1. Substance Related Disorders Dr. Anurag Mishra M.D. Coordinator- Psychoanalytical Wing Max Hospitals- Delhi

2. Substance vs Drug Drug- Manufactured chemical Many substances associated with abuse patterns : 1.Occur Naturally- opium, cannabis 2.Not meant for human consumption- petrol, solvents Illegal - cocaine Legal but obtained by illegal means or for non prescribed purposes- morphine

3. Addiction Describes the degree to which drug use pervades an individual’s life Possible to be dependent without being addicted- individual’s life is not organized around finding & using drug e.g. those who become addicted to drugs used in prolonged medical treatment Possible to be addicted without being physically dependent 1964- WHO substituted Dependence

4. Substance Use Disorders Substance Dependence Substance Abuse “Codependence”

5. Substance Dependence Impairment or distress because of 3 or more of the following at any time in a year: 1.Tolerance: increased amount of substance to produce same effect / decreased effect with same amount 2.Withdrawal: typical withdrawal syndrome/ substance or related compound used to relieve or avoid withdrawal 3.Use of substance in greater amounts or for a longer time than originally intended 4.Unsuccessful attempts or wishes to cut down 5.Significant time spent in obtaining, using, recovering 6.Giving up social, occupy, recreational activities 7.Continued use despite knowledge of physical/ mental problems

6. Substance Dependence Physiological Dependence: presence of withdrawal or tolerance Psychological Dependence (Habituation) : continuous intermittent craving for substance to avoid dysphonic state (difficulty in speaking) dysphoria = anxiety

7. Substance Abuse Pt. not meeting criteria for Dependence with any one of following in a year: 1.Failure to fulfill major role obligations 2.Recurrent use of substance in hazardous situations 3.Recurrent legal problems resulting from substance use 4.Continued use of substance despite social or interpersonal problems caused by substance

8. Codependence Behavioral patterns of family members who have been significantly affected by another family member’s substance use or addiction Enabling Unwillingness to accept addiction as disease, voluntary behavior, responsibility shifted to family Denial

9. Substance Induced Disorders 1.Intoxication: Reversible substance specific syndrome 2.Substance withdrawal 3.Substance induced delirium 4.Substance withdrawal delirium 5.Substance induced persisting dementia 6.Substance induced persisting Amnestic disorder 7.Substance induced psychotic disorder 8.Substance induced mood disorder 9.Substance induced anxiety disorder 10.Substance induced sexual dysfunction 11.Substance induced sleep disorder

12. Alcohol Intoxication Mild Overconfidence Mood swings, emotional outbursts, euphoria Nausea, vomiting Restlessness Severe Stupor or coma Hypothermia Slow respiration Tachycardia Increased I C T Dilated pupils Death Diagnosis Slurred speech Loss of coordination Unsteady gait Nystagmus Impaired attention/ memory Stupor/ coma T/t (treatment) 1.Conscious pt.- wait! Agitation- BZD, anti psychotic 2.Unconscious pt.- keep warm Prevent aspiration Increased ICT- mannitol Hemodialysis in extremes

13. Sedative, Hypnotic, Anxiolytic Intoxication BZD, Barbiturates Mild Euphoria Sedation Paradoxical excitement Nystagmus, dysarthria, impaired attention & memory Postural hypotension Severe (suicide attempts, overdose) Coma Respiratory depression Low BP Low cardiac output Low temp. Coma Death T/t 1.Protect airway 2.Oxygen 3.Ventilation 4.Prevent further body heat loss 5.I.v. fluids and BP maintenance with Dopamine 6.Forced diuresis 7.Hemodialysis

14. Stimulant Intoxication Amphetamines, methamphetamine, cocaine Mild Elevated mood Increased energy & alertness Decreased apppetite Talkativeness Anxiety & irritability Insomnia Increased/ decreased heart rate & BP Nausea/ vomiting Loss of appetite & weight Severe Psychotic symptoms- visual, auditory & tactile hallucinations, delusions, mania Fighting Dilated pupils Increased BP & pulse Arrhythmias Seizures Exhaustion Coma & I C Hemorrhage T/t: hypertension & hyperthermia Psychosis- antipsychotics

15. Hallucinogen Intoxication LSD, PCP, Mescaline Most hallucinogens Dilated pupils Increased pulse & BP Increased temp Delusions & hallucinations Anxiety Distortion of time sense Inappropriate affect PCP Intoxication Violence & hyperactivity Increased hearing Mutism Echolalia Muscular rigidity Seizures, coma, IC hemorrhage T/t: Quiet setting Antipsychotic/ BZD

16. Hallucinogen Intoxication

17. Cannabis Intoxication Marijuana, hash, ganja, bhang Euphoria Anxiety Increased appetite Increased suggestibility Distortion of time & space Red conjunctiva No change in pupils Dry mouth Tachycardia T/t: Quiet setting, BZD

18. Opioid Intoxication Opium Morphine Heroin Crack Brown sugar Codeine Pethidine Fortwin (pentazocin)

19. Opioid Intoxication Mild- Moderate Analgesia without loss of consciousness Drowsiness Nausea & vomiting Apathy & lethargy Euphoria Itching Constricted pupils Constipation Flushed & warm skin Impaired attention & memory Illusions Severe Miosis Respiratory depression Hypotension or shock Pulmonary edema Seizures & Coma T/t Supportive care Naloxone- narcotic antagonist, reverses coma & apnea but also produces severe withdrawal

20. Inhalant Intoxication Erasex, petrol, glue, paint thinner, solvents Dizziness, confusion Euphoria Confusion, nystagmus, ataxia, dysarthria Tremors Muscle weakness Blurred vision Delirium Chronic use- Dementia T/t: prevent access to drug

21. Anticholinergic Drug Intoxication Cough syrups, imipramine, pacitane Confusion Memory loss Delirium Hallucinations Amnesia Drowsiness Tachycardia Decreased peristalsis Fever Warm dry skin Fixed dilated pupils Coma T/t Protect pt & wait for drug to be metabolized Physostigmine

22. Alcohol Withdrawal “The Shakes” Tachycardia Tremors Sweating Nausea Hypotension Weakness Anxiety, irritability T/t: Thiamine, BZD

23. Alcohol Withdrawal Motor Seizures (Rum fits) Seizure in<48 hrs after stopping T/t: I.v. BZD Alcohol withdrawal delirium Delirium Autonomic hyperactivity Agitation, hallucinations, tremors T/t: Hydration Thiamine, BZD, antipsychotic Psychosis Hallucinations in clear sensorium - threatening or derogatory T/t: Anti psychotics Wernicke-Korsakoff Syndrome Wernicke’s Encephalopathy/ Alcoholic encephalopathy- ataxia, giddiness, eye signs Korsakoff’s Syndrome/ Chronic Amnestic Syndrome: Impaired memory T/t: thiamine

24. Sedative, Hypnotic, Anxiolytic Withdrawal Anxiety, agitation Low BP Weakness & tremors Fever Sweating Delirium Seizures Cardiovascular collapse T/t Withdrawal can be life threatening Hospitalization BZD substitution Other drugs

25. Stimulant Withdrawal ( Crash ) Increased sleep Nightmares Fatigue Lassitude Increased appetite Depression ( cocaine blues) Suicide attempts Intense drug craving Hospitalization if suicidal Antidepressants

26. Hallucinogen Withdrawal Dr. Albert Hoffman discovered/ invented LSD! Flashbacks: 15- 80% Spontaneous transitory occurrences of substance induced experience: visual distortion, hallucinations, trails of images, micro/ macropsia, time expansion, relived intense experience T/t : Reassurance, BZD

27. Opioid Withdrawal Watering from nose and eyes Sweating Restlessness & sleepiness Gooseflesh Dilated pupils Irritability Yawning Insomnia Craving Substitution with medicinal opioid and gradual withdrawal Clonidine to control BP and other autonomic symptoms BZD Non opioid pain killers Symptomatic t/t

28. Anti Cholinergic Withdrawal Influenza like syndrome Depression Seizures Mania T/t :Atropine Reintroduction and gradual discontinuation of drug

29. Nicotine Withdrawal Malaise Irritability Anxiety Craving for tobacco T/t: Nicotine patches Nicotine gum SSRI

31. Treatment Five Stages 1.Pre contemplation 2.Contemplation 3.Preparation 4.Action 5.Maintenance Treatment approach tailored to pt.’s stage of readiness Pharmacological agents: Alcohol: disulfiram, naltrexone, acamprosate, gabapin Opioid: Naltrexone Nicotine: Nicotine gum, patches

32. Treatment 1.Detoxification 2.Insistence on abstinence 3.Avoidance of other substance associated with dependence or abuse 4.Involvement of family 5.Toxicology screens 6.Self help groups 7.Treat complications 8.Psychotherapy 9.Treat co morbidities 10.Treat complications