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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 9-nicotine(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

Opiumنبات الخشخاش "أبو النوم" its 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

i- impaired motor coordination ii-euphoria iii- Anxiety

iv- sensation of slowed time v- impaired judgment

v- social 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 .

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