1. SUBSTANCE ABUSE BY DR. RABIE A. HAWARI Consultant Psychiatrist Clinical Assistant Professor

2. W.H.O.1969:- -A drug is any substance that, when taken, into the living organism, may modify one or more of its functions, -Drug Abuse is the persistent or sporadic excessive use of a drug inconsistent with, or unrelated to, acceptable medical practice, -Drug Dependence is a state – psychic and sometimes also physical – resulting from interaction between a living organism and a drug, characterized by behavioral and other responses that always include a compulsion to take the drug on a continuous or periodic basis in order to experience its psychic effect, and sometimes to avoid the discomfort of its absence. Tolerance may or may not be present, a person may be dependent on more than one drug.

3. Dependence :- = Psychological :- overwhelming repetitive need to seek whatever ease, pleasure or stimulus is provided by a drug, is common to all drugs of dependent, = Physical :- relates to the pharmacology of a drug, in the course of repeated administration of certain drug the body's metabolic processes adapt themselves to these drugs, if such a drug is suddenly withdrawn, the metabolic balance is upset and this lead to withdrawal symptoms. = Tolerance :- diminishing response to repeated dose of a drug.

4. Dependence continue :- = Withdrawal or Abstinence Symptoms :- symptoms occur after a sudden stoppage of a drug which are due to hyperactivity of those functions preciously depressed by the drug, e.g. 1- convulsions and/or delirium tremens following a rapid withdrawal of barbiturates or alcohol. 2- vomiting, diarrhea, lacrimation, sweating, sneezing, and restlessness following abrupt cessation of large morphine intake.

5. Elements of dependence :- 1- Withdrawal Symptoms :- e.g. fits 2- Withdrawal relief :- need to get a relief from WDS. 3- Tolerance :- diminished response to repeated dose. 4- Subjective change :- sense of compulsiveness. 5- Narrowing repertoire :- taking more. 6- Salience :- important thing. 7- Reinstatement :- back to drinking level fast.

6. Classes of drugs :- 1.Stimulants :- coffee, amphetamine, cocaine, 2.General Depressants :- alcohol, barbiturates, 3.Opiates :- pethidine, morphine, heroin, 4.Hallucinogenic :- muscolain, L.S.D. ( lysergic acid diethylamide ), 5.Others :- cannabis = sedative & stimulants. benzodiazepines = sedative & hypnotics. nicotine = stimulant & depressive. solvents = (glue, petrol, acetone) C.N.S. depressants.

7. Routes of Administration :- a.Smoked = hash, tobacco, heroin, b.Sniffed = cocaine, c.Chewed = tobacco, ghat, d.Orally = tablets, alcohol, e.Injected = i.v. or i.m. – heroin, barbiturates.

8. Epidemiology :- = age :- alcohol 40 – 54 drugs 20 – 39. = sex :- alcohol M : F - 2.5 : 1 drugs M : F - 4 : 1 = social class :- all social classes. = urban / rural :- increased in urban areas. = general hospital patients :- 20% male – 4% female  with alcohol problem.

9. Etiology :- Multifactorial a) Genetics :- no conclusive evidence. For alcohol = parents & siblings  2&1/2 times that of general population, = MZ : DZ  71% : 32%, = adoption  4 x control. b) Psychological theories :- * Behavioral :- 1. Modeling,

10. Etiology continue :- Psychological theories – behavioral ( continue ) 2. Primary direct reinforcement e.g. stimulus, sedation  reinforce abuse behavior. 3. Secondary reinforcement e.g. the environment. cues are linked with pharmacological effect of drugs i.e. advertisement on t.v. and newspapers. * Analytic :- “ addicts considered fixed at or regressed to an oral level of sexual development.

11. Etiology continue :- c) Social & Family factors :- - peer group pressures, - demands of culture and subculture, - associated with parental disharmony & use of drugs & alcohol, d) Other factors :- - personality & attitudes :- * break rules, truancy, * grow before time, sexual promiscuity, * miserable and anxious.

12. Etiology continue :- Other factors continue:- - supply and easy availability * prescribed  Benzodiazepine, * legal  alcohol & tobacco, * illegal  cocaine & hash. - occupation risk :- * those involved in manufacture and sale of alcohol, * company directors and commercial travelers, * services, * journalists, entertainers, doctors, nurses.

13. Problem of dependence :- a) Physical :- = over dose  death, = contamination e.g. AIDS, = tissue damage e.g. ulcerative (stomach, nasal), perforation, thrombosis, cancer, = dietary deficiency. b) Psychological :-= intoxication  accidents, poor function, = WDS. e.g. hallucinations & delusions. c) Social :- = harm to self and other, = family problems e.g. divorce, battered wives, = crimes, prostitution.

14. Alcohol related psychiatric illness:- - Blackout : amnesia with high blood level, - Fits : with heavily alcohol dependent, - Delirium Tremens : 2-4 days of sudden cessation  delirium, tremor, hallucination, delusion, dehydration, low bp, seizure, coma, death., - Alcohol Hallucination : auditory, 3 rd. Person, conscious. - Agoraphobia, depression, suicide, morbid jealousy, low sexual drive, impotence, - Anemia (B12, folate ), Fetal Alcohol Syndrome ( poor growth, impaired intellect, craniofacial, cardiovascular defects ),

15. Alcohol related psy. Illnesses continue:- - Wernicke – Korsakoff`s Syndromes : - ( degenerative changes in upper brain stem, thalamus hypothalamus, mammillary bodies), * Wernicke’s Encephalopathy = neuropathy, confusion, nystagmus, staggering gait. * Korsakoff’s Psychoses = dementia, impaired recent memory, confabulation, perseveration., - Dementia : following prolonged heavy intake and persist at least 3 wks. After cessation of alcohol ingestion., - Brain damage :- studies showed excess cerebral atrophy among alcoholics.

16. Management & Treatment :- # Assessment :- - full Hx. + family Hx. of abuse, - drug Hx. = type(s), rout, amount, effect, last use, cast, - physical examination = general health, needle tracks, - social (isolation), psychiatric (hallcin., delusion) & criminal (theft, jail) Hx., - urine tests ( except for LSD,& solvents ), - evidence of dependent, - withdrawal signs & symptoms, - legal requirements.

17. Manage.& treatment continue:- a)Opiate -: Methadone = cross - tolerance= in decrease dose regime, b) Alcoholism:- Detoxification = - sedation : chlormethiazone, benzodiazepine, - nutritional ; balanced diet, - rehydration : correct electrolytes imbalance, - vitamin : hi – potency parentrovite or thiamine inj. - anticonvulsant : for fits, - antabuse : for longer term aims ( Disulfiram )

18. Management & treatment continue : c) Amphetamine Psychoses = phenothiazine, usually psychoses fades after 5 – 7 days., d) Barbiturates = - inpatient care & close observation, - short acting barbiturates to control WDS. e.g. pentobarbitone 4 – 6 hourly, - after stabilization a very gradual redaction, 10% of total dose each day, - phenytoin – as anticonvulsant cover.

19. Prognosis & Abstinence :- Predictors of good prognosis= ( older, social support, motivated, first treatment, adequate intelligence, absence of antisocial personality traits.) Abstinence = - mature – out, mid 30’s, - relationship with non-addict, - dramatic change in context of addiction, - intensive support : Alcohol Anonymous (AA), self- helped group, good rehabilitation.