Transcript SUBSTANCE USE lec.ppsx

ALCOHOL &
SUBSTANCE ABUSE
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ABDULLAH AL-SUBAIE, MBBS, FRCP (C)
PROFESSOR OF PSYCHIATRY
Substance use/ Prof. Subaie
TYPES OF ABUSED SUBSTANCES
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 Anxiolytics and hypnotics
 Opioids
 Stimulants
 Hallucinogens
 Cannabis
 Organic solvents
Substance use/ Prof. Subaie
Prevalence:
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Substance use/ Prof. Subaie
Prevalence:
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Substance use/ Prof. Subaie
DSM-IV Criteria for Substance Intoxication
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A. The development of a reversible substance-specific
syndrome due to recent use of a substance. Different
substances may produce similar or identical syndromes.
B. Clinically significant maladaptive behavioral or
psychological changes that are due to the effect of the
substance on the central nervous system (eg, belligerence,
mood lability, cognitive impairment, impaired judgment,
impaired social or occupational functioning) and develop
during or shortly after use of the substance.
C. The symptoms are not due to a general medical condition
and are not better accounted for by another mental
disorder.
Substance use/ Prof. Subaie
DSM-IV Criteria for Substance Withdrawal
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A. The development of a substance-specific syndrome due to
the cessation of (or reduction in) substance use that has
been heavy and prolonged.
B. The substance-specific syndrome causes clinically
significant distress or impairment in social, occupational,
or other important areas of functioning.
C. The symptoms are not due to a general medical condition
and are not better accounted for by another mental
disorder.
Substance use/ Prof. Subaie
DSM-IV Diagnostic Criteria for Substance
Dependence - 1
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A. Maladaptive pattern of substance use, leading to clinically
significant impairment or distress, as manifested by three
(or more) of the following, occurring at any time in the same
12-month period:
1. Tolerance, as defined by either of the following:
(a) a need for markedly increased amounts of the substance
to achieve intoxication or desired effect
(b) markedly diminished effect with continued use of the
same amount of the substance
2. Withdrawal, as manifested by either of the following:
(a) the characteristic withdrawal syndrome for the substance
(refer to criteria of withdrawal of the specific substance)
(b) the same (or closely related) substance is taken to relieve
or avoid withdrawal symptoms.
Substance use/ Prof. Subaie
DSM-IV Diagnostic Criteria for Substance
Dependence - 2
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(3) the substance is often taken in larger amounts or over a longer
period than was intended
(4) there is a persistent desire or unsuccessful efforts to cut down
or control substance use
(5) a great deal of time is spent in activities necessary to obtain
the substance (eg, visiting multiple doctors or driving long
distances), use the substance (eg, chain-smoking), or recover
from its effects
(6) important social, occupational, or recreational activities are
given up or reduced because of substance use
(7) the substance use is continued despite knowledge of having a
persistent or recurrent physical or psychological problem that
is likely to have been caused or exacerbated by the substance
(eg, current cocaine use despite recognition of cocaine-induced
depression, or continued drinking despite recognition that an
ulcer was made worse by alcohol consumption)
Substance use/ Prof. Subaie
DSM-IV Diagnostic Criteria for Substance
Dependence - 3
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Specify if:
with physiological dependence: evidence of tolerance or
withdrawal (i.e, either item 1 or 2 is present)
without physiological dependence: no evidence of tolerance
or withdrawal (i.e, neither item 1 nor 2 is present)
Substance use/ Prof. Subaie
WHEN TO SUSPECT SUBSTANCE ABUSE /
DEPENDENCE ? 1
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When medical or psychiatric problems may be
related to alcohol or drugs.
If patient requests certain drugs for unsatisfactory
reasons.
When needle tracks and thrombotic
veins are found.
Finding scars of previous abscesses.
When forearms are concealed.
Substance use/ Prof. Subaie
WHEN TO SUSPECT UBSTANCE ABUSE /
DEPENDENCE ? 2
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 In cases of self neglect, and school or
occupational decline.
 In history of former friends loss and
joining the “drug culture.”
 In history of thefts and prostitution.
 When urine tests positive (except LSD
and solvents).
 When Gamma–Glutmyle–transferase
(GGT) and MCV are elevated.
Substance use/ Prof. Subaie
PREVALENCE ISSUES - 1
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Availability:
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Prescribed e.g. Benzodiazepines
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Legal
e.g. alcohol & nicotine
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Illegal
e.g. cocaine, hash
Substance use/ Prof. Subaie
PREVALENCE ISSUES - 2
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Personal characteristics:
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Difficulty accepting authority, truancy and poor
schooling in teenagers.
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Disorganized families.
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Unhappy childhood.
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History of mental illness or personality disorder in
family.
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Personality disorder, disorganized life & unstable
relationships.
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Sexual promiscuity.
Substance use/ Prof. Subaie
PREVALENCE ISSUES - 3
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Social Pressures:
- especially in teenagers & school
children.
- unemployment.
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Primary effect of the substance
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Secondary effect of the substance (milieu).
Substance use/ Prof. Subaie
MANGEMENT OUTLINES - 1
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Review history with the patient regarding:
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Type of drug (s) and amount
I.V. usage and its dangers
Evidence of dependence
Complications of drugs (physical, psychological and
social).
Personal and social resources and problems
Substance use/ Prof. Subaie
MANGEMENT OUTLINES - 2
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2
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Manage withdrawal symptoms
Treat urgent medical and psychiatric
complications
Set attainable goals:
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Abstaining from drug
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Parting from drug culture
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Dealing with personal and financial problems
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Establishing new interests
Substance use/ Prof. Subaie
MANGEMENT OUTLINES - 3
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5.
6.
Set longer-term goals:
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Individual or group counseling
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Help for family
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Rehabilitation
Self-help groups
Substance use/ Prof. Subaie
PREVENTION
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Improved education
Preventive measures
Of availability
Increased restrictions
Of advertising
Substance use/ Prof. Subaie
COMPLICATIONS
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General medical complications e.g. AIDS, endocarditis
Local effects of I.V. injections e.g. thrombosis.
Frequent intoxication leading to poor functioning, failure
of social relations, accidents, family problems and
neglect.
Debts due to expensive illicit drugs leading to prostitution
and crime.
Death.
Substance use/ Prof. Subaie
ALCOHOL ABUSE / DEPENDENCE
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QUICK ASSESSMENT:
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Cut down
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Annoyed
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Guilty
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Eye opener
Substance use/ Prof. Subaie
ALCOHOL ABUSE / DEPENDENCE
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1 unit= 8 gm
or 1
centiliter
PREVALENCE:
 In England, 6% of men & 1% of women admitted to
consumption of >50 units/week.
 Lifetime prevalence rate was 0.45% among Chinese in
Shanghai & 23% among Native Mexican-Americans
 Dependence is usually established in mid-forties for men
and a few years later for women.
 Dependence is also increasing in teenagers and women.
 Dependence is generally more common in disadvantaged
areas.
 Age, sex: Young males but rate in females is rising.
 Occupation: Executives, service men, journalists, Salesmen
and movie industry.
Substance use/ Prof. Subaie
ALCOHOL ABUSE / DEPENDENCE
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PERSONALITY TRAITS:
 Self-indulgence
Stress leads to
anxiety that is
relieved by
alcohol
 Anxiety
 Painful reality is denied and pleasure is obtained by
immediate oral gratification (drinking)
 “Alcoholism is a conditioned behavioral response”
 “Alcoholism is a series of transactions designed to obtain
personal advantage or hide deficiencies”
Substance use/ Prof. Subaie
ALCOHOL ABUSE / DEPENDENCE
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PHYSICAL COMPLICATIONS SUCH AS:
 G.I.T.: Gastritis and peptic ulcer, esophageal varices,
acute and Chronic pancreatitis, hepatitis and
cirrhosis.
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C.N.S.: Peripheral neuropathy, dementia, epilepsy.
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Others: Anemia, episodes of hypoglycemia, obesity,
Cardiomyopathy, Myopathy
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Alcohol fetal syndrome: Facial abnormalities, low birth
weight, low intelligence and over activity.
Substance use/ Prof. Subaie
ALCOHOL ABUSE / DEPENDENCE
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NEUROPSYCHIATRIC COMPLICATIONS:
1.
INTOXICATION STATES:
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Blackouts: amnesia to events that occur during the
period of intoxication.
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Idiosyncratic intoxication: markedly changed behavior
(usually aggressive) occurring within minutes of
drinking a small amount of alcohol.
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Other effects:
 Mood: euphoria/dysphoria, irritability
 Cognition: sedation, memory & judgment
impairment
 Behavior: disinhibition, aggression, violence, accident
proneness.
Substance use/ Prof. Subaie
ALCOHOL ABUSE / DEPENDENCE
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NEUROPSYCHIATRIC COMPLICATIONS:
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TREATMENT OF WITHDRAWAL STATES:
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Dehydration & correction of electrolytes
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Sedation (Chlormethiazole & Benzodiazepines(
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Multivitamins
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Thiamine
Substance use/ Prof. Subaie
ALCOHOL ABUSE / DEPENDENCE
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TOXIC AND NUTRITIONAL STATES:
1. Wernicke’s encephalopathy: due to thiamin deficiency leading
to bilateral degeneration of the posterior hypothalamus,
hippo- campus and mamillary bodies.
Features include: delirium, ataxia and ophthalmoplegia.
2.
Korsakov’s syndrome (alcohol amnestic syndrome):
Features include: prominent disturbance of recent memory in
the absence of generalized intellectual impairment
(Immediate recall is good but recent memory is impaired).
Confabulation and disorientation to time may occur. New
learning is impaired.
Occurs after prolonged use. On CT scan: Ventricles may be
enlarged and sulci may be widened. CT changes may partially
resolve on abstinence.
Substance use/ Prof. Subaie
ALCOHOL ABUSE / DEPENDENCE
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ASSOCIATED COMORBIDITY & COMPLICATIONS:
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Depression/ Suicide
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Anxiety
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Personality changes
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Pathological jealousy
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Sexual dysfunction
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Hallucinations
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Social damage
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Crimes
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Road traffic accidents
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Occupational problems
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Family conflicts and losses
Substance use/ Prof. Subaie
ALCOHOL ABUSE / DEPENDENCE
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MANAGEMENT:
1. Assess:
- Extent of drinking
- Evidence of dependence
- Alcohol related disability
2. Arrange for and treat withdrawal symptoms:
- Sedation
- Thiamin and Vitamin B supplements
- Rehydration
Substance use/ Prof. Subaie
ALCOHOL ABUSE / DEPENDENCE
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MANAGEMENT:
3. Treat urgent psychiatric or medical problems:
4. Arrange for rehabilitation and long term treatment:
 Of medical and psychiatric disability
 Resolving interpersonal problems
 Social support ( work, law, finance, interests)
 Individual and / or group counseling
 Self help group e.g. alcohol anonymus
 Help for family
 Disulfiram (antabuse)- inhibits acetaldehyde
dehydroginase…
Substance use/ Prof. Subaie
ALCOHOL ABUSE / DEPENDENCE
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PROGNOSIS:
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Generally poor:
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At 6/12: 25% remain abstinent
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At 18/12: 10% remain abstinent
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Good prognostic factors include:
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Good insight
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Strong motivation
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Supportive family
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Stable job
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Ability to form good relationship
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Control of impulsivity and ability to defer gratification
Substance use/ Prof. Subaie
OUTCOME
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Outcome depends more on the patient
than on the treatment
Substance use/ Prof. Subaie
CANNABIS
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Derived from the plant Cannabis sativa
Effects vary with: dose, user’s expectation and social
setting
Exaggerates the preexisting mood (euphoria or
dysphoria)
Physical dependence and withdrawal symptoms do not
occur
Acute intoxication may lead to psychosis while chronic
use may lead to “amotivational syndrome”
Substance use/ Prof. Subaie
ORGANIC SOLVENTS (INHALENTS)
Due to: hepatorenal, brain & bone marrow toxicity, bronchial
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asthma & cardiorespiratory
arrest, coma, asphyxiation with
plastic bags, trauma …
ADHESIVES, CLEANING FLUIDS, PETROL, AEROSOLS,
BUTANE GAS.
 Most common among teenagers.
 Intoxication leads to drunkenness, delirium, uncoordinated
gait, nausea, vomiting, and coma.
 Visual hallucinations are common.
 More psychological than physical dependence.
 It has a neurotoxic effect leading to peripheral neuropathy
and cerebellar dysfunction.
 Over dosage may be fatal and chronic use may lead to
psychosis.
 Very cheap and easily obtained.
Substance use/ Prof. Subaie
STIMULANTS
34 Due to: hyperpyrexia, coma, CV shock,
fits…
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AMPHETAMINES AND COCAINE
Lead to elevation of mood, over-activity, insomnia, overtalkativeness, and anorexia.
Cardiac arrhythmia and malignant hypertension may result
from high doses.
Death
Prolonged use may result in paranoid psychosis
resembling schizophrenia
Physical dependence is not severe
Withdrawal may lead to severe depression and suicide
Treatment includes abstinence, antidepressants and
neuroleptics
Substance use/ Prof. Subaie
HALLUCINOGENS
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LSD, DISMETHYL TRYPTAMINE AND ANTICHOLINERGIC
DRUGS
 Lead to distortion or intensification of perceptions or frank
hallucinations.
 Time moves slowly
 Profound meaning of ordinary events.
 Body image distortions and depersonalization may occur.
 Experience may be pleasant, distressing, or frightening
leading to dangerous unpredictable behavior.
 Physical effects include hypertension
 Flashbacks may occur
 More psychological than physical dependence
 Treatment is diazepam or phenothiazines (avoid in case of
anticholinergic over-dose)
Substance use/ Prof. Subaie
OPIOIDS
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HEROIN, MORPHINE, CODEINE AND PETHEDIN
 Lead to immediate effects of euphoria, analgesia, reduced
appetite, respiratory depression, drowsiness,
gastrointestinal spasms, fits…
 Tolerance develops rapidly
 Withdrawal symptoms: craving, agitation, insomnia, pains and
arthralgia, abdominal cramps, runny nose and eyes,
sweating, diarrhea, piloerection, dilated pupils, tachycardia
and disturbed temperature control.
 Withdrawal starts within 6 hours, peaks in 24–48 hours and it is
not life threatening
 Short-term treatment includes: relief of withdrawal symptoms.
 Long-term treatment includes: methadone replacement and
rehabilitation
 Treatment outcome remains poor in the best hands.
 Death results in about: 10%-20% in 7 years.
Substance use/ Prof. Subaie
Substance use/ Prof. Subaie
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