SUBSTANCE ABUSESUBSTANCE ABUSE

By Dr.Fareed A. MinhasAssociate Professor

Rawalpindi Medical College

•Substance use disorder (DSM-IV)

•Disorders due to psychoactive drug use (ICD 10)

•refer to conditions arising from the use of alcohol, psychoactive drugs, and other chemicals such as volatile solvents

SUBSTANCE-RELATED DISORDERS

DSM-IV ICD 10

Intoxication IntoxicationAbuse Harmful useDependence Dependence syndromeWithdrawal Withdrawal stateWithdrawal delirium Withdrawal state with deliriumPsychotic disorders Psychotic disorderDementiaAmnestic disorder Amnestic syndromeMood disorders Residual and late-onset psychotic diso.Anxiety disorders Other mental and behavioral disord.Sexual dysfunctionSleep disorders

DEFINITIONSDEFINITIONS

DRUG:

I t is any substance which when taken into the living organism, may modif y one or more of its f unctions.

Originally Plants, animals or minerals. Synthetic drugs Created artifi cially in lab by

combination of chemicals. CHIEF EFFECT: of a drug is a Physical or mental change f or

which it is taken. SIDE EFFECT: is a diff erent or undesirable reaction to a drug. TOXIC DOSE: is the dose taken in excess of the

therapeutic limit, which produces toxic eff ects.

TOXIC DOSE: is the dose taken in excess of the therapeutic limit, which produces toxic eff ects.

OVER DOSE: is taking excess of a drug and may

cause shock, coma or death. LETHAL DOSE: is taking enough of a drug to cause

death. PRESCRIPTION DRUGS: are drugs taken f rom

the medical stores on doctors written orders only.

OVER THE COUNTER DRUGS: can be obtained

without doctors order.

CROSS TOLERANCE: Occurs when one drug is taken and

results in tolerance not only to that drug but also to another drug of the same or unrelated group.

ESCALATION: refers to a phenomenon when a person

taking so called sof ter drugs goes on to harder drugs;

DETOXIFICATION: is the removal of all drugs f rom the

body. REHABILITATION: refers to the process of providing

vocational, educational and social services in conjunction with medical and or psychological treatment with a view of reintegrating him usefully in the society.

ABSTINENCE OR WITHDRAWAL SYNDROME:Signs and symptoms which develop on withdrawl of a drug or its

effects inherited by an antagonist.

SYMPTOMS:are the subjective sensations a patient reports to the physician 

SIGNS: are objective indicators of a disease and are perceptible to the examining Physicians e.g. rapid pulse rate/respiratory rate etc.

   LEGAL DRUGS:

are those that are considered useful and are designed to treat various illnesses. They can be obtained as prescribed drugs or

overthe counter.

   ILLEGAL DRUGS:

are drugs forbidden by law, their harmful effects outweigh any useful purpose. Their possession and sale is prohibited by law. 

MEDICAL USE:is the use of a drug with or without Medical Supervision, which isindicated for generally accepted medical reasons.

  NON-MEDICAL USE:is the use of a drug, which is not indicated on generally accepted

medical grounds. 

DRUG MISUSE:medical or non-medical use of a drug for a disease state not

consideredto be appropriate by medical science.

 DRUG ABUSE:persistent or sporadic excessive use of a drug inconsistent with, or

unrelated to acceptable medical practice.  

TOLERANCE:is an adaptive state characterized by diminished responses to the

same quantity of a drug or by the fact that a larger dose is required toproduce same degree of pharmacodynamic effect.

DRUGS GENERALLY DRUGS GENERALLY ABUSEDABUSED

CATEGORIES OF SUBSTANCE ABUSE AND DEPENDENCE

1. ALCOHOL2. SYMPATHOMIMETICS3. CANNABIS4. COCAINE5. HALLUCINOGENS6. INHALANTS7. NARCOTICS8. ARYLCYCLOHEXYLAMINES (e.g.,phencyclidine)9. SEDATIVE-HYPNOTICS10.ANXIOLYTICS11.NICOTINE

Causes of drug misuse

• availability of drugs

• a vulnerable personality

• adverse social environment

 I OPIATES or (OPIOIDS)

Direct from opium poppy: Morphine & codeine.

Semi Synthetic: Heroin or diacetylmorphine.

Synthetic Subs: methadone, meperidine (Pethidine or

Demerol)Dipipanone, (diconal)Dextromoramide.Dihydrocodeine.

 

USES:

Pain relief, suppression of coughs, Treatment of acute heart failure, symptomatic treatment of diarrhea.

EFFECTS; Pleasant mood, euphoric detachment rather thansimply a dulled sedation.

WITHDRAWAL SYMPTOMS (MORPHINE TYPE)

 Restlessness insomnia, Pain in muscles & joints, running nose & eyes, Sweating, abdominal Cramps, Vomiting & diarrhea, Piloerection; dilated pupils, raised pulse rate and disturbance of temperature control. Begin about 6 hours after last dose; Peak 36-48 hrs. 

II GENERAL DEPRESSANTS: 

·  Ability to suppress the activity of the brain leads to sedation,Sleepiness and relief of anxiety.·  Includes: Alcohol, Barbiturates, Chloral, Paraldehyde

Chlormethiazole. ·Misconception:Can produce stimulation & excitement as

result of disinhibition.

Alcohol use history

• Typical days drinking. What time is the first drink of the day?

• When did daily drinking start?

• Presence of withdrawal symptoms in morning?

• Previous attempts at treatment

• Medical complications.

• Patients attitude towards drinking

Approach to treatment of alcohol misuse

• Raise awareness of problem

• Increase motivation to change

• Withdraw alcohol( controlled drinking)

• Support and advice

• CBT ( social skills, relapse prevention)

• Marital therapy

• AA

• Medication( disulfram)

Motivational interviewing

• Express empathy

• Avoid arguing

• Detect and roll with resistance

• Point out discrepancies in history

• Raise awareness about contrast between drug users aims and behavior

BARBITURATE TYPE: Abrupt withdrawal is highly dangerous. May result in a mental disorder, similar to alcohol withdrawal, may lead to seizure & sometimes to death. Withdrawal symptoms may not appear for several days. Anxiety, restlessness, and disturbed sleep anorexia, nausea. May progress to vomiting hypotension, pyrexia, tremulousness, Major Seizures, disorientation & hallucinations.

III MINOR TRANQUILLIZERS: (BENZODIAZIPINES)

 Chlordiazepoxide (Librium), Diazepam (Valium),

Lorazepam (Ativan) Nitrazepam (Mogadon).

Cause:Sedation, anxiety relief and Muscle relaxation.

IV STIMULANTS:

Elevate mood, increase wakefulness, give an enhancedsense of mental and physical energy.

Pleasurable stimulation & excitement potential ofmisuse.

Cocaine, amphetamines, Synthetic (Phenmetrazinediethylpropon). Khat, Caffeine.  

COCAINE:

Effects similar to these Amphetamines.Strong Psychological dependence.

 Excitation, dilated pupils, tremulousness.

Dizziness and sometimes convulsions. 

Confusion, depression Paranoid PsychosisFormication.

 

V HALLUCINOGENS (Psychedelics, or Psychotomimetics)

·   Produce strange, intense, & transcendental effects,

which gives them ‘recreational’ popularity.

·        Peyote, mescaline, ‘Magic mushroom’ LSD:lysergic

acid diethyl-amide.

·        Do not give rise to dependence in true sense, nonetheless use is intensely hazardous.

HALLUCINOGENS: 

Psychedelics alteration in mood & perception.

Mental effects develop during 2 hours after LSD consumption & generally last 8-14

hours. 

Distortions, intensification of sensory perception. 

Synaesthesia:Confusion between sensory modalities.Objects seem to be merged with one another.Panic with fears of insanity.

 VI.  DRUGS NOT CONFORMING TO THE GENERAL CLASSIFICATION

CANNABIS: 

Indian Hemp Plant. Active ingredient 9-delta, tetrahydrocannabinol (TCH).

·       Actions of both general depressants & hallucinogenic type.

 NICOTINE:

·        Produces Complex effects. Has both stimulant and Sedative properties.

VOLATILE INHALANTS: ·   Industrial solvents, anesthetic gasses, glues,

lacquers, lighter fuels.

·        Produce rather mixed & complicated effects including sedative, anesthetic & hallucinogenic

experiences. 

OTHERS: 

·        Phencyclidine angel dust:·        Amyl nitrite.·        “Designer drugs” North America. Synthetic

drugs mimicking properties of Known drugs, but also display dangerous & new side effects. 

SOLVENT ABUSE: 

Psychological dependence. Tolerance may develop.Stimulation leads to depression.Disorientation, hallucination.Peripheral neuropathy can be fatal.

CANNABIS

• Effects vary with dose, persons expectation , mood, & social setting.

Exaggerates Pre-existing mood: exhilaration, depression or anxiety

• increased enjoyment of aesthetic experience & distortion of time & space.

•  Reddening of the eyes dry mouth irritation of respiratory treat & coughing.

CANNABIS

No definite withdrawal Syndrome.No evidence of Tolerance. No serious side effects amongst intermittent users. No evidence of teratogenecity. Not safe in first trimester. Psychosis: disagreement. Amotivational Syndrome: apathy & intolerance objective study Beavburn & Knight: failed to demonstrate this.Campbell et al: reported such use may result in cerebral atrophy.

Stages of change model

• Pre-contemplation Misuser does not believe there is a problem, though others recognize it

• Contemplation Individual weighs up pros and cons. Considers that change might be necessary.

• Decision Point reached where decision is made to act on this issue.

• Action User choose necessary strategy for change and peruses this.

• Maintenance Gains are maintained and consolidated.

• Relapse Return to previous pattern of behavior.

PRINCIPLES OF TREATMENT OF SUBSTANCE ABUSE

1. DETOXIFICATION

2. INSISTENCE ON ABSTINENCE

3. INVOLVEMENT OF FAMILY4. TOXICOLOGY SCREENS (periodic urine screens

are often essential in identifying relapse and noncompliance)

5. SELF-HELP GROUPS

Some consequences of intravenous drug misuse

• Local - Vein thrombosis,Infection of injection site, damage to arteries.

• Systemic - Bacterial endocarditis, Hepatitis B & C, HIV infection

6. SANCTIONED TREATMENT (patient forced to remain in therapy by a legal sanction e.g. drivers/professional license)

7. CONTINGENCY CONTRACTING (This approach provides a powerful negative contingency for leaving treatment or relapsing or a positive contingency for remaining drug-free. In the most widely used contingency contracting, the patient agrees in advance i.e. in writing that the therapist will notify an employer or licensing body if relapse occurs. The patient may leave a letter with the therapist outlining the problem, which is to be mailed if a urine screen is positive or the patient does not keep an appointment)