Transcript Basics Substance Abuse_2011 Dr Lau_compressed

Substance Use
Disorders
REVIEW OF
PSYCHIATRY
T. Lau, MD, FRCPC [psych], Director of Undergraduate Education
Faculty of Medicine, Department of Psychiatry, UNIVERSITY OF OTTAWA
NOTEABLE QUOTABLES
• “It's easy to quit smoking. I've done it hundreds of times.”
Mark Twain, 1835-1910
• “It provokes the desire but it takes away the performance.”
William Shakespeare
• “I'm not so think as you drunk I am.”
John Squire
Pre-Test Questions
• What of the following causes pupillary dilation
(mydriasis)
a)
b)
c)
d)
e)
Cholinergics
Opiates
Organophosphates
Crystal met
Clonidine
CASE 1
• 35 year old man whose alcohol consumption started in his teens. For
many years, he drank alcohol mostly on social occasions.
• He is not sure what happened first but he began having problems with
his wife and his work. It was during this time that his alcohol
consumption increased.
• Although he doesn’t drink everyday he often drives to work somewhat
intoxicated and his coworkers have noticed that he has not been himself
lately.
• He has been having problems with intimacy with his wife and she had
been wondering if it was related to alcohol he had been consuming
more of.
• What is the diagnosis?
• What treatment options exist?
CASE 2
• 58 year old divorced man with alcohol problems who drinks everyday,
needing an “eye opener” to get going in the morning and to avoid
feeling shakey. He sometimes consumes more than 10 drinks at a
time.
• He has lost several jobs over the years and is estranged from his wife
and 3 children largely because of his drinking and behaviour.
• He has had a heart attack, has hypertension and is obese. He saw his
family physician who tells him his bloodwork and MRI abdomen is
consistent with cirrhosis.
• What is the diagnosis?
• What blood work would be consistent with this picture?
• What treatment options would you offer?
CASE 3
• 38 year old female who lives with her husband and 3 year old
daughter. She suffers from chronic pain following a MVA 2
years ago.
• She was treated at that time with Percocet, however her GP
“cut her off ” after 6 months of medications and now will
only prescribe her NSAIDs.
• She works as a purchasing agent in the civil service but is
getting in trouble at work for repeated work absences.
• She is currently using 2x80 mg oxycontin which she gets from
a friend who refers to them as “oxys”. She is paying $80 per
day for these narcotics and can’t really afford to continue like
this.
CASE 3
• Based on the history above what is the most likely
diagnosis?
a) Opiod abuse
b) Fibromyalgia
c) Dependent personality disorder
d) Opiod dependence
e) Addictive personality disorder
CASE 3
• You ask her when her last “oxy” was and she states 2h
ago. Which of the following are symptoms of opiod
intoxication?
a)
b)
c)
d)
e)
Hypotension
Miosis
Lacrimation
Respiratory depression
euphoria
CASE 3
• She states that when she doesn’t take the pills she feels
sick. Which of the following are symptoms of opiod
withdrawal.
a)
b)
c)
d)
e)
Nausea or vomiting
Seizures
Myalgias
Yawning
Rhinorrhea
CASE 3
CASE 3
• What pharmacologic options are suitable for opiod
tapering?
a) Buprenorphine
b) Naloxone
c) Methadone
d) Topamax
e) Depot injectable naltrexone
Case 4
• The patient was a 20-year-old man who was brought to the hospital,
trussed in ropes, by his four brothers. This was his seventh hospitalization
in the last 2 years, each for similar behavior.
• One of his brothers reported that he “became home crazy,” threw a chair
through a window, tore a gas heater off the wall, and ran into the street.
The family called the police, who apprehended him shortly thereafter as
he stood, naked, directing traffic at a busy intersection.
• He punched two of the officers and appeared to have no pain. He
assaulted the arresting officers, escaped from them, and ran home
screaming threats at his family. There, his brothers were able to subdue
him.
• One of his brothers also suggested that “he gets dusted every day.”
Case 4
• On admission, the patient was observed to be agitated, with his
mood fluctuating between anger and fear. He had slurred speech and
staggered when he walked. He had visible nystagmus, tachycardia,
was hypertensive, and febrile. He was particularly sensitive to noise.
• He remained extremely violent and disorganized for the first several
days of his hospitalization, then began having longer and longer
lucid intervals, still interspersed with sudden, unpredictable periods
in which he displayed great suspiciousness, a fierce expression,
slurred speech, and clenched fists.
• After calming down, the patient denied ever having been violent or
acting in an unusual way (“I’m a peaceable man”•
) and said he could
not remember how he got to the hospital. DSM IV Case Manual.
Case 4
• What is the most likely substance abused?
a) Amphetamines
b) Cocaine
c) Speak K
d) PCP
e) LSD
CASE 5
• 38year old male advertising executive, who presents with a
history of altered behaviour. His girlfriend who accompanied
him describes that he has been behaving like Jeckyl and Hyde.
• Lately she has been hearing a crackling sound when he is in
the bathroom and strange smells that linger afterwards. He
sometimes acts like he’s energized, outgoing, hypervigilant,
talkative and becomes interpersonally sensitive.
• These periods that last several hours are often followed by
intense and unpleasant feelings of lassitude and depression
with increased appetite generally requiring several days of
recuperation. During this crash, he sleeps much more and
often has nightmares and vivid dreams. He has also expressed
feeling suicidal during these lows.
• What is the most likely offending substance?
CASE 5
• Which of the following is the most addictive
method of abuse
a)
b)
c)
d)
e)
Inhalation
Free basing
IV injection
Oral
Subcutaneous
CASE 6
• 23 year old student who began using diet pills to stay awake to study.
This helped him stay up for days at a time. He later found a friend of a
friend who offered other pills that were more potent.
• He called some of these pills: Black Beauties, Glass, Bikers Coffee,
Chicken Feed, Shabu, Stove Top, Trash, Go-Fast, Yaba, and Yellow Bam.
• After he took them orally and found that his wakefulness improved as did
his energy level but his appetite went down. The next day however he
would feel irritable, unhappy and paranoid.
• Over time these runs of energy where followed by increasing paranoia,
visual and auditory hallucinations, and out-of-control rages that can be
coupled with extremely violent behavior.
• What is the most likely substance?
CASE 7
• 17 year old female who was at a party. Her friends pressured her
into trying some strange drug. Shortly after consuming them she
started seeing radiant colors and she felt that some of the things
she was looking at appeared to ripple or “breathe”. She described
seeing colored patterns behind her closed eyelids. She also started
describing a sense that time was stretching, repeating itself, or
changing speed and stopping.
• Her friends then described that she started to freak out and have “a
bad trip”. She felt she was going insane and became intensely
anxious, depressed, and suicidal. After a week the depressive
symptoms subsided but she continued to periodically have
“flashbacks of the same symptoms she had during her “bad trip”.
• What is the most likely substance?
CASE 8
• 25 year old female university student who went to a party. Somebody
slipped something in her drink and her personality changed. Although
she had always been a chronic worrier she suddenly became more relaxed
and euphoric.
• She began touching people and described feeling very close to everyone
stating that she had compassion for all of mankind and was willing to
forgive everyone.
• She went with some of her new friends to a club where loud electronic
music was being played. Eventually she passed out from heat exhaustion.
• Over the next few days she felt depressed, irritable, tired with a loss of
appetite. She continued for awhile afterwards to feel a sense of closeness
to others. She had problems sleeping as well with aches, pains and jaw
tightness.
• What is the drug that someone slipped her?
CASE 9
• 24 year old female medical student. Drinks 6
cups of starbucks each day. When she gets up
in the morning she feels a bit shakey and
needs coffee to think clearly. The coffee clears
her head and calms her but at the same time
wakens her up.
• How much caffeine is in a Starbuck’s Verona
or a Pepsi MAX?
• Are you one of us that needs coffee everyday?
What is the connection between substance
abuse and mental illness?
ECA
Lifetime prevalence
Regier et al. JAMA 1990
Substance Abuse % w Psych illness, O.R.
Alcohol
THC
Cocaine
Opiods
37%,
50%,
76%,
65%,
2.3
3.8
11.3
6.7
Psych illness and % w
substance abuse
SCZ
47%
Affective
32%
Anxiety
24%
Antisocial
84%
classification
• DSM IV
• Substance use disorders
• Abuse (COLD) & dependence (TWISTED)
• Substance induced disorders
• Intoxication & withdrawal
• Mood / Anxiety / Psychotic / Sexual dysfxn / Sleep
disorder / Delirium / Persisting dementia / amnestic
disorder / Hallucinogen persisting perception disorder
What is the difference between abuse and
dependence?
• Which of the following is the most true?
a) Abuse is more harmful to the person
b) Dependence means physiological dependence
c) Clinically significant impairment or distress is
part of dependence not abuse
d) Dependence is a more severe problem
e) Criteria for both can be met simultaneously
Substance Use
Disorders
• Substance Abuse > 1 at anytime over a 12
month period
C
continued use despite interpersonal
problems
O
obligations, missed
L
legal problems, recurrent
D
dangerous related behaviour
Substance Dependence
• > 3/7 at anytime over a 12 month period
T Tolerance
W Withdrawal
I Increased amount than intended
S Substance use despite symptoms
(physical or psychological)
T Time spent
E Essential social occupational dysfxn
D Desire to cut down or unsuccessful
attempts to Diminish
• Epid
•
•
•
Generally M>F, low SES, unemployed, minority.
THC most common illicit drug
ETOH, nicotine, caffeine common
Suicide risk inc 20x
• Etiology
•
•
•
Bio- ML VTA-NA (reward pathway), LC (NA
somatic sx). Family studies
Psy- dynamic fixation @ oral stage,
Soc- codependence, learned social behaviour,
cues from environment trigger relapse
• Comorbidity
•
•
Other substance M 76%, F 67%
ASPD, SP, MDD, Dysthymia
• Treatment goals
Modifiers:
–Early >1<12, partial remission = abuse, full
no abuse/dependence. Full > 12 months
–with and without physiological dependence
•
Abstinence, physical/emotional wellbeing
How addicting?
• Probability of becoming dependent when you
have tried the substance at least once:
•
•
•
•
•
•
•
•
•
Tobacco
Heroin
Cocaine
Alcohol
Stimulants
Anxiolytics
Cannabis
Analgesics
Inhalants
33%
23%
17%
15%
11%
9%
9%
8%
4%
Stahl’s
Psychopharm
Specific Substances
• Stimulants
•
•
•
•
Cocaine
Amphetamines
Caffeine
Nicotine
Others
Hallucinogens
LSD
Ecstasy
shrooms
PCP
Cannabinoids
• Sedatives
•
•
•
•
ETOH
Benzos
Barbiturates
Opiods
• Heroin
• Codeine
• morphine
Specific Substances
• Alcohol
• Benzos
• Opiods
• THC
• Cocaine
• Others
•
•
•
•
Amphetamines
Hallucinogens
PCP
Inhalents
Physiological
dependence with
prolonged
withdrawal sx
Pleasure pathway
• Mesolimbic dopaminergic tract from the ventral
tegmental area to the nucleus accumbens
• VTA releases dopamine not only into the nucleus
accumbens, but also into the septum, the amygdala,
and the prefrontal cortex. The nucleus accumbens
then activates the individual’s motor functions, while
the prefrontal cortex focuses his or her attention.
• Mesocortical/limbic median forebrain bundle MFB
forms pleasure reward bundle whose activation leads
to the repetition of the gratifying action to strengthen
the associated pathways of the brain (Olds and
Milner)
• All drugs of abuse have either receptors directly on
(eg mu opiods) or indirectly through interneurons
(GABA).
CASE
• 35 year old man who has been drinking since he was in
his teens. He usually had alcohol on mostly social
occasions. He began having problems with his wife
and his work and his alcohol consumption increased.
Although he doesn’t drink everyday he often drives to
work somewhat intoxicated. He has been having
problems with intimacy with his wife and she had been
wondering if it was related to alcohol he had been
consuming more of.
• What is the diagnosis?
CASE
• 58 year old divorced man with alcohol problems who drinks
everyday, needing an “eye opener” to get going in the
morning. He consumes more than 10 drinks at a time. He
has lost several jobs and is estranged from his wife and 3
children largely because of his drinking and behaviour. He
has had a heart attack, has hypertension and is obese. He
saw his family physician who tells him his bloodwork and
MRI abdomen is consistent with cirrhosis.
• What is the diagnosis?
• What blood work would be consistent with this picture?
ETOH
•
Low-Risk Drinker:
•
•
•
•
•
•
•
Men: 3-4/day max & 15/wk. max
Women: 2-3/day max & 10/wk. max
"1 drink"
= 12-oz beer
= 5-oz wine
= single mixed drink
Clues of problem drinking
•
•
•
•
•
•
•
•
•
•
•
Hypertension
Liver dysfunction
Sleep disorders
Sexual dysfunction
Depression
Blackouts
Trauma, falls, MVAs
Prescription drug abuse
Chronic abdominal pain
Tobacco use
Illicit drug use
ETOH
ETOH
• Epid
•
•
•
5% F, 10% M dependence. 10% F, 20% M abuse.
Inc ETOH w education (differs from illicit drugs)
Inc risk of ASPD, MDD (30-40%), anxiety: phobias&PD (25-50%), suicide 10-15%
• Etiology
•
•
•
Bio-genetics: 3-4x inc risk & inc severe use w 1st degree relative. MZ 60%, MZ>DZ.
Adoption studies support genetic link.
Psychol- neuro deficits Dec P300, EEG abn, fixated @ oral stage
Social- reward, social learning theory
• Subtypes of dependency:
•
Type A late onset, dec childhood RF’s, few problems. B: early onset, severe dependency,
strong FHx, poly, severe psychopathology, inc # stressors
• Labs:
•
GGT sensitive, not specific. MCV (60%, F>M), TG, UA, AST/ALT also CHO-deficient
transferrin. γ-glutamyltransferase
• Sleep effects:
•
dec sleep latency, dec REM, dec stage 4, inc # of awakenings.
ETOH
• Intoxication (GAS-IN)
•
Gait abnormality, attentional, stupor/coma (risk of asp pneum), slurred speech, incoordination,
nystagmus. Also mood lability, dec judgement, inappropriate physical/sexual fxn
• Withdrawal (PINT ASA)
•
•
•
Perceptual abn, insomnia, nausea, tremor, onset (hrs-days), facial flushing, agitation, seizures,
anxiety (ANS hyperactivity: inc HR, HTN)
Shakes 6-12h, hallucinations 8-12, sz 12-24, DT’s >72h
Inc risk w malnutrition, physical illness, depression, fatigue
• Short term Complications
•
Withdrawal, sz’s, blackouts, DT’s, psychotic sx, depression, suicide, coma / pneumonia
• Long term Complications:
•
Medical: cirrhosis, CHAOS, malnutrition, ETOH persisting amnestic disorder (Wernicke’s-ataxia,
confusion, nystagmus: Rx thiamine, Korsakoff’s: 20% irreversible anterograde amnesia due to
thiamine deficiency in the mammilary bodies) / ETOHlic dementia.
Alcohol Dependence
• Naltrexone
• NEJM 2008
• Small effect size, variable results in
multi-centered trials
Alcohol dependence tx
AJP Editorial June 2010
• Identification of at-risk drinkers:
•
Alcohol Use Disorders Identification Test (AUDIT) recommended by the National
Institute on Alcohol Abuse and Alcoholism Clinicians Guid.
• For at-risk drinkers, a more detailed history about the pattern of drinking,
associated medical and psychiatric comorbidities, family history, and sufficient
clinical information to make a DSM–IV diagnosis should be obtained.
• In the case of the middle-aged man who has severe chronic alcohol dependence
with regular and frequent heavy drinking and medical complications, a trial with
topiramate (25–300 mg/day with a target dose of ≥100 mg/day) is recommended.
• For the young adult man with early-onset drinking, antisocial behavior, binge
drinking, and emerging alcohol dependence, low-dose ondansetron (4 μg/kg) or
oral naltrexone, up to 100 mg/day, along with brief intervention is considered
appropriate.
• Finally, for an elderly, recently retired woman who feels gloomy and is drinking to
alleviate her low mood, long-acting injectable naltrexone, 380 mg once a month
for 4 months, is recommended along with brief intervention.
Alcohol Dependence
• Topiramate
• JAMA Oct 2007
Case
• 23 year old student who began using diet pills to stay awake to study.
This helped him stay up for days at a time. He later found a friend of a
friend who offered other pills that were more potent. He called some of
these pills: Black Beauties, Glass, Bikers Coffee, Chicken Feed, Shabu,
Stove Top, Trash, Go-Fast, Yaba, and Yellow Bam.
• After he took them orally and found that his wakefulness improved as did
his energy level but his appetite went down. The next day however he
would feel irritable, unhappy and paranoid.
• Over time these runs of energy where followed by increasing paranoia,
visual and auditory hallucinations, and out-of-control rages that can be
coupled with extremely violent behavior.
• What is the most likely substance?
Amphetamines
• AKA:
• Speed, Meth, Ice, Crystal, Chalk, Crank, Tweak, Uppers, Black Beauties, Glass,
Bikers Coffee, Methlies Quick, Poor Man's Cocaine, Chicken Feed, Shabu, Crystal
Meth, Stove Top, Trash, Go-Fast, Yaba, and Yellow Bam
• Intoxication like cocaine (24-48 h)
• As a powerful stimulant, methamphetamine, even in small doses, can increase
wakefulness and physical activity and decrease appetite. A brief, intense sensation, or
rush, is reported by those who smoke or inject methamphetamine. Oral ingestion or
snorting produces a long-lasting high instead of a rush, which reportedly can
continue for as long as half a day.
• Withdrawal (see cocaine-peak 2-4d-wk)
• Less addictive than cocaine
• no physical manifestations of a withdrawal syndrome
• Other sx include depression, anxiety, fatigue, paranoia, aggression, and an intense
craving for the drug.
• Methamphetamine has toxic effects. In animals, damages nerve terminals in the
dopamine-containing regions of the brain. High doses can elevate body temperature to
dangerous, sometimes lethal, levels, as well as cause convulsions
Amphetamines
• Chronic Use
• Tolerance can develop. Abusers sometimes forego food and sleep in a form
of binging known as a “run,” injecting as much as 1 gm q 2-3 hrs over
several days until the user runs out of the drug or is too disorganized to
continue.
• Chronic abuse can lead to psychotic behavior, characterized by intense
paranoia, visual and auditory hallucinations, and out-of-control rages that
can be coupled with extremely violent behavior.
• As much as 50 percent of the dopamine-producing cells in the brain can be
damaged after prolonged exposure to relatively low levels of
methamphetamine. Serotonin-containing nerve cells may be damaged even
more extensively. Whether this toxicity is related to the psychosis is
unknown
• Psychotic syndrome
• Similar (paranoia, perceptual abn) to SCZ except increased VHs, appropriate
affect, hyperactivity, hypersexuality, confusion/incoherent but usually no
thought disorder
• Rx: haldol
Amphetamines
• Psychopharmacology
• D and L enantiomers have different effects. Direct and indirect
sympathomimetics (mostly cause vesicular release of DA or NA).
• Adverse effects
• CVA, cardiac (MI, HTN), GI ischemic colitis, HIV/hepatitis
• Designer amphetamines (which also have 5HT
properties) inc use
• Rx indications
• ADHD, narcolepsy, depression +/- augmentation
Caffeine
• Intoxication
• >250 mg/d
• Restlessness, nervousness,
twitching, excitement, dec sleep,
periods of inexhaustion, nausea,
diuresis, tachy, arrhythmia,
flushed face, rambling thoughts
• At > 1g tinnitis, light flashes,
>10g sz, resp failure
• Withdrawal (not formally recognized
DSM IV)
• 50-75%, H/A, fatigue, anxiety,
irritability, psychomotor
retardation, N/V, craving.
Onset 12-24h, peak 24-48h.
• Epid: most widely used substance
• Pharmacology
•
•
•
•
Methylxanthine
T ½ 3-10 h (peak 30-60 min)
Blocks adenosine R->CAMP
Theoxanthane and caffeine are
adenosine antagonists.
• Through adensine blockade, these
substances activate DA in the nucleus
accumbens and NA in the locus
coeruleus.
• Comorbidity
• Sedative hypnotic abuse
• Adverse effects
• Cardiac arrhythmias, fibrocystic
disease, ?birth defects, panic attacks
CASE
• 38year old male advertising executive, who presents with a
history of altered behaviour. His girlfriend who
accompanied him describes that he has been behaving like
Jeckyl and Hyde. Lately she has been hearing a crackling
sound when he is in the bathroom and strange smells that
linger afterwards. He sometimes acts like he’s energized,
outgoing, hypervigilant, talkative and becomes
interpersonally sensitive.
• These periods that last several hours are often followed by
intense and unpleasant feelings of lassitude and depression
with increased appetite generally requiring several days of
recuperation. During that time he sleeps much more and
often has nightmares and vivid dreams. Sometimes he also
feels like committing suicide during these lows.
• What is the most likely diagnosis?
Cocaine
• AKA
•
Blow, nose candy, snowball, tornado, wicky stick, Perico, crack
• Epidemiology
• M=F
• Forms:
•
Powdered, HCl salt form of cocaine can be snorted or dissolved in water and injected.
Crack (free base) is cocaine that has not been neutralized by an acid to make the
hydrochloride salt. This form of cocaine comes in a rock crystal that can be heated and its
vapors smoked. The term “crack” refers to the crackling sound heard when it is heated
• Concomitant use of other drugs
•
The combination of cocaine with alcohol (some studies report up to 70% of cocaine
consumers) produces cocaethylene (ethylbenzoylecgonine), which has more potent
proconvulsant and cardiotoxic properties than cocaine itself, coupled with a longer half-life.
Heroin is also commonly used with cocaine as a "speedball" in an effort to combine a
cocaine high (initial phase) with a heroin high (latter phase) of intoxication. Furthermore,
nicotine dependence is reported in up to 88% of patients who use cocaine, thus adding to
cocaine cardiovascular risk factors.
Cocaine
• Comorbidity
•
Mood, ASPD, Anxiety d/o, BAD-II, cyclothymia, ?ADHD
• Psychopharm
•
•
Blocks DA reuptake, T ½ 30-60 min
Urine screen – lasts 10 days
• Tolerance
•
Physiologic and psychologic tolerance to cocaine emerges between the first and second dose.
In other words, the psychologic high and the physiologic body response (eg, pulse, blood
pressure) do not increase with additional doses of cocaine once the initial effect is reached.
• Treatment
•
•
•
B- abstinence (alone, OP, assisted, residential, DP, inpatient), consider beta blocker,
clonidine, NDRI, or Nefazadone for withdrawal sx. Tx underlying psych comorbidity
P- supportive, CBT, relapse prevention
S- family therapy, psychoeducation, vocation, residential support
Cocaine
• Intoxication (MAGIC)
•
•
•
•
•
•
Maladaptive behavioral or psychological changes + 2 of
ANS: dilated pupils, sweating, chills, HR inc/dec, HTN
GI: N/V
Inc muscle weakness, resp depression
Cardiac: chest pain, arrhythmia
CNS: psychomotor change, confusion, sz, dystonia, dyskinesia
• Withdrawal (FASTD)
•
•
•
•
•
Fatigue
Appetite change
Sleep change
Too fast/slow :[psychomotor changes]
Dysphoric mood, Dreams
Cocaine
• Adverse effects
• Non-hemorrhagic CVA, TIA, MI, arrhythmia,
cardiomyopathy, Sz 3-8%, inc risk w preexisting sz d/o
(the chicken). IVDU: HIV/HCV, HBV
• Acute cocaine abstinence syndrome:
• depression, irritability, lethargy, amotivation,
hypersomnolence, confusion, and drug craving
Cocaine
• Hyperthermia:
• Temperatures as high as 114°F . Rapid cooling important through conduction
and evaporation. Benzodiazepines may be used generously in order to control
psychomotor agitation and shivering.
• Psychomotor agitation:
• Benzodiazepines, such as diazepam and lorazepam until sedated. Avoid physical
restraints in patients with psychomotor agitation because they may interfere with
heat dissipation. Likewise, avoid neuroleptic agents because they interfere with
heat dissipation and, perhaps, lower the seizure threshold.
Cocaine
• Convulsions:
• Aggressively treat recurrent seizures because they may worsen
hyperthermia, rhabdomyolysis, hypoxia, and acidosis. Seizures may
also be a manifestation of an acute intracerebral complication. Imaging
studies and, when indicated, cerebrospinal fluid (CSF) analysis should
follow immediate seizure control.
• Phenytoin may be ineffective in this circumstance and may be part of
the street additives to cocaine bulk. Incremental doses of
benzodiazepines, such as diazepam (0.1-0.3 mg/kg, intravenously) and
lorazepam, are the preferred but if ineffective barbiturates anesthesia
with ventilatory support and neuromuscular blockade should be
considered.
Cocaine
• Hypertension:
• due to alpha-mediated vasoconstriction, secondary to
norepinephrine from CNS.
• Commonly responds to benzodiazepines.
• Vasodilators, such as nitroprusside and nitroglycerin, are effective.
• If a contraindication to nitrate therapy exists, alpha-blockers, such
as phentolamine, which block the vasomotor effect of
norepinephrine, may be used.
• Beta-blockers are best avoided in the setting of cocaine toxicity
because they may result in unopposed alpha effects of cocaine. Betablockers have been reported to increase the blood pressure, reduce
coronary blood flow, reduce left ventricular function, accentuate
vasoconstriction and reduce the cardiac output and tissue perfusion
in patients with cocaine toxicity
Case
• 38 year old female who lives with her husband and 3 year old
daughter. She suffers from chronic pain following a MVA 2
years ago. She was treated at that time with Percocet,
however her GP “cut her off ” after 6 months of medications
and now will only prescribe her NSAIDs.
• She works as a purchasing agent in the civil service but is
getting in trouble at work for repeated work absences.
• She is currently using 2x80 mg oxycontin which she gets from
a friend who refers to them as “oxies”. She is paying $80 per
day for these narcotics and can’t really afford to continue like
this.
Case
• Based on the history above what is the most likely
diagnosis?
a) Opiod abuse
b) Fibromyalgia
c) Dependent personality disorder
d) Addictive personality
e) Opiod dependence
Case
• You ask her when her last “oxy” was and she states 2h
ago. Which of the following are symptoms of opiod
intoxication?
a)
b)
c)
d)
e)
Hypotension
Miosis
Lacrimation
Respiratory depression
euphoria
CASE
• She states that when she doesn’t take the pills she feels
sick. Which of the following are symptoms of opiod
withdrawal.
a)
b)
c)
d)
e)
Nausea or vomiting
Seizures
Myalgias
Yawning
Rhinorrhea
CASE
• What pharmacologic options are available for opiod
tapering?
a) Buprenorphine
b) Naloxone
c) Methadone
d) Topamax
e) Depot injectable naltrexone
Heroin
•
AKA
•
Smack, thunder, hell dust, big H, nose drops
•
Most abused and the most rapidly acting of the
opiates.
•
Forms
•
•
•
Processed from morphine, a naturally occurring
substance extracted from the seed pod of certain varieties
of poppy plants. Sold as a white or brownish powder or
as the black sticky substance known on the streets as
“black tar heroin.”
Although purer heroin is becoming more common, most
street heroin is “cut” with other drugs or with substances
such as sugar, starch, powdered milk, or quinine. Street
heroin can also be cut with strychnine, fentanyl or other
poisons.
Patterns of use
•
Heroin can be injected, smoked, or sniffed/snorted.
Injection is the most efficient way to administer lowpurity heroin. The availability of high-purity heroin,
however, and the fear of infection by sharing needles has
made snorting and smoking the drug more common.
• Dangers
• Because heroin abusers do
not know the actual strength
of the drug or its true
contents, they are at risk of
overdose or death.
• Heroin also poses special
problems because of the
transmission of HIV and
other diseases that can occur
from sharing needles or
other injection equipment.
hallucinogens
• The general group of pharmacological agents can be divided into three
broad categories:
1
2
3
Psychedelics,
Dissociatives,
Deliriants.
• These classes of psychoactive drugs have in common that they can cause
subjective changes in perception, thought, emotion and consciousness.
• The term "hallucinogen" is a misnomer because these drugs do not cause
hallucinations at typical doses. Alters normal perceptions; therefore are
more illusions.
• Deliriants, such as diphenhydramine and atropine, may cause
hallucinations in the proper sense.
Hallucinogens:
PSYCHEDELIC
• Perception altering. The term "psychedelic" is used interchangeably with
"psychotomimetic" and "hallucinogen"
• The word psychedelic was coined to express the idea of a drug that makes
manifest a hidden but real aspect of the mind.
• It is commonly applied to any drug with perception-altering effects such as
LSD, psilocybin, DMT, 2C-B, mescaline and DOB as well as a panoply of
other tryptamines, phenethylamines and yet more exotic chemicals.
• It can refer to a large number of drugs such as classical hallucinogens
(LSD, psilocybin, mescaline, etc.), entactogens (e.g. MDMA),
cannabinoids and dissociative drugs (e.g. ketamine). The classical
hallucinogens are considered to be the representative psychedelics and
LSD is generally considered the prototypical psychedelic.
Hallucinogens: dissociative
• Dissociative drugs produce analgesia, amnesia and catalepsy at anesthetic
doses.
• They also produce a sense of detachment from the surrounding
environment, hence "the state has been designated as dissociative
anesthesia since the patient truly seems disassociated from his
environment.”
• Dissociative symptoms include the disruption or compartmentalization of
"...the usually integrated functions of consciousness, memory, identity or
perception.”
• Dissociation of sensory input can cause derealization, the perception of
the outside world as being dream-like or unreal. Other dissociative
experiences include depersonalization (eg. not recognizing yourself in a
mirror)
Hallucinogens: dissociative
• The primary dissociatives are similar in action to PCP
(angel dust) and include ketamine (an anaesthetic) and
DXM (dextromethorphan, though evidence suggests
that its metabolite dextrorphan DXO, is mostly
responsible for its PCP-like effects.
• Also included are nitrous oxide, muscimol, and from
the Amanita muscaria (fly agaric) mushroom.
• Also, dissociation is remarkably administered by
Salvinorin A's potent κ-Opioid receptor agonism
Hallucinogens: deliriants
• The deliriants (or anticholinergics) are a special class of
dissociative which are antagonists for the acetylcholine
receptors (unlike muscarine and nicotine which are agonists
of these receptors). Deliriants are sometimes called true
hallucinogens, because they do cause hallucinations in the
proper sense.
• While dissociatives can produce effects similar to lucid
dreaming (during which one is consciously aware of
dreaming), the deliriants have effects akin to sleepwalking
(during which one does not remember the experience).
Hallucinogens: deliriants
• Included in this group are such plants as deadly
nightshade, mandrake, henbane and datura, as
well as a number of pharmaceutical drugs,
when taken in very high doses, such as the firstgeneration antihistamines diphenhydramine
(Benadryl), its close relative dimenhydrinate
(Dramamine or Gravol) and hydroxyzine, to
name a few.
Hallucinogens
Other classifications
• Psychedelics (5-HT2A receptor agonists)
• Tryptamines
• Lysergamides
• Phenethylamines
• Amphetamines
• Piperazines
• Cannabinoids (CB-1 receptor agonists)
• Dissociatives
• NMDA receptor antagonists
• κ-Opioid receptor agonists
• Deliriants (anticholinergics)
Hallucinogens
• Chemical Classification
• Ergots: LSD
• Phenylakylamines (amphetamine derivatives):
• Mescaline (Peyote Cactus), MMDA
(nutmeg/mace), TMA, MDA, STP, MDMA
(ecstasy)
• Indole alkaloids (serotonin activity):
• Psilocybin (magic mushrooms)
• DMT (cohaba snuff) (IV)
• Befotenine (skins of toads)
• Anticholinergic drugs
• Hyoscyamine, atropine, scopolamine, gravol
Hallucinogens
• Intoxication
•
•
•
•
Behavioural or psychological change: depression / anxiety / ideas
of reference, paranoia, impaired judgement
Perceptual changes ( intensification, depersonalization,
derealization, illusions, hallucinations, synthesthesias)
Associated physical si/sx (PTSD)
• Pupillary dilation/ Blurred vision
• Tremor, Tachycardia
• Sweating (hyperthermia)
• Dizziness/in-coordination
Death by hyperthermia, HTN
•
Tolerance develops/reverses quickly
•
Hallucinogen Persisting Perceptual Disorder
• Flashbacks
• prev 15-80%, can be after single use. DDx: migraine, PTSD, sz’s,
visual changes
Hallucinogens
• Patterns of use
•
Limited to a few times per week to
prevent tolerance (also cross
tolerance)
• Adverse effects
•
•
• Pharmacology
•
•
•
Post synaptic 5 HT-2 receptor
antagonists
Rapid tolerance to euphoria and
psychedelic effects but not to
autonomic effects (mydriasis,
hyperreflexia, HTN, pyrexia,
piloerection, tachycardia)
Many have long half life/duration of
action
•
•
MDMA
rapid onset, peak 30 min,
lasts 4-6h
LSD onset minutes, peaks 2-4 h, lasts
12-14 hrs
•
“bad trips” usually panic
attacks/flashbacks
Hangover effects w MDMA (insomnia,
fatigue, drowsiness, sore jaw muscles,
loss of balance, H/A’s)
Dangerous behavioural reactions
•
•
•
Jumping out of windows due to lack of
insight while intoxicated
MDMA causes hyperthermia, which is
exacerbated by such excessive activity as
wildly dancing in a crowded, hot room
(ie. RAVE). Deaths reported. MDMA
causes damage to serotonergic neurons.
MDMA (less disorientation and
perceptual distortion cf LSD) but more
a sense of closeness, personal comfort
and increased luminescence of objects
Case
• The patient was a 20-year-old man who was brought to the
hospital, trussed in ropes, by his four brothers. This was his
seventh hospitalization in the last 2 years, each for similar
behavior.
• One of his brothers reported that he “became home crazy,” threw
a chair through a window, tore a gas heater off the wall, and ran
into the street. The family called the police, who apprehended him
shortly thereafter as he stood, naked, directing traffic at a busy
intersection. He punched two of the officers and appeared to have
no pain. He assaulted the arresting officers, escaped from them,
and ran home screaming threats at his family. There, his brothers
were able to subdue him.
• One of his brother reported that thought “he gets dusted every
day.”
Case
• On admission, the patient was observed to be agitated, with his
mood fluctuating between anger and fear. He had slurred speech and
staggered when he walked.
• He remained extremely violent and disorganized for the first several
days of his hospitalization, then began having longer and longer
lucid intervals, still interspersed with sudden, unpredictable periods
in which he displayed great suspiciousness, a fierce expression,
slurred speech, and clenched fists.
• After calming down, the patient denied ever having been violent or
acting in an unusual way (“I’m a peaceable man”•
) and said he could
not remember how he got to the hospital. DSM IV Case Manual.
Case
• What is the most likely substance abused?
a) Amphetamines
b) Cocaine
c) Speak K
d) PCP
e) LSD
PCP
• Intoxication PCPHardens
• P Psych/Beh changes:
belligerent/assaultive,
unpredicatable, agitated
• C coma/sz
• P pain sensitivity dec
• H hyperacusis
• A ataxia
• R rigidity
• D dysarthia
• E elevated BP/HR
• N nystagmus
• S S-GMC other d/o
exclusion
(angel dust)
• Psychopharm
•
•
Blocks NMDA-R of glutamate, activates DA
via VTA-NA
Tolerance but no withdrawal
• Delirium in 25% (in DDx for NMS but
usually no fever)
• Urine x 1 wk
• Adverse effects
•
Hyperthermia (looks like NMS), rhabdo,
CK
• Tx:
•
BDZ+/- haldol (not talking down),
supportive monitor VS, dec sensory
stimulation.
Phencyclidine Dependence
dsm iv p 307
• Some of the generic criteria for Substance Dependence do not apply to
phencyclidine. Although "craving" has been reported by individuals with heavy use,
neither tolerance nor withdrawal symptoms have been clearly demonstrated in
humans (although both have been shown to occur in animal studies).
• Phencyclidine is usually not difficult to obtain, and individuals with Phencyclidine
Dependence often use it at least two to three times per day, thus spending a
significant proportion of their time using the substance and experiencing its effects.
Phencyclidine use may continue despite the presence of psychological problems
(e.g., disinhibition, anxiety, rage, aggression, panic, flashbacks) or medical problems
(e.g., hyperthermia, hypertension, seizures) that the individual knows are caused by
the substance. Individuals with Phencycldine Dependence can manifest dangerous
behavioral reactions due to lack of insight and judgment while intoxicated.
• Aggressive behavior involving fighting-probably the result of disorganized thinking,
agitation, and impaired judgment has been identified as an especially problematic
adverse effect of phencyclidine. As with hallucinogens, adverse reactions to
phencyclidine may be more common among individuals with preexisting mental
disorders.
Cannabis
cannabis
• Cannabis, from the Indian hemp plant Cannabis sativa, is a hardy, aromatic
annual herb. The cannabis plant has been used in China, India and the Middle
East for approximately 8,000 years for its fiber and as a medicinal agent. It is the
most commonly used illicit drug in the United States and, by most estimates,
around the world as well.
• All parts of Cannabis sativa contain psychoactive cannabinoids, of which delta9tetrahydrocannabinol (delta-9-THC) is most abundant. At least 66 other
cannabinoids are also present in cannabis, including cannabidiol (CBD),
cannabinol (CBN) and tetrahydrocannabivarin (THCV) among many others,
which are believed to result in different effects than those of THC alone
• The most potent forms of cannabis come from the flowering tops of the plants or
from the dried, black-brown, resinous exudate from the leaves, which is referred
to as hashish or hash.
• The cannabis plant is usually cut, dried, chopped, and rolled into cigarettes
(commonly called “joints―
), which are then smoked.
cannabis
• Common names
•
marijuana, grass, pot, weed, tea, and Mary Jane. Other names, which describe
cannabis types of various strengths, are hemp, chasra, bhang, ganja, dagga, and
sinsemilla. The potency of marijuana preparations has increased in recent years
because of improved agricultural techniques used in cultivation so that plants may
contain up to 15 or 20 percent THC.
• Prevalence and Recent Trends
•
•
Based on the 2003 National Surveys on Drug Use and Health (NSDUH), an
estimated 90.8 million adults (42.9 percent) aged 18 years or older had used
marijuana at least once in their lifetime. Among this group, about 2 percent used
the drug before age 12, about 53 percent between 12 and 17 and about 45 percent
after age 18.
According to the text revision of the fourth edition of Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV-TR), there is a 5 percent lifetime rate of
cannabis abuse or dependence, but that figure may be too low according to
NSDUH surveys.
Miscellaneous Notes on
Substance use disorders
• Death by hyperthermia with
MDMA
• Inhalants a common cause of
cognitive impairment
• PCP commonly presents with
catatonia
• No withdrawal w PCP
according to the DSM IV
Reasons to suspect an underlying
psychiatric disorder…
• Sx precede use of substance
• Sx persist after discontinuation
(eg. One month)
• Sx out of proportion or
unusual for offending
substance
• Cross sectional, longitudinal,
epidemiology, FHx and past tx
responsiveness suggest a
specific axis 1 pathology
Treatment
• 2 approaches
• Abstinence
• Harm reduction
• Treatment settings
• Outpatient
• Residential tx programs
• Psychotherapy
WHO 2006
Treatment
• Motivational Interviewing
• Cognitive Behavioural Therapy
• Social Skills Training
• Contingency Management
• Pharmacological therapy - A number of medications have been approved for the
treatment of substance abuse. These include replacement therapies such as
buprenorphine and methadone as well as antagonist medications like disulfiram
and naltrexone in either short acting, or the newer long acting form (under the
brand name Vivitrol).
• Several other medications, often ones originally used in other contexts, have also
been shown to be effective including bupropion (Zyban or Wellbutrin), Modafinil
(Provigil) and more.
Change theory
STAGES OF CHANGE
1. Precontemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance
Prochaska &
DiClemente
Psychotherapy
• Motivational Interviewing
• Focuses on the present interests, concerns and
perspectives of the individual
• Focuses on the resolution of ambivalence
• Elicits and selectively reinforces change talk
• Is a method of communicating rather than a set of
techniques
• It is fundamentally a way of being with and for people“facilitative approach to communication that evokes
natural change”.
• Illicits the persons intrinsic motivation for change.
Motivational interviewing
• Four General Principles
1. Express Empathy
• Acceptance facilitates change
2. Develop Discrepancy
• Between behaviour and personal goals
3. Roll with resistance
• Patient primary resource for solutions
• Signal to respond differently
4. Support self-efficacy
• Patient responsible for choosing and carrying out
change
CBT for substance
• Cognitive Behavior Therapy for substance has two main components:
functional analysis and skills training.
• Functional Analysis: Working together, the therapist and the patient try to
identify the thoughts, feelings and circumstances of the patient before and after
they drank or used drugs. This helps the patient determine the risks that are
likely to lead to a relapse.
• Functional analysis can also give the person insight into why they drink or use
drugs in the first place and identify situations in which the person has coping
difficulties.
• Skills Training: If someone is at the point where they need professional
treatment for their alcohol or drug dependence, chances are they are using
alcohol or drugs as their main means of coping with their problems. The goal
of cognitive behavior therapy is to get the person to learn or relearn better
coping skills.
WHO 2006
WHO 2006