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Disorders Related to Substance Use

Prof.Bahagia Loebis, PsychiatristPsychiatric Department FK USU

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1. Substance Use Disorders

A. Substance abuseB. Substance dependence

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2. Substance-Induced Disorder could generate

A. substance intoxicationB. substance withdrawalC. substance-induced deliriumD. substance-induced persisting dementiaE. substance-induced persisting amnestic disorder

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F. substance-induced psychotic disorderG. substance-induced mood disorderH. substance-induced anxiety disorderI. substance-induced sexual dysfunctionJ. substance-induced sleep disorder

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According to Ausubel there are 3 types of dependence :

1. Primary dependence : marked with the existence of anxiety & depression which is generally at people with inadequate personality.2. Symptomatic dependence : substance abuse as one of the underlying personality disorder symptoms; generally at people with antisocial personality, criminal and substance use for the pleasure reason.

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3. Reactive dependence : especially at adolescence, because of the inquiring motivation, environmental influence and peer group pressure.

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Evans divided substance abuse from psychological point of view

1. Substance abuse as incarnation of personality disorder; marked with disability to solve various problem and unable to learn from experience.2. Substance abuse because experiencing personal conflict, for example anxiety or depression.

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3. Substance abuse because of peer group pressure.

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Psychoactive Substances1. Alcohol2. Opioida3. Cannabinoida4. Sedative & hypnotic5. Stimulantia; including caffein

6. Coccaine7. Hallucinogenic8. Tobacco9. Solvent10. Multiple substance; or other psychoactive substances

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Substance Abuse1. Existence of pathological pattern of usage, could generate : - all day long intoxication - continue to use substance - existence of uncomplication episode, in

the form of substance intoxication

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2. Damage in social or occupational function because of pathologic use; and existence of failure to fulfill duty, as worker or student; and existence of failure to fulfill duty for environment and family, because of the strange & impulsive behavior.

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- difficulties from law facet, conducting criminal behaviour; in a intoxication condition could experience a traffic accident, fallen down.- reduced occupational function or can't function effectively, because of the intoxication; and followed with trouble in social function.

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3. Duration : at least 12 months.

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For substance dependence :

The condition equal to substance abuse, only added with : 1. Substance tolerance : a need for

markedly increased amounts of the substance to achieve desired effect; or markedly diminished effect with continued use of the same amount of the substance.

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2. Withdrawal syndrome = abstinence syndrome

Is a specific substance syndrome which arise because of the reducing or stopping substance use; which the substance had been used for a long time period, continuous or periodical, to get the physiologic intoxication effect.

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Medical treatment1. Phase I: crisis service (1-2 days) treatment of overdosage, acute withdrawal syndrome, acute medical problem2. Phase II: short term stabilization (1-4 weeks) detoxification process

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3. Phase III : long term stabilization ( 4-24 weeks)evaluation & treatment for chronic medical problem 4. Phase IV : rehabilitation (6 months-2 yrs) medic & psychiatric care, religious & cultural approach

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Many expert describe, patient which have free oftentimes fall again & become dependence to substance, because of : - easy to persuaded by group of friend with

substance user . - and when he face problems, he returns to

use the substance.

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Prevention in order not to become a substance abuser :1. Get an explanation concerning substance abuse & dependence2. The condition in the family are good & healthy3. Religious life in family4. Choose peer group friend with none of them are substance abuser

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5. Had activities to fill the leewayThe substance aren’t easy to get, so the substance abuse or dependence are difficult to happened

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Common substance that had been used in Indonesia :

1. Alcohol - whiskey, kamput, tuak, etc

2. Sedative & hypnotic Sedative : bromazepam, alprazolam, lorazepam Hypnotic : nitrazepam, flurazepam, triazolam

3. Cannabis - tetrahidrocannabinol (=THC)

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4. stimulantia - amphetamin, methamphetamin - coccaine, shabu-shabu

5.opiate & opioida -morphine - heroine, putaw

6. etc

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Alcohol intoxicationRecently ingestion of alcoholThere are maladaptive behavior, for example : quarreling, impairment in judgment, social & occupational function.

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At least 1 of these physiological symptoms :

1. Slurred speech2. Incoordination3. Unsteady gait4. Nystagmus5. Flushed face

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At least 1 of these psychological symptoms :

1. Change of affect2. Instability 3. Talkative4. Impairment in focusing attention

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Alcohol withdrawalCessation or reduction of prolonged heavy alcohol consumption; discovered the present of harsh tremor at hand, tongue, eyelid and at least one of the following symptom:1. nausea & vomiting2. Iethargy or weakness

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3. Autonomic hyperactivity, eg tachycardia, sweating, increased blood pressure4. Anxiety5. Depressive affect or irritable6. Orthostatic hypotension

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Opioida intoxicationRecently used opioidaPupil constriction (or pupil dilatation because of anoxia from overdosage)At least 1 psychological symptoms :1. euforia2. disforia3. apathy4. psychomotor retardation

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At least 1 neurologic symptoms :1. Drowsiness 2. Slurred speech3. Impaired attention or memory

Effect on maladaptive behavior, eg impaired judgment, social or occupational

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Opioida withdrawal syndrome (eg : morphine, heroine, pethidine, etc)

Prolonged & heavy used of opoidaAt least 4 of the following symptoms because of the cessation or reduction in the use of opioida :1. lacrimation2. rinorrhea3. pupil dilatation4. pilo erection

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5. sweating6. diarrhea7. yawning8. mild hypertension9. tachycardia10. fever11. inability to fall asleep

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Amphetamine intoxication

A. Recently used of amphetamine or other sympatomimetic/same effectB. Within 1 hour after the use, at least 2 of the following psychological symptom :1. Psychomotor agitation2. Elation3. Grandiosity4. Talkative5. Hypervigilance

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C. Within 1 hour after the at least 2 of the following physical symptoms : 1. tachycardia2. pupil dilatation3. increased blood pressure4. sweating or feeling cold5. nausea or vomiting

D. maladaptive behavior effect; eg quarreling, impaired judgment, social & occupational function

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Amphetamine withdrawal syndrome

A. Prolonged & heavy used of amphetamine or other sympatomimetic that had the same mechanism of action or effectB. Present of depressive affect & at least 2 of the following symptoms after cessation or reduction of the substance :1. fatigue2. sleep problem3. increased dreams

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Opiate & OpioidaOpioid receptor consist ofmu receptor : responsible for cravingkappa receptordelta receptorsigma receptorepsilon receptor lamda receptor

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Treating overdosage (OD)Give naloxon (NarcanR/) 0,8 mg IV; wait 15

minutes, not yet improvement, give again naloxon 1,6 mg IV; wait again 15 minutes; still no response add naloxon 3,2 mg IV

Signs if there a response, increased respiratory rate, systolic blood pressure & pupil dilatation

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Mirin & Weiss suggest interval for 5 minutes If overdosage is treated continue to give naloxon 0,4 mg/hour/iv until the patient awake

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Cessation the use of opiate & opioida

Detoxification process could be : 1. Natural : “cold turkey”, very suffered, duration

10-20 days 2. Detoxification by giving symptomatic drugs to

treat the withdrawal syndrome 3. Methadone substitution

begin with 30 mg (must not be more than 40 mg/day). Some suggest must not be more than 60 mg/day. At day 3 the dosage reduce 5 mg/day; & give symptomatic drugs to treat the symptoms

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4. Clonidine & naltrexonclonidine given 0,1-0,2 mg/3-4 hours, not more than 0.8 mg/day; reduce slowly, & at day 3 give 50 mg/day5. buprenorphinepartial agonist receptor μ opioid. Give with dose 6-20 mg/day/sublingual (target dosage 16 mg/day)Rapid opioid detoxification giving the naloxon & patient in anesthetic condition; duration 4-8 hour

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Using naltrexon 50 mg at day 1: ¼ tablet

day 2: ½ tablet day 3: 1 tablet

Can be added clonidine & symptomatic treatment to the withdrawal opioida syndromeNote : opioida withdrawal, eg heroine, begin 6-8 hour & reach the peak at day 2-3, & continued for 7-10 days

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