Prof. Fareed A.Minhas

Head,

Institute of Psychiatry

Rawalpindi Medical College

Rawalpindi

Substance use disorder (DSM IV)

Disorders due to psychoactive drug use (ICD 10)

Conditions arising from the abuse of alcohol, psychoactive drugs and other chemicals such as volatile solvents

DSM IV ICD 10Intoxication

AbuseDependenceWithdrawal

Withdrawal deliriumPsychotic disorders

DementiaAmnestic Disorder

Mood disordersAnxiety disorders

Sexual dysfunctionsSleep disorders

IntoxicationHarmful useDependence

syndromeWithdrawal stateWithdrawal with

deliriumPsychotic disorder

Amnestic syndromeResidual and late--onset psychotic

disorderOther mental and

Behavioral disorders

INTOXICATION – transient syndrome due to recent substance ingestion that produces clinically significant psychological and physical impairment

ABUSE – maladaptive patterns of substance use that impair health

DEPENDENCE – certain physiological and psychological phenomena induced by repeated taking of a substance (strong desire, neglect to other sources of satisfaction, development of tolerance and a physical withdrawal state)

TOLERANCE – state in which, after repeated administration, a drug produces a decreased effect or increasing doses are required to produce the same effect

WITHDRAWAL – state is a group of symptoms and signs occurring when a drug is reduced in amount or withdrawn, lasting for a limited time

ESCALATION – refers to a phenomenon when a person taking so called softer drugs moves on to harder drugs

DSM IV ICD 10Alcohol

AmphetaminesCaffeineCannabisCocaine

HallucinogensInhalentsNicotineOpioids

PhencyclidineSedatives/Hypnotics

Polysubstance /Others

AlcoholOther stimulants such as caffeine

CannabinoidsCocaine

HallucinogensVolatile solvents

TobaccoOpioids

Sedatives/Hypnotics

Multiple drug use

Availability ofdrugs

AdverseSocial

circumstancesA vulnerablepersonality

EXTENT OF THE PROBLEM –

- Atleast 300,000 ppl in UK have this problem - Ppl with drinking problems have a 2 to 3 percent greater chance of dying - 1 in 5 admissions in acute medical wards in UK is directly or indirectly related to alcohol

- Admissions to psychiatric hospitals for this purpose have increased 25 fold

TERMINOLOGY OF DRINKING -

HEAVY

DRINKERS

PROBLEM

DRINKERSBINGE

DRINKERS

DETECTION – History

Absenteeism from workUnexplained dyspepsia or GI bleedsAdmissions for accidentsFits, turns or falls

SignsPlethoric face with/without

telangiectasesBlood shot conjuctivaeSmell of stale alcoholFacial resemblance to Cushing’s

SyndromeMarked tremors and other signs of

disease

‘At risk’ factorsMarital discordDays off workAn affected relative having similar

problemsHigh-risk occupations eg. SalesmenAssociated physical/mental conditions

MarkersGamma-glutamyl transpeptidaseMean corpuscular volume (MCV)Carbohydrate-deficient transferrin HDL CholesterolBlood/Urinary Alcohol

The subjective Awareness of a

Compulsion to drink

A narrowing of theDrinking repertoire

Primacy of drinkingOver other activitiesIncreased tolerance

To alcohol. Need forMore to achieve

Same results

Withdrawal symptoms

Relief from withdrawalBy further drinking

Rapid reinstatementOf syndrome on drinking

After a period ofabstinence

ALCOHOL

DEPENDENCE

SYNDROME

SYMPTOMS OF ALCOHOL DEPENDENCE –Unable to keep a drink limit/Difficulty avoiding getting drunkSpending considerable time drinkingMissing meals/Memory lapses, blackoutsRestless without drink/Trembling after drinkingOrganizing day around drink Morning retching and vomitingSweating at night/Withdrawal fitsMorning drinking/Increased toleranceHallucinations/ frank delirium tremens

DIAGNOSTIC CRITERIA OF ALCOHOL WITHDRAWAL

Any THREE of the following :

Tremor of outstretched hands, tongue or eyelidsSweatingNausea / retching/ vomitingTachycardia or hypertensionAnxietyPsychomotor agitationHeadacheInsomniaMalaise or weaknessTransient visual, auditory or tactile hallucinations/illusionsGrandmal convulsions

TREATMENT – Raise awareness of the problemIncrease motivation to changeWithdraw alcohol (controlled drinking)Support and adviceCBT (Social skills, relapse prevention)Marital therapyMedication (Diazepam/chlormethiazole/Disulfiram or Acamprosate)

Psychological dependence Glue-sniffing – adolescents. Tolerance develops in weeks or months Intoxication characterized by euphoria, excitement, floating sensation, dizziness, slurred speech and ataxia Acute intoxication – amnesia + visual hallucinations There is risk of tissue damage including that to bone marrow, brain, liver and kidneys which can prove fatal

Derived directly from opium poppy: Morphine/Codeine Semi-synthetic Heroine / DiacetylmorphineSynthetic Methadone/Meperidine/Dihydrocodeine Uses Pain relief; suppression of cough; treatment of acute myocardial infarction and also diarrhea Effects Pleasant mood and a euphoric detachment Causes of death in narcotics addicts

Heart disease (including infective endocarditis)TuberculosisGlomerulonephritisTetanus/Malaria/Hepatitis B

NARCOTIC ABSTINENCE SYNDROME –

Yawning/Rhinorrhea/LacrimationPupillary dilatationSweating/Piloerection/Restlessness

Muscle twitches/Aches and painsAbdominal

cramps/Vomiting/DiarrheaHypertensionInsomnia/Anorexia/AgitationProfuse sweating/Weight loss

12 – 16HRS AFTERDOSE

24 – 72 HRS AFTER

LAST OPIATE DOSE

Abrupt withdrawal is highly dangerous. May result in a mental disorder, similar to alcohol withdrawal, may lead to seizure & sometimes to death. Withdrawal symptoms may not appear for several days. Anxiety, restlessness, and disturbed sleep anorexia, nausea. May progress to vomiting, hypotension, pyrexia, tremulousness, major Seizures, disorientation & hallucinations.

Elevate mood, increase wakefulness, give an enhanced sense of mental and physical energy

Pleasurable stimulation & excitement potential of misuse

Cocaine, amphetamines, Synthetic (Phenmetrazine diethylpropon), Khat, Caffeine  

Effects similar to these Amphetamines

Strong Psychological dependence

Excitation,dilated pupils, tremulousness

Dizziness and sometimes convulsions

Confusion, depression, paranoid psychosis and formication

Chlordiazepoxide (Librium), Diazepam (Valium),

Lorazepam (Ativan) and Nitrazepam (Mogadon)

Cause: Sedation, anxiety relief and Muscle relaxation

Withdrawal Symptoms:Anxiety, restlessness, tachycardia and sensory disturbances

Produce strange, intense, & transcendental effects,which gives them ‘recreational’ popularity

Peyote, mescaline, ‘Magic mushroom’

LSD:lysergic acid diethyl-amide

Do not give rise to dependence in true sense, nonetheless use is intensely hazardous

Effects vary with dose, persons expectation , mood, & social setting

Exaggerates pre-existing mood: exhilaration, depression or anxiety

Increased enjoyment of aesthetic experience & distortion of time & space

Reddening of the eyes, dry mouth, irritation of respiratory treat & coughing

No definite withdrawal Syndrome

No evidence of Tolerance. No serious side effects amongst intermittent users

No evidence of teratogenecity. Not safe in first trimester

Psychosis: disagreement

PRE-COMTEMPLATION:Misuser doesn’t see the problem; others recognize it

ACTION USER:Choose necessary strategy for change

DECISION POINT:Where the decision is made to act on this issue

CONTEMPLATION:Individual weighs pros/cons. Considers change is needed

MAINTENANCE GAINS:Are maintained and consolidated

RELAPSE:Return to previous pattern of behavior

1.DETOXIFICATION

2.INSISTENCE ON ABSTINENCE

3.INVOLVEMENT OF FAMILY

4.TOXICOLOGY SCREENS (periodic urine screens are often essential in identifying relapse and noncompliance)

5.SELF-HELP GROUPS

6. SANCTIONED TREATMENT (patient forced to remain in therapy by a legal sanction e.g. drivers/professional

license)7. CONTINGENCY CONTRACTING

(This approach provides a powerful negative contingency for leaving treatment or relapsing or a positive contingency

for remaining drug free)