Substance Abuse

Alison Freeland MD FRCPC

Schizophrenia Program

Royal Ottawa Hospital

Definitions

Dependence: the repeated use of a drug

Abuse: Use of any drug in a manner that deviates from approved social or medical patterns

Addiction: the repeated and increased use of a substance, the deprivation of which gives rise to symptoms of distress and an irresistible urge to use again

Definitions

Intoxication: a reversible syndrome caused by a specific substance that effects 1 or more of the following – memory, orientation, mood, judgment, and level of functioning Withdrawal: a substance specific syndrome that occurs after stopping or reducing the amount of the substance used

Definitions

Tolerance: phenomenon in which, after repeated administration, a given dose of a substance produces a decreased effect

Cross tolerance: ability of one drug to be substituted for another each usually producing the same physiologic and psychologic effects

Drugs that can be tested in the urine

Alcohol: 7-10 hours

Benzodiazepine : 3 days

Cocaine : 6-8 hrs (metabolites 2-3 days)

Marijuana: 3 days to 4 weeks ( depending on use)

Codeine: 48 hours

Heroin: 36-72 hours

Alcohol

90% absorbed through the stomach

Peak blood concentrations in 30-90 mins

Rapid consumption and consumption on an empty stomach enhance absorption and decrease time to peak blood levels

Intoxication more pronounced as blood levels are rising

90% metabolized by hepatic oxidation

Alcohol

Body metabolizes approx one moderately sized drink per hour (ie one 12 oz beer, 4 oz wine, 1 oz liquor)

Alcohol: epidemiology

10% women and 20% men meet criteria for alcohol abuse

5% women and 10% men have met criteria for alcohol dependence

60% alcohol abusers are men

Caucasians have highest rates of alcohol abuse ( 60%)

Alcohol: Etiology

Genetic: close family members of alcoholics have 4x increased risk

Cultural: Asians show increased acute toxic effects, Native Americans and Inuit have higher rates

Alcohol: comorbidity

Anxiety

Depression

Insomnia

Schizophrenia

Other substance disorders

Alcohol related disorders

DependenceAbuseIntoxication (delirium)Withdrawal (delirium)Persisting dementiaPersisting amnestic disorderPsychotic disorderDepressionAnxietySexual dysfunctionSleep disorder

Subtypes of Alcohol Dependence

A: late onset, mild dependence, few alcohol related problems, little psychopathology

B: severe dependence, early onset, strong family history, life stressors, severe psychopathology

Alcohol Withdrawal

Begins within several hours of alcohol cessation

2 of the following: autonomic hyperactivity, tremor, insomnia, nausea/vomiting, transient illusions/hallucinations, anxiety, grand mal seizures, agitation

Rx: benzodiazepines

Alcohol Withdrawal delirium

1-3% of alcohol dependent patients

Symptoms: delirium, marked autonomic hyperactivity (tachycardia, sweating, agitation, anxiety), vivid hallucinations, agitation tremor, fever, seizures

Tx: monitor vitals, decrease stimulation, hydrate, benzodiazepines, thiamine, Folic acid, multivite, mag sulphate as needed for seizures

Alcohol induced amnestic disorder

Wernickes encephalopathy: acute syndrome caused by thiamine deficiency (nystagmus, ataxia, confusion). Treat with thiamine –symptoms may resolve

Korsakoffs syndrome: chronic condition result of thiamine deficiency, amnesia, confabulation, disorientation, polyneuritis, Rx with thiamine, 25% patients fully recover

Alcohol induced psychotic disorder

Vivid persistent hallucinations following a decrease in alcohol consumption in an alcohol dependent person

May persist and progress into a more chronic psychotic presentation

Condition usually requires at least 10 years of alcohol dependence

Tx: benzodiazepines +/- antipsychotic med

Opioids

Natural derivatives of opium: codeine, morphine

Synthetic opioids: methadone, oxycodone, dilaudid, talwin, demerol

Semisynthetic opioids: heroin

Opioids

Heroin most commonly associated with abuse

600,000 heroin users in the US

Lifetime rate of heroin abuse is 2%

Male to female ratio is 3 :1

Most users in their 30s and 40s

Dependance on other opioids most commonly seen in patients who are prescribed as part of medical treatment

Opiate Overdose

Can be a medical emergency

Often accidental

Often results from combined use with other CNS depressants ( alcohol, benzodiazepines)

Clinical signs: pinpoint pupils, respiratory and CNS depression

Rx: naloxone ( antagonist)

Opiate Withdrawal

Seldom a medical emergency

Symptoms include flu like sx, craving, lacrimation, rhinorrhea, yawning, sweating, insomnia, abdominal cramps, dilated pupils, piloerection, N/V/D

Treatment: methadone, clonidine, supportive

Cocaine Epidemiology

10% of US population has tried it

Lifetime rate for use/dependence is 2%

Most commonly used in 18 to 25 year old range

Male to female ratio of 2:1

Delusions and hallucinations may occur in 50% of those who use

Cocaine

Intoxication: restlessness, agitation, anxiety, pressured speech, paranoid ideation, aggressivity, increased sexual interest, tachycardia, hypertension, pupillary dilation, chills, anorexia, insomnia, stereotypic movementsTreatment:supportive, benzos, antipsychotics

Cocaine Withdrawal

Most prominent sign is craving

Symptoms include fatigue, lethargy, guilt, anxiety and feelings of helplessness

Withdrawal symptoms usually peak in several days but can last for weeks

Treatment: supportive, SSRIs

Sedative hypnotics

Benzodiazepines

Barbiturates

Methaqualone

Meprobamate

About 6% of general population have used these illicitly

Female: male 3:1

Sedative and Hypnotic Intoxication

Slurred speech

Uncoordination

Unsteady gait

Impaired attention

Respiratory depression, particularly if used with other sedative agents (ie alcohol)

Sedative and Hypnotic Withdrawal

Nausea, vomiting

Malaise, weakness

Autonomic hyperactivity

Anxiety, irritability

Increased sensitivity to light and sound

Tremor

Insomnia

seizures

Hallucinogens

Natural and synthetic substances

Produce hallucinations, loss of contact with reality, experience of heightened consciousness

Egs: psilocybin (mushrooms), mescaline (peyote), MDMA, LSD

Hallucinogens

Act as sympathomimeticsCause hypertension, tachycardia, hyperthermia and dilated pupilsTolerance develops rapidly and remits within several days of abstinencePhysical dependence and withdrawal do not occurOften contaminated with anticholinergic drugs

Hallucinogen Intoxication

Maladaptive behavioral changes (anxiety, paranoia)

Changes in perception (hallucinations)

Sympathomimetic changes

Panic reactions (bad trips)

Duration variable (shrooms 4-6 hrs, LSD 6-12 hrs)

Phencyclidine (PCP)

“angel dust”A dissociative anaesthetic and hallucinogenCommonly causes paranoia and violenceMay remain detectable in urine up to a weekAssociated with 3% substance abuse deaths

PCP

Effects are dose dependent

At low doses acts as a CNS depressant, with nystagmus, blurry vision, incoordination

At moderate doses hypertension, dysarthria, ataxia, muscle rigidity

At high doses agitation, fever, rhabdomyolysis, renal failure

Inhalants

Volatile hydrocarbons inhaled for psychotropic effect

eg gasoline, kerosene, laquers, paint thinner, fingernail polish remover

Typically abused by adolescent males of low SEC groups

Inhalants: Intoxication

Mild euphoria, belligerence, assaultiveness, impaired judgmentAtaxia, confusion, slurred speech, decreased reflexes, nystagmusCan go on to delirium and seizuresLonger term risk of brain injury, liver damage, bone marrow depression, peripheral neuropathies, immunosuppression

Cannabis

5% lifetime useHighest among 18-21 y.o.Highest use among caucasians compared to other ethnic groupsEuphoric effects appear within minutes, peak at 30 mins and last 2-4 hoursMotor and cognitive effects can last 5 to 12 hours

Cannabis

Intoxication: euphoria, anxiety, suspiciousness, time distortion, conjuctival injection, increased appetite, dry mouth, tachycardia

Can cause depersonalization and hallucinations

High doses can cause cannabis psychosis lasting up to 6 weeks

Amphetamines

Release catecholamines, primarily dopamine

Effects are euphoric and anorectic

Usually taken orally, but can be smoked, inhaled and injected

Clinical syndromes similar to cocaine

Amphetamines

7% of population

Highest use in 18 to 25 year old range

Men = women

Examples: dexedrine, speed, methylphenidate, khat, methcathinone crystal meth

Can induce a paranoid psychosis

Intoxication resolves in 24 - 48 hours

MDMA

3,4 methylenedioxyamphetamine

“ecstasy” “E”

Increased self confidence, sensory sensitivity, sense of personal closeness with others

Activating, energizing, some hallucinogenic potential,

Associated with hyperthermia

“poppers”

Amyl nitrate

Used during sex to intensify orgasm through vasodilation

Can produce light headedness, euphoria and giddiness

Should not be used with viagra as combo can cause cardiovascular collapse and death