Chapter 20

Chapter 30Substance-Related disordersEpidemiology 47% of those with substance abuse have mental health problems 29% of those with a mental health disorder have a substance use disorder 47% of those with schizophrenia and 25% of those with an anxiety disorder have a substance use disorder

Types of Substance Use DisordersSubstance abuse: maladadaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 1 of the following occurring within a 12 month period recurrent use resulting in failure to fulfill major role obligation recurrent use in situations in which it is physically hazardous (e.g. driving) recurrent use in situations in which it is physically hazardous (e.g. driving) recurrent substance-related legal problems continued use despite interference with social or interpersonal function substance dependence: maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by 3 occurring at any time in the same 12 month period tolerance (need for increased amount to achieve intoxication or diminished effect with same amount of substance) withdrawal/use to avoid withdrawal taken in larger amount or over longer period than intended persistent desire or unsuccessful efforts to cut down excessive time to procure, use substance, or recover from its effects important interests/activities given up or reduced continued use despite physical/psychological problem caused/exacerbated by substance Classification of SubstancesDepressantsAlcohol, Opioids, Barbibaturates, Banzodiazepines, CHBStimulantsAmephetamines, Methylphenidate, CcianeHallucinogesCannabis, LSD, PCP, ketamine, psilocybinAlcoholSee Family Medicine, Alcohol, FM12 and Emergency Medicine, BR47

History validated screening questionnaire C ever felt the need to Cut down on drinking? A ever felt Annoyed at criticism of your drinking? G ever feel Guilty about your drinking? E ever need a drink first thing in morning (Eye opener)? for men, a score of 2 is a positive screen; for women, a score of 1 is a positive screen if positive CAGE, then assess further to distinguish between problem drinking and alcohol dependenceGeneral Assessment When was your last drink? Do you have to drink more to get the same effect? Do you get shaky or nauseous when you stop drinking? Have you ever had a withdrawal seizure? How much time and effort do you put into obtaining alcohol? Has your drinking affected your ability to work, go to school, or have relationships? Have you suffered any legal consequences? Has your drinking caused any medical problems? Table 5. US Department of Health and Human Services Recommended Drinking GuidelinesModerate DrinkingMen: 2 or less/d (14/wk)Women: 1or less/d (9/wk)Elderly: 1or less/dAlcohol Intoxication legal limit for impaired driving is 10.6 mmol/L (50mg/dL) reached by 2-3 drinks/h for men and 1-2 drinks/h for women coma can occur with > 60 mmol/L (non-tolerant drinkers) and 90-120 mmol/L (tolerant drinkers)Alcohol Withdrawal occurs within 12 to 48 h after prolonged heavy drinking and can be life-threatening alcohol withdrawal can be described as having 4 stages, however not all stages may be experienced stage 1 (onset 6-12h after last drink): tremor, sweating, agitating, anorexia, cramps, diarrhea, sleep disturbance stage 2 (onset 1-7d): visual, auditory, olfactory or tactile hallucinations stage 3 (onset 12-72h and up to 7d): seizures, usually tonic-clonic, nonfocal and brief stage 4 (onset 3-5d): delirium tremens, confusion, delusions, hallucinations, agitation, tremors, autonomic hyperactivity (fever, tachycardia, hypertension) course: in young almost completely reversible; elderly often left with cognitive deficits mortality rate 20% if untreatedManagement of Alcohol Withdrawal monitor using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A) areas of assessment include nausea and include tactile disturbances tremor auditory disturbances agitation paroxysmal sweets visual disturbances anxiety headache, fullness in head orientation and clouding of sensorium all categories are scored from 0-7 (except: orientation/sensorium 0-4), maximum score of 67 mild20

Table 6. CIWA-A Scale Treatment Protocol for Alcohol Withdrawal Basic ProtocolDiazepam 20mg PO q1-2h pm until CIWA-A 65 or patient has severe liver disease, severe asthma or respiratory failureUse a short acting benzodiazepineLorazepam PO/SL/IM 1-4 mg q1-2hIf Hallucinations are presentHaloperiodol 2-5mg IM/PO q1-4h-max 5 doses/d or atypical antipsychotics (olanzapines, risperidone)Diazepam 20mg x 3 doses as seizure prophylaxis (haloperidol lowers seizure threshold)Admit to Hospital ifStill in withdrawal after>80 mg of diazepamDelirium tremens, recurrent arrhythmias, or multiple seizuresMedically ill or unsafe to discharge homeWernicke- Korasakoff Syndrome alcohol- induced amnestic disorders due to thiamine deficiency necrotic lesions- manunillary bodies, thalamus, brainstem Wernickes encephalopathy (acute and reversible): triad of nystagmus (CN VI palsy), ataxia and confusion Korasakoffs syndrome (chronic and only 20% reversible with treatment): anterograde amnesia and confabulations; cannot occur during an acute delirium or dementia and must persist beyond usual duration of intoxication/withdrawal management Wernickes: thiamine 100mg PO OD x 1-2 weeks Korsakoffs: thiamine 100mg PO bid/tid x 3-12 monthsTreatment of Alcohol DependenceNon-pharmacological behavior modification: hypnosis, relaxation training, aversion therapy,, assertiveness training, operant conditioning supportive services: half-way houses, detoxification centers, Alcoholics Anonymous psychotherapy, motivational interviewing individual readiness for change must always be considered with non-pharmacological interventions (refer to Prochaskas Stages of Change Model, Population Health and Epidemiology, PH6)Pharmacological naltrexone: opioids antagonist, shown to be successful in reducing the high associated with alcohol, moderately effective in reducing cravings, frequency or intensity of alcohol binges disulfiram (Antabuse*): blocks oxidation of alcohol (blocks acetaldehyde dehydrogenase); with alcohol consumption, acetaldehyde accumulates to cause a toxic reaction (vomiting, tachycardia, death); if patient relapses, must wait 48h before restarting Antabuse*

Opioids types of opioids: heroin, morphine, oxycodone, Tylenol#3* (codcine), hydromorphone major risks associated with the use of contaminated needles; increased risk of hepatitis B and C, bacterial endocarditis, HIV/AIDSAcute Intoxication direct effect on receptors in CNS resulting in decreased pain perception, sedation, decreased sex drive, nausea/vomiting, decreased GI motility (constipation and anorexia), and respiratory depression

Toxic Reaction typical syndrome includes shallow respirations, miosis, bradycardia, hypotermia, decreased level of consciousness treatment ABCs IV glucose naloxone hydrochloride (Narcan*): 0.4mg upto 2mg IV for diagnosis treatment: intubation and mechanical ventilation, + naloxone drip, until patient alert without naloxone (up to 48+h with long-acting opioids ) caution with longer half-life; may need too observe for toxic reaction for at least 24hWithdrawal symptoms: depression, insomnia, drug-craving, myalgias, nausia, chills, autonomic instability (lacrimation, rhinorrhea, piloerection) onset: 6-12h, durations: 5-10d complications: loss of tolerance (overdose on relapse), miscarriage, premature labor management: long-acting oral opioids (methadone, buprenorphine), -adrenergic agonists (clonidine)Treatment of Chronic Abuse psychosocial treatment (e.g. Narcotics Anonymous); usually emphasize total abstinence long-term treatment may include withdrawal maintenance treatment naltrexone or naloxone (opioid antagonists) may also be used to extinguish drug-seeking behavior

Amphetamines intoxication characterized by euphoria, improved concentration, sympathetic and behavioral hyperactivity and at high doses can cause coma chronic use can produce a paranoid psychosis diagnostically similar to schizopherenia with agitaton, paranoia, delusions and hallucinations withdrawal symptoms include dysphoria, fatigue, and restlessness treatment of stimulant psychosis: antipsychotics Cannabis marijuana is the most often used illicit drug psychoactive substance: delta-9-tetrahydrocannabinal (A9-THC) intoxication characterized by tachycardia, conjunctival vascular engorgement, dry mouth, altered sensorium, increased appetite, increased sense of well-being, euphoria/laughter, muscle relaxation, impaired performance on psychomotor tasks including driving high doses can cause depersonalization, paranoia, anxiety and may trigger psychosis and schizophrenia if predisposed chronic use associated with tolerance and an apathetic, amotivational state cessation doesnot produce significant withdrawal phenomenon treatment of dependence: behavioral and psychological interventions to maintain an abstinent stateHallucinogens types of hallucinogens: LSD, mescaline, psilocybin, PCP, cannabis, ecstasy, salvia LSD is a highly potent drug: intoxication characterized by tachycardia, HTN, mydriasis, tremor, hyperpyrexia and a variety of perceptual and mood changes high doses can cause depersonalization, paranoia, and anxiety no specific withdrawal syndrome characterized treatment of agitation and psychosis: support, reassurance, diminished stimulation; benzodiazepines or high potency antipsychotics seldom requiredDrugMechanismEffectAdverse EffectsMDMA (Ecstasy, X, E)Acts on serotonergic and dopaminergic pathways properties of a hallucinogen and stimulantEnhanced sensorium; feelings of well-being, empathySweating, tachycardia fatigue, muscle spasms (especially jaw clenching), ataxia, hyperthemia, arrhythmias, DIC, rhabdomyolysis, renal failure, seizures, death Club DrugsTable 7. The Mechanism and Effects of Common Club DrugsGamma Hydroxybutyrate (GHB, G, Liquid Ecstasy)Biphasmic dopamine response (inhibition then release) and releases opiate-like substanceEuphoric effects, increased aggression, impaired judgmentSweating, tachycardia fatigue, muscle spasms (especially jaw clenching), ataxia, severe withdrawal from abrupt cessation of high doses: tremor, seizures, psychosisFlunitrazepam (Roehypnol, Roofies, Rope, The Forget Pill)Potent benzodiazepine, rapid oral absorptionSedation, psychomotor impairment, amnestic effects, decreased sexual inhibitionCNS depression with EtOHKetamine (Special K, Kit-Kat)NMDA receptor antagonist, rapid-acting general anaesthetic used in pediatrics and by veterinariansDissociative state, profound amnesia/analgesia; hallucinations and sympathomimetic effectsPsychological distress, accidents due to intensity of experience and lack of bodily control, in overdose, decreased LDC, respiratory depression, caraloniaMethamphetamine (speed, meth, chalk, ice, crystal)Amphetamine stimulant, induces norepinephrine, dopamine and serotonin release Rush begins in min, effects last 6-8h, increased activity, decreased appetite general sense of well-being, tolerance occurs quickly, users often binge and crashShort term use: high agitation, rage, violent behavior, occasionally hyperthermia and convulsionsLong term use: addiction, anxiety, confusion, insomnia, paranoia, auditory and tactile hallucinations (esp. fonnication), delusions, ood disturbance, suicidal and homicidal thoughts, stroke, may be contaminated with lead, and IV users may present with acute lead poisoningPhencyclidine (PCP, angel dust)Not understood, used by veterinarians to immobilize large animalsAmnestic, euphoria, hallucinatory stateHorizontal/vertical nystagmus, myoclonus, ataxia, autonomic instability (treat with diazepam IV), prolonged agitated psychosis (treat with haloperidol); high risk for suicide; violence towards othersHigh dose can cause comaThe End