1. Substance Abuse Alison Freeland MD FRCPC Schizophrenia Program Royal Ottawa Hospital

2. Definitions Dependence: the repeated use of a drug Abuse: Use of any drug in a manner that deviates from approved social or medical patterns Addiction: the repeated and increased use of a substance, the deprivation of which gives rise to symptoms of distress and an irresistible urge to use again

3. Definitions Intoxication: a reversible syndrome caused by a specific substance that effects 1 or more of the following – memory, orientation, mood, judgment, and level of functioning Withdrawal: a substance specific syndrome that occurs after stopping or reducing the amount of the substance used

4. Definitions Tolerance: phenomenon in which, after repeated administration, a given dose of a substance produces a decreased effect Cross tolerance: ability of one drug to be substituted for another each usually producing the same physiologic and psychologic effects

5. Drugs that can be tested in the urine Alcohol: 7-10 hours Benzodiazepine : 3 days Cocaine : 6-8 hrs (metabolites 2-3 days) Marijuana: 3 days to 4 weeks ( depending on use) Codeine: 48 hours Heroin: 36-72 hours

6. Alcohol 90% absorbed through the stomach Peak blood concentrations in 30-90 mins Rapid consumption and consumption on an empty stomach enhance absorption and decrease time to peak blood levels Intoxication more pronounced as blood levels are rising 90% metabolized by hepatic oxidation

7. Alcohol Body metabolizes approx one moderately sized drink per hour (ie one 12 oz beer, 4 oz wine, 1 oz liquor)

8. Alcohol: epidemiology 10% women and 20% men meet criteria for alcohol abuse 5% women and 10% men have met criteria for alcohol dependence 60% alcohol abusers are men Caucasians have highest rates of alcohol abuse ( 60%)

9. Alcohol: Etiology Genetic: close family members of alcoholics have 4x increased risk Cultural: Asians show increased acute toxic effects, Native Americans and Inuit have higher rates

10. Alcohol: comorbidity Anxiety Depression Insomnia Schizophrenia Other substance disorders

11. Alcohol related disorders Dependence Abuse Intoxication (delirium) Withdrawal (delirium) Persisting dementia Persisting amnestic disorder Psychotic disorder Depression Anxiety Sexual dysfunction Sleep disorder

12. Subtypes of Alcohol Dependence A: late onset, mild dependence, few alcohol related problems, little psychopathology B: severe dependence, early onset, strong family history, life stressors, severe psychopathology

13. Alcohol Withdrawal Begins within several hours of alcohol cessation 2 of the following: autonomic hyperactivity, tremor, insomnia, nausea/vomiting, transient illusions/hallucinations, anxiety, grand mal seizures, agitation Rx: benzodiazepines

14. Alcohol Withdrawal delirium 1-3% of alcohol dependent patients Symptoms: delirium, marked autonomic hyperactivity (tachycardia, sweating, agitation, anxiety), vivid hallucinations, agitation tremor, fever, seizures Tx: monitor vitals, decrease stimulation, hydrate, benzodiazepines, thiamine, Folic acid, multivite, mag sulphate as needed for seizures

15. Alcohol induced amnestic disorder Wernickes encephalopathy: acute syndrome caused by thiamine deficiency (nystagmus, ataxia, confusion). Treat with thiamine –symptoms may resolve Korsakoffs syndrome: chronic condition result of thiamine deficiency, amnesia, confabulation, disorientation, polyneuritis, Rx with thiamine, 25% patients fully recover

16. Alcohol induced psychotic disorder Vivid persistent hallucinations following a decrease in alcohol consumption in an alcohol dependent person May persist and progress into a more chronic psychotic presentation Condition usually requires at least 10 years of alcohol dependence Tx: benzodiazepines +/- antipsychotic med

17. Opioids Natural derivatives of opium: codeine, morphine Synthetic opioids: methadone, oxycodone, dilaudid, talwin, demerol Semisynthetic opioids: heroin

18. Opioids Heroin most commonly associated with abuse 600,000 heroin users in the US Lifetime rate of heroin abuse is 2% Male to female ratio is 3 :1 Most users in their 30s and 40s Dependance on other opioids most commonly seen in patients who are prescribed as part of medical treatment

19. Opiate Overdose Can be a medical emergency Often accidental Often results from combined use with other CNS depressants ( alcohol, benzodiazepines) Clinical signs: pinpoint pupils, respiratory and CNS depression Rx: naloxone ( antagonist)

20. Opiate Withdrawal Seldom a medical emergency Symptoms include flu like sx, craving, lacrimation, rhinorrhea, yawning, sweating, insomnia, abdominal cramps, dilated pupils, piloerection, N/V/D Treatment: methadone, clonidine, supportive

21. Cocaine Epidemiology 10% of US population has tried it Lifetime rate for use/dependence is 2% Most commonly used in 18 to 25 year old range Male to female ratio of 2:1 Delusions and hallucinations may occur in 50% of those who use

22. Cocaine Intoxication: restlessness, agitation, anxiety, pressured speech, paranoid ideation, aggressivity, increased sexual interest, tachycardia, hypertension, pupillary dilation, chills, anorexia, insomnia, stereotypic movements Treatment:supportive, benzos, antipsychotics

23. Cocaine Withdrawal Most prominent sign is craving Symptoms include fatigue, lethargy, guilt, anxiety and feelings of helplessness Withdrawal symptoms usually peak in several days but can last for weeks Treatment: supportive, SSRIs

24. Sedative hypnotics Benzodiazepines Barbiturates Methaqualone Meprobamate About 6% of general population have used these illicitly Female: male 3:1

25. Sedative and Hypnotic Intoxication Slurred speech Uncoordination Unsteady gait Impaired attention Respiratory depression, particularly if used with other sedative agents (ie alcohol)

26. Sedative and Hypnotic Withdrawal Nausea, vomiting Malaise, weakness Autonomic hyperactivity Anxiety, irritability Increased sensitivity to light and sound Tremor Insomnia seizures

27. Hallucinogens Natural and synthetic substances Produce hallucinations, loss of contact with reality, experience of heightened consciousness Egs: psilocybin (mushrooms), mescaline (peyote), MDMA, LSD

28. Hallucinogens Act as sympathomimetics Cause hypertension, tachycardia, hyperthermia and dilated pupils Tolerance develops rapidly and remits within several days of abstinence Physical dependence and withdrawal do not occur Often contaminated with anticholinergic drugs

29. Hallucinogen Intoxication Maladaptive behavioral changes (anxiety, paranoia) Changes in perception (hallucinations) Sympathomimetic changes Panic reactions (bad trips) Duration variable (shrooms 4-6 hrs, LSD 6-12 hrs)

30. Phencyclidine (PCP) “angel dust” A dissociative anaesthetic and hallucinogen Commonly causes paranoia and violence May remain detectable in urine up to a week Associated with 3% substance abuse deaths

31. PCP Effects are dose dependent At low doses acts as a CNS depressant, with nystagmus, blurry vision, incoordination At moderate doses hypertension, dysarthria, ataxia, muscle rigidity At high doses agitation, fever, rhabdomyolysis, renal failure

32. Inhalants Volatile hydrocarbons inhaled for psychotropic effect eg gasoline, kerosene, laquers, paint thinner, fingernail polish remover Typically abused by adolescent males of low SEC groups

33. Inhalants: Intoxication Mild euphoria, belligerence, assaultiveness, impaired judgment Ataxia, confusion, slurred speech, decreased reflexes, nystagmus Can go on to delirium and seizures Longer term risk of brain injury, liver damage, bone marrow depression, peripheral neuropathies, immunosuppression

34. Cannabis 5% lifetime use Highest among 18-21 y.o. Highest use among caucasians compared to other ethnic groups Euphoric effects appear within minutes, peak at 30 mins and last 2-4 hours Motor and cognitive effects can last 5 to 12 hours

35. Cannabis Intoxication: euphoria, anxiety, suspiciousness, time distortion, conjuctival injection, increased appetite, dry mouth, tachycardia Can cause depersonalization and hallucinations High doses can cause cannabis psychosis lasting up to 6 weeks

36. Amphetamines Release catecholamines, primarily dopamine Effects are euphoric and anorectic Usually taken orally, but can be smoked, inhaled and injected Clinical syndromes similar to cocaine

37. Amphetamines 7% of population Highest use in 18 to 25 year old range Men = women Examples: dexedrine, speed, methylphenidate, khat, methcathinone crystal meth Can induce a paranoid psychosis Intoxication resolves in 24 - 48 hours

38. MDMA 3,4 methylenedioxyamphetamine “ecstasy” “E” Increased self confidence, sensory sensitivity, sense of personal closeness with others Activating, energizing, some hallucinogenic potential, Associated with hyperthermia

39. “poppers” Amyl nitrate Used during sex to intensify orgasm through vasodilation Can produce light headedness, euphoria and giddiness Should not be used with viagra as combo can cause cardiovascular collapse and death