Substance use disorders

1. Substance use disorders By: Doaa Ahmed Khalifa MD in Psychiatry Psych. Consultant, King Abdulaziz university

2. Substance use disorders They are common disorders which have an impact on the society. Medical illness and psychiatric disorders are frequently complicated or associated with these disorders

3. Substance use disorders Criteria Intense desire urge and compulsion: to take the substance on continuous basis Physical and/or psychological dependance: Physical dependance: requirement for regular supply of drug to experience the physiological effects or avoid discomfort of its abstain Psychological dependance( addiction): compulsion to take substance for pleasure and release of inner tension Tolerance: The need to increase the dose to reach the same effect or to prevent withdrawal syndrome Withdrawal: Stopping the drug causes withdrawal symptoms Abuse: maladaptive pattern of substance use in physical hazardous situations, with recurrent legal, social and interpersonal problems.

4. Signs of Dependance Continued use despite harm Difficulty controlling the use Development of tolerance Appearance of signs of withdrawal

5. Main presentations Mood changes( elevation, depression, anxiety) Sleep and sexual problems Physical complications of the substance or from contaminated needles Accidents or injuries Legal and social problems (family, work, and financial problems)

6. Epidemiology Life time prevalence = 20% Lower education Lower income Unemployed Blacks Age=15-25 years Males Vulnerable personalities: antisocial, dependent, and borderline personality

7. Etiology I) Cognitive theory Dependence is a life style with common core beliefs:- Immediate pleasure Impulsivity Does not estimate consequences Compulsion Counts time in small units Low self esteem Life centered around the substance

8. II) Behavioral theory Modeling with parents Operant conditioning( +ve and �ve) Classical conditioning (external and internal cues) Reinforcement from the society

9. III) Sociocultural theory Childhood traumatic event Family theory Peer influence Social preferences Effect of media Drug availability IV) Genetic factors V) Pharmacological mechanisms Increased neurotransmitter receptor supersenstivity Dysfunction of endorphins

10. Classification of substances CNS depressants Alcohol- opiates-benzodiazepines- barbiturates CNS hallucinogens Cannabis- LSD- PCP CNS stimulants Ephedrine- amphetamines- cocaine- ecstacy

11. Alcohol related disorders Alcohol dependance (chronic use) Liver(hepatitis,cirrhosis, fatty liver, late stage liver failure) GIT( oesophagitis, gastritis, portal hypertension, pancreatitis, peptic ulcer) CVS( cardiac arrythmias, hypertension, cardiomyopathy) CNS( diffuse brain damage, Wernick-Korsakoff syndrome,cerebellar degeneration, epilepsy, amnesia) Metabolic( hypoglycemia, hypercholostrolemia, ketoacidosis) Hematological (anemia, iron deficiency anemia, thrombocytopenia) Psychiatric complications( hallucinations, depression, suicide, anxiety)

12. Alcohol related disorders Alcohol intoxication( evidence of recent ingestion of sufficient amount) Unsteady gait, ataxia, nystagmus, slurred speech, diminished attention, memory, stupor and coma Alcohol withdrawal( evidence of stoppage or decrease in dose) Hand trmors, hallucinations, seizures, nausea and vomiting, delirium

13. Treatment Intoxication According to blood level 0.15-0.25% No treatment 0.25-0.35% Symptomatic treatment If ?0.35% in ICU Withdrawal High CHO diet good hydration Benzodiazepines with gradual tapering Clonidine, inderal for ANS Tegretol for convulsion control

14. Benzodiazepines & Barbiturates Chronic use Slurred speech, cognitive impairment, dysphoria, behavioral disturbances, impaired concentration Intoxication Disorientation, sedation, nystagmus, ataxia, respiratory depression, CVS collapse, coma Withdrawal Anxiety, tremors, agitation, insomnia, irritability, seizures, delirium

15. Treatment Intoxication Hospitalization BDZ antagonist, anexate (flumazinil) Airway safety Consciousness and vital signs observation Withdrawal Gradual tapering from short to longer acting + antiepileptic( Tegretol)

16. Opioid related disorders Opiates : naturally occurring derivative of opium( heroin, codeine, morphine) Opioids : Synthetic narcotic with same action ( methadone) Route: oral, snored, IV, SC

17. Opioid related disorders Chronic use Euphoria, followed by sedation, analgesia, behavioral changes, cognitive impairment, flushy face, warmth and heaviness of extremities, legal problems, risk of AIDS, hepatitis, and phlebitis. Intoxication Constricted pupil, colic, respiratory depression, decrease pulse, temp., retardation, drowsiness, slurred speech, CVS collapse and coma. Withdrawal Nausea, vomiting, sweating, diarrhea, lacrimation, pains and abdominal cramps, shivering, pupillary dilatation, fever, tachycardia, and hyperthermia.

18. Treatment of opioid related disorders Overdose Triad: Coma, pinpointed pupil, respiratory depression Treatment: airway, vital signs, opioid antagonist(Naloxone) IV Opioid withdrawal 1.Hospitalization 2.Substitute(Methadone) 3.Symptomatic treatment ( analgesics, antiepileptics, antipsychotics, sedatives for sleep, good nutrition and fluids, clonidine for noradrenergic hyperactivity,SSRI for drug seeking behavior). 4. Opiate antagonist (Naltrexone) as aversive therapy

19. Treatment of opioid withdrawal (cont.) 5. Rehabilitation Psychological treatment, Cognitive behavioral therapy Relapse prevention strategies Occupational therapy Religious group Support group

20. Hallucinogens related disorders (Cannabis-LSD) Chronic use: depression, lack of motivation, pulmonary complications, cognitive impairment, psychosis, panic attacks. Intoxication: red eye, increased heart rate, perceptual disturbances( hallucinations and illusions), impaired coordination, euphoria, impaired consciousness, sweating, hypoglycemia. Withdrawal: irritability, mood changes.