Substance- Related Disorders
Professor
Dr Sirwan K Ali
Department of Psychiatry
Introduction Addiction 5 C’s
Chronic
Compulsive use, not associate with willpower
Control-impaired--unable to limit intake
Craving--desire for the drug when it is absent
Continued use despite
SUBSTANCE ABUSE
DIAGNOSIS AND DSM-IV CRITERIA
Abuse is a pattern of substance use leading to
impairment or distress for at least 1 year with one or
more of the following manifestations:
1. Failure to fulfill obligations at work, school, or home
2. Use in dangerous situations (i.e., driving a car)
3. Recurrent substance-related legal problems
4. Continued use despite social or interpersonal
problems.
Substance Dependence
A maladaptive pattern of substance use
leading to clinically significant impairment or
distress, manifested by 3 or more of the
following occurring at any time within the
same 12 month period:
Tolerance
-need for more to achieve the same effect
-decreased effect with same amount
Substance Dependence
Withdrawal
-Characteristic withdrawal syndrome
-Using substance to avoid withdrawal Sx.
Substance taken in larger amount or for longer
time than intended
Persistent unsuccessful attempts to cut down or
control use
Substance Dependence
Great deal of time spent obtaining, using, or
recovering from use
Important social, occupational, recreational
activities given up or reduced
Use is continued despite knowledge that has
persistent or recurrent physical or psychological
problems that were caused or exacerbated by use
EPIDEMIOLOGY
Lifetime prevalence of substance abuse or
dependence in the United States:
Approximately 17%
More common in men than women
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Estimated Economic Cost to Society from
Substance Abuse and Addiction:
o Illegal drugs: $181 billion/year
o Alcohol: $185 billion/year
o Tobacco: $158 billion/year
Total: $524 billion/year
Surgeon General’s Report, 2004; ONDCP, 2004; Harwood, 2000.
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Vulnerability
Why do some people
become addicted while
others do not?
We Know There’s A
Big Genetic Contribution To
Drug Abuse and Addiction…
And the Nature of this Contribution
Is Extremely Complex
What Other Environmental
Factors Contribute to Addiction?
Co-morbid mental illness
Early physical or sexual abuse
Witnessing violence
Stress
Peers who use drugs
Drug availability
COMORBIDITY
Drug Users have a Higher Risk of
Developing Mental Disorders
•Psychosis
•Depression
•Anxiety
•Panic attacks
Example: SMOKING EPIDEMIOLOGY
normal population: 23%
alcoholism: 90%+
other addictions: 90%+
schizophrenia: 85%
depression: 80%
Risk Factors
General Risk Stress and
Factors Addiction are
1. Psychological closely linked.
2. Behavioral
3. Social Increased stress
4. Demographic creates a
5. Family significant
6. Genetics increase in risk
for addiction.
Is addiction a Disease?
Disease is a departure from health.
Defect (malady)
Signs & Symptoms
Predictable Natural Course
Disease –” a disordered or incorrectly
Specific Outcome if left untreated
functioning organ, part, structure or
Risk Factors
system of the body.
Early Warning Signs
Diagnostic Criteria
Alcohol
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Patterns of Use or Abuse
Phase I: Pre-alcoholic phase:
characterized by use of alcohol to relieve everyday
stress and tensions of life
Phase II: Early alcoholic phase:
begins with blackouts: brief periods of amnesia that
occur during or immediately following a period of
drinking; alcohol is now required by the person.
Patterns of Use or Abuse
Phase III: The crucial phase:
person has lost control; physiological dependence
clearly evident
Phase IV: The chronic phase:
characterized by emotional and physical
disintegration; person is usually intoxicated more
often than sober
Alcohol Withdrawal
The pathophysiology of the alcohol
withdrawal syndrome is poorly understood.
Patients experiencing mild withdrawal may be
irritable and complain of insomnia. Those in
more severe withdrawal may experience
fever, disorientation, seizures, or
hallucinations.
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Delirium tremens (DTs)
Delirium tremens (DTs) is the most serious
form of EtOH withdrawal
and often begins within 72 hours of cessation of
drinking.
In addition to delirium, symptoms of DTs may
include visual or tactile hallucinations, gross
tremor, autonomic instability, and fluctuating
levels of psychomotor activity.
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DIAGNOSTIC EVALUATION
Accurate and frequent assessment of vital signs is
essential, as autonomic instability may occur in
cases of severe withdrawal and DTs.
Careful attention must be given to the level of
consciousness, and the possibility of trauma should
be investigated.
Signs of hepatic failure (e.g., ascites, jaundice,
coagulopathy) may be present.
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TREATMENT
Tapering doses of benzodiazepines
(chlordiazepoxide, lorazepam)
Thiamine.
folic acid, and a multivitamin to treat nutritional
deficiencies
Magnesium sulfate for post with-drawal seizures
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Long-Term Complications of Alcohol Intake
Wernicke–Korsakoff syndrome:
is caused by thiamine (vitamin B1) from
the poor diet of alcoholics.
Wernicke’s encephalopathy is acute and
can be reversed with thiamine therapy:
1. Ataxia
2. Confusion
3. Ocular abnormalities (nystagmus, gaze palsies)
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Long-Term Complications of Alcohol Intake
If left untreated, Wernicke’s
encephalopathy may progress into
Korsakoff’s syndrome, which is chronic and
often irreversible.
1. Impaired recent memory
2. Anterograde amnesia
3. +/− Confabulation
Confabulation: Making up answers when memory has
failed
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Cocaine
Cocaine blocks dopamine
reuptake from the synaptic cleft,
causing a stimulant effect.
Dopamine plays a role in
behavioral reinforcement
(“reward” system of the brain).
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Cocaine Intoxication
Cocaine intoxication often produces euphoria, increased
or decreased blood pressure.
tachycardia or bradycardia.
nausea, dilated pupils, weight loss. psychomotor
agitation or depression.
It may also cause respiratory depression, seizures,
arrhythmias, and hallucinations (especially tactile).
Cocaine’s vasoconstrictive effect may result in (MI) or
(CVA).
DIFFERENTIAL DIAGNOSIS
Amphetamine or phencyclidine (PCP)
intoxication, sedative withdrawal.
DIAGNOSTIC EVALUATION:
Urine drug screen (positive for 3 days, longer
in heavy users)
Treatment
Intoxication
1. For mild-to-moderate agitation: Benzodiazepines
2. For severe agitation or psychosis: Haloperidol
3. Symptomatic support (i.e., control hypertension,
arrhythmias)
Dependence
1. Psychotherapy, group therapy
2. Tricyclic antidepressants (TCAs)
3. Dopamine agonists (amantadine, bromocriptine)
Cocaine Withdrawal
Abrupt abstinence is not life threatening but
produces a dysphoric “crash”:
malaise, fatigue, depression, hunger.
constricted pupils, vivid dreams.
psychomotor agitation or retardation.
Treatment: Usually supportive—let patient sleep
off crash.
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CAFFEINE:
Is the most commonly used psychoactive
substance usually in the form of coffee or tea.
Caffeine acts as an adenosine antagonist , causing
increased cyclic adenosine monophosphate
(cAMP) and a stimulant effect via the dopaminergic
system.
One cup of coffee :100 to 150 mg caffeine.
One cup of tea : 40 to 60 mg caffeine.
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Nicotine:
-
is derived from the tobacco plant and stimulate
nicotinic receptors in autonomic ganglia of the
sympathetic and parasympathetic nervous systems.
Cigarette smoking leads to many health risks and
nicotine is rapidly addictive through its effect on the
dopaminergic system.
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Sedatives-hypnotics:
These drugs are highly abused since they are more
readily available than other drugs such as cocaine or
opioids.
Benzodiazepines are commonly used in the treatment of
anxiety disorders and are therefore obtained easily via
prescription.
They potentiate the effects of GABA by increasing the
frequency of chloride channel opening.
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Opiates:
Examples : heroin, codeine, dextromethorphan ,
morphine, methadone, meperidine (demerol ).
These compounds stimulate opiate receptors (mu,
kappa , and delta ) which are normally stimulated by
endogenous opiates and are involved in
analgesia ,sedation, and dependence.
Opiates also have effects on the dopaminergic
system , which mediates their addictive and
rewarding properties.
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LSD in forms
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hallucinogens:
Examples : psilocybin (mushrooms) , mescaline , lysergic
acid diethylamide (LSD).
Pharmacological effects vary , but LSD is known to act on
the serotonergic system.
Tolerance to hallucinogens do not cause physical
dependence or withdrawal .
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Marijuana leaves seeds
In joint rolling
In plastic bag In block
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Marijuana:
The main active component in marijuana or cannabis is THC
(tetrahydrocannabinol).
Cannabinoid receptors in the brain inhibit adenylate cyclase.
Marijuana has been shown to successfully treat:
nausea in CA patient and to increase appetite in AIDS pt.
No dependence or withdrawal syndromes has been shown.
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Inhalants:
Examples : solvents glue , paint thinners , fuels ,
isobutyl nitrates.
Inhalants generally act as CNS depressant , user
is typically an adolescent male.
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Complications
(a) . physical complications:
malnutrition
neurological disorder
gastrointestinal
hepatic problem
cardiovascular
HIV/AIDS by parental substance
use
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(B) . Psychiatric complications:
Depression
Anxiety disorder
Obsessive compulsive neurosis
Panic disorder
Sexual dysfunction
Somatoform disorder
Psychosis
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(C) . Social complications :
Absenteeism from work
Unemployment
Marital tension
Child abuse
Financial difficulties
Problem with law
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Drug Abuse is a
preventable behavior
and
Drug Addiction is
a treatable disease
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In Treating Addiction…
We Need to Keep Our Eye on
the Real Target
Abs
tine
nce
a l ity in
un ction ork
F ily , W ity
m
Fa ommun
and C
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Questions…..
Comments….. (welcome)
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