Substance Abuse & Dependence

Substance Abuse l A residual category (i.e., a diagnosis of last resort) for patients whose substance use produces problems but does not fulfill the more rigorous criteria for Substance Dependence. l Not applicable for caffeine and nicotine

Substance Dependence l The user has taken a substance frequently enough to produce clinically important distress or impaired functioning, as well as certain behavioral characteristics. Use is maladaptive and patterned. Found in connection with all classes of drugs but caffeine. l Substance dependence does not have to be intentional; can develop from medicinal use.

Substance Intoxication l An acute clinical condition resulting from recent overuse of a substance. Anyone can become intoxicated; this is the only substance-related diagnosis that can apply to a person who uses a substance only once. l All drugs but nicotine have a specific syndrome of intoxication.

Substance Withdrawal l A collection of symptoms (specific for the class of substance) that develops when a person who has frequently used a substance discontinues or markedly reduces the amount used. l All substances except caffeine, cannabis, PCP, the hallucinogens, and the inhalants have an officially recognized withdrawal syndrome.

Craving* l Somoza (1995) rated preference –Cocaine/Alcohol (1.81) –Opiates/Cocaine (1.32) –Cocaine/Marijuana (18.4) l Craving Scale –Marijuana (1.0) –Alcohol (10.0) –Cocaine (18.4) –Opiates (24.3)

Craving vs. Withdrawal l Craving appears to be distinct from “psychological symptoms” (Mezinskis, 1995) l Cue extinction procedures and behavioral procedures should be used for craving. l Pharmacological agents can directly attenuate craving (Ex. Naltrexone-ReVia)

C A G E l Cut down l Annoyed l Guilty l Eye-opener

Sedative, Hypnotic, or Anxiolytic Intoxication l Slurring of speech l Poor coordination l Unsteady walking l Nystagmus l Impaired attention or memory l Poor judgment l Mood lability l Stupor or coma

Sedative, Hypnotic, or Anxiolytic Withdrawal l Autonomic overactivity (sweating, rapid heartbeat) l Worsened tremor of hands l Sleeplessness l Nausea or vomiting l Short-lived hallucinations or illusions (visual, tactile, or auditory) l Speeded-up psychomotor activity l Inappropriate aggressive or sexual behavior l Anxiety l Grand mal seizures

Criteria for Phencyclidine Intoxication l Recent use, leading to maladaptive behavior including assault, belligerence, impulsivity, agitation, unpredictability, and impaired judgment. l Two of the following sxs. develop within an hour of use –Nystagmus –Rapid heartbeat or high blood pressure –Numbness or decreased response to pain –Trouble walking –Trouble speaking –Rigid muscles –Abnormally acute hearing –Coma or seizures

Opiod Intoxication l Shortly after using an opiod, one may feel depression, anxiety, feeling speeded up or slowed down psychomotor activity as well as impaired role function l During or shortly after the use, the patient develops constricted pupils and one of the following: –Sleepiness or coma –Slurred speech –Impaired memory or attention

Opioid Withdrawal l Recent reduced use and have been given an opioid antagonist l Within minutes or days of using the antagonist, 3 or more of the following symptoms develop: –Dysphoria –Nausea or vomiting –Aching muscles –Tearing or runny nose –Dilated pupils, piloerection, or sweating –Diarrhea –yawning –Fever –Sleepiness

Cannabis Intoxication l After use of cannabis, pt. develops clinically important behavioral and psychological changes that are maladaptive. l Includes motor performance deficits, anxiety, euphoria, impaired judgment, social withdrawal and the sensation that time has slowed down. l Within 2 hours, two or more symptoms occur: –Red eyes; Increased appetite; Dry mouth; and Rapid heart Rate

Cocaine Intoxication l Blunted affect, hypervigilance, interpersonal sensitivity, anger, anxiety, changes in sociability, impaired judgment and role functioning l Two or more of the following: –Slowed or rapid HR –Dilated pupils –Raised or lowered BP –Chills or sweating –Nausea or vomiting –Weight loss –Speeded up or slowed down psychomotor activity –Muscle weakness, shallow or slowed breathing, chest pain, or heart arrhythmias –Coma, confusion, dyskinesias, dystonia or seizures

Cocaine Withdrawal l Within a few hours to days of reduced intake, the pt. develops dysphoric mood and 2 or more of the following: –Fatigue –Unpleasant, vivid dreams –Excessive sleepiness or sleeplessness –Increase in appetite –Speeded up or slowed down psychomotor activity

Other Substance-related D/O’s l Anabolic steroids- driven by powerful urge for attractiveness and athletic ability. Effects- improved physique, euphoria, increased libido, and occasional aggression. Withdrawal symptoms include depression, fatigue, restlessness, insomnia, loss of appetite and libido. l Nitrous Oxide- An anesthetic inhalant that produces lightheadedness and mild euphoria. Therefore, AKA-laughing gas l People in many cultures chew betal nuts to achieve a mild high or sensation of floating. l Kava- South Pacific pepper plant. Causes sedation and loss of coordination and weight.

What AA Can Provide that Psychiatrists Cannot l Sober social meeting places with sober alcoholics/addicts l 24 hour a day STAT availability of individual supportive counsel by the patient’s 12 Step sponsor or the AA group at no cost to the patient (e.g. Friends of Bill) l Spirituality-based recovery program l 90 meetings in 90 days

What MH Can Provide that AA Cannot l Safe medical detoxification l Differential diagnosis to rule out mental or physical disorders l Drugs prescribed as needed or helpful (no antidepressants in the first month) l Psychiatric evaluation and treatment of family members l Written, required documentation of the patient’s progress to employers, DMV, Federal Aviation Administration, etc.