1. Motivation & Substance Abuse Al Mustansiriya 5 th and 6 th Dec. 2015 Sami Adil

2. Motivation What energize and direct behavior Most are learned Arise from two sources: internal drives, and external incentive factors Hunger, thirst, sex, aggression

3. Reward System …. mesolimbic

4. Mesolimbic pathway disturbed in schizophrenia, mania, and depression Antipsychotic drugs therapeutic effect Deep brain stimulation in depression and Nas Addiction Placebo

5. Homeostasis It is the tendency to preserve of a constant internal state and it occurs in all organisms. Homeostasis motivates us sometimes without us understanding it. (e.g.Addison’s …. Develop preference to eat salty ) Addiction and homeostasis (Tolerance and withdrawal). Set point of hunger, thirt… hypothalamus Complex drives…. Hypothalamus, signals from other body parts, cultural factors (eating.. Anorexia nervosa)

9. Most abused substances can be classified as stimulants, sedatives, opioids, or hallucinogens, and related agents.

10. Substance abuse is a pattern of abnormal substance use that leads to impairment of occupational, physical, or social functioning. Substance dependence is substance abuse plus withdrawal symptoms, tolerance, or a pattern of repetitive use.

11. Withdrawal is the development of physical or psychological symptoms after the reduction or cessation of intake of a substance. Tolerance is the need for increased amounts of the substance to achieve the same positive psychological effect. Cross-tolerance is the development of tolerance to one substance as the result of using another substance.

12. Epidemiology differs from a country to another but usually it is more common among young adult males. Any substance abuse life time prevalence according to the IMHS is 0.9% (1.5% in males, and 0.25 in females) in Iraq. More common in young than older, urban than rural (1).

13. In study 2014 all over Iraq lifetime prevalence of drug use: Tobacco: (29.0%); Alcohol, (8.6%); Licit drug misuse (2.5%,) and Illicit drug use (0.4%) (2). This study also found that: Anabolic steroids are the most widely used licit drug in Iraq followed by bnz & benzhexol. In the North of Iraq, there are concerns of increasing misuse of tramadol. Cannabis is the most widely used illicit drug, but use of stimulants (Amphitamines and Captagon) in the South of Iraq is present. This finding is consistent with worldwide data, but in Iraq, this gender difference is either particularly great. Lifetime rates of licit and illicit drug use were higher among younger participants (18-34 years), those with less education (less than primary school) and those who were not working.

14. Stimulants Dopamine Psychosis with Cocaine -- bug

16. Cigarette smoking decreases life expectancy more than the use of any other substance.

19. Nicotine Caffeine Amphetamine Cocaine

20. SubstancesEffects of UseEffects of Withdrawal Psychological Caffeine & Nicotine Increased alertness and attention span Mild improvement in mood Agitation and insomnia Lethargy Mild depression of mood Physical Decreased appetite Increased blood pressure and heart rate (tachycardia) Increased GIT activity Increased appetite with slight weight gain Fatigue headache

21. Effects of useEffects of withdrawal Amphetamines & Cocaine Psychological Significant elevation of mood (lasting only 1 hour with cocaine) Increased alertness and attention span Aggressiveness, impaired judgment Psychotic symptoms (e.g., paranoid delusions with amphetamines and formication with cocaine) Agitation and insomnia Significant depression of mood Strong psychological craving (peaking a few days after the last dose) Irritability Physical Loss of appetite and weight Pupil dilatation Increased energy Tachycardia and other CVS effects which can be life- threatening Seizures (particularly with cocaine) Reddening (erythema) of the nose due to "snorting" cocaine Hypersexuality Hunger (particularly with amphetamines) Pupil constriction Fatigue

22. SEDATIVES GABA

25. أبو الحاجب، أبو الصليب، الدموي

26. BNZ Barbiturates Alcohol

27. SubstancesEffects of useEffects of withdrawal Alcohol, Benzodiazepines, & Barbiturates Psychological Mild elevation of mood Decreased anxiety Somnolence Behavioral disinhibition Mild dression of mood Increased anxiety Insomnia Psychotic symptoms (e.g. delusions and formication) Disorientation Physical Sedation Poor coordination Respiratory depression Tremor Seizures CVS symptoms, such as tachycardia and hypertension

28. Wernicke and Korsakoff Delirium Tremens

29. Opioids

34. سيمو، توسيرام

35. SubstancesEffects of useEffects of withdrawal Heroin, Methadone, and Other Opioids Psychological Elevation of mood Relaxation Somnolence Depression of mood Anxiety Insomnia Physical Sedation Analgesia Respiratory depression (overdose maybe fatal) Constipation Pupil constriction (miosis) Sweating, muscle aches, fever Rhinorrhea (running nose) Piloerection (goose bumps) Yawning Stomach cramps and diarrhea Pupil dilatation (mydriasis)

36. hallucinogens

38. LSD

39. SubstanceEffects of use Effects of withdrawal Cannabis, LSD, PCP, Psilocybin, Mescaline Psychological Altered perceptual state (auditory and visual hallucinations, alterations of body image, distortions of time and space) Elevation of mood Impairment of memory (maybe long-term) Reduced attention span "Bad Trips" (panic reactions that may include psychotic symptoms) "Flashbacks" (a re-experience of the sensations associated with use in the absence of the drug even months after the last dose) Few if any psychological withdrawal symptoms Physical Impairment of complex motor activity CVS symptoms Sweating Tremor Nystagmus (PCP) Few if any physical withdrawal symptoms

40. أبو الجمجمة، آرتان، باركيزول

41. CategoryImmediate treatment/detoxificationExtended treatment/maintenance Caffeine and nicotine Eliminate or taper from diet Analgesics to control headache due to withdrawal Substitute decaffeinated beverage Nicotine-containing gum, patch or nasal spray Antidepressants (particularly bupropion) Support Hypnosis to prevent smoking Amphetamine s and cocaine Benzodiazepines to decrease agitation Antipsychotics to tr. Psychosis Medical and psychological support Education for initiation and maintenance of abstinence Sedative (alcohol, BNZ, Barbiturates) Hospitalization Flumazenil to reverse affects of BNZ Use of long acting BNZ in decreasing doses (detoxification) Specifically for alcohol: thiamine, restoration of nutritional state. Education Specifically for alcohol: disulfiram, naloxone, naltrexone, acamprosate, psychotherapy, and Alcoholic Anonymous AA or other peer support groups Opioids Hospitalization and naloxone for overdose Clonidine to stabilize ANS during withdrawal Substitution of long-acting opioids (methadone) in decreasing doses to decrease withdrawal symptoms (detoxification) Methadone, LAAM or buprinorphine maintenance program Naloxone, naltrexone (or buprenorphine) used prophylactically to block the effects of abused opioids Narcotic Anonymous or other peer support groups HallucinogensCalming or "talking down" the patient BNZ to decrease agitation Antipsychotics to tr psychosis Education for initiation and maintenance of abstinence

42. THANK YOU