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Substance Disorders- part different drugs change body
- 1. Substance Abuse –part 2
- 2. Learning Objectives At theend of the course, students should be able to: Understand and able to identify different drug of abuse Diagnosis and classification under the DSMIV TR/ DSM5 Recognized and discuss the neurological and physiological impact of the abuse substance Identify psychological effect on behavior Apply best treatment and intervention
- 3. Substance Abuse 1) Recurrentuse resulting in failure to fulfill major obligations at work, school, or home 2) Recurrent use in physically hazardous situations 3) Recurrent substance-related legal problems 4) Continued use in spit of persistent problems
- 4. Substance Dependence 3 ormore of the following signs in one year Tolerance Withdrawal signs Substance taken in larger amts or longer time Desire/attempt to cut down Significant energy spent obtaining, using or recovering from substance Decreased social, occupational or recreational activities Continued use in spite of knowing the problems
- 5. What does the board wantyou to know?
- 6. Cocaine AKA “CRACK” Blocks the reuptake of catecholamines at the synapse Intense euphoriacrash Can cause hyperactivity and growth retardation in pregnancy
- 7. Cocaine Intoxication Euphoria Hypervigilance Anxiety Grandiosity Impaired judgment Hallucinations Tachycardia Pupillary dilation Paranoia Sudden cardiac death Withdrawal Depression (CRASH) Suicidal Increased appetite Unpleasant dreams Hyper somnolence Fatigue Severe psychological craving
- 8. Cocaine 2002 and2003 5.9 million (2.5%) age 12 and over used cocaine in the past year Highest rate in age group 18 to 25 years Higher rate in males than female (males 3.4 and females 1.6) in the past year Reinforcement - Learning and conditioning also play a unique role in the perpetuation of cocaine abuse. Each inhalation and injection of cocaine causes pleasurable feelings that reinforce the drug-taking procedure patient's environment also plays a role in cueing and reinforcing the experience in the patient's mind
- 9. Treatment Psychotherapy- CBT Self help groups Medication has failed to be proven effective
- 10. Amphetamine Another abusedstimulant drug Releases catecholamine from the synaptic terminals Some similarity to cocaine Street names- Speed, ice, crystal Group of powerful and highly addictive substances that dramatically affect the central nervous system. They induce a feeling of well-being and improve alertness, attention, and performance on various cognitive and motor tasks Used clinically to treat ADHD, depression, Narcolepsy and obesity
- 11. Amphetamine Intoxication Psychomotoragitation or retardation Impaired judgment Pupillary dilation Elevated or lowered blood pressure Tachycardia(fast heart beat) Euphoria Arrhythmias(irregular heart beat) Delusions Hallucinations Withdrawal Post use “crash” Depression Lethargy Headache Stomach cramps Hunger Insomnia or hypersomnia Unpleasant dreams
- 12. Epidemiology National HouseholdSurvey on Drugs Abuse(NHSDA) 2001- 7.1 percent of persons aged 12 and over reported lifetime nonmedical use of stimulants Significant increase from 4.5 percent in 1997 Highest rate in past year were (1.5 %) were among 18 to 25 years old
- 13. Treatments Psychotherapy- mosteffective treatments are cognitive- behavioral interventions. Helps the individual learn to identify their problematic patterns of thoughts and beliefs, and to change them. As a result of changed thoughts and beliefs, feelings become more manageable and less painful Medication- antidepressant medications can help combat the depressive symptoms frequently experienced. Antipsychotics or benzodiazepines
- 14. DSM-1V-TR related disorder Amphetamine intoxication delirium Induced psychotic disorder Induced mood disorder Induced anxiety disorder Induced sexual dysfunction Induced sleep disorder
- 15. Caffeine Common substanceused for many on a daily basis Coffee Pills Injections
- 16. As ananaleptic, or central nervous system stimulant Most widely used psychoactive substance in the world About 200mg of caffeine per day is consumed by an adult in the United States 20 to 30 percent of all adults in the United States consumes more than 500gm per day
- 17. Caffeine Intoxication Restlessness Agitation Insomnia Diuresis Cardiac arrhythmias Gastrointestinal disturbances Excitement Withdrawal Headache Fatigue Drowsiness Nausea or vomiting Dysphoric mood, depressed mood, or irritability
- 18. Nicotine Withdrawing canlead to severe cravings Associated with many medical conditions such as: Cardiovascular disease Cancers Hypertension Withdrawal - Irritability, frustration, or anger. Anxiety, difficulty concentrating, increased appetite, restlessness, depressed mood, insomnia
- 19. One ofthe most highly additive and heavily used drug in the United States WHO estimate that tobacco kills more than 3 million person per year Most common form of nicotine 25 percent of Americans smoke, 25 percent are former smokers and 50 percent never smoke cigarettes Mean age of onset of smoking in 16 years Contributes to 400,000 premature deaths each year in the United States, 25% of all deaths Forms 30 percent of cancer death in the United States
- 20. Treatment Bupropion (Zyban)helps reduce cravings for nicotine. - also relieve symptoms of depression for some patients. Varenicline (Chantix) -approved byFDA for smoking cessation. help smokers quit in two ways. -blocks some of the rewarding effects of nicotine (acts as an antagonist) -at the same time stimulates the receptors in a way that reduces withdrawal (acts as an agonist).
- 21. Treatment cont’d Nicotinechewing gum as a prescription drug for smoking cessation Nicotine transdermal patches Psychosocial therapy- ( behavioral therapy) Hypnosis Solution focus therapy Smoke free environment
- 23. Opioids Morphine Codeine Heroin Methadone OD harmful, but really can be FATAL however withdrawal is rarely difficult Induce euphoria and sedation as well as analgesia Used on the streets and also in medicine Depresses the respiratory system
- 24. Opioids Intoxication Pupillary constriction Constipation Drowsiness Slurred speech Respiratory depression Bradycardia(slow heart rate) Coma Withdrawal Pupillary dilation “Flu-like” muscle aches Nausea/ vomiting Piloerection(goose bumps) Yawning Lacrimation (excessive tears) Rhinorrhea(running noise) Fever Insomnia
- 25. Treatment Psychotherapy Clonidine– ease withdrawal Methodone- substitute addiction Buprenorphine- like methadone, suppresses withdrawal and cravings. No additional effects
- 26. Heroin 50% ofheroin addicts in the US live in NYC More prevalent in males Crosses blood-brain barrier to produce an euphoric action Clonidine, an adrenergic agonist can block heroin withdrawal syndrome
- 27. Heroin Other complications IVdrug users Infective endocarditis (right sided) Tricuspid valve Prolapse Staph Aures Septic emboli Can go to the lungs!! Hepatitis C Liver failure HIV
- 28. Ectasy Aka MDMA(methylenedioxymethamphetamine) Acts as a hallucinogen when combined with amphetamine Dehydration Party drug
- 29. Methadone Synthetic opioidto treat heroin addiction “Methadone” clinics May get physical dependence and tolerance….still has advantages for the addict Taken orally and suppresses heroin withdrawal symptoms Longer duration of action and causes less euphoria ect. While taking this, patient can maintain work status an avoid criminal activity
- 30. Hallucinogen-related agents Lysergicacid diethylamide (LSD)-ingested Phencyclidine (PCP, “angel dust”)- smoked Promote altered state of consciousness religious rituals (Shamans in Siberia were known to eat the hallucinogenic mushroom) Most common among young 15 to 35 white men Again 18 to 25 with highest recent use Cultural factor an influence- significant high use in the western United State than in the southern
- 31. PCP Aka AngelDust AGRESSIVE!!! Impulsiveness Vertical and horizontal nystagmus(eye movement) Homicidal Psychosis Seizures and coma LSD Delusions Visual hallucinations Pupillary dilation
- 32. Cannabis/Marijuana Intoxication Euphoria Anxiety Paranoid delusions Perception of slowed time Impaired judgment Social withdrawal Increased appetite Dry mouth Hallucinations Withdrawal (heavy and prolonged use) after 1 week • Irritability, anger, or aggression • Nervousness or anxiety • Sleep difficulty • Decreased appetite or weight loss • Restlessness • Depressed mood
- 33. Inhalant-related agents Theinhalants are a class of drugs that include a broad range of chemicals found in hundreds of different products, many of which are readily available to the general population. chemicals include volatile solvents include glue, gasoline, paint thinner, hair spray, lighter fluid, spray paint, nail polish remover, correction fluid, rubber cement, felt-tip marker fluids route of administration— that is, they are all drawn into the body by breathing
- 34. Epidemiology Mostly usedby poor and young persons Three factors contribute to high use- Easily available Legal Inexpensive Most common in age group 18 to 25 years Most common in white than black and hispanic Most users are males (80%) Forms 1% of substance related deaths
- 35. Causes and Symptoms often used by children (ages six to 16) and the poor Factors that are associated with inhalant use include poverty; a history of childhood abuse; poor grades; and dropping out of school. Influence by peers Symptoms of dependency- tolerance, loss of control, interference with activities Abuse- danger to self, legal problems, social problems Intoxication- personality change, dizziness, fatigue, tremor, blurred visions, slow reflexes
- 36. Clinical features Insmall doses can be disinhibiting and produce feeling of euphoria and excitement High doses can cause psychological symptoms like- fearfulness, sensory illusion, auditory and visual hallucination and distortion in body size Neurological symptoms- slurred speech, decreased speed in talking, impaired memory( long term)
- 37. Treatment involves enlistingthe support of the person's family; changing the friendship network if the individual uses with others; teaching coping skills; and increasing self-esteem. Day treatment and residential programs has been effective Abstinent psychotherapy
- 38. Sedatives Benzodiazepine Anxiety Sleep aid Alcohol withdrawal Only causes a minor respiratory depression Barbiturates Depresses the respiratory system Withdrawal can be very dangerous Where used as sleeping aid and anticonvulsants
- 39. Intoxication- Slurredspeech Incoordination Unsteady gait Nystagmus Impairment in cognition (e.g., attention, memory) Stupor or coma. Withdrawal – Autonomic hyperactivity Hand tremor. Insomnia Nausea or vomiting Transient visual, tactile, or auditory hallucinations or illusions Psychomotor agitation Anxiety Grand mal seizures
- 42. Helpful hints ofsubstance abuse Paranoia Cocaine/ amphetamine intoxication Depression Cocaine/ amphetamine withdrawal Arrhythmias (abnormal heart beat) Cocaine intoxication Violence PCP Vertical nystagmus (eye movement) PCP Pinpoint pupils Opiate overdose (treatment= naloxone) Flu-like Opiate withdrawal (treatment=clonidine)
- 43. Screening for substanceuse Step 1: (all patients) “Do you sometimes drink alcoholic beverages?” or “When was your last use of marijuana or other drugs?” (If answer is “No” or “Years ago” or “Never” move on to another topic.) Step 2: Screen for dependence “In the last year, have you ever drunk or used drugs more than you meant to?” “Have you ever felt you wanted or needed to cut down on your drinking or drug use in the last year?” CAGE questions (alternative screen) Cut back Annoyed Guilty Eye-opener
- 44. Step 3:If Step 2 negative, screen for hazardous use National Institute of Alcohol Abuse & Addiction (NIAAA) recommended questions about quantity: “On average, how many days a week do you drink?” “On a typical day when you drink, how many drinks do you have?” “What is the maximum number of drinks you had on any given occasion in the last month?”
- 45. Step 4:If Step 2 positive, screen for problems and clarify extent Problem examples: Somatic: gastritis, trauma, hypertension, liver function disorder, new-onset seizure Psychosocial: anxiety, depression, insomnia, sexual dysfunction, family conflict, memory blackouts Legal: DUI (Driving under the influence)
- 46. Red flags Intoxication(even in ER, healthy drinkers seldom arrive intoxicated) Odor of alcohol (without intoxication indicates tolerance) If alcohol easily smelled, (blood alcohol level) BAL > 0.125 Less dramatic odor, BAL 0.075 – 0.125 Tolerance indicates brain adaptation to heavy use = dependence Withdrawal - symptoms
- 47. Spontaneous mentionof alcohol or drug use behavior: “partying,” hangover, tolerance, blackouts Family history, DUI Spouse-initiated concerns Previous history of problems
- 48. Physical exam &labs Illicit drugs detectable in urine, with variable ability to identify them. Marijuana detected up to 30 days in urine for daily smokers (1-3 days for intermittent smokers All other illicit drugs cleared in 72 hours (positive test for cocaine indicates use in past 2-3 days).
- 49. Intervention strategies Assesspatient’s commitment to change. Support autonomy. Dialogue about information. Tell, ask Dialogue about recommendations. Confirm results of dialogue.
- 50. On ascale of 0-10, how interested are you in quitting drinking at this time, where 0 means not at all and 10 means it is a top priority?” If 4, ask “Why did you select 4 rather than 0?” “What would it take to move it from 4 to 8?”
- 51. Stages ofreadiness to change Pre-contemplation- not interested in changing Contemplation- starting to think about changing their behavior. Preparation- a decision to change has been made. The client is now thinking about putting it into effect Action- clients are changing their behavior. The counsellor can assist with relapse prevention and management and reinforcing positive changes. Maintenance-clients are focused on maintaining the positive changes Relapse- can happen in any stage
- 52. Support autonomy Listento patient’s perspectives without judgment. Reflect what you hear. Offer your expertise, recommendations, and support. Create dialogue:
- 53. Dialogue about information Tell: “Research shows that treatment helps,” or “Steady drug use changes brain function,” or “Guidelines from extensive research show that drinking more than 14 drinks a week is risky.” Ask: “What are your thoughts about this?” Tell (information about patient’s condition as information, rather than judgment or conclusion): “Three of your liver tests are abnormal,” rather than “Alcohol has damaged your liver.” “You have a serious infection in your arm,” rather than “You got this infection because you were injecting.” Ask what patient thinks of this information
- 54. Do Physicians abusedrugs????
- 55. Psychiatrists andanesthesiologists have highest rate Physician impairment issues are dealt with by the State Licensing Board If you suspect that a colleague has a substance abuse problem: - get the colleague to suspend patient contact - you must report it to the hospital administration and the State Board - ideally, get the colleague into treatment
Editor's Notes
- #46 BAL = Blood alcohol level (.08) g/dl