Download Substance related disorders

Substance related disorders
Nosology: We have two large categories :
1- substance dependence and substance abuse
2- substance induced mental disorders
we will deal with the descriptions of the clinical phenomena associated with the
use of 11 designated classes of pharmacological agents: alcohol, amphetamines or
similarly acting agents; caffeine; cannabis; cocaine; hallucinogens; inhalants;
nicotine; opioids; phencyclidine (PCP) or similar agents; and sedatives, hypnotics,
and anxiolytics. The ICD-10 includes caffeine in the category of other stimulants
such as amphetamine and (PCP) phencyclidine is included with hallucinogens
Substance Dependence:
“a cluster of behavioural, cognitive, and physiological phenomena that develop
after repeated substance use and typically include a strong desire to take the drug,
difficulties in controlling its use, persisting in its use despite harmful consequences,
a higher priority given to drug use than to other activities and obligations, increased
tolerance, and sometimes a physical withdrawal state.”
DSM-IV uses seven criteria requires three to describe dependence. ICD-10 requires
three of six criteria .
DSM-IV Diagnostic Criteria for Substance Dependence
A maladaptive pattern of substance use, leading to clinically significant impairment
or distress, as manifested by three (or more) of the following, occurring at any time
in the same 12-month period:
(1) Tolerance, as defined by either of the following:
(a) A need for markedly increased amounts of the substance to achieve
intoxication or desired effect
(b) Markedly diminished effect with continued use of the same amount of the
substance
(2) Withdrawal, as manifested by either of the following:
(a) The characteristic withdrawal syndrome for the substance (refer to criteria A
and B of the criteria sets for withdrawal from the specific substances)
(b) The same (or closely related) substance is taken to relieve or avoid withdrawal
symptoms
(3) The substance is often taken in larger amounts or over a longer period than was
intended
(4) There is a persistent desire or unsuccessful effort to cut down or control
substance use
(5) A great deal of time is spent in activities necessary to obtain the substance
(e.g., visiting multiple doctors or driving long distances), use the substance (e.g.,
chain-smoking), or recover from its effects
(6) Important social, occupational, or recreational activities are given up or
reduced because of substance use
(7) The substance use is continued despite knowledge of having a persistent or
recurrent physical or psychological problem that is likely to have been caused or
exacerbated by the substance (e.g., current cocaine use despite recognition of
cocaine-induced depression, or continued drinking despite recognition that an ulcer
was made worse by alcohol consumption)
Specify if:
With physiological dependence: evidence of tolerance or withdrawal (i.e., either
item 1 or 2 is present) Without physiological dependence: no evidence of tolerance
or withdrawal (i.e., neither item 1 nor 2 is present)
Course specifiers:
Early full remission
Early partial emission
Sustained full remission
Sustained partial remission
On agonist therapy
In a controlled environment
N.B
- Intoxication: is a mental disorder caused by recent ingestion or presence in the
body of an exogenous substance producing maladaptive behaviour by virtue of its
effects on the central nervous system. The most common psychiatric changes
involve disturbances of perception, wakefulness, attention, thinking, judgment,
emotional control, and psychomotor behaviour; the specific clinical picture
depends on the substance ingested.
-Withdrawal: it is the appearance of signs and symptoms following cessation or
reduction of dose.
-Tolerance: it is the need to increase the dose to obtain the same effect
-abuse: means any use of an illicit substance, as well as the harmful or excessive
use, of legally available substances, such as alcohol and tobacco.
It is used popularly.
-Substance Abuse in DSM- IV do not include tolerance, withdrawal, or a pattern of
compulsive use and instead include only the harmful consequences of repeated
use.
-Dependence: it is a psychological or physiological need to continue taking the
substance.
A-Psychological dependence(habituation):it is continuous or intermittent craving of
the substance.
B-Physiological dependence: it is the need to take the substance to prevent the
withdrawal symptoms.
Why the impact of dependence varies on different people
1-the expectation of the user has an impact on the effect of the substance.
2-the past experience
3-the personality of the abuser
4-the condition surrounding the patient
Classification of substance:
1- alcohol 2-opioids 3-cannabinoids 4-sedatives or hypnotics(benzodiazepines and
barbiturates)5- cocaine 6-amphetamine 7- caffeine 8- hallucinogens 9nicotine(tobacco) 10-volatile substance(inhalant)
Alcohol dependence: Alcohol is a C.N.S central nervous system, we will discuss the
following:
Alcohol intoxication , alcohol withdrawal, alcohol medical complications, induced
alcohol psychosis, and treatment of alcohol dependence.
Epidmiology: 10% male and 4 -5% female in a ratio of 2:1
Common in the upper social class
Symptoms of alcohol intoxication:
(1) disinhibition (2) argumentativeness (3) aggression
(4) lability of mood (5) impaired attention(6) impaired judgment
(7) interference with personal functioning (8) unsteady gait
(9) difficulty in standing (10) slurred speech (11) nystagmus
(12) decreased level of consciousness (e.g., stupor, coma)
(13) flushed face (14) conjunctival injection
It may ends in coma and death, the most common causes of death are accident the
most frequent, cardiac, suicide only or suicide after homicide, cancer liver or
oesophagus.
Symptoms of alcohol withdrawal: occurs several hours after discontinuation or
reduction of dose, it is the most dangerous stage of alcohol dependence.
(1) tremor of the tongue, eyelids, or outstretched hands
(2) sweating (3) nausea, retching, or vomiting (4) tachycardia or hypertension
(5) psychomotor agitation (6) headache (7) insomnia
(8) malaise or weakness(9)Delirium tremens
(10) transient visual, tactile, or auditory hallucinations or illusions
(11) grand mal convulsions.(treated by benzodiazepines)
Alcohol’s medical complications:
-Gastro-intestinal: gastritis, peptic ulcer, pancreatitis(ask for amylase analysis),
hepatoma, oesophageal varices and carcinoma, hepatitis and cirrhosis.Increased
GGT liver enzyme is diagnostic of alcohol dependence
-Central nervous system: Wernicke-Korsakoff syndrome characterized by amnesia,
confusion, nystagmus , ophthalmoplegia (abducent cranial nerve it is due to
thiamine deficiency caused by alcohol and treated by ingestion of thiamine.The
acute form are reversible(wernick encephalopathy) the chronic form 80%
irreversible.
-Delirium tremens( Acute and sometimes fatal reaction(death rate 5-15%) to
withdrawal from alcohol, usually occurring 72 to 96 hours(4 to 6 days) after the
cessation of heavy drinking; distinctive characteristics are marked autonomic
hyperactivity (tachycardia, fever, hyperhidrosis, dilated pupils), usually
accompanied by tremulousness, hallucinations(olfactory and tactile), illusions, and
paranoiddelusions.This period should be covered by benzodiazepines at the
hospital.
- Dementia
-optic nerve atrophy
-peripheral neuropathy
-alcohol memory blackouts : amnesia occuring in intoxication for 5-15 minutes
-cardiomyopathy (increase heart rate and cardiac output with sudden death due
to myocardial infarction.
-obesity , gynaecomastia and anemia
Alcohol induced psychosis:
Full picture of psychosis with hallucinations mainly visual the auditory hallucination
are in the second person usually, agitation. Morbid jealousy syndrome induced by
alcohol may lead to homicide suicide act the husband kills his wife than kills
himself.
Treatment of alcohol intoxication:
Supportive approach(I.V lines, hydration, protection of the airways)
Restrain the patient and give short acting haloperidol 5mg to be repeated every
hour if needed
Give thiamine injection I.M 100 mg per day
Sedatives are better avoided
Wait for alcohol to be metabolized
Alcohol withdrawal treatment:
In-patient treatment is required .
Close observation and monitoring of vital signs
Rehydration and correction of electrolyte
Thiamine supplement should be given before the I.V fluids or put together in the
bottle.
Sedation with long acting benzodiazepines( diazepam) lorazepam is better because
it is metabolized to inactive metabolites, so minimal effect on the liver
Treat in emerging medical problems
Anticonvulsants if seizure develops (phenytoin)
Detoxification (planned alcohol withdrawal)
-long acting benzodiazepines are prescribed to reduce withdrawal
-vitamin supplement (thiamine)
-monitoring of vital signs, consciousness and orientation
-good hydration and glucose intake
-anticonvulsant to control seizure if it develops
Maintaining abstinence:
Disulfiram (ant abuse)
It blocks the oxidation of alcohol so that acetaldehyde accumulates with
consequent unpleasant flushing of face choking sensation , headache, nausea,
vomiting tachycardia and anxiety. It is a sort of aversive technique depending on
conditioned learning. It should not be given within the 12 hours after the last
injection.
Naltrexone (Rivea) 50mg to be taken in the morning for duration not less than one
year, monitor the liver enzymes.
2-Stimulants
Example amphetamine,cocaine,Khat,LSD,Caffeine
i-Amphetamines:
a- Amphetamines were introduced into clinical use in the early 1930s until as
late as 1971.
b- The Food and Drug Administration (FDA) placed them under regulatory
control in the mid-1960s.
c- There is potential toxicity of the amphetamines, especially when used
intravenously
d- In the late 1980s there were reports that smoking of crystalline
e- Amphetamines are used legitimately almost exclusively for the treatment of
narcolepsy and attention-deficit/hyperactivity disorder, and as appetite
suppressant.
f- Amphetamines enhance talkativeness, self-confidence, and sociability.
increase sexual drive and performance
g- Mechanisms of Action is the release of monoamines from storage sites in
axon terminals leading to reinforcement and mood-elevation effects
h- The release of nor epinephrine is probably responsible for the cardiovascular
effects.
i- Common Routes of Administration Amphetamines and amphetamine-like
drugs can be taken orally, by injection, by absorption through nasal and
buccal membranes, or by heating, inhalation of the vapours, and absorption
through the pulmonary alveoli.
j- Metabolism Amphetamine and methamphetamine are extensively
metabolized in the liver. The half-lives of amphetamine and
methamphetamine ranges from 7 to 19 hours and that of methamphetamine
appears slightly longer. It is detected by urine screening for 2 to 3 days
k- It induces paranoid states and toxic psychoses
l- Withdrawal State in form of dysphoria and anhedonia withdrawal.
m- Students, truck drivers, those who take night duties depend on the drugs for
high energy.
Ii-Cocaine:
a-Very rapid onset
b-route is by inhalation, rarely smoked or injected
iii-Khat
a-Causing dependence in high rate
b-Accepted socially in certain country.
Intoxication signs:
(1) tachycardia or bradycardia(2) pupillary dilation
(3) elevated or lowered blood pressure(4) perspiration or chills
(5) nausea or vomiting(6) evidence of weight loss
(7) psychomotor agitation or retardation
(8) muscular weakness, respiratory depression, chest pain, or cardiac
arrhythmias
(9) confusion, seizures, dyskinesias, dystonias, or coma
Withdrawal signs:
(1) fatigue(2) vivid, unpleasant dreams (3) insomnia or hypersomnia
(4) increased appetite(5) psychomotor retardation or agitation
3- Opiates
Opium"‫ نبات الخشخاش "أبو النوم‬its clinical extract is morphine,heroin methadone
are semi-synthetic opioid derivatives.
It can be used orally, I.V ,I.M, S/C.
Heroin is the most addictive because of rapid effect and has the most painful
withdrawal.
Intoxication of opioids:
i - Pupillary constriction ii drowsiness or coma
iii slurred speech iv) impairment in attention or memory
N.B the overdose is usually fatal due to CNS depression, may be due to taking
opium while on naltrexone or taking a pure form in the same dose of the
previously impure form.
Withdrawal of opioids:
(1) craving for an opioid drug(2) rhinorrhea or sneezing (3) lacrimation
(4) muscle aches or cramps (5) abdominal cramps (6) nausea or vomiting
(7) diarrhea(8) pupillary dilatation (9) piloerection, or recurrent chills
(10) tachycardia or hypertension(11) yawning (12) restless sleep
Treatment of opioid overdose:
-It is an emergency to be treated in ICU intensive care unit.
-characterized by coma, pinpoint pupils, respiratory depression
-It is treated by opiate antagonist (Naloxone) used as antidote.
-keep open airway ,oxygen and IV fluids
-Monitoring of vital signs
Treatment:
Naltrexone to prevent craving for opioid
Get away from the places or friends which remembers him of the substance
Treating the co-morbid psychiatric conditions
Treating the physical conditions( hepatitis,HIV)
Supportive psychotherapy
Rehabilitation program
If failed to be maintained on methadone replacement therapy accepted in
many countries.To minimize the rate of crime due to opioid withdrawal.
4- Cannabinoids:
-example: hashish , marijuana
-route by smoking,It may also be eaten and is often baked in lipid-rich foods,
such as brownies not a popular in Arabic countries.
-It occupies fourth place in worldwide popularity among psychoactive drugs,
after caffeine, nicotine, and alcohol.
it can be detected 2 to 3 days after smoking a single cannabis cigarette.
Cannabis Intoxication
iimpaired motor coordination ii-euphoria iii- Anxiety
ivsensation of slowed time v- impaired judgment
vsocial withdrawal that develop during, or shortly after, cannabis use.
within 2 hours of cannabis use:
(1) conjunctiva injection(2) increased appetite
(3) dry mouth (4) tachycardia
Withdrawal of cannabinoids:
Cannabinoid Withdrawal State
ICD-10 notes cannabinoid withdrawal state; DSM-IV does not. In ICD-10
include anxiety, irritability, tremor of outstretched hands, sweating, and
muscle aches.
Cannabis Intoxication can cause delirium, short-lived anxiety states that are
often provoked by paranoid thoughts.
Cannabis can induce psychotic Disorder, anxiety disorder
Amotivational Syndrome is associated with chronic cannabis use was
marked by apathy, poor concentration, social withdrawal, and loss of interest
in achievement. Those features may correlate with the reversible decrement
in cerebral blood flow that has been documented as an effect of marijuana.
5-Sedatives,Hypnotics and Anxiolytics:
They have sedative or calming effects and sleep-inducing effects.
(1) benzodiazepine receptor agonists
(2) barbiturates,
The drugs that are most important clinically are the benzodiazepines.
If used more than three weeks in a regular dose they produce physiological
dependence,marked by both tolerance and withdrawal.
• Sales of drugs with short elimination half-lives (e.g., alprazolam) have
increased compared with drugs with long half-lives (e.g., diazepam)
• Persons who abuse alcohol and drugs use and abuse benzodiazepines at
higher rates than do anxiety disorder patients without substance abuse
histories
Sedative, Hypnotic, or Anxiolytic Intoxication
- inappropriate sexual or aggressive behaviour - mood lability
- impaired judgment-impaired social or occupational functioning
- slurred speech- incoordination- unsteady gait- nystagmus
- impairment in attention or memory- stupor or coma
Sedative, Hypnotic, or Anxiolytic Withdrawal
(1) autonomic hyperactivity (e.g., sweating or pulse rate greater than 100)
(2) increased hand tremor(3) insomnia (4) nausea or vomiting
(5) transient visual, tactile, or auditory hallucinations or illusions
(6) psychomotor agitation(7) anxiety (8) grand mal seizures
(9)distress or impairment in social, occupational, or other important areas of
functioning.
6-Inhalants(volatile solvents)
Inhalants are volatile substances that can be inhaled for their psychotropic
effects. They include the following:
Solvents, cleaners, glues, spray paints, typewriter correction fluids, finger nail
polisher removers.
- These agents generally act as brain depressants similar to alcohol and
sedative hypnotics in their effects
- Use of inhalants occurs mainly among adolescents in lower socioeconomic
groups.
- Inhalants are rapidly absorbed through the lungs and delivered through
the blood to the brain.
- Their effects usually appear within 5-10 minutes and may last for several
hours.it is detected in blood but the sample should be freezed rapidly till
analysed.
Inhalant Intoxication
-Belligerence- assaultiveness- apathy- impaired judgment
-impaired social or occupational functioning - dizziness
- nystagmus
- incoordination - slurred speech - unsteady gait
- lethargy - depressed reflexes - psychomotor retardation
- tremor - generalized muscle weakness
- blurred vision or diplopia- stupor or coma
- euphoria, excitement, disinhibition and pleasant floating sensation are
present with small doses
Long term use can cause irreversible brain damage due to low cerebral blood
flow, affects the lung, kidney, liver and bone marrow .
7-Nicotine
-It has a stimulatory CNS effects
-It improves attention, learning, reaction time, and problem solving
ability.
-Nicotine dependence develops rapidly and is strongly affected by
environmental conditioning.
-Features of nicotine withdrawal occur after abrupt cessation or reduction
in the amount of nicotine used :
- irritability -Frustration -poor concentration
-insomnia -dysphoric mood -increase appetite
These features generally are at a peak in the first 24-48 hours and can continue for
several weeks.
It is a psychological more than physical dependence, the irritability and
tension are the causes of return to cigarettes and for women the
increased weight in addition.
Treatment:
Nicotine patch for gradual withdrawal
Bupropion has a dopaminergic as well as adrenergic properties which
lead to stoppage of smoking(50% almost get rid of smoking)
The combination of both treatment has a better result than each one
alone .