abdullah al-subaie, mbbs, frcp (c) professor of psychiatry substance use/ prof. subaie 1 alcohol...

ABDULLAH AL-SUBAIE, MBBS, FRCP (C) PROFESSOR OF PSYCHIATRY

Substance use/ Prof. Subaie

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ALCOHOL & SUBSTANCE

ABUSE

TYPES OF ABUSED SUBSTANCES

Anxiolytics and hypnotics

Opioids

Stimulants

Hallucinogens

Cannabis

Organic solvents


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Prevalence:


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Prevalence:


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DSM-IV Criteria for Substance Intoxication


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A. The development of a reversible substance-specific syndrome due to recent use of a substance. Different substances may produce similar or identical syndromes.

B. Clinically significant maladaptive behavioral or psychological changes that are due to the effect of the substance on the central nervous system (eg, belligerence, mood lability, cognitive impairment, impaired judgment, impaired social or occupational functioning) and develop during or 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 Criteria for Substance Withdrawal


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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 significant 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 Diagnostic Criteria for Substance Dependence - 1


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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 of withdrawal of the specific substance)(b) the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms.




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(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 (eg, visiting multiple doctors or driving long distances), use the substance (eg, 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 having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (eg, current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)




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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 tolerance or withdrawal (i.e, neither item 1 nor 2 is present)


WHEN TO SUSPECT SUBSTANCE ABUSE / DEPENDENCE ? 1


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When medical or psychiatric problems may be related to alcohol or drugs.

If patient requests certain drugs for unsatisfactory reasons.

When needle tracks and thrombotic veins are found.

Finding scars of previous abscesses. When forearms are concealed.


WHEN TO SUSPECT UBSTANCE ABUSE / DEPENDENCE ? 2


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In cases of self neglect, and school or occupational decline.

In history of former friends loss and joining the “drug culture.”

In history of thefts and prostitution.When urine tests positive (except

LSD and solvents).When Gamma–Glutmyle–transferase

(GGT) and MCV are elevated.


PREVALENCE ISSUES - 1


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Availability:

Prescribed e.g. Benzodiazepines

Legal e.g. alcohol & nicotine

Illegal e.g. cocaine, hash




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Personal characteristics: Difficulty accepting authority, truancy and poor

schooling in teenagers. Disorganized families. Unhappy childhood. History of mental illness or personality

disorder in family. Personality disorder, disorganized life &

unstable relationships. Sexual promiscuity.




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Social Pressures: - especially in teenagers & school children.- unemployment.

Primary effect of the substance

Secondary effect of the substance (milieu).


MANGEMENT OUTLINES - 1


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1. Review history with the patient regarding:

Type of drug (s) and amount I.V. usage and its dangers Evidence of dependence Complications of drugs (physical,

psychological and social). Personal and social resources and problems




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2 Manage withdrawal symptoms3 Treat urgent medical and psychiatric

complications4 Set attainable goals:

Abstaining from drug Parting from drug culture Dealing with personal and financial problems Establishing new interests




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5. Set longer-term goals: Individual or group counseling Help for family Rehabilitation

6. Self-help groups


PREVENTION


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Preventive measures

Improved education

Increased restrictions

Of availability

Of advertising


COMPLICATIONS


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General medical complications e.g. AIDS, endocarditis

Local effects of I.V. injections e.g. thrombosis. Frequent intoxication leading to poor functioning,

failure of social relations, accidents, family problems and neglect.

Debts due to expensive illicit drugs leading to prostitution and crime.

Death.


ALCOHOL ABUSE / DEPENDENCE


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QUICK ASSESSMENT:

Cut down

Annoyed

Guilty

Eye opener




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PREVALENCE: In England, 6% of men & 1% of women admitted to

consumption of >50 units/week. Lifetime prevalence rate was 0.45% among Chinese

in Shanghai & 23% among Native Mexican-Americans

Dependence is usually established in mid-forties for men and a few years later for women.

Dependence is also increasing in teenagers and women.

Dependence is generally more common in disadvantaged areas.

Age, sex: Young males but rate in females is rising.Occupation: Executives, service men, journalists,

Salesmen and movie industry.

1 unit= 8 gm or 1

centiliter




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PERSONALITY TRAITS:

Self-indulgence

Anxiety

Painful reality is denied and pleasure is obtained by immediate oral gratification (drinking)

“Alcoholism is a conditioned behavioral response”

“Alcoholism is a series of transactions designed to obtain personal advantage or hide deficiencies”

Stress leads to anxiety that is

relieved by alcohol




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PHYSICAL COMPLICATIONS SUCH AS: G.I.T.: Gastritis and peptic ulcer, esophageal

varices, acute and Chronic pancreatitis, hepatitis and cirrhosis.

C.N.S.: Peripheral neuropathy, dementia, epilepsy.

Others: Anemia, episodes of hypoglycemia, obesity, Cardiomyopathy, Myopathy

Alcohol fetal syndrome: Facial abnormalities, low

birth weight, low intelligence and over activity.




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NEUROPSYCHIATRIC COMPLICATIONS:1. INTOXICATION STATES:

Blackouts: amnesia to events that occur during the period of intoxication.

Idiosyncratic intoxication: markedly changed behavior (usually aggressive) occurring within minutes of drinking a small amount of alcohol.

Other effects: Mood: euphoria/dysphoria, irritability Cognition: sedation, memory & judgment

impairment Behavior: disinhibition, aggression, violence,

accident proneness.




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NEUROPSYCHIATRIC COMPLICATIONS: TREATMENT OF WITHDRAWAL STATES:

Dehydration & correction of electrolytes

Sedation (Chlormethiazole & Benzodiazepines(

Multivitamins

Thiamine




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TOXIC AND NUTRITIONAL STATES:1. Wernicke’s encephalopathy: due to thiamin deficiency

leading to bilateral degeneration of the posterior hypothalamus, hippo- campus and mamillary bodies. Features include: delirium, ataxia and ophthalmoplegia.

2. Korsakov’s syndrome (alcohol amnestic syndrome):Features include: prominent disturbance of recent memory in the absence of generalized intellectual impairment (Immediate recall is good but recent memory is impaired). Confabulation and disorientation to time may occur. New learning is impaired. Occurs after prolonged use. On CT scan: Ventricles may be enlarged and sulci may be widened. CT changes may partially resolve on abstinence.




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ASSOCIATED COMORBIDITY & COMPLICATIONS: Depression/ Suicide Anxiety Personality changes Pathological jealousy Sexual dysfunction Hallucinations Social damage Crimes Road traffic accidents Occupational problems Family conflicts and losses




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MANAGEMENT:

1. Assess: - Extent of drinking - Evidence of dependence - Alcohol related disability

2. Arrange for and treat withdrawal symptoms: - Sedation

- Thiamin and Vitamin B supplements

- Rehydration




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MANAGEMENT:3. Treat urgent psychiatric or medical problems:4. Arrange for rehabilitation and long term

treatment: Of medical and psychiatric disability Resolving interpersonal problems Social support ( work, law, finance, interests) Individual and / or group counseling Self help group e.g. alcohol anonymus Help for family Disulfiram (antabuse)- inhibits acetaldehyde

dehydroginase…




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PROGNOSIS: Generally poor:

At 6/12: 25% remain abstinent At 18/12: 10% remain abstinent

Good prognostic factors include: Good insight Strong motivation Supportive family Stable job Ability to form good relationship Control of impulsivity and ability to defer

gratification


OUTCOME

Outcome depends more on the patient than on the treatment


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CANNABIS


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Derived from the plant Cannabis sativa Effects vary with: dose, user’s expectation and

social setting Exaggerates the preexisting mood (euphoria or

dysphoria) Physical dependence and withdrawal symptoms

do not occur Acute intoxication may lead to psychosis while

chronic use may lead to “amotivational syndrome”


ORGANIC SOLVENTS (INHALENTS)


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ADHESIVES, CLEANING FLUIDS, PETROL, AEROSOLS, BUTANE GAS.

Most common among teenagers.Intoxication leads to drunkenness, delirium,

uncoordinated gait, nausea, vomiting, and coma.

Visual hallucinations are common.More psychological than physical dependence.It has a neurotoxic effect leading to peripheral

neuropathy and cerebellar dysfunction.Over dosage may be fatal and chronic use may lead

to psychosis.Very cheap and easily obtained.

Due to: hepatorenal, brain & bone marrow toxicity, bronchial asthma & cardiorespiratory arrest, coma, asphyxiation with

plastic bags, trauma…


STIMULANTS


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AMPHETAMINES AND COCAINELead to elevation of mood, over-activity, insomnia,

over- talkativeness, and anorexia. Cardiac arrhythmia and malignant hypertension

may result from high doses.DeathProlonged use may result in paranoid psychosis

resembling schizophreniaPhysical dependence is not severeWithdrawal may lead to severe depression and

suicideTreatment includes abstinence, antidepressants

and neuroleptics

Due to: hyperpyrexia, coma, CV shock, fits…


HALLUCINOGENS


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LSD, DISMETHYL TRYPTAMINE AND ANTICHOLINERGIC DRUGS

Lead to distortion or intensification of perceptions or frank hallucinations.

Time moves slowlyProfound meaning of ordinary events.Body image distortions and depersonalization may

occur. Experience may be pleasant, distressing, or

frightening leading to dangerous unpredictable behavior.

Physical effects include hypertensionFlashbacks may occurMore psychological than physical dependenceTreatment is diazepam or phenothiazines (avoid in

case of anticholinergic over-dose)


OPIOIDS


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HEROIN, MORPHINE, CODEINE AND PETHEDINLead to immediate effects of euphoria, analgesia,

reduced appetite, respiratory depression, drowsiness, gastrointestinal spasms, fits…

Tolerance develops rapidlyWithdrawal symptoms: craving, agitation, insomnia,

pains and arthralgia, abdominal cramps, runny nose and eyes, sweating, diarrhea, piloerection, dilated pupils, tachycardia and disturbed temperature control.

Withdrawal starts within 6 hours, peaks in 24–48 hours and it is not life threatening

Short-term treatment includes: relief of withdrawal symptoms.

Long-term treatment includes: methadone replacement and rehabilitation

Treatment outcome remains poor in the best hands. Death results in about: 10%-20% in 7 years.


Substance use/ Prof. Subaie 37

abdullah al-subaie, mbbs, frcp (c) professor of psychiatry substance use/ prof. subaie 1 alcohol...

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