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					SUBSTANCE ABUSE

   Andrzej Kokoszka
        SUBSTANCE ABUSE
• 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.


                General information
         SUBSTANCE ABUSE
 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.

                  General information
        SUBSTANCE ABUSE
• Routes of administration that provide quick
  access to the bloodstream, and hence the
  brain, are often preferred by abusers (e.g.,
  snorting into the nose and smoking).




                General information
    SUBSTANCE INTOXICATION
A. The development of a reversible substance-specific
   syndrome due to recent ingestion of (or exposure to) a
   substance.
• Note: Different substances may produce similar or
   identical syndromes.
B. Clinically significant maladaptive behavioral or
   psychologi-cal changes that are due to the effect of the
   substance on the central nervous system (e.g.,
   belligerence, mood lability, cognitive impairment,
   impaired judgment, impaired social or occupational
   functioning) and develop during nr shortly after use of
   the substance.
C. The symptoms are not due to a general medical
   condition and are not better accounted for by another
   mental disorder.
                          DSM-IV TR
   SUBSTANCE WITHDRAWAL
A. The development of a substance-specific
  syndrome due to the cessation of (or reduction
  in) substance use that has been heavy and
  prolonged.
B. The substance-specific syndrome causes
  clinically signifi-cant distress or impairment in
  social, occupational, or other important areas of
  functioning.
C. The symptoms are not due to a general medical
  condition and are not better accounted for by
  another mental disorder.
                     DSM-IV TR
              SUBSTANCE ABUSE
A. A maladaptive pattern of substance use leading to clinically significant
   impairment or distress, as manifested by one (or morel of the following,
   occurring within a 12-month period:
• (1) recurrent substance use resulting in a failure to fulfill major role
   obligations at work, school, or home (e.g., repeated absences or poor work
   performance related to substance use; substance-related absences,
   suspen-sions, or expulsions from school; neglect of children or household)
• (2) recurrent substance use in situations in which it is phys-ically hazardous
   (e.g., driving an automobile or operat-ing a machine when impaired by
   substance use)
• (3) recurrent substance-related legal problems (e.g., arrests fur substance-
   related disorderly conduct)
• (4) continued substance use despite having persistent or recurrent social or
   interpersonal problems caused or exacerbated by the effects of the
   substance (e.g., argu-ments with spouse about consequences of
   intoxication, physical fights)
B. The symptoms have never met the criteria for Substance Dependence for
   this class of substance


                                  DSM-IV TR
        SUBSTANCE DEPENDENCE
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as
     manifested by three (or more) of the following, occurring at any time in the same 12-month period:
(1) tolerance, as defined by either of the following:
•    (a) a need for markedly increased amounts of the substance to achieve intoxication or desired
     effect
•    (b) markedly diminished effect with continued use of the same amount of the substance
(2) withdrawal, as manifested by either of the following:
•    (a) the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the
     criteria sets for With-drawal from the specific substances)
•    (b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
(3) the substance is often taken in larger amounts or over a longer period than was intended
(4) there is a persistent desire or unsuccessful efforts to cut down or control substance use
(5) a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple
     doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its
     effects
(6) important social, occupational, or recreational activities are given up or reduced because of
     substance use
(7) the substance use is continued despite knowledge of hav-ing a persistent or recurrent physical or
     psychological problem that is likely to have been caused or exacerbated by the substance (e.g.,
     current cocaine use despite recog-nition of cocaine-induced depression, or continued drink-ing
     despite recognition that an ulcer was made worse by alcohol consumption)



                                             DSM-IV TR
     SUBSTANCE DEPENDENCE
Specify if:
• With Physiological Dependence: evidence of tolerance or withdrawal
  (i.e., either Item 1 or 2 is present)
• Without Physiological Dependence: no evidence of toler-ance or
  withdrawal (i.e., neither Item 1 nor 2 is present)

Course specifiers:
• Early Full Remission
• Early Partial Remission
• Sustained Full Remission
• Sustained Partial Remission
• On Agonist Therapy
• In a Controlled Environment



                             DSM-IV TR
      SUBSTANCE INTOXICATION
            DELIRIUM
A. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment)
    with reduced ability to focus, sustain or shift attention.
B. A change in cognition (such as memory deficit, disorientation, language disturbance)
    or the development of a perceptual disturbance that is not better accounted for by a
           preexisting, established, or evolving dementia.
C. The disturbance develops over a short period of time (usually hours to days) and
    tends to fluctuate during the course of the day.
D. There is evidence from the history, physical examination, or laboratory findings of
    either (1) or (2):
• (1) the symptoms in Criteria A and B developed during substance intoxication
• (2) medication use is etiologically related to the disturbance*       ,

•   Note is diagnosis should be made instead of a diagnosis of substance intoxication
    only when the cognitive symptoms are in excess of those usually associated with the
    intoxication syndrome and when the symptoms are sufficiently severe to warrant
    independent clinical attention.
•   Note: The diagnosis should be recorded as substance-induced delirium if related to
    medication use.
•   Code: Specific substance intoxication delirium


                                      DSM-IV TR
      SUBSTANCE WITHDRAWAL
            DELIRIUM
A. Disturbance of consciousness (i.e., reduced clarity of aware-ness of the
   environment) with reduced ability to focus, sus-tain, or shift attention.
B. A change in cognition (such as memory deficit, disorienta-tion, language
   disturbance) or the development of a percep-tual disturbance that is not
   better accounted for by a preexisting, established, or evolving dementia.
C. The disturbance develops over a short period of time (usu-ally hours to
   days) and tends to fluctuate during the course of the day.
D. There is evidence from the history, physical examination, or laboratory
   findings that the symptoms in Criteria A and B developed during, or shortly
   after, a withdrawal syndrome.

•   Note: This diagnosis should be made instead of a diagnosis of substance
    withdrawal only when the cognitive symptoms are in excess of those usually
    associated with the with-drawal syndrome and when the symptoms are
    sufficiently severe to warrant independent clinical attention.
•   Code: Specific substance withdrawal delirium:



                                  DSM-IV TR
        SUBSTANCE ABUSE
Classification of abused substances:
• stimulants,
• sedatives,
• opioids,
• hallucinogens and related agents




                General information
           STIMULANTS

- central nervous system activators:
• caffeine,
• nicotine,
• amphetamines,
• cocaine.


              General information
            STIMULANTS
• Caffeine is found in coffee (125 mg/cup),
  tea (65 mg/cup), cola (40 mg/cup),
  nonprescription stimulants, and diet
  agents.
• Nicotine is a toxic substance present in
  tobacco. Cigarette smoking decreases life
  expectancy more than the use of any other
  substance. Smoking is increasing most in
  teenaged girls.
               General information
              STIMULANTS
Amphetamines
• indicated in the treatment of attention-deficit
  hyperactivity disorder and narcolepsy,
  sometimes in depression in the elderly and
  terminally ill, and depression and obesity in
  patients who do not respond to other treatments.
• the most common clinically used amphetamines
  are dextroamphetamine (Dexedrine),
  methamphetamine (Desoxyn), and a related
  compound, methylphenidate (Ritalin).
                  General information
            STIMULANTS
• "Speed", "ice" (methamphetamine), and
  "ecstasy" [methylene
  dioxymethamphetamine (MDMA)] are
  street names for amphetamine
  compounds.




               General information
AMPHETAMINE                         Marie, 20.    Rose, 18.
                                     After a     After a year
AND METAMPHETAMINE                    year




                     James, 34.                           Jessica, 28.
                     After a year                         After a year
              STIMULANTS
Cocaine
• "Crack" and "freebase" are cheap, smokable
  forms of cocaine; in expensive pure form,
  cocaine is sniffed into the nostrils ("snorted").
• Hyperactivity and growth retardation are been in
  newborns of mothers who used cocaine during
  pregnancy.
• Tactile hallucinations of bugs crawling on the
  skin (formication) is seen with use of cocaine
  ("cocaine bugs").
                  General information
                   STIMULANTS
Neurotransmitter associations
• Stimulant drugs work primarily by increasing the availability of
  dopamine (DA).
• Amphetamine use causes the release of DA.
• Cocaine blocks the reuptake of DA.
• Both the release of DA and the block of DA reuptake result in
  increased availability of this neurotransmitter in the synapse.
• Increased availability of DA in the synapse is apparently involved in
  the euphoric effects of stimulants and opioids (the "reward" system
  of the brain). As in schizophrenia, increased IMA availability may
  also result in psychotic symptoms.




                          General information
STIMULANTS




Effects of use and withdrawal
STIMULANTS




Effects of use and withdrawal
            SEDATIVES
central nervous system depressants:
- alcohol,
- barbiturates,
- benzodiazepines.




               General information
              SEDATIVES
- work primarily by increasing the activity of
  the inhibitory neurotransmit-ter y-
  aminobutyric acid (GABA).

- hospitalization of patients for withdrawal
  from sedatives is prudent; the withdrawal
  syndrome may include seizures and
  cardiovascular symptoms that could be
  life-threatening.
                 General information
            SEDATIVES
Alcohol
Acute associated problems
• Traffic accidents, homicide, suicide,
  and rape, are correlated with the
  concurrent use of alcohol.
• Child physical and sexual abuse,
  spouse abuse, and elder abuse are
  also associated with alcohol use.
               General information
                 SEDATIVES
Alcohol
Chronic associated problems
• Thiamine deficiency resulting in Wernicke and Korsakoff
  syndromes is associated with long term use of alcohol.
• Liver dysfunction, gastrointestinal problems (e.g.,
  ulcers), and reduced life expectancy also are seen in
  heavy users of alcohol.
• Fetal alcohol syndrome (including facial abnormalities,
  reduced height and weight, and mental retardation) is
  seen in the offspring of women who drink during
  pregnancy.
• dA childhood history of problems such as ADHD and
  conduct disorder correlate with alcoholism in the adult.

                     General information
                  SEDATIVES
Identification of alcoholism
• Positive responses to the CAGE questions:
"Do you ever:
a. . . . try to Cut down on your drinking?"
b. . . . get Angry when someone comments on your
   drinking?
c. . . . feel Guilty about your drinking?"
d. . . . take a drink as an Eye-opener in the morning?"




                      General information
             SEDATIVES
Intoxication
• Legal intoxication is defined as 0.08%-
  0.15% blood alcohol concentration,
  depending on individual state laws.
• Coma occurs at a blood alcohol
  concentration of 0.40% - 0.50% in non-
  alcoholics


                General information
                  SEDATIVES
• Psychotic symptoms (e.g., hallucinations) may be seen
  in alcohol intoxication as well as in withdrawal
• Delirium tremens ("the DTs")
• Alcohol withdrawal delirium (delirium tremens "the DTs")
  may occur during the first week of withdrawal from
  alcohol (most commonly on the third day of
  hospitalization). It usually occurs in patients who have
  been drinking heavily for at least 5 years.
• Delirium tremens is life threatening; the mortality rate is
  about 20%.


                      General information
               SEDATIVES
Barbiturates
• are used medically as sleeping pills, sedatives,
  antianxiety agents (tranquilizers),
  anticonvulsants, and anesthetics.
• ffrequently used and abused: amobarbital,
  pentobarbital, and secobarbital.
• cause respiratory depression
• have a low safety margin;
• most commonly drugs taken to commit suicide.
                  General information
                  SEDATIVES
Benzodiazepines
• are used medically as tranquilizers, sedatives, muscle
   relaxants, anticonvulsants, and anesthetics, and to treat
   alcohol withdrawal (particularly long-acting agents such
   as chlordiazepoxide and diazepam).
• have a high safety margin unless taken with another
   sedative, such as alcohol.
Flumazenil (Mazicon, Romazicon), a benzodiazepine
   receptor antagonist, can reverse the effects of
   benzodiazepines in cases of overdose.


                      General information
 SEDATIVES




Effects of use and withdrawal
                    OPIOIDS
  Narcotics or opioid drugs include agents used medically
  as analgesics (e.g., morphine) as well as drugs of abuse
  (e.g., heroin).
  Compared to medically used opioids like morphine and
  methadone, abused opioids such as heroin are more
  potent, cross the blood-brain barrier more quickly, have
  a taster onset of action, and have more euphoric action.
In contrast to barbiturate withdrawal, which may be fatal,
  death from withdrawal of opioids is rare unless a serious
  physical illness is present.


                     General information
                        Heroine



Marie 28y




            Marie 29y             Marie 30y
                             OPIOIDS
    Synthetic opioids used to treat heroin addiction:
    - Methadone, 1-alpha-acetylmethadol acetate (LAMM),
    - buprenorphine (Temgesic)
    - can cause physical dependence and tolerance
    - legal opioids can be substituted for illegal opioids, such as heroin, to
    prevent withdrawal symptoms.
Advantages over heroin
a. Methadone and LAMM are dispensed by federal health authorities.
b. Buprenorphine, a partial opioid receptor agonist that can block both
    withdrawal symptoms and the euphoric action of heroin, can now be
    prescribed by physicians.
c. They can be taken orally. The intravenous method may involve sparing
    contaminated needles, thus contributing to.AIDS and hepatitis B infection.
d. They have a longer duration of action.
e. They cause less euphoria and drowsiness, allowing people on maintenance
    regimens to keep their jobs and avoid the criminal activity that is necessary
    to maintain a costly heroin habit.

                              General information
    OPIOIDS




Effects of use and withdrawal
     HALLUCINOGENS AND
      RELATED AGENTS
• lysergic acid diethylamide (LSD),
• phencyclidine (PCP "angel dust")
• cannabis (tetrahydrocannabinol,
  marijuana, hashish),
• psilocybin (from mushrooms),
• mescaline (from cactus),
• ketamine ("Special K").

                General information
    HALLUCINOGENS AND
     RELATED AGENTS
• promote altered states of consciousness.
• increased availability of serotonin is
  associated with the effects of some of
  these agents (e.g., LSD)..




               General information
      HALLUCINOGENS AND
       RELATED AGENTS
Marijuana
• Tetrahydrocannabinol (THC) - the primary active
  compound.
• In low doses, marijuana increases appetite and
  relaxation, and causes conjunctival reddening.
• Chronic users experience lung problems associated with
  smoking and a decrease in motivation ("the
  amotivational syndrome") characterized by lack of desire
  to work, and increased apathy.
• illegal in the US, but some states permit limited medical
  use to treat glaucoma and cancer-related nausea and
  vomiting.
                     General information
       HALLUCINOGENS AND
        RELATED AGENTS
LSD and PCP
• LSD is ingested and PCP is smoked in a marijuana or other
  cigarette.
• While LSD and PCP both cause altered perception, in contrast to
  LSD, episodes of violent behavior occur with PCP use.
• Emergency department findings for PCP include hyperthermia and
  nystagmus (vertical or horizontal abnormal eye movements).
• PCP bind with NMDA receptors of glutamate-gated ion channels
• Consumption of more than 20 mg of PCP may cause convulsions,
  coma, and death.




                        General information
HALLUCINOGENS AND
 RELATED AGENTS




   Effects of use and withdrawal
  TREATMENT OF SUBSTANCE
          ABUSE
• ranges from abstinence and peer support groups to
  drugs that block physical and psychological withdrawal
  symptoms.
• of withdrawal symptoms includes immediate treatment or
  detoxification ("detox") and extended treatment aimed at
  preventing relapse or maintenance
Dual diagnosis or mentally ill-chemically addicted (MICA)
  patients require treatment for both substance abuse and
  the comorbid psychiatric illness (e.g., major depression),
  often on a special unit in the hospital.


                        General rules
     Lab




General information
Diagnosis




 Substance abuse
TREATMENT




  General rules
TREATMENT




  General rules

				
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