Substance Use Disorders

1. SubstanceUse Disorders By: Dr. Majid Al-Desouki Consultant and Clinical Assistant Professor

2. Introduction • Many implications for brain research & clinical psychiatry. • Affect mental state and behavior. • Sx similar to the psychiatric disorders.

3. What is addiction? • In Aug 2011, The American Society of Addiction Medicine (ASAM) has officially recognized Addiction as mostly: • a social problem • a moral problem • a criminal problem • a primary chronic brain problem • a behavioral disorder occur as the result of other causes such as emotional or psychiatric problems. Addiction is not a choice, but choice still plays an important role in getting help. 

4. Introduction (cont.) • DSM-5: • Substances + substance related disorders • Substance vs. drug • Legal & illegal substances • Chemicals with brain-altering properties (e.g. organic solvents)

5. Terminology Abuse:self-administration of any substance in a culturally disapproved manner that causes adverse consequences. Intoxication:the transient effect (physical and psychological) due to recent substance ingestion, which disappears when the substance is eliminated. Withdrawal: a group of symptoms and signs occurring when the drug is withdrawn or reduced in amount.

6. Terminology (cont.) Dependence:the physiological state of neuroadaptation produced by repeated administration of a drug, necessitating continued administration to prevent appearance of withdrawal state. Addiction:a nonscientific term that implies dependence and associated deterioration of physical mental health as well as high tendency to relapse after discontinuation.

9. Family/neighborhood disorganization Authorianism; coercive parent- child interactions Aggression and/or anxiety problems Parental substance use Elementary-age rejected or isolated peer relationships Low parental monitoring Early experimenting with substance use Deviant peer associations in early youth Substance abuse and dependence

10. Psychopharmacological model of dependence

11. Reward Circuitry of the Brain

12. Complications Psychological Drugs Social Medical

13. Assessement • Collateral history. • Urine screening tests. • blood screening tests (alcohol, barbiturates). • Pattern of Abuse: • What? (type, dose, route, effect: nature and duration). • How? (frequency, duration, how long, source, and situation) • Why? (? psychosocial problems). • Dependence? • Complications : • Psychosocial….. • Physical…..

15. Alcohol and Related Mental Disorders

16. Alcohol Kills More Than AIDS, TB or Violence-WHO report (Feb 2011) • Alcohol causes nearly 4% of deaths worldwide, more than AIDS, tuberculosis or violence. • Alcohol is the world's leading risk factor for death among males aged 15-59 • Alcohol is a causal factor in 60 types of diseases and injuries. • Now we have strong evidence of a causal relationship between drinking and breast cancer.

17. Epidemiology • dependence is most common in those aged 40 – 55 years. • In USA : • 13 % men and 4 % women age 18 • 20-40% hospital admissions • Alcoholics who continue drinking have a shortened life-span of 15 years why?

18. Clinical presentation • Alcohol intoxication: early intoxication includes sense of well-being, emotional lability, irritability and incoordination  to ataxia and slurred speech • Heavy intoxication (bl > 300 mg/ml)  alcoholic coma & death

20. Alcohol Dependence • Current rate of alcohol dependence is 5%. • Common symptoms: need for daily use of larger amounts of alcohol for adequate functioning, and inability to cut down or stop the drinking.

22. Clinical presentation (cont) • Alcohol withdrawal:Sx may begin after 6 hours of cessation or reduction of alcohol and peak by 48 hours, they follow a drop in blood concentration, symptoms subside over the course of 6-7 days • epileptic tonic clonic seizures may develop within 12-24 hours after cessation of alcohol intake • Delirium tremens may develop after about 48 hours

23. DSM-5 criteria for Alcohol withdrawal : • - Cessation or reduction in heavy alcohol use. • - two or more of the following (several hours – few days): - autonomic hyperactivity - increased hand tremor - insomnia - nausea or vomiting - transient hallucinations or illusions - psychomotor agitation - anxiety - grand mal seizures - impairment in function • Not due to a general medical condition or mental disorder

25. Delirium Tremens (DTs): Severe form of alcohol withdrawal after 2-3 days: - gradual onset of delirium, fluctuating consciousness, disorientation, agitation, hallucinations, illusions and delusions. - gross tremors - autonomic disturbance - dehydration and electrolyte disturbance - marked insomnia

26. Peaks on 3rd or 4th day and lasts 3-5 days, worsens at night and followed by a period of prolonged deep sleep from which the person awakes with no symptoms and has amnesia for the period of the delirium. • Complications include: • Seizures • Chest infection & aspiration • Violent behavior • Coma • Death (mortality rate: 5-15%) Causes: • Volume depletion • Cardiac arrhythmias • Electrolyte imbalance • Infections DT is a serious MEDICAL emergency  detection and treatment

27. Alcohol-Induced Persisting Amnestic disorder • Wernicke-Korsakoff syndrome • Prolonged heavy use of alcohol • Wernicke’s encephalopathy is an acute reversible syndrome characterized by ataxia, vestibular dysfunction, confusion and ocular motility abnormalities, it may resolve spontaneously in a few days or progress to: • Korsakoff’s syndrome: a chronic amnestic syndrome that can follow Wernicke’s encephalopathy, characterized by impaired mental syndrome (esp. recent memory)and anterograde amnesia in an alert and responsive pt. • Only 20% of Korsakoff’s syndrome fully recover • Treated by thiamine 100mg two – three times daily for 1 to 2 weeks (if the case develops to Korsakoff’s syndrome treatment should be continued for 3 to 12 months)

28. Complications of chronic alcohol abuse

30. How much is too much?

31. Alcohol intoxication Ethanol plasma concentrations Vs. CNS effects

33. Alcohol withdrawal • 70 % of AD patients & Rate in the elderly. • No gender/ethnic differences • 85% mild-to-moderate • 15% severe and complicated: • Seizures • Delirium Tremens • Features : • Tremulousness (hands, legs and trunk). • Nausea, retching and vomiting. • Sweating, tachycardia and fever. • Anxiety, insomnia and irritability. • Cognitive dysfunctions. • Thinking and perceptual disturbances.

34. Course of AW Stages • I (24 – 48 hours): • II (48 – 72 hours): • III (72 – 105 hours): • IV (> 7 days): Symptoms • Peak severity at 36 hours 90% of AW seizures Most cases self-limited •  Stage I symptoms • “Delirium Tremens” • Protracted withdrawal

35. Risk factors of Alcohol abuse • Vulnerable personality: impulsive, gregarious, less conforming, isolated or avoidant persons. • Vulnerable occupation: senior businessmen, journalists, doctors. • Psychosocial stresses: social isolation, financial, occupational or academic difficulties, and marital conflicts. • Emotional problems: anxiety, chronic insomnia depression.

36. Is your patient ETOH dependent?CAGE questionnaire • C = Have you ever felt you must Cut down your drinking? • A= Have people Annoyed you by criticizing your drinking? • G = Have you ever felt Guilty about your drinking? • E = Have you ever had a drink first thing in the morning as an “Eye opener”?

37. Laboratory Tests • Identify acute and/or heavy drinking (> 5 drinks/day): • Blood Alcohol Levels (BAL). • Gamma-glutamyltransferase (GGTP > 35 IU/L) • Carbohydrate Deficient Transferrin (CDT > 20 IU/L) • Erythrocyte mean corpuscular volume (MCV >91.5 3) • High AST/ALT *** CDT + GGTP best diagnostic combination.

38. Treatment • Treating Alcohol Intoxicated Patient: Conscious : supportive, antipsychotic if agitated. Unconscious: ABC • Treating Alcohol Withdrawal: Supportive, thiamine & long acting BDZ ± anticonvulsants for seizure. • Maintaining Abstinence: • Medications: • Disulfiram – blockade of aldehydedehydrogenase cummulation of acetaldehyde - nausea, flushing, tachycardia, hyperventilation, panic… • Naloxone – reduces alcohol-induced reward. • Acamprosate – anti-craving effects . • Psychological: group Tx, AA, relapse prevention.

40. Sedatives, Hypnotics, and Anxiolytics • Similar clinical manifestations to alcohol. • withdrawal from short-acting substances (e.g. triazolam) can begin within 4 - 6 hours. • Alcohol and all drugs of this class are brain depressants any risk? - are cross-tolerant and cross-dependant. • withdrawal can be accomplished safely using diazepam, phenobarbital, and pentobarbital, dose reduced in steps (about 1/4 - 1/10 of daily benzodiazepine dose, every two weeks). • BDZ have a large margin of safety & less addiction potentials. • Flumazenil is a BDZ receptor antagonists used in BDZ overdose.

41. OPIOIDS

42. Introduction • Opioids have been used for at least 3500 years • Mostly in the form of crude opium • Morphine was the first to be isolated in 1806 and codeine in 1832 • Opium comes from the juice of the opium poppy (papaversomniferum) which contains about 20 opium alkaloids including morphine

43. This group includes several narcotic substances • Opium • Heroin • Morphine • Codeine • Pethidine • Methadone • Pentazocain • Some of these compounds are naturally occurring (e.g. opium, codeine) while others are synthetic or semi-synthetic • Some of these substances are for medical use like pethidine while others are solely substance of abuse like heroin • The medical use of opioids are mainly for there powerful analgesic effect - while they are abused for they are euphorianteffect

44. Clinical effects

45. Intoxication • Significant maladaptive behavior • Including : dysphoria, agitation, retardation, impaired judgment … • Papillary constriction or dilatation (in OD) • Or one or more of the following: drowsiness or coma, slurred speech, impairment in attention or memory. • Symptoms are not due to a medical condition.

46. Opioid withdrawal .. • The symptoms due to withdrawal from opiods are flulike including: • Lacrimation • Dysphoric mood • Insomnia • Muscle and joint pain • Cold and hot flushes • Nausea, vomiting and diarrhea • Intense craving for the drug is a recognized feature of the drug - it begins about 6 hours after the last dose and peaks after 36-48 hours - then wanes • Untreated withdrawal result in no serious medical sequence - but they cause great distress • Tolerance can develop very rapidly (esp. in IV use) leading to increasing dosage - then it diminishes very rapidly

47. TX. Opioids OD,, • Opioids overdose can be very dangerous (due to respiratory depression) therefore they should be treated carefully in the ICU - Naloxone is a short acting antidote that is used to normalize respiration and to restore consciousness - open airway, O2, IV fluids - vital signs monitoring. • Opioid withdrawal • - Assess the severity and give symptomatic treatment: pain killer and sedatives - Treatment of complications; counseling; individual and group therapy

48. PsychostimulantsandHallucinogens

49. Commonly used Stimulants • Nicotine • Caffeine • Cocaine – Freebase/crack • Amphetamine/Methamphetamine • Methylenedioxymethamphetamine (MDMA) • Appetite suppressants • (e.g. phentermine and diethylpropion)

50. Psychostimulants The most common psychostimulants (cocaine, MDMA and amphetamine) act on the synapse to increase the activity of dopamine, noradrenaline and serotonin. Cocaine blocks pre-synaptic reuptake