2) Substance-related & Addictive Disorders - Dr. Nzar

Transcription

1 The substances include ten classes of drugs; 2) Substance-related & Addictive Disorders - Dr. Nzar Alcohol Caffeine Cannabis Hallucinogens Inhalants Opioids Sedatives Hypnotics and anxiolytics Stimulants Tobacco and unknown substances The substance related disorders are divided into two main groups: Substance use disorders Substance induced disorders Substance induced include: Intoxication Withdrawal Other substance/medication induced mental disorders including psychotic disorders, bipolar and related disorders, depressive disorders, anxiety disorders, obsessive complusive and related disorders, sleep disorders, sexual dysfunctions, delirium, and neurocognitive disorders. Substance Intoxication: Is the development of a reversible substance syndrome due to the recent ingestion of a substance. The clinically significant problematic behavioural or psychological changes associated with intoxication ( e.g. belligerence, mood lability, impaired judgment ) are attributable to the physiological effects of the substance on the central nervous system and develop during or shortly after use of the substance. Intoxication is common among patients with substance use disorders but could occur in patients without a substance use disorder. The symptoms are not attributable to another medical condition and are not better explained by another mental disorder. Abuse Is maladaptive patterns of substance use that impairs health. Misuse could be used to refer to the same issue. The Impairment in health includes social, psychological and physical aspects of health. Dependence Psychological and physiological phenomena that are induced by repeated intake of substance. o Strong desire to take the substance o The substance becomes the sole source of satisfaction and neglect of other sources. o Development of tolerance o Physical withdrawal state Tolerance Is the state in which with repeated administration of a drug, its effect is reduced and larger doses are required to produce the same effect. 1

2 Withdrawal Refers to the problematic behavioural change with physiological and cognitive concomitants, that is due to the cessation of or reduction in, heavy and prolonged substance use. It causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. It is not due to another medical condition and are not better explained by mental disorder. Individuals have an urge to readminister the substance to reduce the symptoms. Intoxication and withdrawal frequently involve more than one substance sequentially or simultaneously. The highest prevalence rate is around years. Substance induced mental disorders develop in the context of intoxication or withdrawal from substances of abuse, and medication-induced mental disorders are seen with the prescribed or over the counter medications that are taken at the suggested doses. Alcohol Related Disorders Alcohol is used by ordinary people socially or on occasions without causing harm to those who drink it. However alcohol drinking behaviour might become abnormal and problematic. We can divide them into the following: 1. Excessive consumption of alcohol 2. Alcohol misuse 3. Alcohol dependence 4. Problem drinking 1) Excessive alcohol consumption Also called harmful drinking or hazardous drinking This depends on the normal pattern of drinking in different countries. A unit of alcohol is equal to half a pint of beer, one glass of table wine, one conventional glass of sherry or port and one single bar measure of spirits. Each unit is about 8 g of alcohol. The problem is different in different countries. It is more in men than women, more in unmarried, seperated or divorced. In the UK it is less in Muslims, Hindus and followers of the Baptist church. 2) Alcohol misuse Occupations liable for harmful use of alcohol include chefs, kitchen porters, barmen and brewery workers, who have easy access to alcohol, executives and salesmen who entertain on expense accounts, actors and entertainers, seamen, and journalists. 3) Alcohol dependence The same features of depedence on substances are applied her. o Strong desire to take the substance o The substance becomes the sole source of satisfaction and neglect of other sources. o Development of tolerance o Physical withdrawal state and this is not a must for the diagnosis of dependence. The patient gives up all social, recreational and occupational activities are decreased because of drinking. He continues to drink despite knowledge that drinking is harmful to his physical and psychological health. The person starts in the early twenties and increase the amount of alcohol intake and looses control despite all the harm in all the social, physical, psychological and occupational harm. 2

3 The alcohol withdrawal syndrome Occurs with various severity depending on the amount and duration of drinking. The symptoms appear when the patient reduces or stops drinking. They appear early in the morning therefore they have early morning drinking. He becomes more secretive about drinking, hides bottles and does not declare the amount he drinks. They develop tremor the shakes, restlessness, startle and avoids facing people. Nausea, retching, and sweating are common. Insomnia is common and all those symptoms disappear when he drinks. The withdrawal continues and if the patient is not treated or he drinks so he develops misperception and hallucinations. Perceptions are distorted and things become distorted, frightening or funny and sounds become louder. Patient might develop withdrawal seizures & if lasted 48 hours develop delirium tremens. Complications related to alcohol: There are many complication including: Physical complications: o Gastritis, peptic ulcer, esophageal varices and acute and chronic pancreatitis. o Fatty infiltration of the liver, hepatitis, cirrhosis and hepatoma. o Peripheral neuropathy, epilepsy, and cerebellar degeneration. o Dementia and head injuries. o Misuse is associated with hypertension and increased risk of stroke. o The association with ischemic heart disease is controversial. o Misuse is also linked to development of cancers of mouth, pharynx, esophagus, liver, and breast. o It might lead to amenorrhea, anovulation and menopause. o Fetal alcohol syndrome: facial abnormality, small stature, low birth weight, low intelligence and overactivity. o Idiosyncratic alcohol intoxication occurs with a small amount of alcohol consumption and marked by aggression. o Memory blackouts and short term amnesia o Delirium tremens Occurs in people after prolonged and heavy drinking. The patient stops drinking or reduces the amount and develops this condition. Clouding of consciousness, disorientation, impairment of recent memory, illusions and hallucinations, agitation, restlessness, Insomnia, tremor and fumbling with things, sweating, tachycardia, fever, and raised blood pressure, dilated pupils, electrolyte disturbance, leucocytosis and impaired liver function. It is worse at night and there is high risk of mortality. The patient forgets all the condition after recovery. Other psychiatric complications : o Alcoholic dementia o Personality deterioration o Mood and anxiety disorders o Suicidal behaviour ( more in young men, impulsivity, negative affect, and hopelessness) o Morbid jealousy o Alcoholic hallucinosis Social complications: o Marital and family problems o Occupational difficulties o Road traffic accidents o Violation of law 3

4 Etiology There are many theories regarding etiology and could be divided into individual and society factors. Individual factors: o Genetic factors The condition runs in families, more in monozygotic twins than dizygotic twins, and adoption studies. Genes for alcohol dependence are controversial & it is believed that those with genetically impaired activity of alcohol metabolizing enzyme are at lower risk of becoming dependents. Mutations in aldehyde dehydrogenase gene is another theory rendering enzyme inactive. Other suggestions included dopamine D2 receptor and GABA receptor association. o Other biological factors Abnormalities that antedate and predict the development of alcohol dependence including impaired performance on cognitive tasks especially executive function. Sons of alcohol dependent men are less sensitive to the acute intoxicating effect of alcohol. o Learning factors Modelling has been proposed but is not always true. Reward dependence: the ability of alcohol to give pleasure and reduce anxiety and release of dopamine in the mesolimbic pathways o Personality factors Those with chronic anxiety, antisocial personality and those with traits that lead to risk taking and novelty seeking. o Psychiatric disorders Chronic anxiety, social phobia, panic disorder, major depressive disorder, bipolar disorder and schizophrenia. Societal factors o This is related to general consumption of the people in the society, economic control, formal and informal control Treatment There are tests to detect alcohol dependence: o Gamma-glutamyl-transpeptidase GGT o Mean corpuscular volume (MCV) o Carbohydrate-deficient- transferrin o Blood alcohol concentration Approach to treatment of alcohol misuse: o Raise awareness of the problem o Increase motivation to change o Support and advice. o Withdraw alcohol ( or controlled drinking) (controversial) o High intensity psychological treatments. o Alcoholic Anonymous o Medication (disulfiram, acomprosate) o Drinking history is taken properly o Assessment of the physical, psychological and social problems. o Assess factors that precipitate and maintain excessive drinking o Avoid confrontation o Involve partners in the assessment 4

5 Hospitalization is necessary o Medications used for detoxification: o Chlordizepoxide and lorazepam o Carbamazepine o Chlormethiazole o Antipsychotics with benzodiazepines o Vitamin supplements History of DTs o Very high alcohol consumption o Concomitant benzodiazepine misuse o Medical or psychiatric comorbidity Other substance related disorders The etiology is multifactorial: Availability of drugs: o Legally without prescription o Prescription from doctors o Illicit sources Personal factors: o Broken homes, poor schools record, truancy or delinquency, traits as sensation seeking and impulsivity. o History of mental illness or personality disorder in the family. o Genetic factors to develop harmful use or dependence. Social environment: o Substance use by peers or parents, social deprivation, unemployment and homelessness. Pharmacological factors: o Drugs have a positive reinforcing property by inducing euphoria or reduce anxiety. They act on the dopamine pathway in the midbrain. These pathways form part of physiological reward system. o Dependence occurs when the patient develop tolerance or has withdrawal symptoms. Patient has desire to drink and a drug seeking behaviour o Craving and dysphoria is associated with altered brain function. o Continued use of drugs lead to adaptive changes in GABA neurotransmission and this explains the need to increase the intake to produce the same pharmacological effect. Complications of drug misuse The direct physical complications include intravenous drug might lead to HIV infection and hepatitis and death from heroin overdose. There are risks of fetal abnormalities and become dependent on the drugs. Infants develop withdrawal symptoms and are usually neglected. Psychiatric disorders might be comorbid with substance related disorder such as personality disorder, depression, anxiety disorders. The symptoms of those disorders might be result of drug misuse or the misuse could be secondary to those disorders as self medication. Social complications include Unemployment, motoring offences, traffic accidents, family problems and neglect of children. They commit offences to obtain drugs, solicit it by prostitution or create gangs to obtain the drugs illegally. 5

6 Diagnosis It is necessary to take a proper drug history from the patient with external verification whenever possible. We should look for signs of needle tracks, thrombosed veins and scars. We must observe job decline, social isolation and new friends from drug culture. The patient might present with medical problems that he tries to hide being due to dependency on drugs such as colic, muscle pain, cellulitis, pneumonia, accidents, withdrawal symptoms or adverse reaction to hallucinogenic drugs. Laboratories need to be equibbed with facilities to test for substances in the urine, blood, saliva and hair according to the level of services in that area. Prevention It is important to make the youth the focus of all the measures. Restricting the availability of substances Reduction of overprescribing of medication Education at schools and mass media Dealing with family problems Lessening social deprivation Targeting the homeless, truant and street children Treatment The aim of the treatment varies according to the patient and availability of resources. Withdrawal and detoxification alone has no long term effect. The treatment setting could be at home or in a special unit in the hospital. We should aim at harm reduction therefore, we might let the pt continue with substance aiming at minimum harm. The work needs recruiting all the available resources in the hospital and community. Social workers, psychologists, psychotherapists, councilors and key workers all have a share in process. Rehabilitation aims at abandoning the drug culture and be involved in new friendships. Patients could transferred to hostels or therapeutic communities. Misuse of opioids This group includes morphine, heroin, codeine, pethidine,and methadone. They have analgesic, anxiolytic and euphoriant effect. Many people use opioids but only some of them become dependent on it. Routes of misuse include Intravenous Subcutaneous Sniffing or snorting Inhalation Clinical effect Euphoria, analgesia, respiratory depression Constipation, anorexia, low libido. Tolerance occurs with continued use but diminishes rapidly when the use is stopped leading to intoxication with reintake of the substance. 6

7 Withdrawal Craving Restless and insomnia Pain in the muscles and joints Running nose and eyes Abdominal cramps, vomiting and diarrhea Piloerection sweating, dilated pupils and tachycardia Thermodysregulation The symptoms start six hours after the last dose and peak in hours and then decrease in intensity. Withdrawal causes distress but is not dangerous Methadone which is used as a replacement in some patients, has a longer half life, therefore the symptoms of withdrawal appear after 36 hours and peak in 3-5 days. Some studies revealed that 50% of users are abstinent after 10 years of follow up. Death occurs from accidental overdose, suicide and infections such as hepatitis and HIV. Employment, marriage and change of life circumstances help better prognosis. Detoxification This could be done jointly with the patient and relatives. It could be rapid or slow according to the severity 4 weeks of inpatient or 12 weeks of outpatient. Close personal contact is needed Loperamide or metoclopramide for GI symptoms. NSAID as analgesics. Lofexidine as α2 agonist Methadone if necessary Buprenorphine as partial agonist Rapid detoxification is done with Naltrexone with sedation or with general anesthesia. Misuse of anxiolytic and hypnotics Includes benzodiazepines, barbiturates They act by enhancing the inhibitory brain GABA and binding to BDZ receptors. Benzodiazepines Withdrawal symptoms include the following: o Anxiety, irritability, sweating, tremor and insomnia o Altered perception- depersonalization,derealization, hypersensitivity to stimuli, abnormal body sensations and abnormal sensation of movements. o Others: depression, suicidal behavior, seizures and DTs. These drugs were very popular in the 1970s and 1980s They were prescribed by doctors and abused by the youth and anxious people. The use has declined because of the availability of other drugs. A significant proportion of people are dependent on alcohol and benzodiazepines. The dependent patients use them because of euphoriant and calming effect. Availability of these drugs leads to their dependence. Many of the pts who are prescribed these drugs may continue using them and become dependent on them. 7

8 Treatment Is by gradual reduction of the drug Counseling and support Cannabis The active substance is tetrahydrocannabinl. (THC) There are cannabinoid receptors in the CNS. Also called marijuana or grass. Intermittent use of cannabis is common in North America and Europe and about 2.7% in one survey met the criteria of dependence. Clinical effects Increased enjoyment of aesthetic experiences, distortion of the perception of time and space Red eyes, dry mouth, tachycardia, irritating cough Dangerous driving Adverse effects Irritation of the respiratory tract and carcinogenic Anxiety Paranoid ideation Toxic confusional states Psychosis in clear consciousness Cannabis can modify the course of schizophrenia Users are more likely to experience psychotic episodes and relapse Users are more likely to develop schizophrenia than nonusers Teenagers might develop mood disorders, poor educational performance and poly drug abuse Stimulants Amphetamine Clinically used for the treatment of attention deficit hyperactivity disorder ADHD and Narcolepsy Acts by the release and blocking reuptake of Noradrenaline and Dopamine It is used as a street drug with the name of speed or whiz. Taken orally, smoking, intravenously and snorting Clinical effects o Talkativeness, overactivity, insomnia, dryness of the mouth,lips and nose with anorexia o Dilatation of the pupils, tachycardia and hypertension o Larger doses cause arrhythmias, severe hypertension, CVA and shock. o Higher doses cause seizures and coma. o Psychiatric effect include: Dysphoria, irritability, insomnia, confusion & acute paranoid psychosis. Tolerance develops and dependents need to take higher doses. Withdrawal symptoms (crash) : include depression, fatigue, tremor, lethargy, nightmares, suicidal ideation and intense craving. 8

9 Treatment of overdose includes sedation, antipsychotics and control of arrhythmias and hyperpyrexia Chronic use leads to amotivational state and apathy. Withdrawal leads to irritability, nausea, insomnia and anorexia. Psychosocial intervention is used for management. Withdrawal symptoms are managed by psychological and social interventions as well as benzodiazepines. Cocaine Is a stimulant drug with strong dependence It blocks the reuptake of dopamine into the presynaptic nerve terminals and activates reward system Used as injection, smoking and sniffing into the nostrils that might perforate the nasal septum. Crack is a street drug with a very rapid onset of action. Clinical effects include: o Excitement, increased energy, euphoria o Grandiose thinking, impaired judgment, sexual disinhibition, hallucinations, paranoid ideation and aggressive behavior. o Formication cocaine bugs o Tachycardia, hypertension, cardiac arrhythmias, dilated pupils, MI and cardiomyopathy Withdrawal crash include: o Dysphoria, anhedonia, anxiety, irritability, fatigue and hypersomnolence o Craving and suicidal ideation Treatment is by social and psychological support with benzodiazepines. MDMA (Ecstasy) 3,4 methylenedioxymethamphetamine Is both a stimulant and hallucinogenic It releases dopamine and 5HT Causes euphoria, sociability and intimacy. Leads to anorexia, bruxism, sweating, and tachycardia. Hyperthermia might dangerous and death might occur due to arrhythmias or stroke. Prolonged use leads to acute and chronic paranoid psychosis Hallucinogens Lysergic acid diethylamide (LSD) Is the most encountered member of this group Magic mushroom is used too. They act as partial agonists of 5-HT₂A receptors Initially cause sympathetic activity as tachycardia, hypertension, and dilated pupils. The effect starts 2 hours after consumption and lasts 8-14 hours. There s distortions or intensification of sensory perception Synaesthesia: confusion between sensory modalities e.g. sounds being received as visual. Passage of time is slowed and experiences seem to have profound meaning Distressing of body image They may become dangerous and kill themselves Tolerance occurs but withdrawal does not and dependence is rare. 9

10 Volatile substances (solvents,inhalants) A group of organic substances They could increase brain GABA function Used by youth, homeless and in gangs Includes solvents, adhesives, petrol, cleaning fluid, aerosols, fire extinguishers, toluene and acetone They are inhaled from top of bottles, clothes, plastic bags, and sprays. Cause stimulation of CNS and then depression and possible hallucinations Toxic effects include peripheral neuropathy, encephalitis and dementia 10