addiction medicine
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Addiction-Medicine: An Overview
Ramkumar G. S. MD
Dept. of Psychiatry.
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Over view of presentation
Why do people take drugs and why some of them become addicted?
Neurobiological understanding of addiction. Alcohol Use Disorder. Treatment processes in deaddiction care/
drugs used/psychotherapy.
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Why use drugs?
Is it simply a search for fun?
Image courtesy: Google images
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Why use drugs?
many people also take drugs to feel comfortably numb.
Feel pleasantly drowsy. Feel full of energy and confidence. As a self administered medicine for negative
emotional states, aversive states like drug withdrawal
Feel normal Peer pressure
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Why use drugs?
Individual development (Thrill seeking predispositions, impulsive temperament)
Social background. Unidentified disorders of mood. Unopposed and chronic stress responses. Genetic predisposition.
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Why use drugs?
In a “Drug using career” different motivations may become dominant at different point of time.
Different perspectives – molecular, genetic, pharmacological, psychological, Social.
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Alcoholism
Substance use. Problematic use. Substance misuse. Abuse. Harmful use. Addiction
Dependence Spectrum
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Addiction/Dependence
PHYSICAL vs Psychological Dependence
Conditioning to Pathological neuroadaptation…..
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Neurobiology of addiction.Reward circuitry
Neurotransmitters involved Dopamine, Endogenous opoids
+ve reinforcement, compulsive drug seeking behaviour
Pleasure seeking
Neuroadaptive process… an altered biological homeostasis
Involvement of stress hormones like NYP and CRP
-ve reinforcement, craving, tolerance, salience in drug usage
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Neuroadaptation (+ve reinforcement) in Chronic alcohol use
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Mu opoid receptor
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Neuroadaptation (-ve reinforcement) in Chronic alcohol use
CRF/Glutamate tone is upregulated
NYP/GABA is down regulated.
Alcohol is neuro inhibitory/depressant/ anxiolyticGlutamate is excitatoryGABA is inhibitoryCRF stress promotingNYP stress reducing
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Changing pattern of motivation in a “drug using career”
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AUD
Heterogenous disorder eg. Type 1 and 2 Course: remission and relapse. Disease management approach rather than
the cure approach in acute illness. Chronic illness needing long term long
intensity treatment with brief high intensity treatment for relapse and on the front end of the abstience process.
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Treatment approach
Detoxification Pharmacological detoxification treatment.
Psychological Treatment.
Pharmacology for reversing pathological neuroadaptation.
Maintenance treatment
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Containing the withdrawal response by detoxification Withdrawal symptoms arise
when alcohol is being used regularly and withdrawn rapidly.
Excitatory glutamatergic tone. Delerium tremens Treatment is via sedation with
adequate dosage of benzodiazepines, Thiamine supplementation.
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Reversing pathological neuroadaptation. With appropriate help, withdrawing from
alcohol is not the dependent drinkers’s main difficulty.
The main difficulty is avoiding relapse into further problematic drinking or dependence.
Differentiation of physical vs psychological dependence as therapeutic implications.
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Drugs.
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Psychological therapy
Motivational enhancement therapy.(MET) 12 Step facilitation program/ AA group. Relapse prevention. Craving management. Cognitive Behavioural therapy ( dealing with
high risk situation, contingency management, community reinforcement techniques)
Social skills training, Behavioural contracting, Behavioral Family therapy.
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MET (stages of changer model- Miller)
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Off label drugs in AUD
Topiramate Buspirone Fluoxetine Ondansetron Baclofen
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Summary. Addiction which sets in because of the conditioning
effects of the self reinforcing reward sensations associated with substance use.
It is maintained by the underlying neuro-adaptive process that sets in.
There are biological, psychological and social vulnerabilities that directly influence it in addition to the environment.
Effective treatment takes on a bio-psycho-social-spiritual approach.
Matching treatment to the person.
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Sources:
Oxford textbook of Psychiatry. Medscape Psychiatry, July 22,2014, What is
Addiction? by Denck E Vergne MD Psychiatric Times, Nov 2, 2012, Advances
and challenges in treating alcohol dependence by Hellen M Pattinatti PhD
Other internet resources.
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