Tomasz Kucmin MD PhD

Transcription

1 Tomasz Kucmin MD PhD

2 Psychoactive substances are substances that, when taken in or administered into one's system, affect mental processes, e.g. cognition or affect. This term and its equivalent, psychotropic drug, are the most neutral and descriptive term for the whole class of substances, licit and illicit, of interest to drug policy. Psychoactive does not necessarily imply dependence-producing, and in common parlance, the term is often left unstated, as in drug use or substance abuse.

3 Alcohol consumption: Worldwide consumption in 2010 was equal to 6.2 litres of pure alcohol consumed per person aged 15 years or older, which translates into 13.5 grams of pure alcohol per day. A quarter of this consumption (24.8%) was unrecorded, i.e., homemade alcohol, illegally produced or sold outside normal government controls. Of total recorded alcohol consumed worldwide, 50.1% was consumed in the form of spirits.

4 Alcohol consumption: Worldwide 61.7% of the population aged 15 years or older (15+) had not drunk alcohol in the past 12 months. Worldwide about 16.0% of drinkers aged 15 years or older engage in heavy episodic drinking. In general, the greater the economic wealth of a country, the more alcohol is consumed and the smaller the number of abstainers. High-income countries have the highest alcohol per capita consumption (APC) and the highest prevalence of heavy episodic drinking among drinkers.

5 Alcohol - health consequences In 2012, about 3.3 million net deaths, or 5.9% of all global deaths, were attributable to alcohol consumption. There are significant sex differences in the proportion of global deaths attributable to alcohol, for example, in % of deaths among males and 4% of deaths among females were attributable to alcohol. In million net DALYs (disability-adjusted life years), or 5.1% of the global burden of disease and injury, were attributable to alcohol consumption.

6 Other psychoactive substances Recent estimates are that in 2008, 155 to 250 million people, or 3.5% to 5.7% of the world's population aged 15-64, used other psychoactive substances, such as cannabis, amphetamines, cocaine, opioids, and nonprescribed psychoactive prescription medication. Globally, cannabis is the most commonly used ( million people), followed by amphetamine type stimulants, then cocaine and opioids.

7 Other psychoactive substances The use of psychoactive substances causes significant health and social problems for the people who use them, and also for others in their families and communities. WHO estimated that 0.7% of the global burden of disease in 2004 was due to cocaine and opioid use, with the social cost of illicit substance use being in the region of 2% of GDP in those countries which have measured it.

8 Depressants, such as alcohol, sedatives/hypnotics and volatile solvents, that diminish the activity of the central nervous system. Stimulants, such as nicotine, cocaine, amphetamines and ecstasy, that increase the activity of the central nervous system. Opioids, such as morphine and heroin, that relieve pain, dull the senses, and induce sleep. Hallucinogens such as PCP and LSD, that can distort perceptions to induce delusions or hallucinations. Cannabis, though classified as a hallucinogen, also displays characteristics of depressants and stimulants.

9 Disorders due to use of (ICD-10): F10.x alcohol F11.x opioids F12.x cannabinoids F13.x sedatives or hypnotics F14.x cocaine F15.x other stimulants (caffeine) F16.x hallucinogens F17.x tobacco F18.x volatile solvents F19.x multiple drugs and other psychoactive drugs

10 Specific Clinical Conditions (ICD-10): F1x.0 Acute intoxications F1x.1 Harmful use F1x.2 Dependence syndrome F1x.3 Withdrawal state F1x.4 Withdrawal state with delirium F1x.5 Psychotic disorder F1x.6 Amnesic syndrome F1x.7 Residual state, late-onset psychotic disorder F1x.8 Other mental and behavioural disorders F1x.9 Unspecified mental and behavioural disorder

11 Alcohol dependence is a cluster of behavioural, cognitive, and physiological phenomena that may develop after repeated alcohol use. Typically, these phenomena include a strong desire to consume alcohol, impaired control over its use, persistent drinking despite harmful consequences, a higher priority given to drinking than to other activities and obligations, increased alcohol tolerance, and a physical withdrawal reaction when alcohol use is discontinued.

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13 A transient condition following the administration of psychoactive substance resulting in disturbances in level of consciousness, cognition, perception, affect or behaviour, or other psychophysiological functions and responses Closely related to dose levels Uncomplicated With trauma or other medical complications With delirium With coma With convulsions Pathological intoxication (applies only to alcohol)

14 The damage may be physical and/or mental. Socially negative consequences are not evidence (neither acute intoxication or hangover).

15 a) A strong desire or sense of compulsion to take the substance ( craving ) b) Difficulties in controlling substance-taking c) Withdrawal sy characteristic for the substance d) Evidence of tolerance e) Progressive neglect of pleasures and interests f) Persisting with substance use despite clear evidence of overtly harmful consequences Physical dependence Psychic (psychological) dependence

16 F1x.20 currently abstinent (remission) F1x.21 currently abstinent in a protected environment F1x.22 currently abstinent on a maintenance regime F1x.23 currently abstinent - receiving treatment with aversive or blocking drugs (naltrexone, disulfiram) F1x.24 currently active dependence F1x.25 continuous (chronic) use F1x.26 episodic use (dipsomania)

17 Symptoms occurring on absolute or relative withdrawal of a substance after repeated and prolonged use of the substance Uncomplicated With convulsions

18 Delirium tremens - in severely dependent users with a long history of use of alcohol Prodromal symptoms: insomnia, tremor, fears followed by illusions, hallucinations, clouding of consciousness and marked tremor

19 Psychotic phenomena occurring during or immediately after psychoactive substance use Schizophrenia-like Predominantly delusional, hallucinatory, depressive, manic (alcoholic hallucinosis, jealousy) Persistence for more than 48 hours

20 Impairment of recent memory (learning of new material) Absence of defect in immediate recall, of impairment of consciousness, and of generalized cognitive impairment History of chronic use of psychoactive substance (Korsakov s psychosis or syndrome)

21 Onset related to the use of psychoactive substance, the disorder should persist beyond any period of time during which direct effects of the psychoactive substance might be assumed Flashbacks - duration in seconds or minutes, duplication of previous drugrelated experiences Personality disorders Dementia

22 Acute intoxication: euphoria, flushed face, ataxia, slowed reaction time, impaired motor performance, slurred speech, poor concentration; in higher doses behavioural changes disinhibition of sexual and aggressive impulses, increased suicidal and homicidal behaviour Pathological intoxication: sudden change of consciousness with aggressive behaviour and amnesia Harmful use: physical complications hypertension, arteriosclerosis, heart infarction, cardiomyopathy, brain stroke, liver cirrhosis, fatty liver, gastritis, etc. psychic complications - depression

23 Dependence syndrome: increased tolerance to alcohol, morning drinking, alcohol bouts, blackouts, deterioration in occupational and marital life, behavioural changes, withdrawal symptoms Withdrawal state: tremor, anxiety, easy getting startled, agitation, insomnia, nausea, sweating, epileptic seizures and delirium tremens Delirium tremens: usually starts in evening hours growing tremulousness, severe agitation, anxiety and perceptual distortion a state seriously endangering patient's life recovery after several days, retrograde amnesia

24 Other psychotic disorders: alcoholic hallucinosis pathological jealousy Korsakov's psychosis Wernicke encephalopathy alcoholic dementia Treatment of alcoholism Withdrawal from alcohol, benzodiazepines, clomethiazol Aversion therapy Alcohol-Antabuse (disulfiram) Reaction (AAR) Psychotherapy

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27 1. How often do you have a drink containing alcohol? (0) Never [Skip to Qs 9-10] (1) Monthly or less (2) 2 to 4 times a month (3) 2 to 3 times a week (4) 4 or more times a week

28 2. How many drinks containing alcohol do you have on a typical day when you are drinking? (0) 1 or 2 (1) 3 or 4 (2) 5 or 6 (3) 7, 8, or 9 (4) 10 or more

29 3. How often do you have six or more drinks on one occasion? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily Skip to Questions 9 and 10 if Total Score for Questions 2 and 3 = 0

30 4. How often during the last year have you found that you were not able to stop drinking once you had started? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

31 5. How often during the last year have you failed to do what was normally expected from you because of drinking? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

32 6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

33 7. How often during the last year have you had a feeling of guilt or remorse after drinking? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

34 8. How often during the last year have you been unable to remember what happened the night before because you had been drinking? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

35 9. Have you or someone else been injured as a result of your drinking? (0) No (2) Yes, but not in the last year (4) Yes, during the last year

36 10. Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down? (0) No (2) Yes, but not in the last year (4) Yes, during the last year

37 Total scores of 8 or more are recommended as indicators of hazardous and harmful alcohol use, as well as possible alcohol dependence. AUDIT scores between 8 and 15 are most appropriate for simple advice focused on the reduction of hazardous drinking. AUDIT scores between 16 and 19 suggest brief counseling and continued monitoring. AUDIT scores of 20 or above clearly warrant further diagnostic evaluation for alcohol dependence.

38 Morphine, heroin (diacetylmorphine), codeine, pethidine, methadone Heroin: dependence develops within two weeks of daily use overdose may lead to death withdrawal symptoms are extremely unpleasant needle-sharing represents a serious risk of transmission of HIV and hepatitis B + C viruses treatment of the withdrawal state buprenorphine, benzodiazepines, spasmolytics; in serious cases of dependence heroin is replaced by methadone

39 Marijuana (marihuana) is a colloquial term for dried leaves and flowers of cannabis plant (Cannabis sativa L.) Δ 9 -tetrahydrocannabinol (Δ 9 -THC) is responsible for the psychoactive properties of the cannabis plant Complex physiological functions of the cannabinoid system: motor coordination, memory procession, control of appetite, pain modulation and neuroprotection Summary of adverse effects: acute: anxiety, panic, impaired attention, memory, reaction time and psychomotor performance and coordination, increased risk of road accident, and increased risk of psychotic symptoms among vulnerable persons chronic: chronic bronchitidis, a cannabis dependence syndrome, subtle impairments of attention, short-term memory and ability to organize and integrate complex information

40 Effect of cannabinoids on central nervous system: Euphoria, enhancement of sensory perception, tachycardia, antinociception, difficulties in concentration, impairment of memory Cannabis use may exacerbate symptoms of schizophrenia and may precipitate disorders in persons who are vulnerable to developing psychosis; heavy cannabis use may increase depressive symptoms among some users Tolerance develops; the relatively long half-life and complex metabolism of cannabis may result in a low intense withdrawal syndrome Marijuana use tends to impair executive function in the brain, e.g. higher risk for all types of injuries is associated with cannabis use Cannabis abuse and dependence were highly associated with increasing risks of other substance dependence

41 Benzodiazepines potentiate the action of GABA risk of dependence short-acting benzodiazepines: alprazolam, flunitrazepam, oxazepam, lorazepam, temazepam long-lasting benzodiazepines: diazepam, clorazepate, chlordiazepoxide, etc. withdrawal state can be accomplished with epileptic seizures interaction with alcohol may induce qualitative changes of consciousness

42 Cocaine, amphetamine, metamphetamine (pervitine), phenmetrazine, methyphenidate, MDMA (ecstasy, methylenedioxymetamphetamine) Positive mood, activity, planning, diminished need of sleep Tachycardia, arrhythmia, hypertension, hyperthermia, intracerebral haemorrhage Withdrawal symptoms: severe craving, depression, decreased energy, fatigue, sleep disturbance Prolonged use can trigger paranoid psychoses, impulsivity, aggressivity, irritability, suspiciousness and anxiety states

43 Fagerstrom Test for Nicotine Dependence (FND)

44 How soon after you wake up do you smoke your first cigarette? Do you find it difficult to refrain from smoking in places where it is forbidden (e.g., in church, at the library, in the cinema)? Which cigarette would you hate most to give up? How many cigarettes per day do you smoke? Do you smoke more frequently during the first hours after waking than during the rest of the day? Do you smoke when you are so ill that you are in bed most of the day? Within 5 minutes 6 to 30 minutes 31 to 60 minutes After 60 minutes Yes No The first one in the morning Any other 10 or less 11 to to or more Yes No Yes No

45 Fagerstrom Test for Nicotine Dependence (FND) scoring: 1-2 low depemdence 3-4 low to moderate dependence 5-7 moderate dependence 8+ high dependence

46 Lysergid acid diethylamide (LSD), psilocybin, mescaline, phencyclidine Acute intoxication: distorted perception (optic hallucinations and illusions); unpredictable and dangerous behaviour Withdrawal syndrome has not been described

47 Toluene, acetone, adhesives, petrol, cleaning fluids, etc. Acute intoxication: euphoria, disorientation, incoordination, slurred speech; optic hallucinations The way of use is very dangerous

48 HEALTH SERVICE: acute states (detox program, tox. psychosis) weaning treatment after-treatment care substitution (maintainance) treatment OUT OF HEALTH SERVICE: contact centers daily static centers therapeutic communities after-treatment centers protected workshops and habitations mutual help groups Alcoholics Anonymous, Narcotics Anonymous

49 European Monitoring Centre for Drugs and Drug Addiction:

50 Designer drugs

51 Trainspotting Requiem for a dream The lost weekend Leaving Las Vegas Narc

52 gambling sex exercise shopping