Chapter 21 Substance-Related Disorders

Epidemiology 1.47% of those with substance abuse have mental health problems 2.29% of those with a mental health disorder have a substance use disorder 3.47% of those with schizophrenia and 25% of those with an anxiety disorder have a substance use disorder Types of substance use disorders 1.Substance abuse: maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by ≥1 of the following occuring within a 12 month period # recurrent use resulting in failure to fulfill major role obligation P.T.O

# recurrent use in situations in which it is physically hazardous # recurrent substance related legal problems # continued use despite interference with social or interpersonal function 2. Substance dependance: maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by ≥3 occuring at any time in the same 12 months period. # tolerance (need for increased amount to achieve intoxication or diminished effect with same amount of substance) # withdrawal /use to avoid withdrawal # taken in larger amount or over longer period than intended P. T.O

# persistent desire or unsuccesssful efforts to cut down # excessive time to procure, use substance, or recover from its effects # important interests/ activities given up or reduced # continued use despite physical/ psychological problem caused/excerbated by substance Classification of substances DepressantsAlcohol, opioids, Barbiturates, Benzodiazepines, GHB stimulantsAmphetamines, methylphenidate, cocaine hallucinogensCannabis, LSD, PCP, ketamine, psilocybin

Alcohol History 1.Validated screening questionnaire C ever felt the need to cut down on drinking? A ever felt Annoyed at criticism of your drinking? G ever felt guilty about your drinking? E ever need a drink first thing in morning (eye opener)? # for men, a score of ≥2 is a positive screen; for women, a score of ≥1 is a positive screen # if positive CAGE, then assess further to distinguish between problem drinking and alcohol dependance.

Clinical assessment 1.When was your last drink? 2.Do you have to drink more to get the same effect? 3.Do you get shaky or nauseas when you stop drinking? 4.Have you ever had a withdrawal seizure? 5.How much time and effort do you put into obtaining alcohol? 6.Has your drinking affected your ability to work, go to school, or have relationships? 7.Have you suffered any legal consequences? 8.Has your drinking caused any medical problems? US department of health and human services recommended drinking guidelines Moderate drinking Men: 2 or less/d (≤14/weeks) Women: 1 or less/d (≤9/weeks) Elderly: 1 or less/d

Alcohol intoxication 1.Legal limit for impaired driving is 10.6 mmmol/L reached by 2-3 drinks/h for men and 1-2 drinks/h for women. 2.Coma can occur with >60 mmol/L (tolerant drinkers) Alcohol withdrawal 1.Occurs within 12 to 48 h after prolonged heavy drinking and can be life threatening 2.Alcohol withdrawal can be described as having 4 stages, however not all stages may be experienced # stage 1 (onset 6-12 hours after last drink): tremor, sweating, agitation, anorexia, cramps, doarrohea, sleep disturbance #stage 2 (onset 1-7 days): visual, auditory, olfactory or tactile hallucinations

# stage 3 (onset h and up to 7 days): seizures, usually tonic-clonic, nonfocal and brief #Stage 4 (onset 3-5 days): delirium tremors, confusion, delusions, hallucinations, agitation, tremors, autonomic hyperactivity (fever, tachycardia, hypertension) 3. course: in young almost completely reversible; elderly often left with cognitive deficits 4. Mortality rate 20% if untreated

Management of alcohol withdrawal 1.Monitor using the clinical institute withdrawal Assessment for Alcohol scoring system # areas of assessment include nausea and vomitting tactile disturbances tremor auditory disturbances agitation paroxysmal sweats visual disturbances anxiety headache, fullness in head orientation and clouding of sensorium

# all catagories are scored from 0-7, maximum score of 67 mild <10 moderate severe >20 Wernicke-korsakoff syndroms 1.Alcohol induced amnestic disorders due to thiamic deficiency 2.Necrotic lesions- manmillary bodies, thalamus, brainstem 3.Wernicks- encephalopathy (acute and reversible): triad of nystagmus ( CN VI palsy), ataxia and confusion 4.Korsakoffs syndrome (chronic and only 20% reversible with treatment): anterograde amnesia and confabulations; cannot occur during an acute delirium or dementia and must persist beyond usual duration of intoxication/withdrawal

5. Management Wernickes: thiamine 100 mg PO OD *1-2 weeks Korsakoffs: thiamine 100 mg PO bid/tid * 3-12 months Treatment of alcohol dependance Non-pharmacological 1.Behaviour modification: hypnosis, relaxation training, aversion therapy, assertiveness training, operant conditioning 2.Supportive services: half way houses, detoxifications centres, alcoholics anonymous 3.Psychotherapy 4.Individual readiness for change must always be considered with non pharmacological interventions

Pharmacological 1.naltrexone: opioid antagonist, shown to be successful in reducing the high associated with alcohol, moderately effective in reducing cravings, frequency or intensity of alcohol binges 2.Disulfiram (antabuse): blocks oxidation of alcohol; with alcohol consumption, acetaldehyde accumulates to cause a toxic reaction (vomiting, tachycardia, death); if patient relapses, must wait 48 h before restarting antabuse.

Opioids 1.Types of opioides: heroin, morphin, oxycodone, Tylenol #3 (codcine), hydromorphine 2. Major risks associated with the use of contaminated needles; increased risk of hepatitis B and C, bacterial endocarditis, HIV/AIDS Acute intoxication 1.Direct effect on receptors in CNS resulting in decreased pain perception, sedation, decreased sex drive, nausea/vomiting, decreased GI motility (constipation and anorexia) and respiratory depression. Toxic reaction 1.Typical syndrome includes shallow respiration, miosis, bradycardia, hypothermia, decreased level of consciousness

2. Treatment ABCs iv glucose naloxone hydrochloride: 0.4 mg up to 2 mg IV for diagnosis treatment: intubation and mechanical ventilation + naloxone drip, until patient alert without naloxone (up to 48+ h with long acting opioids) 3. Caution with longer half life; may need to observe for toxic reaction for at least 24 h Withdrawal 1.symptoms: depression, insomnia, drug craving, myalgias, nausea, chills, autonomic instability 2.Onset: 6-12 h, duration: 5-1o d P.T.O

3. complications: loss of tolerance, miscarriage, premature labour 4. management: long acting oral opioids (methadone, buprenorphine), alpha adrenergic agonists (clonidine) Treatment of chronic abuse 1.Psychosocial treatment (narcotics anonymous); usually emphasize total abstinence 2.Long term treatment may include withdrawal maintenance treatment # methadone relieves drug cravings and withdrawal symptoms without inducing sedation or euphoria 3. Naltrexone or naloxone (opioid antagonist) may also be used to extinguished drug seeking behaviour.

Amphetamines 1.Intoxication characterized by euphoria, improved concentration, sympathetic and behavioural hyperactivity and at high doses can cause coma. 2.Chronic use can produce a paranoid psychosis diagnostically similar to schizophrenia with agitation, paranoia, delusions and hallucinations 3.Withdrawal symptoms include dysphoria, fatigue and restlessness 4.Treatment of stimulant psychosis: antipsychotics.

Cannabis 1.Marijuana is the most often used illicit drug 2.Psychoactive substance: delta-9 tetrahydrocannabinol 3.Intoxications characterized by tachycardia, conjunctival vascular engorgement, dry mouth, altered sensorium, increased appetite, increased sense of well being, euphoria/laughter, muscle relaxation, impaired performance on psychomotor tasks including driving 4.High doses can cause depersonalization, paranoia, anxiety, and many trigger psychosis and schizophrenia if predisposed 5.Chronic use associated with tolerance and an apathic, amotivational state 6.Cessation does not produce significant withdrawal phenomenon. P.T.O

7. Treatment of dependence: behavioural and psychological interventions to maintain an abstinent state photo

Hallucinogens 1.Type of hallucinogens: LSD, mescaline, psilocybin, PCP, cannabis, ecstasy, salvia. 2.LSD is a highly potent drug; intoxication characterized by tachycardia, HTN, mydriasis, tremor, hyperpyrexia, and a variety of perceptual and mood changes 3.High doses can cause depersonalization, paranoia, and anxiety. 4.No specific withdrawal syndrome characterized 5.Treatment of agitation and psychosis: support, reassurance, diminished stimulation; benzodiazepines or high potency antipsychotics seldom required.

Club Drugs 1.MDMA Mechanism Acts on serotonergic and dopaminergic pathways, properties of a hallucinogen and stimulant Effect Enhanced sensation, feelings of well-being, empathy Adverse effects Sweating, tachycardia, fatigue, muscle spasms,ataxia, hyperthermia, arrythmias, DIC, renal failure, seizure, death 2. Gamma hydroxybutyrate Mechanism Biphasic dopamine response and release opiate like substance P.T.O

Effects Euphoric effects, increased agression, impaired judgement Adverse effects Sweating, tachycardia, fatigue, muscle spasm, ataxia, severe withdrawal from abrupt cessation of high doses; tremor, seizure, psychosis 3. Flunitrazepam Mechanism Potent benzodiazepine, rapid oral absorption Effects Sedation, psychomotor impairment, amnestic effects, decreased sexual inhibition Adverse effects CNS depression with EtOH P.T.O

4.Ketamine Mechanism NMDA receptor antagonist, rapid acting general anesthetic used in paediatrics and by veterinarians Effects Dissociative state, profound amnesia/analgesia; hallucinations and sympathomimetic effects Adverse effects Psychological distress, accidents due to intensity of experience and lack of bodily control, in overdose decreased LDC, respiratory depression, catatonia. 5. Methamphetamine Mechanism Amphetamine stimulant, induces norepinephrine, dopamine and serotonin release P.T.O

Effects Rush begins in min, effects last 6-8 h, increased activity, decreased appetite, general sense of well being, tolerance occurs quickly, users often binge and crash Adverse effects Short term use: high agitation, rage, violent behaviour, occasionaly hyperthermia, and convulsions Long term use: addiction, anxiety, confusion, insomnia, paranoia, auditory and tactile hallucinations, delusions, mood disturbamce, suicidal and homicidal thoughts, stroke, may be contaminated with lead, and IV users may present with acute lead poisonong 6. Phencyclidine Mechanism Not understood, used by veterinarians to immobilize large animals

Effect Amnestic, euphoric, hallucinatory state Adverse effects Horizontal/vertical nystagmus,myoclonus, ataxia, autonomic instability, prolonged agitated psychosis,, high risk for suicide, violances towards others, high dose can cause coma. photo