2. Epidemiology 47% of those with substance abuse have mental health problems 29% of those with a mental health disorder have a substance use disorder 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: maladadaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by ≥1 of the following occurring within a 12 month period  recurrent use resulting in failure to fulfill major role obligation  recurrent use in situations in which it is physically hazardous (e.g. driving)

3.  recurrent substance-related legal problems  continued use despite interference with social or interpersonal function 2. substance dependence: maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by ≥3 occurring at any time in the same 12 month 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  persistent desire or unsuccessful efforts to cut down

4.  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/exacerbated by substance Classification of Substances DepressantsAlcohol, Opioids, Barbibaturates, Banzodiazepines, CHB StimulantsAmephetamines, Methylphenidate, Cciane HallucinogesCannabis, LSD, PCP, ketamine, psilocybin

5. Alcohol See Family Medicine, Alcohol, FM12 and Emergency Medicine, BR47 History validated screening questionnaire C ever felt the need to Cut down on drinking? A ever felt Annoyed at criticism of your drinking? G ever feel 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 dependence

6. General Assessment When was your last drink? Do you have to drink more to get the same effect? Do you get shaky or nauseous when you stop drinking? Have you ever had a withdrawal seizure? How much time and effort do you put into obtaining alcohol? Has your drinking affected your ability to work, go to school, or have relationships? Have you suffered any legal consequences? Has your drinking caused any medical problems?

7. Table 5. US Department of Health and Human Services Recommended Drinking Guidelines Moderate Drinking Men: 2 or less/d (≤14/wk)Women: 1or less/d (≤9/wk) Elderly: 1or less/d Alcohol Intoxication legal limit for impaired driving is 10.6 mmol/L (50mg/dL) reached by 2-3 drinks/h for men and 1-2 drinks/h for women coma can occur with > 60 mmol/L (non-tolerant drinkers) and 90-120 mmol/L (tolerant drinkers)

8. Alcohol Withdrawal occurs within 12 to 48 h after prolonged heavy drinking and can be life-threatening alcohol withdrawal can be described as having 4 stages, however not all stages may be experienced  stage 1 (onset 6-12h after last drink): tremor, sweating, agitating, anorexia, cramps, diarrhea, sleep disturbance  stage 2 (onset 1-7d): visual, auditory, olfactory or tactile hallucinations  stage 3 (onset 12-72h and up to 7d): seizures, usually tonic-clonic, nonfocal and brief  stage 4 (onset 3-5d): delirium tremens, confusion, delusions, hallucinations, agitation, tremors, autonomic hyperactivity (fever, tachycardia, hypertension) course: in young almost completely reversible; elderly often left with cognitive deficits mortality rate 20% if untreated

9. Management of Alcohol Withdrawal monitor using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A)  areas of assessment include  nausea and include  tactile disturbances  tremor  auditory disturbances  agitation  paroxysmal sweets  visual disturbances  anxiety  headache, fullness in head  orientation and clouding of sensorium

10.  all categories are scored from 0-7 (except: orientation/sensorium 0-4), maximum score of 67  mild<10  moderate 10-20  severe >20 Table 6. CIWA-A Scale Treatment Protocol for Alcohol Withdrawal Basic ProtocolDiazepam 20mg PO q1-2h pm until CIWA-A <10 points; tapering does not required Observe 1-2 after last does and re-assess on CIWA-A scale Thiamine 100mg IM then 100mg PO OD for 3d Supportive care (hydration and nutrition)

11. History of Withdrawal Seizures Diazepam 20mg PO q1h for minimum of three doses regardless of subsequent CIWA scores If age>65 or patient has severe liver disease, severe asthma or respiratory failure Use a short acting benzodiazepine Lorazepam PO/SL/IM 1-4 mg q1-2h If Hallucinations are present Haloperiodol 2-5mg IM/PO q1-4h-max 5 doses/d or atypical antipsychotics (olanzapines, risperidone) Diazepam 20mg x 3 doses as seizure prophylaxis (haloperidol lowers seizure threshold)

12. Admit to Hospital if Still in withdrawal after>80 mg of diazepam Delirium tremens, recurrent arrhythmias, or multiple seizures Medically ill or unsafe to discharge home Wernicke- Korasakoff Syndrome alcohol- induced amnestic disorders due to thiamine deficiency necrotic lesions- manunillary bodies, thalamus, brainstem Wernicke’s encephalopathy (acute and reversible): triad of nystagmus (CN VI palsy), ataxia and confusion Korasakoff’s 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

13. management  Wernicke’s: thiamine 100mg PO OD x 1-2 weeks  Korsakoff’s: thiamine 100mg PO bid/tid x 3-12 months Treatment of Alcohol Dependence Non-pharmacological behavior modification: hypnosis, relaxation training, aversion therapy,, assertiveness training, operant conditioning supportive services: half-way houses, detoxification centers, Alcoholics Anonymous psychotherapy, motivational interviewing  individual readiness for change must always be considered with non-pharmacological interventions (refer to Prochaska’s Stages of Change Model, Population Health and Epidemiology, PH6)

14. Pharmacological naltrexone: opioids antagonist, shown to be successful in reducing the “high” associated with alcohol, moderately effective in reducing cravings, frequency or intensity of alcohol binges disulfiram (Antabuse*): blocks oxidation of alcohol (blocks acetaldehyde dehydrogenase); with alcohol consumption, acetaldehyde accumulates to cause a toxic reaction (vomiting, tachycardia, death); if patient relapses, must wait 48h before restarting Antabuse* Opioids types of opioids: heroin, morphine, oxycodone, Tylenol#3* (codcine), hydromorphone major risks associated with the use of contaminated needles; increased risk of hepatitis B and C, bacterial endocarditis, HIV/AIDS

15. Acute Intoxication 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 typical syndrome includes shallow respirations, miosis, bradycardia, hypotermia, decreased level of consciousness treatment  ABCs  IV glucose  naloxone hydrochloride (Narcan*): 0.4mg upto 2mg IV for diagnosis

16.  treatment: intubation and mechanical ventilation, + naloxone drip, until patient alert without naloxone (up to 48+h with long-acting opioids ) caution with longer half-life; may need too observe for toxic reaction for at least 24h Withdrawal symptoms: depression, insomnia, drug-craving, myalgias, nausia, chills, autonomic instability (lacrimation, rhinorrhea, piloerection) onset: 6-12h, durations: 5-10d complications: loss of tolerance (overdose on relapse), miscarriage, premature labor management: long-acting oral opioids (methadone, buprenorphine), α-adrenergic agonists (clonidine)

17. Treatment of Chronic Abuse psychosocial treatment (e.g. Narcotics Anonymous); usually emphasize total abstinence long-term treatment may include withdrawal maintenance treatment naltrexone or naloxone (opioid antagonists) may also be used to extinguish drug-seeking behavior Amphetamines intoxication characterized by euphoria, improved concentration, sympathetic and behavioral hyperactivity and at high doses can cause coma chronic use can produce a paranoid psychosis diagnostically similar to schizopherenia with agitaton, paranoia, delusions and hallucinations withdrawal symptoms include dysphoria, fatigue, and restlessness treatment of stimulant psychosis: antipsychotics

18. Cannabis marijuana is the most often used illicit drug psychoactive substance: delta-9-tetrahydrocannabinal (A9- THC) intoxication 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 high doses can cause depersonalization, paranoia, anxiety and may trigger psychosis and schizophrenia if predisposed chronic use associated with tolerance and an apathetic, amotivational state cessation doesnot produce significant withdrawal phenomenon treatment of dependence: behavioral and psychological interventions to maintain an abstinent state

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

20. DrugMechanismEffectAdverse Effects MDMA (“Ecstasy”, “X”, “E”) Acts on serotonergic and dopaminergic pathways properties of a hallucinogen and stimulant Enhanced sensorium; feelings of well- being, empathy Sweating, tachycardia fatigue, muscle spasms (especially jaw clenching), ataxia, hyperthemia, arrhythmias, DIC, rhabdomyolysis, renal failure, seizures, death “Club Drugs” Table 7. The Mechanism and Effects of Common “Club Drugs”

21. Gamma Hydroxybutyrate (GHB, “G”, “Liquid Ecstasy”) Biphasmic dopamine response (inhibition then release) and releases opiate- like substance Euphoric effects, increased aggression, impaired judgment Sweating, tachycardia fatigue, muscle spasms (especially jaw clenching), ataxia, severe withdrawal from abrupt cessation of high doses: tremor, seizures, psychosis Flunitrazepam (Roehypnol, “Roofies”, “Rope”, “The Forget Pill”) Potent benzodiazepine, rapid oral absorption Sedation, psychomotor impairment, amnestic effects, decreased sexual inhibition CNS depression with EtOH

22. Ketamine (“Special K”, “Kit-Kat”) NMDA receptor antagonist, rapid-acting general anaesthetic used in pediatrics and by veterinarians “Dissociative” state, profound amnesia/ analgesia; hallucinations and sympathomimeti c effects Psychological distress, accidents due to intensity of experience and lack of bodily control, in overdose, decreased LDC, respiratory depression, caralonia

23. Methamphetami ne (“speed”, “meth”, “chalk”, “ice”, “crystal”) Amphetam ine stimulant, induces norepinep hrine, dopamine and serotonin release Rush begins in min, effects last 6-8h, increased activity, decreased appetite general sense of well- being, tolerance occurs quickly, users often binge and crash Short term use: high agitation, rage, violent behavior, occasionally hyperthermia and convulsions Long term use: addiction, anxiety, confusion, insomnia, paranoia, auditory and tactile hallucinations (esp. fonnication), delusions, ood disturbance, suicidal and homicidal thoughts, stroke, may be contaminated with lead, and IV users may present with acute lead poisoning

24. Phencyclidine (“PCP,” “angel dust”) Not understood, used by veterinarians to immobilize large animals Amnestic, euphoria, hallucinatory state Horizontal/vertical nystagmus, myoclonus, ataxia, autonomic instability (treat with diazepam IV), prolonged agitated psychosis (treat with haloperidol); high risk for suicide; violence towards others High dose can cause coma

25. The End