ADDICTIONS Mine Özmen, M.D. University of İstanbul Cerrahpaşa School of Medicine Department of Psychiatry
Addictions-terminology drug abuse drug dependence drug addiction intoxication withdrawal tolerance
abuse A maladaptive pattern of substance use resulting in repeated problems and adverse consequences e.g., use in hazardous situations, legal, social, occupational problems
Dependence Psychological or physical need to continue taking the substance. Psychological dependence: (habituation)continuous or intermittent craving for the substance Physical dependence: tolerance, a need to take the substance to prevent the occurrence of a withdrawal or abstinence syndrome
intoxication Maladaptive behavior associated with recent drug ingestion The effects of intoxication of any drug can vary widely among persons and depend on such factors as dose, circumstances, and underlying personality
Withdrawal Psychoactive substance specific syndrome following cessation of heavy use implies tolerance and indicates dependence
tolerance Need for more of a substance to become intoxicated or, the same amount of drug producing decreased effect with continued use
Alcohol dependence 14% of lifetime prevalence men are at more risk (4/1) 47% of alcoholics have another comorbid psychiatric disorder onset is in late teens, insidious course, recognition in 30s urban area, divorced, separated, lowest in middle social groups
Alcohol related disabilities-cns withdrawal symptoms delirium tremens alcoholic hallucinosis Wernicke-Korsakoff syndrome alcoholic dementia seizures cerebellar degeneration
Alcohol related disabilitiesother Psychiatric; suicide, homicide, sexual Respiratory; carcinoma, pneumonia, tbc reactivation Cardiovascular; cardiomyopathy, poorly controlled HTN Gastrointestinal; oesophagitis, esophageal rupture, peptic ulceration, carcinoma, pancreatitis, diabetes mellitus.
Alcohol related disabilities Liver damage; alcoholic hepatitis, cirrhosis Hematological; anemia (iron deficiency, absorption, blood loss, nutritional deficiency, malabsorbtion) Neoplasm; orofacial, GI, respiratory social disabilities
Alcohol dependence-etiology Childhood history: deficits on neurocognitive testing, blunted effect of alcohol in high risk offspring, EEG abnormalities, attention deficit/hyperactivity disorder or conduct disorder, personality disorders (esp.antisocial)
Alcohol dependence Psychoanalytic factors: fixation at the oral stage, punitive superego, shy, isolated, impatient, irritable, anxious, hypersensitive, sexually repressed persons superego is soluble in alcohol May be abused to reduce tension, anxiety,and psychic pain Alcohol consumption may lead to a sense of power and increased self-worth
Alcohol dependence-etiology Social and cultural factors: social settings (college dormitories, military bases), cultural, ethnic, religious factors Behavioral & learning factors: parental drinking habits, positive reinforcing aspects of alcohol (induces feeling of well being and euphoria, reduces fear & anxiety)
Alcohol dependence-etiology Genetic and other biological factors: heritability in males is stronger, 3-4 times more likely to have alcohol related disorder if first degree relative has alcohol related disorder, higher concordance in monozygotic twins, may be associated with D2 receptors, pathology in the reward mechanisms involving the ventral tegmental area and the nucleus accumbens)
Physiological effects of alcohol A single drink increases blood alcohol level of a 150-pound man 15-20mg/dl, which on average can be metabolized in one hour 90% metabolized through oxidation in the liver, 10% excreted by kidneys & lungs Metabolized by alcohol dehydrogenase, and aldehyde dehydrogenase (ADH), ADH is inhibited by disulfiram (antabuse) which is used in the treatment of alcohol dependence
Alcohol withdrawal May be aggravated by fatigue, malnutrition, physical illness, depression Tremulousness (after 6-8 hours) General irritability, gastrointestinal symptoms (nausea, vomiting) Seizures and autonomic hyperactivity (anxiety arousal, sweating, facial flushing, mydriasis, tachycardia, mild hypertension) Psychotic or perceptual symptoms
drug dependence occurs all segments of all societies adolescents and men are at more risk results in decreased performance, accidents, health problems, criminal behavior difficult to detect frequently comorbid with other psychiatric disorders
Causes of drug misuse Availability of drugs (10% of those who experiment will go on to develop problems, legally bought drugs-nicotine-, prescriptions, - benzodiazepin-, street drugs ) A vulnerable personality (disrupted families, sensation seeking & impulsivity, depression & anxiety) Adverse social environment (social pressures, unemployment, homelessness)
Patterns of psychoactive drug use experimental use social-recreational use circumstantial-situational use intensified use compulsive use
Neurobiology of drug dependence Positive reinforcers Midbrain dopamine system (ventral tegmental area-forebrain esp nucleus accumbens) Tolerance and withdrawal may be associated with neuroadaptive changes in brain (alcohol and benzodiazepins enhance GABA functions)
lifetime risk 0.7 % opioids opium, morphine, methadon, codeine mostly abused by patients of lower socioeconomic status
sedatives, hypnotics and anxiolytics most commonly prescribed drugs lifetime prevalence 1.1% dependence develops after at least several months of use
stimulants amphetamines and amphetamine-like substances extremely addictive and dangerous used to increase performance & induce euphoria abused by students, long distance truck drivers etc.
cocaine effects are similar to other stimulants Elation, euphoria, heightened self-esteem, perceived improvement on mental & physical tasks risk of dependency after one dose! iv use is associated with other risks; AIDS, septicemia, venous trombus rhinitis, nosebleeds, perforated nasal semptum
cannabis (marijuana) usually smoked, may be eaten gateway drug
Caffeine present in coffee, tea, chocolate, cola and other carbonated beverages, cold medications, over-the-counter stimulants An average cup of coffee contains 150mg of caffeine high doses may increase symptoms of psychiatric disorders
nicotine dependence develops rapidly and strongly affected by environmental conditioning associated with medical diseases