substance related disorders dr. anurag mishra m.d. coordinator- psychoanalytical wing max hospitals-...
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Substance Related Disorders
Dr. Anurag Mishra M.D.
Coordinator- Psychoanalytical Wing
Max Hospitals- Delhi
Substance vs Drug
• Drug- Manufactured chemical• Many substances associated with
abuse patterns :1. Occur Naturally- opium, cannabis2. Not meant for human consumption- petrol,
solvents
• Illegal - cocaine• Legal but obtained by illegal means or for
non prescribed purposes- morphine
Addiction
• Describes the degree to which drug use pervades an individual’s life
• Possible to be dependent without being addicted- individual’s life is not organized around finding & using drug e.g. those who become addicted to drugs used in prolonged medical treatment
• Possible to be addicted without being physically dependent
• 1964- WHO substituted Dependence
Substance Use Disorders
• Substance Dependence
• Substance Abuse
• “Codependence”
Substance Dependence
• Impairment or distress because of 3 or more of the following at any time in a year:
1. Tolerance: increased amount of substance to produce same effect / decreased effect with same amount
2. Withdrawal: typical withdrawal syndrome/ substance or related compound used to relieve or avoid withdrawal
3. Use of substance in greater amounts or for a longer time than originally intended
4. Unsuccessful attempts or wishes to cut down5. Significant time spent in obtaining, using, recovering6. Giving up social, occupy, recreational activities7. Continued use despite knowledge of physical/ mental
problems
Substance Dependence
• Physiological Dependence: presence of withdrawal or tolerance
• Psychological Dependence (Habituation) : continuous intermittent craving for substance to avoid dysphonic state (difficulty in speaking) dysphoria =
anxiety
Substance Abuse
• Pt. not meeting criteria for Dependence with any one of following in a year:
1. Failure to fulfill major role obligations
2. Recurrent use of substance in hazardous situations
3. Recurrent legal problems resulting from substance use
4. Continued use of substance despite social or interpersonal problems caused by substance
Codependence
• Behavioral patterns of family members who have been significantly affected by another family member’s substance use or addiction
• Enabling• Unwillingness to accept
addiction as disease, voluntary behavior, responsibility shifted to family
• Denial
Substance Induced Disorders
1. Intoxication: Reversible substance specific syndrome2. Substance withdrawal3. Substance induced delirium4. Substance withdrawal delirium5. Substance induced persisting dementia6. Substance induced persisting Amnestic disorder 7. Substance induced psychotic disorder8. Substance induced mood disorder9. Substance induced anxiety disorder10. Substance induced sexual dysfunction11. Substance induced sleep disorder
Alcohol Intoxication
Mild• Overconfidence• Mood swings, emotional
outbursts, euphoria• Nausea, vomiting • RestlessnessSevere• Stupor or coma• Hypothermia• Slow respiration• Tachycardia• Increased I C T• Dilated pupils• Death
Diagnosis• Slurred speech• Loss of coordination• Unsteady gait• Nystagmus• Impaired attention/ memory• Stupor/ comaT/t (treatment)1. Conscious pt.- wait!• Agitation- BZD, anti psychotic2. Unconscious pt.- keep warm• Prevent aspiration• Increased ICT- mannitol• Hemodialysis in extremes
Sedative, Hypnotic, Anxiolytic Intoxication
• BZD, BarbituratesMild• Euphoria• Sedation• Paradoxical excitement• Nystagmus, dysarthria, impaired
attention & memory• Postural hypotensionSevere (suicide attempts, overdose)• Coma• Respiratory depression• Low BP• Low cardiac output• Low temp.• Coma• Death
T/t1. Protect airway2. Oxygen3. Ventilation4. Prevent further body heat loss5. I.v. fluids and BP maintenance
with Dopamine6. Forced diuresis7. Hemodialysis
Stimulant Intoxication• Amphetamines,
methamphetamine, cocaineMild• Elevated mood• Increased energy & alertness• Decreased apppetite• Talkativeness• Anxiety & irritability• Insomnia• Increased/ decreased heart
rate & BP• Nausea/ vomiting• Loss of appetite & weight
Severe• Psychotic symptoms- visual,
auditory & tactile hallucinations, delusions, mania
• Fighting• Dilated pupils• Increased BP & pulse• Arrhythmias• Seizures• Exhaustion• Coma & I C HemorrhageT/t: hypertension & hyperthermia• Psychosis- antipsychotics
Hallucinogen Intoxication
• LSD, PCP, Mescaline
Most hallucinogens• Dilated pupils• Increased pulse & BP• Increased temp• Delusions &
hallucinations• Anxiety• Distortion of time sense• Inappropriate affect
PCP Intoxication• Violence & hyperactivity• Increased hearing• Mutism• Echolalia• Muscular rigidity• Seizures, coma, IC
hemorrhage
T/t: Quiet setting• Antipsychotic/ BZD
Hallucinogen Intoxication
Cannabis Intoxication
• Marijuana, hash, ganja, bhang
• Euphoria• Anxiety• Increased appetite• Increased suggestibility• Distortion of time & space• Red conjunctiva• No change in pupils• Dry mouth• Tachycardia
T/t: Quiet setting, BZD
Opioid Intoxication
• Opium• Morphine• Heroin• Crack• Brown sugar• Codeine• Pethidine• Fortwin (pentazocin)
Opioid Intoxication
Mild- Moderate• Analgesia without loss of
consciousness• Drowsiness• Nausea & vomiting• Apathy & lethargy• Euphoria• Itching• Constricted pupils• Constipation• Flushed & warm skin • Impaired attention & memory• Illusions
Severe• Miosis• Respiratory depression• Hypotension or shock• Pulmonary edema• Seizures & ComaT/t• Supportive care• Naloxone- narcotic antagonist,
reverses coma & apnea but also produces severe withdrawal
Inhalant Intoxication
• Erasex, petrol, glue, paint thinner, solvents
• Dizziness, confusion• Euphoria• Confusion, nystagmus,
ataxia, dysarthria• Tremors• Muscle weakness• Blurred vision • Delirium• Chronic use- Dementia
T/t: prevent access to drug
Anticholinergic Drug Intoxication
• Cough syrups, imipramine, pacitane
• Confusion• Memory loss• Delirium• Hallucinations• Amnesia• Drowsiness• Tachycardia
• Decreased peristalsis• Fever• Warm dry skin• Fixed dilated pupils• Coma
T/t• Protect pt & wait for drug
to be metabolized• Physostigmine
Alcohol Withdrawal
“The Shakes”• Tachycardia• Tremors• Sweating• Nausea• Hypotension• Weakness• Anxiety, irritabilityT/t: Thiamine, BZD
Alcohol Withdrawal
Motor Seizures (Rum fits)• Seizure in<48 hrs after
stopping• T/t: I.v. BZDAlcohol withdrawal delirium• Delirium• Autonomic hyperactivity• Agitation, hallucinations,
tremors• T/t: Hydration• Thiamine, BZD, antipsychotic
Psychosis• Hallucinations in clear
sensorium - threatening or derogatory
• T/t: Anti psychoticsWernicke-Korsakoff Syndrome• Wernicke’s Encephalopathy/
Alcoholic encephalopathy- ataxia, giddiness, eye signs
• Korsakoff’s Syndrome/ Chronic Amnestic Syndrome: Impaired memory
• T/t: thiamine
Sedative, Hypnotic, Anxiolytic Withdrawal
• Anxiety, agitation• Low BP• Weakness & tremors• Fever• Sweating• Delirium• Seizures• Cardiovascular
collapse
• T/t• Withdrawal can be life
threatening• Hospitalization• BZD substitution• Other drugs
Stimulant Withdrawal ( Crash )
• Increased sleep• Nightmares• Fatigue• Lassitude• Increased appetite• Depression ( cocaine
blues)• Suicide attempts• Intense drug craving
• Hospitalization if suicidal
• Antidepressants
Hallucinogen Withdrawal
• Dr. Albert Hoffman discovered/ invented LSD!
• Flashbacks: 15- 80%• Spontaneous transitory
occurrences of substance induced experience: visual distortion, hallucinations, trails of images, micro/ macropsia, time expansion, relived intense experience
• T/t : Reassurance, BZD
Opioid Withdrawal
• Watering from nose and eyes
• Sweating• Restlessness &
sleepiness• Gooseflesh• Dilated pupils• Irritability• Yawning• Insomnia• Craving
• Substitution with medicinal opioid and gradual withdrawal
• Clonidine to control BP and other autonomic symptoms
• BZD• Non opioid pain killers• Symptomatic t/t
Anti Cholinergic Withdrawal
• Influenza like syndrome
• Depression• Seizures• Mania
• T/t :Atropine• Reintroduction and
gradual discontinuation of drug
Nicotine Withdrawal
• Malaise• Irritability• Anxiety • Craving for tobacco• T/t: Nicotine patches• Nicotine gum• SSRI
Treatment
• Five Stages
1. Pre contemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance
Treatment approach tailored to pt.’s stage of readiness
• Pharmacological agents:
• Alcohol: disulfiram, naltrexone, acamprosate, gabapin
• Opioid: Naltrexone• Nicotine: Nicotine
gum, patches
Treatment
1. Detoxification2. Insistence on
abstinence3. Avoidance of other
substance associated with dependence or abuse
4. Involvement of family
5. Toxicology screens6. Self help groups7. Treat complications8. Psychotherapy9. Treat co morbidities10.Treat complications