Chapter 10 Substance Abuse Tolerance: increasing dose day by day to have the needed effect of substance. Withdrawal symptoms: If addict stops taking substance (usually within few hrs.) temporarily, very painful withdrawal sx will appear (psycho-somatic). -Nicotine withdrawal sx is mostly psychological sx as anxiety & irritability. 1

1) Cannabis الحشيش -Marijuana ( البانجو ) is one type of it. -Happy sx of taking Cannabis start after few min. if taken by smoking, & after 1/2 hr. if taken by mouth. -Its effect (if taken by mouth) continues 5-12 hrs. -If big amount taken by mouth, respiratory center may stop & death will result during sleeping. -Wrongly cannabis is known as sex stimulus (longer sexual activity) which is not proved scientifically. 2

Sx of cannabis Abuse: -Feeling of well-being. -Talkative with feeling of euphoria when talking. -Light head. -Hyperactivity. -Difficulty in orientation (esp. time). -If abuser moves up few steps in stair, will imagine that he is over biggest pyramid. -By increasing dose, hallucination will result. 3

Long-term using effect: -Respiratory diseases especially Bronchitis. -Cancer of lung. -Cardio-vascular diseases. N.B: Appetite to sweets will increase -Has negative effect on behavior & ethical manner as laughing in sad situation. 4

2) Opiates ( الأفيون ) -Morphine, Heroin, Codeine, Pethedin, Crack. -Used in medical field as pain killer, cough relief. -If taken for few months, withdrawal sx will appear. -Each time amount should increase. -Withdrawal sx will appear after 3 hrs. of taking previous dose & reach its peak in 1-2 days. -Usually it is white. -Used by IV, smoking or sniffing. -Heroin leads to much happiness for abuser. -Abuser health: chronic constipation, poor r/s. 5

Withdrawal sx: 1-Increase urge to get substance, anxiety. 2- Condition like flue (Rhinitis), much sweating, lacrimation. 3-Pain in joints & muscles. 4-Vomiting, diarrhea, abdominal pain, appetite. 5-Difficulty in breathing. 6

Cocaine: -Made from the leaves of Coca plant (S. America). -Stimulant drug. -White powder used by sniffing, or IV. -Addict may experience grandiosity which can lead addict to take risks, particularly when driving. -Feeling of anxiety will accompany cocaine use. -Effect of cocaine is very short. -Addict of cocaine may become criminal. -Withdrawal sx of cocaine less severity than opiates. 7

Complication of cocaine addiction: -Sleep disturbance. -Decrease appetite, decrease wt. -Skin itching. -Depression. -Criminal behavior. -Impotence. 8

Crack: -Crack is the street name for crystallized freebase cocaine. -It is most commonly smoked; which takes less than 20 seconds for feelings of euphoria & pleasure to start. -The happy feelings fade just few minutes later & resulting low can be dramatically dismal. 9

Rx of addiction (dependence): Criteria (factors) help in Rx: 1-Short period b/w starting of taking substance & Rx. 2-Availability of intention of pt. to be treated. 3-Age of pt. 4-Level of education. 4-Type of substance. 5-Acceptance of pt. to follow up Rx at home. 10

Stages of Rx: 1-Detoxification: l-2wks (weaning) should be in specialized hospital. 2-Rehabilitation: Trial to solve problem with cooperation of family, Reinforcement of positive behavior. 3-Follow up: Very important stage, could be more important than Rx itself. -If pt. is relapsed condition worse. *In some countries they use methadone with small doses. It is not Rx of addiction, but it is substitution by another type with less withdrawal sx. 11

Alcoholism -Alcohol is CNS depressant Effect on the brain: Poor judgment Clumsy motor actions Slurred speech Depressed motor area of brain Emotional lability Confusion Stupor Coma Death (respiratory paralysis) 12

With chronic use: -Alcoholic dementia -Social relation inhibition -Marital problems -Occupational problems -Violence -Legal problems increased accidents. Medical problems: Liver cirrhosis, fatty infiltration, gastritis, gastric ulcers, vitamin deficiency (especially thiamin), peripheral neuropathy. 13

Epidemiology: -In many countries, alcohol is widely used & abused. -Some people take alcohol occasionally for social reasons or to relieve tension. -Prevalent in early years age group. -Onset is in early 20s. -Sx of alcoholism start to appear in 30’s. -Alcoholism can coexist with other psychiatric disorders like: Depression, bipolar, anxiety, & personality disorders. 14

Etiology: -Alcoholism is not single disorder, it can have many causes. -Some alcoholics start to drink in an attempt to treat psychiatric problems: anxiety, depression, mania, etc. or physical disorder: pain. -Some people develop alcoholism & become dependent. -The short-term sedative effect of drinking alcohol is replaced by long term dysphoric mood & withdrawal sx which push alcoholic to drink more. 15

1.Biological Theory: -Some studies found genetic factor behind alcoholism. -In one study it was found that 25% of fathers of alcoholic pts. were alcoholic. -Concordance of alcoholism in monozygotic twins is twice as dizygotic twins. 16

2. Psychoanalytic theory : -Individuals who abuse alcohol (or other substances) have undeveloped egos r/s, failure in completing tasks of separation-individuation. -Person retains highly dependent mature, with characteristics of poor impulse control, low frustration tolerance & low self-esteem. -Superego is weak, resulting in absence of guilt feelings for their behavior. 17

3. Learning theory: Release of anxiety becomes reinforcement for further drinking as it results in temporary reduction of fear & conflict. 18

Clinical Picture : Alcoholic intoxication -Maladaptive behavior: sexual & aggressive behavior, labile impaired judgment, impaired social or occupation functions. -Somatic sx: slurred speech, in-coordination, unsteady gait, nystagmus, flushed face. -Hematomas & contusions due to falls, hypothermia in cold weather. -Other sx like liver cirrhosis, peripheral neuropathy & cerebral ataxia. 19

Alcohol withdrawal: -Syndrome observed after cessation or reduction of alcohol intake after prolonged period of use. Sx: -Nausea & vomiting. -Malaise, headache, insomnia. -Autonomic hyperactivity. - Anxiety, irritability or depression. - Seizures, especially if past hx of epilepsy. - Hallucinations or illusions. 20

1) Delirium Tremens: -Occur in 5% of hospitalized alcoholics within 1 week after cessation or reduction of alcohol intake. -Withdrawal sx progress to state of delirium. Essential features: -Delirium: Clouding of consciousness, disorientation, visual or tactile hallucination. -Autonomic hyperactivity: Tachycardia, sweating, HTN. -Fluctuating level of psychomotor activity: Pt. is sometimes hyperexcitable & sometimes lethargic. Rx: -Benzodiazepines 25 to 50 mg, chlordiazepoxide (librium) 2-4 hrs., adequate nutrition & hydration. 21

2) Alcoholic hallucinosis: -In some pts. visual or auditory hallucinations occur within 48 hrs. after cessation of alcohol with no sx of delirium & continue after recovering from withdrawal sx. -Course is short, hallucinations disappear within several weeks or few months. Rx: -Like delirium, Benodiazepines, nutrition & adequate hydration. -If case is prolonged, anti-psychotics may be used. 22

3) Alcohol Amnestic Disorder Encephalopathy: A) Wernick’s Encephalopathy: -Acute reversible neurological syndrome that results from prolonged heavy drinking of alcohol. -Etiology is due to Thiamin deficiency malnutrition that accompanies as predisposing factor. 23

Essential factors are -Ataxia. -Opthalmoplegia: (cranial nerve paralysis). -Nystagmus. -Confusion. -Spontaneous recovery within few days or weeks. -It can progress to Alcohol Amnestic Disorder. RX: -High doses of parenteral Thiamin & response is rapid. -If Rx delayed, irreversible damage occurs & respond to Rx. 24

B)Alcohol Amnestic Disorder (Korsakoff’s Syndrome): -Chronic irreversible disorder resulting from heavy alcohol intake. -Irreversible impairment of memory occurs. Etiology: is also due to Thiamin deficiency. -Course is short & recovery occurs in only 20% of cases. 25

4) Alcoholic Dementia: -Dementia that persists for longer than 3 weeks after cessation of alcohol intake. -Usually occurs in heavy drinkers above 35 y/o who have been drinking for long period. Essential features: -Impairment of intellectual abilities. -Memory impairment. -Social & occupational impairment. -Condition is chronic & irreversible. -Rx is supportive. 26

Rx of Alcohol Dependence: I. Psychotherapy: -To explore the desire of alcoholic to be intoxicated (drinking is treated as a psychological defense). -Anxiety producing factors are discussed. -There should be supportive & active periods of depression are treated by psychotherapy & anti- depressants. Behavioral Therapy: -Teaching alcoholic other ways to relieve anxiety like relaxation training & assertiveness skills. -Positive reinforcement is used to reinforce abstinence. 27

II. Medications: Disulfuram: (Antabuse): used to produce undesirable side effects if alcohol is taken. -Given in dose of 25 only after last drink. -If pt. drinks alcohol while on disulfuram, he experiences nausea, palpitation, dizziness, hypotension, numbness in extremities. -These effect are toxic reactions due to accumulation of acetaldehyde in blood. Psychotropic medication: Anti-depressants or anxiolotics to treat depression, anxiety or irritability that may occur during abstinence. 28

III. Support Groups: -Some alcoholics who have been treated form support groups to help other alcoholics. -These are voluntary organizations that may help pt. during his Rx. Ex: Alcoholics Anonymous (AA). 29