Substance Use DisorderAddiction (DSM V)

By

Soheir H. ElGhonemy Assist. Professor of Psychiatry- Ain Shams University

Drug Abuse and Addiction are Among

the Most Serious Public Health

Problems Facing Our Society and

frequently coexist with other Mental

and Physical Disorders

Dopamine Pathways

Functions•reward (motivation)•pleasure,euphoria•motor function (fine tuning)•compulsion•perserveration•decision making

Serotonin Pathways

Functions•mood•memory processing•sleep•cognition

nucleusaccumbens

hippocampus

striatum

frontalcortex

substantianigra/VTA

raphe

Medial Forebrain Bundle

Ventral tegmental area (VTA) (Lateral) hypothalamus (LH) Nucleus accumbens (NAc) Frontal cortex (FC) - key portions

Prefrontal cortex (pfc) Orbitofrontal cortex (ofc)

Drugs Associated wth Neurotransmitters

Why do people have “drugs of choice”?

Dopamine - amphets, cocaine, alcohol Serotonin - LSD, alcohol Endorphins - opioids, alcohol GABA - benzos, alcohol Glutamate -alcohol Acetylcholine - nicotine, alcohol

A Brain Chemistry Disease!

Addicting drugs seem to “match” the transmitter system that is not normal

A chronic, relapsing, medical disease There are mild, moderate, and severe forms Detox is traditionally the first step in the total

treatment process Methadone and nicotine maintenance is

evidence that some people require a chemical to overcome the non-normal transmitter system

Figure 5

The combination of neuroadaptations in the brain circuitry for the three stages of the addiction cycle that promote drug-seeking behavior in the addicted state.

Activation of the ventral striatum/dorsal striatum/extended amygdala driven by cues through the hippocampus and basolateral amygdala and stress through the insula.

The frontal cortex system is compromised, producing deficits in executive function and contributing to the incentive salience of drugs compared to natural reinforcers.

Dopamine systems are compromised, and brain stress systems such as CRF are activated to reset further the salience of drugs and drug-related stimuli in the context of an aversive dysphoric state

Common Underlying NeurobiologicalFactors Can Be

Neurochemical (imbalance of

neurotransmitters)

Structural/anatomical (same

regions and pathways)

Genetic (inherited factors

that compromise function)

Drug Disorder

Cocaine and Methamphetamine Schizophrenia, paranoia, anhedonia, compulsivebehavior

Stimulants Anxiety, panic attacks, mania and sleep disorders

LSD, Ecstasy & psychedelics Delusions and hallucinations

Alcohol, sedatives, sleepaids & narcotics

Depression and mood disturbances

PCP & Ketamine Antisocial behavuor

DRUG USE(Self-Medication)

DRUG USE(Self-Medication)

STRESSSTRESS

CRFCRF

AnxietyAnxiety

CRFCRF

AnxietyAnxiety

What Role Does Stress Play In Initiating Drug Use?

What Role Does Stress Play In Initiating Drug Use?

Consequence: There is no “cure”…

To be successful, treatment is a

Lifetime Process

Science is helping to improve our

strategies and successes

History Taking

The history is the chronological story of the patient’s life from birth to present

Personal data:

Name, age, sex, marital status, religion,

address, occupation, education.

n.b.; source of referral could be

mentioned here if the patient won’t

cooperate

Personal History:

Birth and developmental milestones, family

atmosphere, school performance and

general conduct in school, educational

achievement, occupational history, sexual

and marital history.

Attempt to correlate social problems with

evolving drug problems. Enquire about

impact of drug use on lifestyle.

Family History:

Brief vignette of father, mother and

other siblings should include age,

occupation and relation with the

client. History of psychiatric

problems or problems resulting

from alcohol, drugs or nicotine.

Drug History:

This section should attempt to give a clear

picture of initiation of drug use accounting for

each specific drug. The evolution of drug use

with the development of personal and social

problems as a consequences of drug use.

Type, quantity, and route of use of each

individual drug. Alcohol consumption should

be checked as a routine part of drug history

taking.

Drug use in the past 24 hr.:

Detailed and sensitive questioning around this will

not only provide data about drug use and drug

dependence but should give a clear picture of the

client’s lifestyle and daily stresses and strains.Drug use in the past month:

Should try to draw a picture of drug use over the

past 4 weeks.History of abstinence:

Number of trials , how , duration of each and

reason for relapse.

Legal History:

Charges, convictions, imprisonments and

violent incidents.Sexual and Marital History:

Sexual behavior and marital relation and

if extramarital relationships. Relation of

sexual or marital problems to drug use.Occupational History:

Relationships of jobs and relations to

drug use. Current employment status.

Present life situation:

Family and social support. Non drug

use friends, leisure activities and

occupational prospects, financial

status and accommodations.

Mental state examination:On admission:

Describe relevant features. Positive and

negative findings regarding both physical

and mental condition of the client. Focus

on physical signs of drug withdrawal,

liver diseases signs and any neurological

dysfunctions. Sites of injections and any

infections.

Mental state should include level of

consciousness, alertness and orientation and

as well as level of cooperativeness. Ability to

give history will provide data about their

intelligence, cognitive state and level of

insight into their condition.

General state of dress and grooming as well

as evidence of agitation, calmness or

detachment from problem should be checked.

Pattern of sleep, appetite, energy

level, mood state and suicidal

ideations giving data about special

and general psychological state.

Any delusions or hallucinations

should be considered and relation to

client intoxication or withdrawal states

Follow up setting is meant for better

elaboration of the client’s condition and

allow building rapport for setting

management plan.

A thorough history is the substrate for a

considered opinion about the client. What is

the best for the client. History is cornerstone

in the substance abuse field.

Patient with treatment program:

Substance is being used.

Recent regular use.

Psychiatric status.

Medical condition.

Social network.

Legal aspects.

Goals of treatment:

A.Help the individual to be drug free( detoxification).

B.Help to maintain drug free state ( relapse prevention)

C.Long term Rehabilitation.

Classification of substance:

I. CNS depressants: Alcohol Opiates Sedative hypnotics

II.CNS stimulants: Amphetamines Cocaine

III.CNS hallucinogens: Cannabis LSD Anticholinergics

Stimulation : Depression :a. Anxiety .

b. Insomnia.

c. Twitches.

d. Convulsions.

e. Hyperthermia.

f. Tachycardia.

g. Irritability.

h. Excitement.

i. Tremors.

j. Hypertension.

k. Tachypnea

a.Apathy.

b.Retardation.

c. Inattentive.

d.Stupor.

e.Hypotension.

f. Bradypnea.

g.Ataxia.

h.Lethargy.

i. Drowsiness.

j. Confusion.

k. Hypothermia

l. Bradycardia

&Coma.

Drugs of abuse that can be tested in urine:

Alcohol: 7-12 hrs.Amphetamine : 48 hrs.Barbiturate ; short: 24 hrs. , long acting: 3 wks.

Benzodiazepine: 3 days.Cannabinoides : 3 days ---4 wks “ depending on the use; chronic use leads to lengthening of period”

Cocaine : 6- 8 hrs.Codeine : 48 hrs.Heroin : 36—72 hrs.Methadone : 3 days.Morphine : 48 – 72 hrs

The Neuropharmacology of Drugs of Abuse

Psychoactive drugs alter normal neurochemical

processes . This can occur at any level of activity

including :

a. mimicking the action of a neurotransmitter .

b. altering the activity of a receptor .

c. acting on the activation of second

messengers

d. directly affecting intracellular processes that

control normal neuron functioning.

Routes of administration:

It affects how quickly a drug reaches the

brain ,also ,chemical structure of a drug

plays an important role in the ability of a

drug to cross from the circulatory system

into the brain. Four routes:

oral.nasal.Intravenous.inhalation.

alcoholMild and moderate intoxication:

1.Impaired attention , poor motor coordination.

2.Dystharthria- ataxia , nystagmus, slurred speech.

3.Prolonged reaction time, flushed face orthostatic hypotension.

4.Hematemesis and stupor.Pathological intoxication:5.Excited , psychotic state following min.

consumption in susceptible individuals.Intoxication associated with belligerence.

Uncomplicated Withdrawal: Coarse tremors of hands, tongue, eyelids

and at least one of the following: Nausea or vomiting. Malaise or weakness. Autonomic hyperactivity. Anxiety, Depressed mood or irritability. Transient hallucination or illusions. Headache , insomnia.Withdrawal complication:Seizures.Hallucination.Delirium.

Management:

I. Avoid aspiration by placing patient’s face down or on one side. Hospitalization is usually necessary.

II. Parenteral sedatives or physical restrains.III. Low dose sedative ; Lorazepam 1-2 mg, physical

restrains or further sedation by Haloperidol IM 5 mg.

IV. Parenteral dose of Thiamine 100 mg.V. Benzodiazepine tapering.VI. Thiamine 50 mg PO.VII. Multivitamin PO.VIII.Folate 1 mg PO.

Over a week for uncomplicated withdrawal.  

Opiate: Patients rarely seek treatment for intoxication.

Overdose :

I. Respiratory and CNS depression.II. Depression.III.Gastric hypomotility with ileus.IV. Non-cardiogenic pulmonary edema.

Withdrawal:

V. Lacrimation, rhinorrhea.VI. Diaphoresis, yawing, sneezing.VII. Malaise, irritability, nausea and vomiting.VIII.Diarrhea, myalgia, arthralgia, bone ache.

Management of Opiate overdose: I. Respiratory depression : air way support II. Cardiopulmonary suppression: Naloxone

Hydrochloride 0.4 mg or 0.01 mg\ kg IV, repeated dose of Naloxone infusion 0.4 mg\ hr. for 12 hrs. subsequent to the initial boluses.

III. Pulmonary edema : Intubation and pressure ventilation ;ICU admission.

IV. Gastric lavage or induced emesis followed by activated Charcoal for orally ingested overdose.

26 year old heroin addict. He has all the symptoms of

withdrawal. He has a runny nose, stomach cramps,

dilated pupils, muscle spasms, chills despite the warm

weather, elevated heart rate and blood pressure, and is

running a slight temperature. Aside from withdrawal

symptoms, this man is in fairly good physical shape. He

has no other adverse medical problem and no

psychological problems. At first he is polite and even

charming to the staff. He’s hoping you can just give him

some “meds” to tide him over until he can see his

regular doctor. However, he becomes angry and

threatening to you and the staff when you tell him you

may not be able to comply with his wishes.

He complains about the poor service he’s been

given because he’s an addict. He wants a bed

and “meds” and if you don’t provide one for

him you are forcing him to go out and steal and

possibly hurt someone, or, he will probably just

kill himself “because he can’t go on any more in

his present misery.” He also tells you that he is

truly ready to give up his addiction and turn his

life around if he’s just given a chance, some

medication, and a bed for tonight.

The 26 year old is a heroin addict in

withdrawal. His signs and symptoms all

indicate opiate withdrawal. He has a runny

nose, stomach cramps, dilated pupils, muscle

spasms, chills, despite the warm weather,

elevated heart rate and blood pressure, and

is running a slight temperature. He may or

may not have other drug issues. A urine

analysis may provide some answers to this

question.

The second patient is an older man in his late sixties

and is a bit disheveled in appearance. He is

accompanied by his lady. The lady tells you that she

found him earlier this evening trying to enter his

apartment door. He was sweaty, his eyes where

dilated, and his hands were trembling so badly that

he could not get the key in the door. He kept calling

her by another name and saying he was trying to get

into his office to do some work. She says he retired

years ago. His blood/alcohol level is low and his

speech is not slurred.

He can correctly identify himself but, also appears

confused. He is unable to tell you the month or season. His

nose and cheeks are red with tiny spider veins and his

stomach distended and when he extends his hands out in

front of him they are very tremulous. His demeanor is

polite and apologetic to you and the staff. He tells you he

has never had a problem with alcohol. He then admits to

an occasional drink

every now and then. He did have a few drinks earlier

today but can’t say exactly when. However, he is willing to

come into the hospital for a brief stay if really thought it

was necessary.

late 50’s and has all the signs and symptoms of a late stage

alcoholic starting to go into alcohol withdrawal. He was

sweaty, his eyes were dilated and his hands were trembling

so badly that he could not get the key in the door. He kept

calling his lady by another name . His blood/alcohol level is

low and his speech is slurred, but appears confused. His

nose and cheeks are red with tiny spider veins, he has a

distended abdomen and when he extends his hands out in

front of him they are very tremulous. He probably does not

have other drugs in his system like benzodiazepines. They

would act as a stabilizer in his condition and these drugs are

often given to treat Alcohol withdrawal.

Delirium tremors or “DT’s”. The symptoms are

as follows: they begin with anxiety attacks,

increasing confusion, poor sleep, marked

sweating, and fleeting hallucinations or

nocturnal illusions which arouse fear. Some

patients may suffer grand mal seizures, several

in short succession. There is a trembling of the

hands at rest, sometimes extending to the

head and trunk. Walls are falling, floors are

moving, and rooms will be rotating.

Injuries often occur because patients are

unable to maintain their balance at this stage.

These falls can cause severe head and neck

injuries. Animal hallucinations are frequent and

often incite terror. It is also typical that in these

delirious, confused, states the person will

return to a habitual activity usually work

related.

In this case he is imagining himself back at

work and trying to get into his office.