Transcript Substance Abuse - Dr. Alison Freeland

Substance Abuse
Alison Freeland MD FRCPC
Schizophrenia Program
Royal Ottawa Hospital
Definitions
Dependence: the repeated use of a drug
Abuse: Use of any drug in a manner that
deviates from approved social or medical
patterns
Addiction: the repeated and increased use
of a substance, the deprivation of which
gives rise to symptoms of distress and an
irresistible urge to use again
Definitions
Intoxication: a reversible syndrome
caused by a specific substance that
effects 1 or more of the following –
memory, orientation, mood,
judgment, and level of functioning
Withdrawal: a substance specific
syndrome that occurs after stopping
or reducing the amount of the
substance used
Definitions
Tolerance: phenomenon in which,
after repeated administration, a given
dose of a substance produces a
decreased effect
Cross tolerance: ability of one drug
to be substituted for another each
usually producing the same
physiologic and psychologic effects
Drugs that can be tested in the
urine
Alcohol: 7-10 hours
Benzodiazepine : 3 days
Cocaine : 6-8 hrs (metabolites 2-3
days)
Marijuana: 3 days to 4 weeks (
depending on use)
Codeine: 48 hours
Heroin: 36-72 hours
Alcohol
90% absorbed through the stomach
Peak blood concentrations in 30-90 mins
Rapid consumption and consumption on an
empty stomach enhance absorption and
decrease time to peak blood levels
Intoxication more pronounced as blood
levels are rising
90% metabolized by hepatic oxidation
Alcohol
Body metabolizes approx one
moderately sized drink per hour (ie
one 12 oz beer, 4 oz wine, 1 oz liquor)
Alcohol: epidemiology
10% women and 20% men meet
criteria for alcohol abuse
5% women and 10% men have met
criteria for alcohol dependence
60% alcohol abusers are men
Caucasians have highest rates of
alcohol abuse ( 60%)
Alcohol: Etiology
Genetic: close family members of
alcoholics have 4x increased risk
Cultural: Asians show increased acute
toxic effects, Native Americans and
Inuit have higher rates
Alcohol: comorbidity
Anxiety
Depression
Insomnia
Schizophrenia
Other substance disorders
Alcohol related disorders
Dependence
Abuse
Intoxication (delirium)
Withdrawal (delirium)
Persisting dementia
Persisting amnestic disorder
Psychotic disorder
Depression
Anxiety
Sexual dysfunction
Sleep disorder
Subtypes of Alcohol Dependence
A: late onset, mild dependence, few
alcohol related problems, little
psychopathology
B: severe dependence, early onset,
strong family history, life stressors,
severe psychopathology
Alcohol Withdrawal
Begins within several hours of alcohol
cessation
2 of the following: autonomic
hyperactivity, tremor, insomnia,
nausea/vomiting, transient
illusions/hallucinations, anxiety, grand
mal seizures, agitation
Rx: benzodiazepines
Alcohol Withdrawal delirium
1-3% of alcohol dependent patients
Symptoms: delirium, marked autonomic
hyperactivity (tachycardia, sweating,
agitation, anxiety), vivid hallucinations,
agitation tremor, fever, seizures
Tx: monitor vitals, decrease stimulation,
hydrate, benzodiazepines, thiamine, Folic
acid, multivite, mag sulphate as needed for
seizures
Alcohol induced amnestic disorder
Wernickes encephalopathy: acute
syndrome caused by thiamine deficiency
(nystagmus, ataxia, confusion). Treat with
thiamine –symptoms may resolve
Korsakoffs syndrome: chronic condition
result of thiamine deficiency, amnesia,
confabulation, disorientation, polyneuritis,
Rx with thiamine, 25% patients fully
recover
Alcohol induced psychotic disorder
Vivid persistent hallucinations following a
decrease in alcohol consumption in an
alcohol dependent person
May persist and progress into a more
chronic psychotic presentation
Condition usually requires at least 10 years
of alcohol dependence
Tx: benzodiazepines +/- antipsychotic med
Opioids
Natural derivatives of opium: codeine,
morphine
Synthetic opioids: methadone,
oxycodone, dilaudid, talwin, demerol
Semisynthetic opioids: heroin
Opioids
Heroin most commonly associated with
abuse
600,000 heroin users in the US
Lifetime rate of heroin abuse is 2%
Male to female ratio is 3 :1
Most users in their 30s and 40s
Dependance on other opioids most
commonly seen in patients who are
prescribed as part of medical treatment
Opiate Overdose
Can be a medical emergency
Often accidental
Often results from combined use with
other CNS depressants ( alcohol,
benzodiazepines)
Clinical signs: pinpoint pupils,
respiratory and CNS depression
Rx: naloxone ( antagonist)
Opiate Withdrawal
Seldom a medical emergency
Symptoms include flu like sx, craving,
lacrimation, rhinorrhea, yawning,
sweating, insomnia, abdominal
cramps, dilated pupils, piloerection,
N/V/D
Treatment: methadone, clonidine,
supportive
Cocaine Epidemiology
10% of US population has tried it
Lifetime rate for use/dependence is
2%
Most commonly used in 18 to 25 year
old range
Male to female ratio of 2:1
Delusions and hallucinations may
occur in 50% of those who use
Cocaine
Intoxication: restlessness, agitation,
anxiety, pressured speech, paranoid
ideation, aggressivity, increased
sexual interest, tachycardia,
hypertension, pupillary dilation, chills,
anorexia, insomnia, stereotypic
movements
Treatment:supportive, benzos,
antipsychotics
Cocaine Withdrawal
Most prominent sign is craving
Symptoms include fatigue, lethargy,
guilt, anxiety and feelings of
helplessness
Withdrawal symptoms usually peak in
several days but can last for weeks
Treatment: supportive, SSRIs
Sedative hypnotics
Benzodiazepines
Barbiturates
Methaqualone
Meprobamate
About 6% of general population have
used these illicitly
Female: male 3:1
Sedative and Hypnotic Intoxication
Slurred speech
Uncoordination
Unsteady gait
Impaired attention
Respiratory depression, particularly if
used with other sedative agents (ie
alcohol)
Sedative and Hypnotic Withdrawal
Nausea, vomiting
Malaise, weakness
Autonomic hyperactivity
Anxiety, irritability
Increased sensitivity to light and sound
Tremor
Insomnia
seizures
Hallucinogens
Natural and synthetic substances
Produce hallucinations, loss of
contact with reality, experience of
heightened consciousness
Egs: psilocybin (mushrooms),
mescaline (peyote), MDMA, LSD
Hallucinogens
Act as sympathomimetics
Cause hypertension, tachycardia,
hyperthermia and dilated pupils
Tolerance develops rapidly and remits
within several days of abstinence
Physical dependence and withdrawal
do not occur
Often contaminated with
anticholinergic drugs
Hallucinogen Intoxication
Maladaptive behavioral changes
(anxiety, paranoia)
Changes in perception
(hallucinations)
Sympathomimetic changes
Panic reactions (bad trips)
Duration variable (shrooms 4-6 hrs,
LSD 6-12 hrs)
Phencyclidine (PCP)
“angel dust”
A dissociative anaesthetic and
hallucinogen
Commonly causes paranoia and
violence
May remain detectable in urine up to
a week
Associated with 3% substance abuse
deaths
PCP
Effects are dose dependent
At low doses acts as a CNS
depressant, with nystagmus, blurry
vision, incoordination
At moderate doses hypertension,
dysarthria, ataxia, muscle rigidity
At high doses agitation, fever,
rhabdomyolysis, renal failure
Inhalants
Volatile hydrocarbons inhaled for
psychotropic effect
eg gasoline, kerosene, laquers, paint
thinner, fingernail polish remover
Typically abused by adolescent males
of low SEC groups
Inhalants: Intoxication
Mild euphoria, belligerence,
assaultiveness, impaired judgment
Ataxia, confusion, slurred speech,
decreased reflexes, nystagmus
Can go on to delirium and seizures
Longer term risk of brain injury, liver
damage, bone marrow depression,
peripheral neuropathies,
immunosuppression
Cannabis
5% lifetime use
Highest among 18-21 y.o.
Highest use among caucasians
compared to other ethnic groups
Euphoric effects appear within
minutes, peak at 30 mins and last 2-4
hours
Motor and cognitive effects can last 5
to 12 hours
Cannabis
Intoxication: euphoria, anxiety,
suspiciousness, time distortion,
conjuctival injection, increased
appetite, dry mouth, tachycardia
Can cause depersonalization and
hallucinations
High doses can cause cannabis
psychosis lasting up to 6 weeks
Amphetamines
Release catecholamines, primarily
dopamine
Effects are euphoric and anorectic
Usually taken orally, but can be
smoked, inhaled and injected
Clinical syndromes similar to cocaine
Amphetamines
7% of population
Highest use in 18 to 25 year old range
Men = women
Examples: dexedrine, speed,
methylphenidate, khat, methcathinone
crystal meth
Can induce a paranoid psychosis
Intoxication resolves in 24 - 48 hours
MDMA
3,4 methylenedioxyamphetamine
“ecstasy” “E”
Increased self confidence, sensory
sensitivity, sense of personal
closeness with others
Activating, energizing, some
hallucinogenic potential,
Associated with hyperthermia
“poppers”
Amyl nitrate
Used during sex to intensify orgasm
through vasodilation
Can produce light headedness,
euphoria and giddiness
Should not be used with viagra as
combo can cause cardiovascular
collapse and death