izben c. williams, md, mph instructor. substance abuse the abuse of alcohol and other psychoactive...

BEHAVIORAL SCIENCE

IzBen C. Williams, MD, MPHInstructor

SUBSTANCE ABUSE

The Abuse of Alcohol and other

Psychoactive Substances

Overview

Definitions:Substance use disorders are divided

into…….1. Substance abuse – 2. Substance dependence:

1. Abuse plus withdrawal symptoms, tolerance or a pattern of repetitive use

2. Concept of cross tolerance

OverviewDefinitions:

Substance abuse is the use of a psychoactive substance (drug) to such an extent that it seriously interferes with health or occupational and social functioning (obligations, interpersonal and legal problems, risks, )This definition is objective and non-judgmental.

The emphasis is on dysfunction rather than on social or cultural norms, or on the enhancement of pleasure or performance

OverviewSubstance abuse is a major public

health problem globallyAlcoholism is the most common

substance use disorderIn the USA, deaths associated with

alcohol abuse and alcoholism now rank third behind heart disease and cancer

Certain basic principles of diagnosis and treatment apply to all psychoactive substance use disorders


Substance dependence is a pathologic pattern of substance use that results in impairment or distress. Characterized by:Withdrawal: physiological and/or psychological

symptoms after reduction or cessation of intake of a substance

Tolerance: decreased effect with continued use of the same amount of the substance

Other characteristics: CAGE features, time spent, physical or mental problems, compromises commitments


Physiologic dependence

Refers to the presence of either tolerance or withdrawal

OverviewObservation:

Although the focus in this lecture is on “recreational” drugs, it should be noted that prescribed psychoactive medications can also be abused

Physicians who prescribe such drugs have a responsibility to monitor their effects on a patient and to ensure that dependence or toxicity are not developing

Illicit drug use profile

The use of Illicit drugs in the USA has been increasing.In 2002, an estimated 8.3% of the population aged

12 or older had used an illicit drug or abused a psychotherapeutic medication (such as a pain reliever, stimulant, or tranquilizer) in the past month.

In 2012, that figure stood at 9.2 % of the population.

The increase mostly reflects a recent rise in the use of marijuana, the most commonly used illicit drug.

Illicit drugs use profile 2012

Illicit drug use trends

Illicit drug use profile

The use of Illicit substances is more common among young adults, ages 18-25And it is twice as common in males

Most abused substances can be administered by a number of routes

Routes that provide quick access to the bloodstream, and hence the brain, are often preferred by abusers

Specific-substance use

ClassificationA. CNS StimulantsB. Sedatives, Hypnotics and AnxiolyticsC. OpioidsD. Hallucinogens and PhencyclidineE. CannabisF. Inhalants


A. CNS StimulantsThey include:

Caffeine, Nicotine Amphetamines and related compoundsCocaineMethamphetamine Phenmetrazine


A. CNS StimulantsIncrease the availability of

dopamine:Amphetamines cause the release of

dopamineCocaine blocks the reuptake of dopamineIncreased availability of dopamine at the

synapse is believed to be involved in the euphoric effects of stimulants and opioids


A. CNS StimulantsUse of Amphetamines

Depression in the elderly and in the medically ill who cannot tolerate antidepressants,

Augmentation of antidepressants in treatment-resistant depression

NarcolepsyADD in children & Adult (residual) ADD

The most common clinically used amphetamine is methylphenidate (Ritalin)


A. CNS StimulantsCocaine

Clinically used for nosebleed and in local anesthetic of the ENT

NicotineToxic to all systems and decreases life

expectancy more than the use of any other substance


A. CNS StimulantsCocaine

Intoxication: euphoria, fighting, grandiosity, confused speech impaired judgment, high » crash » withdrawal

Withdrawal: dysphoric mood, irritability, anxiety, fatigue, agitation, occurs within 24 hrs after cessation of last use

Delirium: within 24 hoursDelusional Disorder: usually persecutory, distorted

body images and faces » aggression and violence


B. Sedatives, Hypnotics and Anxiolytics

These are CNS depressants; they include:(Alcohol)Barbiturates and related drugsBenzodiazepines (tranquilizers and

hypnotics)Chloral compounds (eg chloral hydrate)


B. Sedatives, Hypnotics and AnxiolyticsThis group of drugs work primarily by

increasing the activity of the inhibitory neurotransmitter GABA

Withdrawal effects could be life threatening (include seizures, and CVS compromise) so inpatient care for withdrawal is often necessary and advisable

Specific-substance use B. Sedatives, Hypnotics and AnxiolyticsAlcohol associated problems:

Acute: relational, suicide, abuse, rape, various indiscretions and infarctions

Chronic: Thiamine deficiency, GI, fetal, liver, CNS including DTs,

IntoxicationLegal intoxication .08%-.15% bacComa usually above .50% dependent on use

history

Specific-substance use B. Sedatives, Hypnotics and

AnxiolyticsBarbiturates:

Uses: sleeping pills, sedatives, tranquilizers, anticonvulsants, anesthetic

Clinically: respiratory depression, low safety margin (suicide), risk of death from withdrawal

Specific-substance use B. Sedatives, Hypnotics and

AnxiolyticsBenzodiazepines:

Uses: tranquilizers, sedatives, muscle relaxants, treats alcohol withdrawal,

Clinically: by itself high safety marginBenzodiazepine receptor antagonists such as

s Flumazeni can reverse benzodiazepine effects in cases of overdose


C. OPIOIDS - These include

Morphine Alphaprodine

Hydromorphone Oxycodone

Oxymorphone Levophanol

Heroin Meperidine

Methadone Propoxyphene

Codine Hydrocodone


C. OpioidsUses:

Analgesia (morphine), drugs of abuse (heroin),

Clinically:Abused opioids cross bbb, have a faster

onset of action, and are more euphoric than medically used opioids, death from withdrawal rare


C. OpioidsMethadone is a synthetic opioid

Others are LAMM and Buprenorphine (Temgesic) Uses: treatment of heroin addiction but can itself

cause physical dependence and tolerance. ‘legal’ opioids can be substituted for illegal opioids to prevent withdrawal symptoms

Advantages over heroin: can be taken orally, have a longer duration of action, and can block both the withdrawal and euphoric actions of heroin (temgesic); they also cause less euphoria and drowsiness


D. Hallucinogens and Phencyclidine

They include:Lysergic acid diethylamide (LSD)MescalinePhencyclidinePsilocybin

Specific-substance use D. Hallucinogens and Phencyclidine

These drugs produce altered states of consciousness, mediated by increased availability of serotonin

LSD is ingested and PCP is smoked in marijuana (*) or cigarette

Both cause altered perception (bad trip) with intoxication

PCP causes more episodes of violent behavior, hypothermia and nystagmus, and consumption of more than 20 mg may cause convulsion, coma and death


E. Cannabis -1Specific substances include:

MarijuanaHashish∆-tetrahydrocannabinol (THC)

Specific-substance use E. Cannabis -2Intoxication by marijuana and related

substances rarely produces hallucinations More common side effects are Euphoria, anxiety, increased suggestibility,

distortion of time and space, increased appetite

Red conjunctivae, dry mouth, tachycardia, no change in pupils

Specific-substance use E. Cannabis -3

In low doses, marijuana increases appetite and relaxation and causes conjunctival reddening

Chronic users experience lung problems associated with smoking and a decrease in motivation ‘the amotivational syndrome’ characterized by apathy and lack of desire to work

Treatment: like most hallucinogens, the psychological effects are eased by reassurance in a quiet setting

Specific-substance use F. Inhalants -1 They include:

GasolineGluePaint thinner solvents

Specific-substance use F. Inhalants -2

Sniffing of inhalants is increasing among children and adolescents.

Brain damage may occur with repeated use, and no antidote or specific treatment exists

Intoxication may cause CNS depression, confusion and delirium

Chronic use may result in dementia

Principles of treatment of Substance-related Disorders

Certain approaches are useful for treatment of abuse and dependence of all substances:i. Detoxification - the first goal of

treatmentii. Insistence on abstinence – few

individuals can use addiction substances in moderation after successful treatment but they cannot be identified, hence complete abstinence is advised


Approaches to treatment for all substances:

iii. Avoidance of other substances associated with dependence (beware of tranquilizers)

iv. Involvement of family – the family can be important allies in insisting that the patient’s drug abuse problem be dealt with, however substance abuse may also provide the family with a convenient distraction from a less palatable family problem



v. Toxicology screens – periodic urine screens are often essential in identifying relapse and non- compliance

vi. Self-help groups – Peer support groups provide credibility and encouragement from individuals who have had similar problems and who are adept at dealing with common resistances to treatment. Twelve step programs have been developed for most substances



vii. Sanctioned treatment: When an patient is forced to remain in therapy by a le gal sanction, the outcome is better individual is better than when free will is at play

viii.Contingency contracting – powerful negative and positive contingencies tied to treatment. Pre-signed letter of patient is mailed by therapist if failures evident. Especially effective in medical licensure

izben c. williams, md, mph instructor. substance abuse the abuse of alcohol and other psychoactive...

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