certain substances and increased
their abstinence from others. However, the increased use of marijuana and
vaping of nicotine and marijuana are having continued negative
consequences on adolescents. In addition, the misuse of prescription drugs
adds a new level of complexity to dealing with adolescent substance abuse.
Due to the potential life changing negative consequences of any substance
use, such as prolonged usage well into adulthood, it is imperative that health
professional address substance use during the period of adolescence to
ensure greater well-being. This chapter addresses trends in substance use
over time, trajectories of substance use, risk and protective factors, access to
care, treatment through: therapy, community-oriented programs, and
pharmacotherapy and ways health professionals can be culturally conscious
in assessing and treating adolescent substance use disorder.
Chapter 8 - Substance use and misuse is a public health problem
impacting families across the life cycle.
The opioid epidemic is devasting for all families often resulting in
relational cut offs, couple and family distress, health problems and untimely
death. Understanding family relationships, interactions, protective and risk
factors are foundational to assessment, determining interventions and
supporting recovery. Therefore, this chapter aims is to provide an overview
of the types of difficulties couple and family members experience living with
substance use disorder. It includes best practices such as using cultural and
trauma informed lens along with evidence informed couple and family
approaches. Implications for self of the health professional is introduced as
a practical tool for promoting self-care and therapeutic effectiveness.
Chapter 9 - This chapter focuses on the intersection between trauma and
substance use disorders. After outlining a definition of trauma, the chapter
identifies the statistics and theoretical conceptualizations explaining the
relationship between trauma and substance use. The characteristics of
trauma informed care and its distinction from trauma specific treatments are
also outlined. Then, recommendations for concurrent assessment and
treatment of trauma and substance use disorders are discussed. Additionally,
 Preface xiii

the impacts of working with trauma on clinicians, under the umbrella of

indirect trauma, is also explained, as well as the risk and protective factors
associated with the development of the negative impacts of indirect trauma.
Lastly, cultural and social justice considerations are discussed, particularly
in reference to the vulnerable population of incarcerated persons. The
chapter culminates with a case example to better elucidate these concepts.
Chapter 10 - Substance use disorders (SUDs) and their devastating
impact on individuals, families and the society continue to be a significant
public health issue. Our societal response in the recent decades has
continually adjusted from the war on drugs and criminalizing drug addiction
to more emphasis one treatment and prevention as science on SUDs
continues to emerge. Drug treatment courts have emerged as one effective
method to treating SUDs, reducing drug-related crime in our communities,
and helping individuals and families find recovery. They are a step forward
in our society towards decriminalizing drug addiction and offering hope and
a pathway to recovery for individuals and families in or seeking recovery.
Instead of imprisonment for nonviolent drug offenses, the justice system
defers prosecution of an individual’s case and offers them participation in
court-ordered drug rehabilitation program. A drug court involves a
multidisciplinary team of professionals under the leadership of the presiding
judge. This chapter is designed to help you become familiar with drug
courts, definition of drug courts, their structure and functioning, design and
program components, best practices, and their effectiveness. In addition, the
authors provide some practical tips and insight from our experience with the
initiation, development, and implementation of a new drug treatment court
program.
In: The Opioid Epidemic ISBN: 978-1-53618-217-0
Editors: A. Rundio and S. Brooks © 2020 Nova Science Publishers, Inc.

Chapter 1

THE OPIOID EPIDEMIC/SUD:

FACTS, FIGURES AND ASSESSMENT TOOLS

Albert Anthony Rundio, Jr., PhD

Nurse Practitioner Addictions Nursing;
College of Nursing and Health Professions,
Drexel University, Philadelphia, PA, US

ABSTRACT

This chapter discusses the history and also provides facts and figures
on the opioid epidemic currently affecting the USA. In addition to various
graphs that tracks and trends the epidemiology of the epidemic the second
part of the chapter displays the various assessment tools for substance use
disorders. As many individuals have co-dependencies these assessment
tools are not only tools for assessing opioids but also other substances.

According to the Centers for Disease Control (CDC) over 700,000

people have died from a drug over dose between the years of 1999 to 2017.


Clinical Professor of Nursing Drexel University. Corresponding Author’s Email:
[email protected].
2 Albert Anthony Rundio, Jr.

Approximately 68% of over 70,200 drug overdoses in 2017 results from an

opioid. Deaths involving opioids was 6 times higher comparing 2017 to
1999. Such opioid deaths results from prescription opioids, heroin and
illicitly manufactured fentanyl, which is now a leading cause of overdose in
the United States. On average at least 130 Americans or more die each day
in the United States from an opioid overdose (CDC, 2019); (CDC, National
Center for Health Statistics; 2017).
CDC outlines 3 waves that have contributed to the rise in opioid
overdose deaths:

Wave 1: Increased prescribing of opioids that began in the 1990s;

Wave 2: A rapid increase in opioid overdose deaths secondary to heroin
starting in 2010;
Wave 3: An increased number of overdose deaths secondary to synthetic
opioids, most notably illicitly manufactured fentanyl. Today much of the
heroin, counterfeit pills and even cocaine contain fentanyl [1, 2, 3].
Figure1 displays these 3 waves:

Figure 1. 3 waves in the rise in opiod overdose deaths, deaths per 100,000population.
 The Opioid Epidemic/SUD 3

Figure 2 demonstrates that 130 or more Americans die each day from
opioid overdose.

Figure 2. 130 or more Americans die each day from opioid overdose.

There are four primary factors that have contributed to the development
of this epidemic.
The four major contributing factors are the following:

1. pharmaceutical companies
2. accreditation standards
3. providers
4. patients

Let us discuss each of these factors.

Pharmaceutical companies developed the first opioids that were used for
pain management in the United States. It soon became a billion-dollar
industry. There were no incentives for pharmaceutical companies not to
develop more opioids for pain control.
In 1995 pain was identified as the fifth vital sign.
In 2001 the Joint Commission on Accreditation of Healthcare
Oganizations developed standards for pain as a quality indicator. The
American Academy of Medicine, most commonly known as the Institute of
4 Albert Anthony Rundio, Jr.

Medicine (IOM) reported on patient satisfaction with pain management, and

the Center for Medicare and Medicaid Services (CMS) developed the
HCAHPS (Hospital Consumer Assessment of Health Providers & Systems)
scoring system for hospitals which assesses patient satisfaction.
Reimbursement is tied to patient satisfaction. Thus pain management
became a critical indicator in healthcare and the goal was to control or
eliminate patient’s pain.
Providers are the ones who prescribe pain medication to patients.
Oftentimes providers are too willing to prescribe opioids for pain
management rather than exploring other non-narcotic options.
And then there are patients themselves. It is estimated that 50 million
Americans have chronic pain. It is also estimated that at least $560 billion
are spent annually on managing patient’s pain. It is a well-known fact that
patients with chronic pain will have increased depression, posttraumatic
stress disorder, and substance use disorders.
The end result of these factors is the opioid epidemic as we know it. At
least 81% of the opioids are prescribed in the United States so it is truly a
United States issue.
Heroin is an illicit opioid in the United States. Its usage has dramatically
increased over the past several years.
Let us now take a look at some statistical information.
There has been a 50% increase in use of heroin by males between 2004
to 2013.
There is an increase of 100% use of heroin during the same time period.
When we look at age groups there is a 109% increase in use by
individuals between the ages of 18 to 25. There is a 58% increase in the use
of heroin by individuals above age 26.
When we look at household income, there is 62% increase in the use of
heroin in individuals with a household income less than $20,000 annually.
There is a 77% increase in the use of heroin when the household income
level is between $20,000 to $49,999. There is a 60% increase in the use of
heroin in households with an income level of $50,000 or more.
When we look at health insurance coverage in patients who have no
health insurance coverage there is a 60% increase in the use of heroin.
 The Opioid Epidemic/SUD 5

Patients who have private or other types of insurance there is a 63% increase
in the use of heroin. And for those patients with Medicaid there is no
significant use of heroin (Figure 3).

Figure 3. Heroin use by demographic group (2002-2004 vs. 2011-2013)/addiction and

deaths by overdose.

Let us now review data secondary to opiates.

Tracing back to 1999 through the year 2017 there has been a dramatic
increase in the number of opioids deaths.
In 1999 there were less than 5,000 deaths per year. It has increased every
year since, in 2017 there were 70,237 – deaths from opioid use. Heroin
accounted for 15,958 deaths. Natural and semi-synthetic opioids accounted
for 14,948 deaths. Synthetic opioids other than Methadone accounted for
29,406 deaths. There were 14,556 deaths from Cocaine, 10,721 deaths from
Methamphetamine and 3295 deaths from Methadone (Figure 4).
Figure 5 displays the states with highest opioid death rates.
6 Albert Anthony Rundio, Jr.

Source: Centers for Disease Control and Prevention, National Center for Health
Statistics. Multiple Cause of Death 1999-2017 on CDC WONDER Online
Database.

Figure 4. Drugs involved in U.S. overdose deaths, 1999 to 2017.

Source: Centers for Disease Control and Prevention, National Center for Health
Statistics

Figure 5. US states with highest opioid death rates.

 The Opioid Epidemic/SUD 7

SBIRT (Screening Brief Intervention Referral to Treatment)

SBIRT is a comprehensive, integrated, public health approach to the

delivery of early intervention and treatment services for persons with
substance use disorders.

 Screening
 Brief intervention
 Referral to treatment

The primary goal of SBIRT is to identify substance use disorders early

so that referral for clients to appropriate treatment can be accomplished.
SBIRT assesses the following.

1. Abstinence
2. Moderate use (lower risk use)
3. At-risk (higher risk use)
4. Abuse
5. Dependence

Brief intervention is a brief motivational awareness raising awareness

for interventions provided to at risk or problematic substance users.
BNI stands for Brief Negotiated Interview. The BNI is a semi-structured
interview process that has its roots in motivational interviewing. It is a
validated evidence-based practice tool that can be completed in 5 to 15
minutes of time [4].
BNI Steps in the Process are:

1. Build rapport with the client in a non-threatening manner.

a. Raise the subject. Start with a general conversation.
b. Ask the client for permission to talk about alcohol and/or other
substances.
c. What happens if the client does not want to discuss his/her alcohol
or substance use? Discuss the pros and cons of use. For example,
8 Albert Anthony Rundio, Jr.

what are the good things about using alcohol or drugs? What are
some of the bad things about using alcohol or drugs?
d. Apply Motivational Interviewing – use open ended questions.
This encourages the client to talk freely and opens the door for
exploration. Use reflective listening. Reinforce what has been
stated. Demonstrate careful listening skills. Summarize the
information provided. Utilize a pro and con checklist.
2. Provide honest feedback.
a. Request permission to provide information
b. Discuss relevant screening findings
c. Make the link of substance use behaviors to consequences of
substance use
d. If the Client elicits a positive reaction then proceed moving
forward.
e. If the Client elicits a negative reaction then revisit the pros and
cons of substance use
3. Encourage a readiness for change.
a. Ask permission to talk a few minutes about the client’s interest in
making a behavior change. For example, one could present a scale
from 1 to 10 with 1 being not ready at all to make a change and
10 being completely ready to make a change in the client’s
substance use.
4. Negotiate a plan for change.
a. Develop with the client a plan to reduce use to a low-risk level
or complete abstinence.
b. Propose an agreement for the client to follow-up with
specialized treatment services.

Case Example
JR is in an automobile accident. He was unconscious at the scene.
Intranasal Naloxone was administered and he woke up. He was transported
to the local hospital emergency department for further evaluation and care.
JR had a complete physical assessment. Laboratory studies were ordered
including a drug screen and a serum blood alcohol level.
 The Opioid Epidemic/SUD 9

JR’s drug screen was positive for opioids and his serum blood alcohol
level was elevated.
JR had a laceration on his right forearm. The emergency department
physician, who was suturing his arm, questioned JR asking him had he ever
considered that he may have a problem with drugs and alcohol and that these
substances had contributed to his having a motor vehicle accident as well as
his loss of consciousness.
By addressing these issues in a non-threatening manner, the physician
can illicit if the patient has a substance use disorder versus this being a one
time event. The physician then can recommend assessment by a provider
experienced in substance use disorders. This is where SBIRT comes in.
Secondary to the opioid epidemic in the United States, many accrediting
bodies have recommended that every patient admitted to a hospital be
evaluated for SBIRT. The earlier one is diagnosed with a possible substance
use disorder the earlier interventions can be initiated.

Tools
There are several tools available for the assessment of opioid use
disorders:

 AUDIT
 Assist Tool
 CAGE
 OOWS – Objective Opioid Withdrawal Scale
 COWS - Clinical Opioid Withdrawal Scale
 CRAFFT
 DSM 5 – Diagnostic Statistical Manual Version 5 Screening Tools
 Buprenorphine Referral Form for Opioid Use Disorder
 NIDA Modified ASSIST Drug Use Screening Tool
 National Institute on Drug Abuse. A short screening tool to assess a
patient’s risk level based on a Substance Involvement (SI) score.

New studies suggest that ED initiated buprenorphine outperforms

SBIRT.
10 Albert Anthony Rundio, Jr.

The Brief Negotiation Interview (BNI) and Emergency Department-

Initiated Buprenorphine/Naloxone for Moderate/Severe Opioid Use
Disorder
The following section displays assessment tools.

SCREENING FOR ALCOHOL PROBLEMS

Ask Current Drinkers (NIAAA questions):

 On average, how many days per week do you drink alcohol?

 On a typical day when you drink, how many drinks do you have?
 What’s the maximum number of drinks you had on a given
occasion in the last month?

CAGE CRAFFT
C: Have you felt you ought to CUT C: Have you ever ridden in a CAR by
down on your drinking or drug use? someone (including yourself) who
was high or was using alcohol or
drugs?
A: Have people ANNOYED you by R: Do you ever use alcohol or drugs
criticizing your drinking or drug use? to RELAX, feel better about yourself
or fit in?
G: Have you ever felt GUILTY about A: Do you ever use alcohol or drugs
your drinking or drug use? while you are by yourself? (ALONE)
E: Have you ever had a drink or used F: Do your family or FRIENDS ever
drugs first thing in the morning (EYE tell you that you should cut down on
OPENER) to steady your nerves, rid your drinking or drug use?
hangover, or get your day started? F: Do you ever FORGET things that
you did while using alcohol or drugs?
T: Have you gotten in TROUBLE
while you were using alcohol or
drugs?
 The Opioid Epidemic/SUD 11

AT-RISK DRINKING
AT-RISK DRINKING
PER WEEK PER OCCASION
MEN Per Week > 14 DRINKSPer Occasion
> 4 DRINKS
Men >14 Drinks >4 Drinks
WOMEN > 7 DRINKS > 3 DRINKS
Women >7 Drinks >3 Drinks
Age >65 >7 Drinks >3 Drinks

Not ready Very ready

SBIRT: Brief Negotiated Interview (BNI) Steps

1. Screen patient (use NIAAA, CAGE or CRAFFT)

2. Raise subject • Hello, I am _______. Would you mind taking a few minutes to talk
with me about your alcohol/ drug use? <<PAUSE>>
3. Provide feedback
Review screen • From what I understand you are drinking/using [insert screening
data]… We know that drinking above certain levels can cause
problems, such as [insert facts]…I am concerned about your
drinking/drug use.
Make connection • What connection (if any) do you see between your drinking/ drug
use and this medical visit?
If patient sees connection: reiterate what patient has said
If patient does not see connection: make one using facts
Show NIAAA guidelines • These are what we consider the upper limits of low risk drinking
& norms for your age and sex. By low risk we mean that you would be less
likely to experience illness or injury if you stayed within these
guidelines.
12 Albert Anthony Rundio, Jr.

SBIRT: Brief Negotiated Interview (BNI) Steps (Continued)

4. Enhance motivation
Readiness to change • [Show readiness ruler] On a scale from 1-10, how ready are you
to change any aspect of your drinking or seek treatment?
Develop discrepancy • If patient says:
>2 ask Why did you choose that number and not a lower one?
<1 or unwilling, ask What would make this a problem for you?
How important would it be for you to prevent that from happening?
Have you ever done anything you wish you hadn’t while drinking?
Discuss pros & cons.
5. Negotiate & advise
Negotiate goal • Reiterate what patient says in Step 3 and say, what’s the next step?
Give advice • If you can stay within these limits you will be less likely to
experience [further] illness or injury related to alcohol/drug use.
Summarize • This is what I’ve heard you say…Here is a drinking/treatment
agreement I would like you to fill out, reinforcing your new drinking
or treatment goals. This is really an agreement between you and
yourself.
Provide handouts • Provide:
‒ Drinking agreement or treatment agreement
‒ Patient general health information handout
Suggest PC f/u • Suggest f/u to discuss drinking/ drug use
Thank patient • Thank patient for his/her time
Source: Project ED Health, D’Onofrio G, Pantalon MV, Degutis LC, Fiellin DA, O’Connor PG.
(NIAAA).

A. WHO - ASSIST V3.0

INTERVIEWER ID C OUNTRY C LIN IC

PATIENT ID DATE

INTRODUCTION (Please read to patient )

Thank you for agreeing to take part in this brief interview about alcohol,
tobacco products and other drugs. I am going to ask you some questions about your
 The Opioid Epidemic/SUD 13

experience of using these substances across your lifetime and in the past three
months. These substances can be smoked, swallowed, snorted, inhaled, injected or
taken in the form of pills (show drug card).
Some of the substances listed may be prescribed by a doctor (like
amphetamines, sedatives, pain medications). For this interview, we will not record
medications that are used as prescribed by your doctor. However, if you have taken
such medications for reasons other than prescription, or taken them more frequently
or at higher doses than prescribed, please let me know. While we are also interested
in knowing about your use of various illicit drugs, please be assured that information
on such use will be treated as strictly confidential.

Note: Before Asking Questions, Give Assist Response Card to Patient

Question 1

(If completing follow-up please cross check the patient’s answers with the
answers given for Q 1 at baseline. Any differences on this question should be
queried)

In your life, which of the following substances have you ever used? No Yes
(NON--MEDICAL USE ONLY)
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) 0 3
b. Alcoholic beverages (beer, wine, spirits, etc.) 0 3
c. Cannabis (marijuana, pot, grass, hash, etc.) 0 3
d. Cocaine (coke, crack, etc.) 0 3
e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) 0 3
f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) 0 3
g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) 0 3
h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) 0 3
i. Opioids (heroin, morphine, methadone, codeine, etc.) 0 3
j. Other - specify: 0 3

Probe if all answers are negative:

“Not even when you were in school?”
If “No” to all items, stop interview.
If “Yes” to any of these items, ask Question 2 for each substance ever used.
14 Albert Anthony Rundio, Jr.

A. WHO - ASSIST V3.0 (Continued)

Question 2

In the past three months, how often Never Once Monthly Weekly Daily
have you used the substances you or or
mentioned (FIRST DRUG, SECOND twice almost
DRUG, ETC)? daily
a. Tobacco products (cigarettes, chewing 0 2 3 4 6
tobacco, cigars, etc.)
b. Alcoholic beverages (beer, wine, 0 2 3 4 6
spirits, etc.)
c. Cannabis (marijuana, pot, grass, hash, 0 2 3 4 6
etc.)
d. Cocaine (coke, crack, etc.) 0 2 3 4 6
e. Amphetamine type stimulants (speed, 0 2 3 4 6
diet pills, ecstasy, etc.)
f. Inhalants (nitrous, glue, petrol, paint 0 2 3 4 6
thinner, etc.)
g. Sedatives or Sleeping Pills (Valium, 0 2 3 4 6
Serepax, Rohypnol, etc.)
h. Hallucinogens (LSD, acid, 0 2 3 4 6
mushrooms, PCP, Special K, etc.)
i. Opioids (heroin, morphine, methadone, 0 2 3 4 6
codeine, etc.)
j. Other - specify: 0 2 3 4 6

If “Never” to all items in Question 2, skip to Question 6.

If any substances in Question 2 were used in the previous three months, continue with Questions 3,
4 & 5 for each substance used.

Question 3

During the past three months, how Never Once Monthly Weekly Daily
often have you had a strong desire or or or
urge to use (FIRST DRUG, SECOND twice almost
DRUG, ETC)? daily
a. Tobacco products (cigarettes, chewing 0 3 4 5 6
tobacco, cigars, etc.)
b. Alcoholic beverages (beer, wine, 0 3 4 5 6
spirits, etc.)
c. Cannabis (marijuana, pot, grass, hash, 0 3 4 5 6
etc.)
 The Opioid Epidemic/SUD 15

During the past three months, how Never Once Monthly Weekly Daily
often have you had a strong desire or or or
urge to use (FIRST DRUG, SECOND twice almost
DRUG, ETC)? daily
d. Cocaine (coke, crack, etc.) 0 3 4 5 6
e. Amphetamine type stimulants (speed, 0 3 4 5 6
diet pills, ecstasy, etc.)
f. Inhalants (nitrous, glue, petrol, paint 0 3 4 5 6
thinner, etc.)
g. Sedatives or Sleeping Pills (Valium, 0 3 4 5 6
Serepax, Rohypnol, etc.)
h. Hallucinogens (LSD, acid, 0 3 4 5 6
mushrooms, PCP, Special K, etc.)
i. Opioids (heroin, morphine, methadone, 0 3 4 5 6
codeine, etc.)
j. Other - specify: 0 3 4 5 6

Question 4

During the past three months, how often Never Once Monthly Weekly Daily
has your use of (FIRST DRUG, or or
SECOND DRUG, ETC) led to health, twice almost
social, legal or financial problems? daily
a. Tobacco products (cigarettes, chewing 0 4 5 6 7
tobacco, cigars, etc.)
b. Alcoholic beverages (beer, wine, spirits, 0 4 5 6 7
etc.)
c. Cannabis (marijuana, pot, grass, hash, 0 4 5 6 7
etc.)
d. Cocaine (coke, crack, etc.) 0 4 5 6 7
e. Amphetamine type stimulants (speed, 0 4 5 6 7
diet pills, ecstasy, etc.)
f. Inhalants (nitrous, glue, petrol, paint 0 4 5 6 7
thinner, etc.)
g. Sedatives or Sleeping Pills (Valium, 0 4 5 6 7
Serepax, Rohypnol, etc.)
h. Hallucinogens (LSD, acid, mushrooms, 0 4 5 6 7
PCP, Special K, etc.)
i. Opioids (heroin, morphine, methadone, 0 4 5 6 7
codeine, etc.)
j. Other - specify: 0 4 5 6 7
16 Albert Anthony Rundio, Jr.

A. WHO - ASSIST V3.0 (Continued)

Question 5

During the past three months, how often Never Once Monthly Weekly Daily
have you failed to do what was normally or or
expected of you because of your use of twice almost
(FIRST DRUG, SECOND DRUG, ETC)? daily
a. Tobacco products
b. Alcoholic beverages (beer, wine, spirits, 0 5 6 7 8
etc.)
c. Cannabis (marijuana, pot, grass, hash, 0 5 6 7 8
etc.)
d. Cocaine (coke, crack, etc.) 0 5 6 7 8
e. Amphetamine type stimulants (speed, diet 0 5 6 7 8
pills, ecstasy, etc.)
f. Inhalants (nitrous, glue, petrol, paint 0 5 6 7 8
thinner, etc.)
g. Sedatives or Sleeping Pills (Valium, 0 5 6 7 8
Serepax, Rohypnol, etc.)
h. Hallucinogens (LSD, acid, mushrooms, 0 5 6 7 8
PCP, Special K, etc.)
i. Opioids (heroin, morphine, methadone, 0 5 6 7 8
codeine, etc.)
j. Other - specify: 0 5 6 7 8

Ask Questions 6 & 7 for all substances ever used (i.e., those endorsed in Question 1)

Question 6

Has a friend or relative or anyone else ever No, Yes, in the Yes, but not in
expressed concern about your use of Never past 3 the past 3 months
(FIRST DRUG, SECOND DRUG, ETC.)? months
a. Tobacco products (cigarettes, chewing tobacco, 0 6 3
cigars, etc.)
b. Alcoholic beverages (beer, wine, spirits, etc.) 0 6 3
Has a friend or relative or anyone else ever No, Yes, in the Yes, but not in the
expressed concern about your use of (FIRST Never past 3 past 3 months
DRUG, SECOND DRUG, ETC.)? moths
c. Cannabis (marijuana, pot, grass, hash, etc.) 0 6 3
d. Cocaine (coke, crack, etc.) 0 6 3
e. Amphetamine type stimulants (speed, diet pills, 0 6 3
ecstasy, etc.)
f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) 0 6 3
 The Opioid Epidemic/SUD 17

Has a friend or relative or anyone else ever No, Yes, in the Yes, but not in
expressed concern about your use of Never past 3 the past 3 months
(FIRST DRUG, SECOND DRUG, ETC.)? months
g. Sedatives or Sleeping Pills (Valium, Serepax, 0 6 3
Rohypnol, etc.)
h. Hallucinogens (LSD, acid, mushrooms, PCP, 0 6 3
Special K, etc.)
i. Opioids (heroin, morphine, methadone, codeine, 0 6 3
etc.)
j. Other – specify: 0 6 3

Question 7

Have you ever tried and failed to control, cut No, Yes, in the Yes, but not in
down or stop using (FIRST DRUG, SECOND Never past 3 the past 3
DRUG, ETC.)? months months
a. Tobacco products (cigarettes, chewing tobacco, 0 6 3
cigars, etc.)
b. Alcoholic beverages (beer, wine, spirits, etc.) 0 6 3
c. Cannabis (marijuana, pot, grass, hash, etc.) 0 6 3
d. Cocaine (coke, crack, etc.) 0 6 3
e. Amphetamine type stimulants (speed, diet pills, 0 6 3
ecstasy, etc.)
f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) 0 6 3
g. Sedatives or Sleeping Pills (Valium, Serepax, 0 6 3
Rohypnol, etc.)
h. Hallucinogens (LSD, acid, mushrooms, PCP, 0 6 3
Special K, etc.)
i. Opioids (heroin, morphine, methadone, codeine, 0 6 3
etc.)
j. Other – specify: 0 6 3

Question 8

No, Yes, in the past 3 Yes, but not in the

Never months past 3 months
Have you ever used any drug by injection? 0 2 1
(NON--MEDICAL USE ONLY)

IMPORTANT NOTE:
Patients who have injected drugs in the last 3 months should be asked about
their pattern of injecting during this period, to determine their risk levels and the
best course of intervention.
18 Albert Anthony Rundio, Jr.

A. WHO - ASSIST V3.0 (Continued)

PATTERN OF INJECTING INTERVENTION GUIDELINES

Once weekly or less or Brief intervention including “risks
Fewer than 3 days in a row associated with injecting “ card
More than once per week or Further assessment and more
3 or more days in a row intensive treatment*

How to Calculate a Specific Substance Invsubstance Involvement Score

For each substance (labelled a. to j.) add up the scores received for questions 2
through 7 inclusive. Do not include the results from either Q1 or Q8 in this score.
For example, a score for cannabis would be calculated as: Q2c + Q3c + Q4c + Q5c
+ Q6c + Q 2c + Q 3c + Q 4c + Q 5c + Q 6c + Q 7cQ7c
Note that Q 5 for tobacco is not coded, and is calculated as: Q 2a + Q 3a + Q 4a +
Q 6a + Q 7a

THE TYPE OF INTERVENTION IS DETERMINED BY THE PATIENT’S

SPECIFIC SUBSTANCE INVOLVEMENT SCORE

Record specific no receive brief more intensive

substance score intervention intervention treatment *
a. tobacco 0-3 4 - 26 27+
b. alcohol 0 - 10 11 - 26 27+
c. cannabis 0-3 4 - 26 27+
d. cocaine 0-3 4 - 26 27+
e. amphetamine 0-3 4 - 26 27+
f. inhalants 0-3 4 - 26 27+
g. sedatives 0-3 4 - 26 27+
h. hallucinogens 0-3 4 - 26 27+
i. opioids 0-3 4 - 26 27+
j. other drugs 0-3 4 - 26 27+
NOTE: *FURTHER ASSESSMENT AND MORE INTENSIVE TREATMENT may be provided
by the health professional(s) within your primary care setting, or, by a specialist drug and
alcohol treatment service when available.

Source: World Health Organization: Accessed on June 16, 2020@ https://www.who.int/management-of-

substance-use/assist
 The Opioid Epidemic/SUD 19

B. WHO ASSIST V3.0 RESPONSE CARD FOR PATIENTS

Response Card -- Substances

a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)

b. Alcoholic beverages (beer, wine, spirits, etc.)
c. Cannabis (marijuana, pot, grass, hash, etc.)
d. Cocaine (coke, crack, etc.)
e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)
f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)
g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)
h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)
i. Opioids (heroin, morphine, methadone, codeine, etc.)
j. Other - specify:

Response Card (ASSIST Q uestions 2 – 5)

Never: not used in the last 3 months

Once or twice: 1 to 2 times in the last 3 months

Monthly: 1 to 3 times in one month

Weekly: 1 to 4 times per week

Daily or almost daily: 5 to 7 days per week

Response Card (ASSIST Questions 6 to 8)

No, Never

Yes, but not in the past 3 months

Yes, in the past 3 months

Source: World Health Organization. Assist Respone Card. Accessed on June 16, 2020 @
https://www.who.int/substance_abuse/activities/assist_test/en/
20 Albert Anthony Rundio, Jr.

C. ALCOHOL, SMOKING AND SUBSTANCE INVOLVEMENT

SCREENING TEST (WHO ASSIST V3.0) FEEDBACK
REPORT CARD FOR PATIENTS

Name________________________________Test Date _____________________

Specific Substance Involvement Scores

Substance Score Risk Level

0-3 Low
a. Tobacco products 4-26 Moderate
27+ High
0-10 Low Moderate
b. Alcoholic Beverages 11-26
27+ High
0-3 Low
c. Cannabis 4-26 Moderate
27+ High
0-3 Low
d. Cocaine 4-26 Moderate
27+ High
0-3 Low
e. Amphetamine type stimulants 4-26 Moderate
27+ High
0-3 Low
f. Inhalants 4-26 Moderate
27+ High
0-3 Low
g. Sedatives or Sleeping Pills 4-26 Moderate
27+ High
0-3 Low
h. Hallucinogens 4-26 Moderate
27+ High
0-3 Low
i. Opioids 4-26 Moderate
27+ High
0-3 Low
j. Other - specify 4-26 Moderate
27+ High
 The Opioid Epidemic/SUD 21

What do your scores mean?

Low: You are at low risk of health and other problems from your current pattern of use.

Moderate: You are at risk of health and other problems from your current pattern of substance
use.
High: You are at high risk of experiencing severe problems (health, social, financial, legal,
relationship) as a result of your current pattern of use and are likely to be dependent

Are you concerned about your substance use?

a. tobacco Your risk of experiencing these harms is:……… Low Moderate High
Regular tobacco smoking is associated with:
(tick one)
Premature aging, wrinkling of the skin
Respiratory infections and asthma
High blood pressure, diabetes
Respiratory infections, allergies and asthma in children of smokers
Miscarriage, premature labour and low birth weight babies for pregnant women
Kidney disease
Chronic obstructive airways disease
Heart disease, stroke, vascular disease
Cancers

b. alcohol Your risk of experiencing these harms is:……… Low Moderate High
Regular excessive alcohol use is associated (tick one)
with:
Hangovers, aggressive and violent behaviour, accidents and injury
Reduced sexual performance, premature ageing
Digestive problems, ulcers, inflammation of the pancreas, high blood pressure
Anxiety and depression, relationship difficulties, financial and work problems
Difficulty remembering things and solving problems
Deformities and brain damage in babies of pregnant women
Stroke, permanent brain injury, muscle and nerve damage
Liver disease, pancreas disease
Cancers, suicide

c. cannabis Your risk of experiencing these harms is:…… Low Moderate High
Regular use of cannabis is associated with: (tick one)
Problems with attention and motivation
Anxiety, paranoia, panic, depression
Decreased memory and problem solving ability
High blood pressure
Asthma, bronchitis
Psychosis in those with a personal or family history of schizophrenia
Heart disease and chronic obstructive airways disease
Cancers
22 Albert Anthony Rundio, Jr.

C. Alcohol, Smoking and Substance Involvement Screening Test

(Continued)

d. cocaine Your risk of experiencing these harms is:…. Low Moderate High
Regular use of cocaine is associated with: (tick one)
Difficulty sleeping, heart racing, headaches, weight loss
Numbness, tingling, clammy skin, skin scratching or picking
Accidents and injury, financial problems
Irrational thoughts
Mood swings - anxiety, depression, mania
Aggression and paranoia
Intense craving, stress from the lifestyle
Psychosis after repeated use of high doses
Sudden death from heart problems

e. Your risk of experiencing these harms is:…. Low Moderate High

amphetamine Regular use of amphetamine type
(tick one)
type stimulants stimulants is associated with:
Difficulty sleeping, loss of appetite and weight loss, dehydration
Jaw clenching, headaches, muscle pain
Mood swings –anxiety, depression, agitation, mania, panic, paranoia
Tremors, irregular heartbeat, shortness of breath
Aggressive and violent behaviour
Psychosis after repeated use of high doses
Permanent damage to brain cells
Liver damage, brain haemorrhage, sudden death (ecstasy) in rare situations

f. inhalants Your risk of experiencing these harms is:…. Low Moderate High
Regular use of inhalants is associated with: (tick one)
Dizziness and hallucinations, drowsiness, disorientation, blurred vision
Flu like symptoms, sinusitis, nosebleeds
Indigestion, stomach ulcers
Accidents and injury
Memory loss, confusion, depression, aggression
Coordination difficulties, slowed reactions, hypoxia
Delirium, seizures, coma, organ damage (heart, lungs, liver, kidneys)
Death from heart failure
 The Opioid Epidemic/SUD 23

g. sedatives Your risk of experiencing these harms is:…. Low Moderate High
Regular use of sedatives is associated with: (tick one)
Drowsiness, dizziness and confusion
Difficulty concentrating and remembering things
Nausea, headaches, unsteady gait
Sleeping problems
Anxiety and depression
Tolerance and dependence after a short period of use
Severe withdrawal symptoms
Overdose and death if used with alcohol, opioids or other depressant drugs

h. Your risk of experiencing these harms is:…. Low Moderate High

hallucinogens Regular use of hallucinogens is associated (tick one)
with:
Hallucinations (pleasant or unpleasant) – visual, auditory, tactile, olfactory
Difficulty sleeping
Nausea and vomiting
Increased heart rate and blood pressure
Mood swings
Anxiety, panic, paranoia
Flash-backs
Increase the effects of mental illnesses such as schizophrenia

i. opioids Your risk of experiencing these harms is:…. Low Moderate High
Regular use of opiods is associated with: (tick one)
Itching, nausea and vomiting
Drowsiness
Constipation, tooth decay
Difficulty concentrating and remembering things
Reduced sexual desire and sexual performance
Relationship difficulties
Financial and work problems, violations of law
Tolerance and dependence, withdrawal symptoms
Overdose and death from respiratory failure

Source: World Health Organization. Assist Response Card. Accessed on June 16, 2020 @
https://www.who.int/substance_abuse/activities/assist_test/en/
24 Albert Anthony Rundio, Jr.

D. WHO RISKS OF INJECTING CARD –

INFORMATION FOR CLIENTS

Using substances by injection increases the risk oisk of harm from

substance use.

This harm can come from:

 The substance
- If you inject any drug you are more likely to become dependent.
- If you inject amphetamines or cocaine you are more likely to
experience psychosis.
- If you inject heroin or other sedatives you are more likely to
overdose.

 The injecting behaviour

- If you inject you may damage your skin and veins and get
infections.
- You may cause scars, bruises, swelling, abscesses and ulcers.
- Your veins might collapse.
- If you inject into the neck you can cause a stroke.

 Sharing of injecting equipment

- If you share injecting equipment (needles & syringes, spoons,
filters, etc.) you are more likely to spread blood borne virus
infections like Hepatitis B, Hepatitis C and HIV.

It is safer not to inject.

If you do inject:
- always use clean equipment (e.g., needles & syringes, spoons,
filters, etc.)
- always use a new needle and syringe
 The Opioid Epidemic/SUD 25

- don’t share equipment with other people

- clean the preparation area
- clean your hands
- clean the injecting site
- use a different injecting site each time
- inject slowly
- put your used needle and syringe in a hard container and dispose
of it safely

If you use stimulant drugs like amphetamines or cocaine the following

tips will help you reduce your risk of psychosis.

- avoid injecting and smoking

- avoid using on a daily basis

If you use depressant drugs like heroin the following tips will help you
reduce your risk of overdose.

- avoid using other drugs, especially sedatives or alcohol, on the

same day
- use a small amount and always have a trial “taste” of a new
batch
- have someone with you when you are using
- avoid injecting in places where no-one can get to you if you do
overdose
- know the telephone numbers of the ambulance service

Source: World Health Organization. Accessed on June 16, 2020 @

https://www.sahealth.sa.gov.au/wps/wcm/connect/195b8b80400eede1ae33bf4826472d56/ASSIS
T+HO9+WHO+-+ASSIST+v3+0+risks+of+ injecting+card+information-DASSA-June2013.pdf?
MOD=AJPERES&amp;CACHEID=ROOTWORKSPACE-195b8b80400eede1ae33bf4826472d
56-n5i-trB
26 Albert Anthony Rundio, Jr.

E. TRANSLATION AND ADAPTATION TO LOCAL

LANGUAGES AND CULTURE: A RESOURCE FOR
CLINICIANS AND RESEARCHERS

The ASSIST instrument, instructions, drug cards, response scales and

resource manuals may need to be translated into local languages for use in
particular countries or regions. Translation from English should be as direct
as possible to maintain the integrity of the tools and documents. However,
in some cultural settings and linguistic groups, aspects of the ASSIST and
its companion documents may not be able to be translated literally and there
may be socio-cultural factors that will need to be taken into account in
addition to semantic meaning. In particular, substance names may require
adaptation to conform to local conditions, and it is also worth noting that the
definition of a standard drink may vary from country to country.
Translation should be undertaken by a bi-lingual translator, preferably a
health professional with experience in interviewing. For the ASSIST
instrument itself, translations should be reviewed by a bi-lingual expert
panel to ensure that the instrument is not ambiguous. Back translation into
English should then be carried out by another independent translator whose
main language is English to ensure that no meaning has been lost in the
translation. This strict translation procedure is critical for the ASSIST
instrument to ensure that comparable information is obtained wherever the
ASSIST is used across the world.
Translation of this manual and companion documents may also be
undertaken if required. These do not need to undergo the full procedure
described above, but should include an expert bi-lingual panel.
Before attempting to translate the ASSIST and related documents into
other languages, interested individuals should consult with the WHO about
the procedures to be followed and the availability of other translations. Write
to the Department of Mental Health and Substance Dependence, World
Health Organisation, 1211 Geneva 27, Switzerland.

Source: World Health Organization. Accessed on June 16, 2020 @

https://www.who.int/substance_abuse/research_tools/translation/en/
 The Opioid Epidemic/SUD 27

CAGE QUESTIONNAIRE

 Have you ever felt you should Cut down on your drinking?
 Have people Annoyed you by criticizing your drinking?
 Have you ever felt bad or Guilty about your drinking?
 Have you ever had a drink first thing in the morning to steady your
nerves or to get rid of a hangover (Eye opener)?

Scoring

Item responses on the CAGE are scored 0 or 1, with a higher score an

indication of alcohol problems. A total score of 2 or greater is considered
clinically significant.
***
Developed by Dr. John Ewing, founding Director of the Bowles Center
for Alcohol Studies, University of North Carolina at Chapel Hill, CAGE is
an internationally used assessment instrument for identifying alcoholics. It
is particularly popular with primary care givers. CAGE has been translated
into several languages.
The CAGE questions can be used in the clinical setting using informal
phrasing. It has been demonstrated that they are most effective when used
as part of a general health history and should NOT be preceded by questions
about how much or how frequently the patient drinks (see “Alcoholism: The
Keys to the CAGE” by DL Steinweg and H Worth; American Journal of
Medicine 94: 520-523, May 1993.
The exact wording that can be used in research studies can be found in:
JA Ewing “Detecting Alcoholism: The CAGE Questionaire” JAMA 252:
1905-1907, 1984. Researchers and clinicians who are publishing studies
using the CAGE Questionaire should cite the above reference. No other
permission is necessary unless it is used in any profit-making endeavor in
which case this Center would require to negotiate a payment.

Source: Dr. John Ewing, founding Director of the Bowles Center for Alcohol Studies, University
of North Carolina at Chapel Hill, NC, US.
28 Albert Anthony Rundio, Jr.

CLINICAL OPIATE WITHDRAWAL SCALE (COWS)

Flow-Sheet for Measuring Symptoms for Opiate Withdrawals

over a Period of Time

For each item, write in the number that best describes the patient’s signs
or symptom. Rate on just the apparent relationship to opiate withdrawal. For
example, if heart rate is increased because the patient was jogging just prior
to assessment, the increase pulse rate would not add to the score.
 The Opioid Epidemic/SUD 29

Source: American Society of Addiction Medicine. Accessed on June 16, 2020 @

https://www.asam.org/docs/default-source/education-
docs/cows_induction_flow_sheet.pdf?sfvrsn=b577fc2_2
30 Albert Anthony Rundio, Jr.

CRAFFT

C: Have you ever ridden in a car driven by someone (including yourself)

who was “high” or had been using alcohol or drugs?
R: Do you ever use alcohol or drugs to relax, feel better about yourself or
fit in?
A: Do you ever use alcohol or drugs while you are by yourself ( lone) a
f
F: Do your family or riends ever tell you that you should cut down on your
drinking or drug use?
f
F: Do you ever orget things you did while using alcohol or drugs?

t
T: Have you gotten in rouble while you were using alcohol

Source: CRAFFT. Accessed on June 16, 2020 @ https://crafft.org/

OBJECTIVE OPIOID WITHDRAWAL SCALE (OOWS)

Date………………………………………Time ……………….

OBSERVE THE PATIENT DURING A 5 MINUTE OBSERVATION PERIOD THEN

INDICATE A SCORE FOR EACH OF THE OPIOID WITHDRAWAL SIGNS LISTED BELOW
(ITEMS 1-13). ADD THE SCORES FOR EACH ITEM TO OBTAIN THE TOTAL SCORE

Sign Measures Score

1 Yawning 0 = no 1 = ≥ 1 yawn
yawns
2 Rhinorrhoea 0=<3 1 = ≥ 3 sniffs
sniffs
3 Piloerection 0 = absent 1 = present
(observe arm)
4 Perspiration 0 = absent 1 = present
5 Lacrimation 0 = absent 1 = present
 The Opioid Epidemic/SUD 31

Sign Measures Score

6 Tremor (hands) 0 = absent 1 = present
7 Mydriasis 0 = absent 1 = ≥ 3 mm
8 Hot and Cold flushes 0 = absent 1 = shivering / huddling for
warmth
9 Restlessness 0 = absent 1 = frequent shifts of position
10 Vomiting 0 = absent 1 = present
11 Muscle twitches 0 = absent 1 = present
12 Abdominal cramps 0 = absent 1 = Holding stomach
13 Anxiety 0 = absent 1 = mild - severe
TOTAL SCORE

Range 0-13

Source: Handelsman, L., Cochrane, K. J., Aronson, M. J. et al. (1987) Two New Rating Scales for
Opiate Withdrawal, American Journal of Alcohol Abuse, 13, 293-308

REFERENCES

[1] Wide-ranging online data for epidemiologic research (WONDER).

Atlanta, GA: CDC, National Center for Health Statistics; 2017.
Available at http://wonder.cdc.gov.
[2] Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and Opioid-
Involved Overdose Deaths – United States, 2013-2017. WR Morb
Mortal Wkly Rep. ePub: 21 December 2018.
[3] Kolodny et al. 2015. The prescription opioid and heroin crisis: A
public health approach to an epidemic of addictionexternal icon.
Annual Review of Public Health 2015 (36); 559-74.
[4] Bernstein, E., Bernstein, J., Stein, J., & Saitz, R. (2009). SBIRT in
emergency care settings: Are we ready to take it to scale? Academic
Emergency Medicine, 16(11), 1072-1077.
[5] Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in Drug and
Opioid Overdose Deaths – United States, 2000-2014. MMWR 2016,
64(50); 1378-82.
In: The Opioid Epidemic ISBN: 978-1-53618-217-0
Editors: A. Rundio and S. Brooks © 2020 Nova Science Publishers, Inc.

Chapter 2

THE NEUROBIOLOGY OF OPIOID

DRUG ADDICTION

William J. Lorman, PhD

College of Nursing and Health Professions, Drexel University,
Philadelphia, PA, US

ABSTRACT

Drug addiction develops as a result of a process that involves complex

interactions between biologic and environmental factors. The risk for
addiction in individuals with mental illness is significantly higher than for
the general population. Although there are psychological elements
involved in the addictive process, the pleasure-seeking behaviors leading
to euphoria are the result of a physiological process in the brain.
Ultimately, active addiction is maintained because of the physiologic
process of cravings. The more common models of addiction are presented.
34 William J. Lorman

CASE STUDY

Ben M. is a 32 year old male raised in an upper middle class

socioeconomic environment. He is the oldest of three siblings – a younger
brother and younger sister. In the household, there had always been a high
level of competition growing up. His brother and sister excelled in school,
while Ben barely got by. He was often berated by his parents because of his
poor scholastic accomplishments which only worsened his self-esteem. He
had few friends and he would often isolate in his room, watching television
and playing video games. In high school, he began experimenting with
drugs, first alcohol and then Percocet. He really didn’t enjoy the alcohol
since it made him feel more depressed. But the Percocet made him feel much
better about himself. Much later, he admitted that the Percocet really only
helped him forget how pathetic he was. With the passing of time, his
acquaintances would no longer supply him with drugs so he was directed to
a dealer in the area who introduced him to oxycodone. His dealer taught him
how to efficiently crush and snort the drug to get its maximum effect. He
also taught him how to hide his addiction by explaining when the ideal time
was for using the drug and recovering from its effects – so that others would
not become suspicious.
Ben eventually graduated from high school earning only marginal
grades. With pressure from his parents, he matriculated at a community
college in Vermont. He moved away from the family home which he felt
was ideal since no one would know about his continued drug use. However,
the oxycodone was no longer ‘doing the trick’ and he had used all his savings
and stipend he was receiving from his parents. At this point, having found
another dealer, he was introduced to heroin. It cost much less and produced
a much more extreme level of euphoria. Again, the instantaneous ‘high’ was
decreasing and he began injecting the heroin – often sharing needles. He
would often skip school because of the time it took to recover from the
heroin and also because of the onset of withdrawal symptoms. After failing
his first two semesters at college, he was forced to leave school and return
home. Armed with ‘believable’ excuses, his family attributed his failure to
his inability to do the work. He decided to take courses in carpentry and
Other documents randomly have
different content
 XLVIII.
OUT OF PRISON.

WONDERFUL ESCAPE FROM A FRENCH PRISON.—PLANS OF ESCAPE.—A LONG

LABOR.—TUNNELLING THROUGH A WALL.—INGENUITY OF A SAILOR.—LUCKY
ACCIDENTS.—DISCOURAGING EVENTS.—HOW SUCCESS WAS ATTAINED.—
ELUDING THE GUARDS.—REACHING A PLACE OF SAFETY.

Among the most remarkable efforts of prisoners to escape from

their confinement was that of some French Communists, who were
sentenced to incarceration upon their failure to establish their
government in France, after the downfall of Louis Napoleon in the
disaster at Sedan. The story, as told by one of them, is of the most
thrilling character.

We were political prisoners—three hundred of us—in the fortress

of Port Louis, a part of that line of fortifications which was built by
Sully to defend the French coast from Brest to La Rochelle. At high
tide the fortress is entirely surrounded by the sea, and
communicates with the land only by a bridge. Round its circuit runs
a rampart on which the casemates abut. The entrance is opposite
the bridge—that is to say, facing the peninsula on which stands the
little town of Port Louis. On the left are the offices of the prison
authorities and the residence of the governor; on the right, the
quarters of the soldiers. In the centre of the fortress are barracks,
forming a square, and having an inner court; and it is here that the
prisoners are confined. The soldiers are strictly forbidden to speak to
the prisoners. Their duty consists in mounting guard on the terrace
running along above the casemates. A road, known as the Round
Road, goes round the citadel, and separates the casemates from the
buildings in which the prisoners are confined. The ground floor,
occupied by the prisoners, is divided into twenty dormitories, of
unequal size, containing from seven to thirty prisoners each.
The dormitories are lighted by windows
looking out on one side on the Round PULLING NAILS WITH
FINGERS.
Road, and on the other side on the inner
court; and these windows are protected by strong iron bars. Having
observed that the floor boards were badly joined, the idea occurred
to us of working out with our finger-nails the nails by which they
were fastened; and having done this, we discovered under our room
large excavations without any outlet, which had doubtless been
formed for ventilation. On lifting two of the floor boards under my
bed, we were able to descend into this cellar; and then, after
working holes in the walls separating the different compartments,
we reached the foundation wall abutting on the Round Road.
Immediately the working party had descended into the cellar, the
floor boards were replaced, and were only lifted again when it was
necessary for those below to remount. The only tools we had were
large nails or spikes, which had been used in fixing the stand for the
arms, these quarters having formerly been occupied by soldiers. We
had worked out these nails with our hands; and to do so had cost us
several days’ labor and no little laceration of fingers. We then
conceived the idea of excavating a tunnel to run from the cellar to
the sea. We found that we were just on a level with the Round
Road; but this road served as a thoroughfare for wagons loaded with
powder, and for all the vehicles bringing provisions and other stores
into the citadel. It was therefore necessary, before excavating the
tunnel, to sink a vertical shaft about thirteen feet in depth, in order
that the superincumbent weight of the wagons passing might not
cause the road to fall in.
Digging with the nails, we loosened the
UNDER THE ROUND
earth, which we then scooped up in a tin
ROAD.
plate which we had been able to conceal.
When we had in this manner filled a dinner napkin, we formed a sort
of chain, and passed from hand to hand the napkin full of earth,
which was deposited in the farthest of the underground
compartments and well trampled down, so that it might occupy as
small a space as possible. There were only six of us to carry on this
work, for the numberless difficulties which stood in the way of our
escape had discouraged the others. We followed to the last the
same method of disposing of the earth and the stones, which we
worked out one by one after incredible efforts. Having finished this
shaft of thirteen feet in depth, we commenced the horizontal tunnel.
We had in the first place to pass under the Round Road, which is
twenty-two or twenty-three feet in width. As the earth was much
easier of excavation than stone, we excavated our gallery with a
downward slope, in order that we might be able to pass underneath
the foundation wall of the casement facing our dormitory. Thanks to
this slope, we succeeded so well that for a space of about forty-six
feet—that is to say, until we reached the wall of the rampart—we
had only to work through earth. This tunnel was just large enough
for one man to creep along in it. We therefore took our turns at the
excavations, lying flat on our faces. Unforeseen accidents occurred
to increase the difficulties, already great, which we had to surmount.
The part of the tunnel passing under the Round Road,
notwithstanding the depth below the surface at which it was
excavated, and notwithstanding the care we took to construct it
arch-shaped, so that it might be better able to support the heavy
weights passing above, threatened entirely to fall in. Heavy rains had
loosened the soil, and pretty large masses of earth fell every day. It
was necessary that this part of the tunnel should be propped up.
How could it be done? One of our number, who had been a sailor,
and who was a resolute and enterprising man, as sailors usually are,
conceived the idea of supporting the earth by packing against the
sides of the tunnel the stones which we had removed from the walls.
This was done; and the downfall from above being thereby
effectually prevented, we were able to continue our labors. A second
accident, which seemed at first much more serious, then occurred,
threw us into a fever of anxiety, and delayed the accomplishment of
our project. When our tunnel had attained a length of about thirty-
three feet, we could not get our light to burn. We thought this
phenomenon was caused by want of air, and this is what we did to
remedy the defect. While one of our number was kept constantly at
work excavating, another, standing in the shaft at the entrance of
the tunnel, and making a sort of fan of his jacket, forced a strong
current of air into the tunnel. However, after some few days, when
the length of the passage had been increased by a little more than a
yard, there was no longer any need of our improvised ventilator, as
the light burned of itself. There doubtless occurred in this part of the
earth some gas which prevented our light from burning; and this
gas, having little by little become dispersed, the phenomenon
ceased.
At length, after being distracted by
doubts and fears, after the innumerable REACHING THE RAMPART.
difficulties which every day for three months we had encountered,—
difficulties which we should never have overcome but by dint of
sheer energy, and thanks to that incredible patience with which
prisoners only are endowed,—we reached the wall of the rampart. A
few more days of labor and suffering and we shall be free. Free! The
reader will understand what courage and hope that word must have
given us to induce us to undertake and enable us to accomplish a
work which, under any other circumstances, would have appeared to
us as simple madness. Alas! it was at the very moment when we
seemed to be approaching the end of our fatigues that the obstacles
became most difficult to surmount. Some of our number seemed
ready to abandon the task which for more than three months we
had been prosecuting. All our labor was going to be thrown away.
Again it was the energy of the sailor which saved us, and gradually
revived the hopes of his weaker brethren. The wall of the rampart
which we had still to pierce, and which is, of course, intended to
resist cannon-shot, seemed to us proof against anything. It is
constructed of enormous blocks of granite, jammed tightly together
by smaller stones driven in like wedges, and the whole is united into
one solid mass by means of Roman cement, which has become as
hard as the stone itself. We endeavored with the nails—the only
tools we had, and which we had put in wooden handles—to loosen
the joints of the stones. With another piece of wood we had made a
mallet, and to get the wood necessary for these purposes we had
broken up the musket-stand and the barrack-shelves.
But the only result of our efforts was to
IMPROVISING TOOLS.
blunt our implements. What could we do
to supply our lack of tools? Our first
A DISCOURAGING
thought was to take away a bar from one SITUATION.
of our bedsteads, which were of iron; and
this we did. This bar which we took was two feet in length and
about as large round as a man’s thumb. After using one of the ends
of this bar against the stone, we tried what use we could make of it
as a lever. But the stones were too hard and too heavy, and our iron
bar bent like a switch. What could we do now? We were not
disposed to abandon at the last moment a project which had cost us
so much toil; and yet we had many times emerged from our tunnel
with the skin rubbed off our hands, and our faces as red as fire,
having hardly succeeded, after long days of fatiguing labor, in
working out a stone about as big as one’s fist. At length the bright
thought occurred to one of us of making the very things which had
been intended to secure our confinement contribute towards our
escape. We determined to remove one of the iron bars which
guarded the window. These bars were five feet and a half in length,
and an inch and a half thick. But, in order that the warders might
not perceive that one of them had been taken away, we first of all
made an imitation bar of a piece of wood, cut from one of the broad
shelves, and which we colored with ink and blacking. When this was
finished and dry, we succeeded in unfastening with nails one of the
bars of the window. We watched for a moment when the sentinel on
the rampart opposite our window had his back towards us, and little
by little loosened the stones in which the bar was set. When this was
done, taking advantage of one very lucky moment, we gave the bar
a wrench, got it out, and instantly replaced it by the imitation bar of
wood. We then took the precaution of stopping up with bread
crumbs—which we kneaded so as to look like mortar—the hole made
in loosening the bar, and afterwards threw a handful of dust over the
whole, that the different shades of color might not betray our
device. This bar of iron became in our hands a formidable weapon.
Without it we must inevitably have lost all the fruit of our labors.
When we were in possession of this formidable tool, as we had now
to attack stone, it was impossible for us to continue to work lying
flat on our faces, as we had done when it was a simple question of
burrowing in the earth. It was absolutely necessary that we should
have complete control over all our movements. We were obliged,
therefore, before resuming our attack on the wall, to enlarge this
part of our tunnel, and to excavate in front of the wall a little
chamber high enough for two men to work there on their knees, and
large enough for us to use the iron bar to advantage. Of this bar we
made, as occasion required, a crowbar or a ram. Then, and not till
then, did we make any real impression on the wall. The scraps of
information which we had been able to gather from the unguarded
talk of the warders had given us a false idea with respect to the
thickness of this rampart. We thought it was only about six or six
and a half feet thick, whereas in reality it was more than sixteen
feet. When, therefore, after indescribable labor, we had worked
away the stone bit by bit, and made our hole six feet and a half in
depth, we were disconcerted to see no sign that we were
approaching the end of our labors. Far from being discouraged by
this, however, we redoubled our efforts, and our astonishment
increased as the hole became deeper. Still we worked on. The hole
became ten feet deep; then twelve feet; then fourteen feet; and it
was not until we had dug sixteen and a half feet into the wall, that
the man who happened just then to be at work giving a heavy blow
to the stone, pierced it, and after being dazzled for a moment by the
sudden entry of the light, saw the sea stretching out in front of him.
He immediately stopped up the aperture, and came to impart the
welcome news to his comrades. We took counsel together, and
decided that our escape should be attempted that very night.
And here I must interrupt the course of
my narrative for a moment in order to give ROUTINE OF THE PRISON.
the reader a few necessary explanations. “How was it,” he will say,
“that the officials did not perceive the destruction of the wood-work
which you had been obliged to break up to make the handles of your
tools, and the bar of wood with which you had replaced the iron bar
of the window?” To this question I have a very simple answer to
give. The officials of the prison had very little to do with us. The
warders never came into our rooms except morning and evening,
when they came to call the muster-roll. These visits were made at
fixed hours, and I need hardly say that we were always sure to be
present when they were made. We took good care, too, to work only
in the daytime, for in the silence of night the dull blows struck
underground would have been audible above. The warders went
from room to room, calling over the muster-roll, and having seen
that all the prisoners were in their places, immediately retired
without troubling themselves about what might be going on.
Besides, no détenu wishing to retain the good opinion of his
comrades ever spoke to the warders; and these latter, finding
themselves thus isolated, sought no intercourse with the prisoners.
Again, détention being an essentially political punishment, we were
not subjected to hard labor, and within the court, as well as in our
rooms, were absolutely free. Another question which the reader will
have asked is this: “How did you manage to keep your secret
unknown during these four months?” Again his curiosity shall be
satisfied. There was no secret, and there could not have been any. It
was impossible for us to descend into our cellar and tunnel, or to
remount to the surface, without being seen by those of our fellow-
prisoners who happened to be in our dormitory. The dormitories
being open all day long, the prisoners passed freely from one room
to another, and by degrees they had all come to know of our
resolution. The majority dissuaded us, and endeavored to point out
all the difficulties which stood in our way. Our project seemed to
them an absolutely impossible one. They thought that, our work
having lasted so long, the officials had got scent of it, and were
letting us go on, because they intended to have soldiers stationed
ready to shoot us when we attempted to make our escape. We
allowed our comrades to talk thus, and only asked one thing of them
—that they would not betray our project. This they all promised,
and, as the reader will see, they kept their word. I must, however,
add that we had deceived them as to the time of our departure.
When they inquired as to the condition of our work, we carefully
guarded ourselves from revealing the stage at which we had arrived.
Several times I gave them to understand that our work would not be
finished before the end of January; and on the very day when
everything was finished, we had given no sign of our approaching
departure until we were about to set out. We had nothing more to
do but to enlarge the hole we had made in the day, and to get out
through that aperture.
The rampart which we had pierced is on
the left of the citadel, and therefore faces DECEIVING THE GUARDS.
seaward. When the tide is low the sea retires and leaves the rocks
dry for a distance of sixty or seventy feet around. On the night of
our escape the evening muster-roll was called as usual, and we were
shut up in our dormitories. Almost immediately two of our number
went down to complete the enlargement of the hole, and this labor
occupied them two hours. On their return we informed our
companions that the moment for our escape had arrived. Their
emotion was certainly greater than ours. Before setting out we took
the precaution of placing in our beds our bolsters, made to look as
much as possible like a man’s body, and with our night-caps stuck at
the top. We also spread our prison clothes on our beds, as we were
in the habit of doing every evening. Our object in adopting these
precautions was to deceive the warder when he came in the
morning to call over the muster-roll. The stratagem succeeded, and
the officials did not know of our flight until six o’clock the next
evening. This was very fortunate for us, as otherwise we should not
have been able to get away any great distance from the citadel, and
we should infallibly have been retaken. It was the 14th of November,
at nine o’clock in the evening; the tide was out, and the rocks at the
foot of the rampart were left bare. We had been able to find out the
times of the tides in the almanac at the canteen. Our precautions
had been all carefully taken, and, thanks to the depth of the shaft
we had sunk at the entrance of the tunnel, and to the slope given to
the tunnel itself, the hole which we had made in the wall of the
rampart was only ten feet above the rocks.
One after another we crept through the
tunnel, and then getting through the hole OUT IN THE OPEN AIR.
in the wall, we were able, while still clinging with our hands to the
wall of the rampart, to reach with a drop the rocks beneath. Then,
following all the bends of the wall, and keeping as near to it as
possible, we passed around to the land side of the fortress. In like
manner we passed along over the beach, keeping as near as
possible to the little town, situated about one thousand yards from
the fortress; and thus at length, after creeping silently between the
huts of the coast-guardsmen, we reached the dry land opposite a
little village called Loe Malo. The tide was now coming in. It had
been our intention to divide, as soon as we were clear of the
fortress, into two groups of three men each, only six prisoners
having ventured to escape. We, however, marched on together, and
without resting during the remainder of the night, in order, as
quickly as possible, to put as much distance as we could between us
and the fortress. Our object was to reach some little port of Brittany,
and then endeavor to take ship for England. When we were brought
to the citadel the authorities had caused us to be minutely searched,
and had not left any money in our possession. I had, however,
succeeded in concealing a small sum by carefully sewing it into the
lining of my coat. This money was of the greatest service to us, as it
enabled us on the following morning to take the railway, and thus in
a few hours to put a considerable distance between us and the
citadel.
After marching all night, however,
through a drenching rain, if we had FREEDOM AT LAST.
presented ourselves at the railway station as we then were, our
appearance would have excited suspicion. We had taken the
precaution of bringing with us from the prison shirts, brushes,
blacking, and, in short, everything necessary to our toilet. In a place
of concealment we carefully brushed up and dressed ourselves to
the best of our ability; and when, at daylight, we presented
ourselves at the railway station, we were clean and tidy, and
appeared to have come from some place very near. I had brought a
book away with me from the prison, and this I carried under my arm
to give myself the look of a traveller. On our way to the railway
station we saw three gendarmes running towards us, gun in hand.
Without faltering we walked coolly on, and the gendarmes, as we
came up, politely stepped aside to let us pass. We took the train for
a small port in Brittany, and in the evening succeeded in getting on
board an English vessel. We were saved!
 XLIX.
THE GAMBLING HELLS OF GERMANY.[5]

THE FOUR GREAT SPAS.—DESCRIPTION OF BADEN, HOMBURG, WIESBADEN,

AND EMS.—ROULETTE AND ROUGE-ET-NOIR.—SPLENDOR OF THE SALOONS.
—THE PERSONS WHO FREQUENT THEM.—PROFITS AND PECULIARITIES OF
THE DIRECTION.—THE PHILOSOPHY OF GAMBLING.—WHY PLAYERS LOSE.—
STRANGE SUPERSTITION OF BETTORS.—THE INVALIDS.—DROLL SCENES AT
THE PUMP-ROOM.—THE MAN WITH A SNAKE IN HIS STOMACH.—THE ROBUST
HYPOCHONDRIAC.

The best known and the most popular of all the fashionable and
gambling watering-places in Europe are Baden-Baden, Homburg,
Wiesbaden, and Ems.
[5] The gambling spas of Germany, but not those of other countries,
have been closed since Chapters XLIX. and L. were written; but the
chapters have been left in their original form, as the present is a
better tense for description than the past.

The first, a town of some seven thousand inhabitants, is

delightfully situated in a valley of the Black Forest, on a small stream
known as the Oehlbach, eighteen miles from Carlsruhe, in the Grand
Duchy of Baden. Homburg von der Hohe, having a population of
about five thousand, is the capital of the Landgraviate of Hesse-
Homburg, and may be considered a suburb of Frankfort on the
Maine, as it is only nine miles from that city. Wiesbaden, fourteen
miles west of Frankfort, contains nearly twenty-five thousand people,
and is the capital of the Duchy of Nassau. This pleasant city is on
the Salzbach, an affluent of the Rhine, and at the foot of the
delightful Taunus Mountains, its situation and climate being almost
identical with those of Homburg. Ems, often called Bad-Ems, is a
hamlet on the Lahn, fifteen miles north of Wiesbaden. It is also in
Nassau; is shut in by hills, has a pleasant terrace along the river, and
is surrounded by delightful scenery.
Though all these spas, or baths, as they
are styled, are in Germany, they are visited COSMOPOLITANISM OF
THE BATHS.
during the season, extending from May to
October, by invalids and pleasure-seekers from every civilized
country. July and August are the most fashionable months, and then
the springs are frequented by French, Spaniards, Dutch, English, and
Americans, as well as Germans. The principal patrons, independent
of the home population, are from France, England, and our own
country, albeit almost every nationality under the sun is represented
at those centres of folly and dissipation. I have seen Turks and
Armenians at Baden, Greeks and Persians at Homburg, Egyptians
and East Indians at Wiesbaden, and Mongols and Arabians at Ems.
Baden (it is called Baden-Baden to distinguish it from other places
of the same name) is the most fashionable of the four resorts, and
cannot be surpassed for the beauty of its scenery. The picturesque
heights rising above the valley, the ruins of the old castle overlooking
it, the magnificent views, the pleasant drives, handsome villas, and
charming walks in the neighborhood, with the agreeable and varied
society, render it remarkably inviting. The number of strangers
annually flocking to Baden is from fifty to sixty thousand, and these,
especially in midsummer, crowd the hotels and countless boarding-
houses to overflowing.
Homburg within the past ten years has also become very
fashionable, and counts its summer visitors by the tens of
thousands. It lacks the pictorial quality of Baden, but its atmosphere
is reputed to be extremely salubrious, and its society is delightful, of
course. Being so near Frankfort, many persons, particularly those in
delicate health, reside there all the year round, and many of the
Frankforters have their residences at the springs.
Wiesbaden, even more than Homburg, is the home of the
denizens of the old German capital, and by reason of its larger
population, has greater attractions than the rival watering-place. A
large number of retired bankers and merchants from various parts of
the Continent have villas at Wiesbaden, and every year the number
increases.
Ems has had, and still has, the
reputation of being patronized extensively QUALITY OF THE
VISITORS.
by crowned heads and the nobility; but the
prosperous and pleasure-loving generally are hieing to the banks of
the Lahn more and more every season, and making its society more
agreeable and democratic at the same time. The annual attendance
is much less than at any of the other three springs, but they who go
to Ems claim that the quality of its visitors more than compensates
for any want of quantity.
The four German spas are on the whole very much alike, barring
topical features. They each claim great antiquity in regard to the
fame of their waters, holding, and upon good grounds, that the old
Romans found vast benefit in the healing virtues of the baths. For
generations they were frequented only by invalids, but of late years
gayety and enjoyment have been the object of the majority of their
patrons. The gambling, it must be confessed, has been, and is still,
the chief attraction; not so much because all the visitors wish to play
themselves, but they like to see others play, and to be part of the
great variety of people whom the tables draw to the different spas.
Since the gambling has ceased, as it did last year (1872), the
German watering-places have lost much of their allurement, and the
thousands who used to go there will be represented by hundreds
merely. What is considered wickedness has unquestionably its spice
and charm for the average mind, and a certain departure from the
customary and conventional creates a species of magnetism.
The games at the baths are roulette and rouge-et-noir, frequently
called trente-et-quarante. The smallest stake allowed at roulette is a
florin (about fifty cents) and at rouge-et-noir two florins. The largest
bet that can be made at the former is four thousand florins, and the
largest bet that can be made at the latter game is five thousand six
hundred florins. The capital at the roulette table is thirty thousand
francs (six thousand dollars), and at rouge-et-noir one hundred and
fifty thousand francs (thirty thousand dollars). When this sum is won
by any of the bettors, the bank is declared broken, and the table is
closed for the day, but is re-opened on the day following for all to
test still further their good or ill luck. Newspaper correspondents are
constantly writing about the breaking of the bank at Baden or
Homburg, depending, as many such writers do, upon their
imagination for their facts. The truth is, the bank is very seldom
broken,—sometimes not more than once or twice during the whole
season,—and when it is, it almost invariably wins back from the
fortunate player all, and much more than he has gained.
The gambling saloons are in large and
SPLENDOR OF THE
splendid buildings, beautifully frescoed and SALOONS.
gilded in the interior, and luxuriously
furnished. They are called the Conversationshaus, the Cursaal or
Curhaus, containing, in addition to the gambling tables, spacious
apartments for reading, dining, dancing, and lounging. The tables
are thronged during the height of the season by elegantly dressed
men and women of divers nationalities. They are presided over by
the banker,—so he is styled,—who receives and pays out the money,
and keeps general watch over the game, and by several croupiers,
who with a little rake, draw in or push out the stakes as they are
won or lost by the bank. During July and August, the gaming
saloons, in which there are generally six or eight roulette or rouge-
et-noir tables, present a brilliant spectacle. Anybody may enter, if he
be respectably dressed and well-mannered, though he must leave
his cane or umbrella with the lackeys in the vestibule, remove his
hat, and refrain from speaking above a whisper. Why the Goddess of
Chance should be entitled to the homage of silence may seem
singular; but when it is remembered that all gamesters, while
engaged at play, are exceedingly nervous, and therefore morbidly
sensitive, it is plain enough why the strictest order and quiet should
be carefully preserved.
CONVERSATIONHAUS AT BADEN.
 CONCERT IN THE GARDENS AT BADEN.

The spectacle, I have said, is brilliant; ALL KINDS OF WOMEN.

and indeed it is. The saloons are adorned
like palaces; immense mirrors, in deep gilt frames, are upon the
walls; rich silk and lace curtains depend from the windows; gorgeous
chandeliers diffuse their radiance; velvet sofas invite to rest, and the
clink of gold tempts to hazard. About the tables are gathered young
and lovely women, richly dressed, from the cities of the old world
and the new, and men in fashionable attire, representing various
ranks, professions, and callings. There are dowager duchesses from
England, pretty countesses from France, fleshy baronesses from
Germany, delicate maidens from America, lorettes from Paris,
adventuresses from Naples, danseuses from Petersburg, and
actresses from Vienna. Spanish grandees stand shoulder to shoulder
with French communists, who fought like tigers for the possession of
the French capital; Calabrian bandits, who have retired,
independent, from the trade of throat-cutting, are in close contact
with honest Holland burghers; Russian princes hand their stakes to
professional blacklegs recently arrived from London; Swiss
statesmen exchange nods with bankrupt gamesters; and Belgian
chevaliers of industry smile, as they win, upon Teutonic
philanthropists risking a few napoleons, simply for lack of something
better to do.
The air of the players is entirely genteel, and their manners
completely negative and subdued. Whether they are lucky or
unlucky, would seem to make no difference to them; they give no
outward sign; their faces are usually immovable, unless high
breeding, as it is commonly understood, prompts them to look
cheerful when they lose, and melancholy when they win.
The slightest disturbance is very rare in the saloons. I have been
in them, day after day, without noticing the least departure from
order, or the smallest violation of conventional courtesy.
Occasionally, some undisciplined man manifests his nervousness and
excitement outwardly, when, if the stony stare or facial disapproval
of those about him does not chill him back to conventional bearing,
the lackeys, always in attendance, induce him to carry his
demonstrations into the open air.
The impression obtained from the saloons by a new comer is, that
all the habitués are amiable, insouciant, comfortable, and
prosperous. He would never suspect that, behind all this fair
comedy, lurks the sombre spirit of tragedy; that the serenest faces
mask an aching mind, and that the softest smiles hide, but do not
help, a breaking heart. Nowhere under the sun is social
masquerading more skilful and complete than in the German
temples of chance. Everything is so smooth, so decorous, so
delicate, so nicely adjusted, that one who seeks for inner contrasts
must seem like a cynic and an iconoclast. To him who can believe in
appearances, Wiesbaden and Ems are the most satisfactory places
of sojourn. They express the essence of formal conventionality, and
the rounded relation between unexceptionable raiment and
unexceptionable manners. They point to the promised land of
adaptation, and predict the millennium of mode.
There have ever been, and there ever will be, any number of
persons foolish enough to think they can break the bank, if they will
only watch the game closely, and profit by the favor of fortune. It is
this delusion which sends, year after year, so many victims to the
Conversationshaus and Cursaal, and keeps up the faith of the
victims, even after they have been ruined again and again.
The gaming saloons are governed and
regulated by a stock company, under the THE DIRECTION.
name of the Direction, which is the closest of close corporations. It is
eminently impersonal too, nobody knowing the names of, or, indeed
anything about, its members. Of course, its stock, like that of some
of our gas companies and banks in New York, is not to be had, and
is never quoted. The directors pay a license to the petty
governments under which the tables are kept, and which are largely
sustained thereby. The license varies materially. At Baden it is about
seventy-five thousand dollars a year, and the Direction, in addition
thereto, pays all the expenses of the Conversationshaus, whatever is
required for the preservation and improvement of the adjoining
grounds and gardens, and makes many other outlays, which must
increase the total sum to fully one hundred and fifty thousand
dollars. At Homburg the license is some fifty thousand dollars, and,
moreover, the Direction of the Cursaal lights the little town, keeps it
in good condition, supports its hospital and other charitable
institutions. At Ems and Wiesbaden, the government tax—for that is
what the license really is—is about sixty thousand dollars for the
former, and forty thousand dollars for the latter place.
The capital of the Direction is set down
at from two million to one million five CAPITAL OF THE BANKS.
hundred thousand dollars, though I seriously question if much more
than one tenth of the sum has ever been paid in. The tables usually
clear from two hundred and fifty thousand to five hundred thousand
dollars annually; the profits being larger, of course, at Baden than at
Ems, and varying with the season, and the luck of the bank. Not
long ago, the Homburg bank was broken five times during the year,
and yet the Direction, even then, declared a dividend, it is said, of
nearly twenty-five per cent. on their capital. The income from the
stocks of the German gambling companies is reputed to be
enormous, and I have met men in many foreign countries who were
credited by rumor with owning such shares. They had no visible
means of support, and still they lived luxuriously, even prodigally,
merely because they had had the good fortune to secure a small
amount of stock in the Cursaal or Curhaus.
The limitations and the percentage at roulette and rouge-et-noir
are seldom taken sufficiently into account by the galerie, as the
bettors are named. Those, in the long run, will beat anybody and
everybody, whatever run of luck they may have now and then. The
games are based on an ultimate certainty, almost mathematical, in
favor of the bank, and the prevalent notion that the players can have
any permanent advantage is simply absurd. The chances on the side
of the bank are so many, that, in a given time, it must inevitably win,
and win largely. All the systems by which the galerie expect to
triumph are utterly false and deceptious. They have done more, by a
certain speciousness, to lead men to their ruin, than anything
connected with the passion for hazard. They invariably fail, because
of the limitations in bets, and the percentage in favor of the tables;
but the advocate of the system very seldom reckons upon these
great drawbacks. This class of men believe that will happen which
they wish to have happen, and are therefore incapable of clear
perception of anything opposed to their theories and desires.
The one adverse fact, above any other,
to bettors generally is, that they very THE ODDS AGAINST
BETTORS.
seldom, if ever, play as recklessly when
they are winning as when they are losing. The reason is that, in the
latter circumstances, they are endeavoring to win back their stakes,
and are consequently in more or less desperate mood; while in the
former case they are satisfied with what comes to them, and not
tempted constantly to augment their bets for the sake of getting
even. Irrational and ridiculous as it appears, there certainly seems to
be such a thing as a run of luck, good or ill. We have all experienced
this many times, albeit we may express the phrase in other words.
On certain days things go wrong with us, and on certain other days
they flow smoothly and prosperously, though we are wholly
unconscious, on any of the days, of doing aught except our best to
accomplish desired results. Sitting down to a game of whist in the
evening, we find we cannot get a good hand, shuffle or change the
cards as we may. The next evening, or the next morning, high cards
and trumps come to us at every deal, as if some good genius had
arranged the deal for us. What is this but a run of luck? In gambling,
as every gambler knows, men are constantly having such runs.
Whatever card or color you lay your stake on is almost sure to win
to-day, and to-morrow almost as sure to lose. When you are
fortunate, you make your ventures with at least a moderate degree
of prudence. When you are unfortunate, your only thought is to get
back the money you have parted with, and you keep doubling your
stakes in the hope of achieving your purpose, instead of quitting the
table, as you ought, when you plainly discover that fate is against
you; or, in other words, that some mysterious and incomprehensible
influence thwarts your every purpose.
Such inexplicable agencies or influences
render gamesters superstitious. Having SUPERSTITION
GAMBLERS.
OF

seen the tribe in almost every part of the

world, I have always found them more or less tinctured with
superstition. No amount of facts or arguments will drive it out of
them, for by long indulgence it has grown to be next to an instinct.
They have implicit faith in luck of every kind—in lucky days, lucky
circumstances, lucky persons, lucky influences. Sometimes they will
not bet themselves, but will ask others to bet for them. Something
occurs in the morning which they interpret as a warning, and for the
remainder of the twenty-four hours they will not touch a card or lay
a wager. At the German baths this peculiarity is frequently observed.
A man in luck is pestered to bet for others, and is offered a
percentage if he will do so. This or that person is regarded as
unlucky, and a patron of the green cloth will not stand on the same
side of the table with him. A passing cloud, a chance-dropped
phrase, a change of position, or any one of a thousand nothings, will
induce a professional gamester to make, or prevent him from
making, risks, concerning which he has ordinarily no prejudice. The
folly of play is much surpassed by the folly of players, who become
so permeated with fancies, theories, and fanaticisms, that on the
subject they are specially interested in they are positively
monomaniacs. I have talked with old habitués of Homburg and
Wiesbaden respecting chances, coincidences, and systems, until I
have discovered that long attendance on and close watching of the
treacherous tables had absolutely turned their brains. They thought
they were the shrewdest and most sagacious of mortals, and pitied
me supremely, because I happened to have a little common sense in
regard to roulette and rouge-et-noir, and because I would not
believe that mere chance should be treated as if it were a positive
science.
No one can form any adequate conception of the mental vagaries,
bordering upon lunacy, of professional gamesters, until he has spent
several seasons at the German spas, and become intimately
acquainted with the men and women composing the galerie. Their
entire conduct is regulated by a desire to obtain luck. They strive to
propitiate fortune, as if it were, as the ancients believed, a personal
agency, subject to unaccountable whims and caprices. Many of their
acts of charity are done not so much from benevolence as from a
notion that it will influence favorably the issues of the games to
which they are so wedded. This is true not only of gamesters
abroad, but of gamesters everywhere. As a rule, they are far from
intellectual, and hence superstition meets with little resisting power
when it has once begun to encroach upon their understanding.
There are not only different classes of
DIFFERENT MOTIVES FOR
players, but players from different motives. PLAY.
The object of the majority is merely
mercenary: they frequent the tables only to win money; they make
hazard a business, foolishly hoping to reduce it to something like a
rule. Other habitués of the springs bet for excitement, as they drink
wine and seek adventures. They are not avaricious. When they win
largely, they spend freely; and at the end of every season, whatever
their success, they are much behind the game. The members of the
third order are sufferers from ennui, and regard roulette and rouge-
et-noir simply as a pastime. They have formed the habit of playing,
and cannot break it. Their stakes are small, generally; but they are
devoted to the tables, sitting there from eleven in the morning to
eleven at night,—the fixed time for the perilous sport,—and
frequently do not win twenty florins a week. A number of persons
play because it is the fashion, though they do not continue it long,
for the same reason. The game proves so magnetic that they either
feel it a duty to abandon it altogether, or they are drawn into it, and
are very soon too weak to resist its fascinations.
Very many, who have begun in the spirit of imitation, have grown
to be confirmed gamblers. One of the most infatuated players I have
ever known was a Spaniard, who went to Homburg to get rid of the
rheumatism, and who, after three seasons of abstinence, put down a
single napoleon, simply because he did not wish to seem odd. The
risking of that little coin has since cost him a small fortune; and if he
were to live a thousand years,—as he told me himself,—he could not
be near rouge-et-noir without taking part in it.
America, or rather the United States, is
more puritanic than other countries. DIVERS NATIONALITIES
AS GAMESTERS.
Gambling is regarded here quite differently
from what it is in Europe. Even our transpontine cousins, the
English, are much more addicted than we to play. They never have
social whist parties without betting at least enough to create an
interest. The Germans, unless in prosperous circumstances, are
preserved from the habit of gambling by their constitutional
economy and thrift. The Latin nations have a natural fondness for
whatever turns upon chance. Of these people, the Spaniards enjoy
gambling most, and the French least, while the Italians are but little
behind the Spaniards in this particular. It is safe to say that all three,
hearing the spinning of the roulette wheel, and the clinking of coin
at rouge-et-noir, could not long be kept from the seductive tables.
The Russians—those who travel, at least—love the green cloth, and
figure prominently among its devotees. Most of them have money,
and are such ardent pleasure-seekers, at the same time possessed
of something like an American vanity for spending and making
display, that they rarely fail to participate in any dissipation which
offers.
It must not be supposed that all the
frequenters of the spas indulge in play; for VIRTUES OF THE WATERS.
many of them go there for recreation, and merely look at the games.
Then, as I have remarked, thousands visit the springs for the benefit
of the waters. That they have medical virtues cannot be well
questioned, after one is told, as I have been told, of extraordinary
cures by those who have been sufferers. Ordinarily, a casual visitor,
who rises late, sees very little of the invalids; but if he has a liking
for early morning air, and bends his steps towards the pump-room
(Trinkhalle), he will encounter men and women afflicted with every
variety of disease. He will observe them also on their way to and
from the baths,—young and old, dark and fair, rich and poor,
handsome and homely, cultivated and coarse, graceful and awkward,
—all in quest of the invaluable boon, which we never appreciate until
it has slipped away. There is something melancholy, as well as
grotesque, in the moving panorama of the distempered. They walk
with canes and crutches, are carried in invalid chairs or wagons, and
look so wan and rueful that I have often felt prompted to
apostrophize health as the sum of all blessings. There are young and
fair women, fragile from their birth, for whom there is not an atom
of hope, and who yet believe they may find some miraculous cure in
the baths for lack of constitution, and for inherited disease. The bon
vivant, peevish and irritable from the gout, limps along, and the
overworked man of brains, paralyzed on one side, is wheeled over
the pavement by the stupid lackey, unconscious that he is the
possessor of nerves or a stomach. The dyspeptic—of course an
American—glowers on everybody as he passes, but appears to hate
no one as much as himself. After having fancied himself cursed with
every disease, and after consulting physicians of the highest grade
on both sides of the Atlantic, he has come to Ems to test the virtue
of the baths. They have done him no good, for he will not be
prudent either in his diet or his habits; and he will go home with his
mind made up that all medicinal springs are humbugs. He is
unaware that the cause of his ailment is dyspepsia, and that it has
gotten into his mind. On Monday, he thinks he has consumption; on
Tuesday, he fancies it is liver complaint; on Wednesday, he is sure
his kidneys are deranged; on Thursday, no one can convince him
that he is not suffering from enlargement of the heart; on Friday, he
declares he has the marasmus; on Saturday, he swears nothing was
the matter with him originally, but that the infernal physicians have
poisoned him; and on Sunday, he contemplates suicide as a means
of relief. The poor man is the victim of bad cooking, for which our
country is famous, and his excessive haste in eating. If he had been
born in France, and taken his meals at the Paris restaurants, he
would be to-day one of the most contented, instead of the most
miserable of men. Talk as we may, digestion is the foundation of
human happiness, and will keep us on good terms with ourselves
when an unsullied conscience and troops of friends are of no avail.
Hypochondriacs are to be met at the
celebrated baths, of course; for wherever HYPOCHONDRIACS.
there are disordered bodies there are disordered minds. No human
creature is so ill as he or she who imagines an illness, since the
subtlest art of healing cannot reach the shadows of emptiness. I
remember an Englishman at Homburg, one of the most robust of
fellows, who, after quitting college, had begun reading medical
works only to convince himself that he had some deep-seated
disease. His belief stimulated his appetite for information. He pored
over all the pathological treatises he could find, and every week
fancied that he had some new ailment. He travelled everywhere,
swallowed entire drug stores, visited every watering-place in
Welcome to Our Bookstore - The Ultimate Destination for Book Lovers
Are you passionate about books and eager to explore new worlds of
knowledge? At our website, we offer a vast collection of books that
cater to every interest and age group. From classic literature to
specialized publications, self-help books, and children’s stories, we
have it all! Each book is a gateway to new adventures, helping you
expand your knowledge and nourish your soul
Experience Convenient and Enjoyable Book Shopping Our website is more
than just an online bookstore—it’s a bridge connecting readers to the
timeless values of culture and wisdom. With a sleek and user-friendly
interface and a smart search system, you can find your favorite books
quickly and easily. Enjoy special promotions, fast home delivery, and
a seamless shopping experience that saves you time and enhances your
love for reading.
Let us accompany you on the journey of exploring knowledge and
personal growth!

ebookball.com