Substance abuse/drug abuse is not limited to mood-altering or psycho-active drugs. If an activity is performed using the objects against the rules and policies of the matter (as in steroids for performance enhancement in sports), it is also called substance abuse. Therefore, mood-altering and psychoactive substances are not the only types of drugs abused
Tolerance: is the need to increase a dose to achieve the desired effect. cross tolerance: i.e. development of tolerance to a drug to which the person has never been exposed, because it contains characteristics similar to those of a drug for which tolerance has developed.
Crack cocaine is the freebase form of cocaine that can be smoked MDMA (3,4-methylenedioxy-N-methylamphetamine
The main route of intake is by inhalation as it undergoes rapid first pass liver metabolism.
Acute harmful effects include arrhythmias, intense anxiety, hypertension and CVA and impaired judgement. Psychic dependence is produced. No tolerance. No physical dependence.
Cocaine overdose can cause death secondary to cardiac arrhythmia , seizure or respiratory depression .
There is chemical similarity to noradrenaline and dopamine, producing similar pharmacological effects to cocaine, but its slower metabolism gives a longer duration of action. Intravenous administration , pill, smoked Acute harmful effects include tachycardia, arrhythmias, hyperpyrexia. Irritability, post-use depression, and quasi-psychotic state with visual, auditory, and tactile hallucinations. Anxiety and depressive symptoms are frequently seen in users w/ psychological dependence.
They have therapeutic uses as anxiolytics, hypnotics, anti-convulsants, and muscle relaxants. All have similar effects and are distinguished by their length of action: short-acting (e.g. temazepam, oxazepam), medium-acting (e.g. lorazepam, alprazolam), long-acting (e.g. diazepam, nitrazepam, chlordiazepoxide). They enhance GABA transmission and produce marked anxiolytic and euphoriant effects.
The opiates are a group of chemicals derived from the opium poppy ; synthetic compounds with similar properties are called opioids. Have potent analgesic , euphoriant and anxiolytic properties. Heroin is the most frequently abused opiate. These include also dihydrocodeine, morphine, methadone, pethidine, buprenorphine, and codeine.
Classic triad of opioid overdose: Respiratory depression Altered mental status Miosis “Rebels Admire Morphine
α2 adrenergic agonist. a semi-synthetic opioid
The forcing of a fluid into the conjuctiva, the mucous membrane that lines the eyelids.
5th year medical student
• Substance abuse is significant problem for
the society and healthcare system all over
the world .
• Substance abuse is a patterned use of a
substance (drug) in which the user consumes
the substance in amounts or with methods
neither approved nor supervised by medical
DIAGNOSIS AND DSM-IV CRITERIA
Abuse is a pattern of substance use leading to impairment
or distress for at least 1 year with one or more of the
following manifestations :
1. Failure to fulfill obligations at work, school, or home
2. Use in dangerous situations (i.e., driving a car)
3. Recurrent substance-related legal problems
4. Continued use despite social or interpersonal problems
due to the substance use
Dependence refers to the state of
needing a drug(s) or substance(s) to
function within normal .
DIAGNOSIS AND DSM-IV CRITERIA
Dependence is substance use leading to impairment or
distress manifested by at least three of the following within a
12-month period :
3. Using substance more than originally intended
4. Persistent desire or unsuccessful efforts to cut down on use
5. Significant time spent in getting, using, or recovering from
6. Decreased social, occupational, or recreational activities
because of substance use
7. Continued use despite subsequent physical or psychological
problem (e.g., drinking despite worsening liver problems)
• Psychological dependence:
Crave for taking the drug or substance is
need → mild desire → craving → compulsion.
• Physical dependence
It is adaptation at the cellular level to drugs such
that when the drug is abruptly stopped , there is
a characteristic withdrawal or abstinence
A diagnosis of substance
dependence supersedes a
diagnosis of substance abuse.
The development of a substance-specific
syndrome due to the cessation of
substance use that has been heavy and
The need for increased amounts of the
substance to achieve the desired effect
or diminished effect if using the same
amount of the substance
• Lifetime prevalence of substance abuse or
dependence in the United States:
• More common in men than women
• Caffeine, alcohol, and nicotine are the most
commonly used substances.
• Depressive symptoms are common among
persons with substance abuse or
Categories of drugs
• Stimulants e.g. amphetamine, cocaine .
• Depressants e.g. benzodiazepines ,
barbiturates, alcohol, GHB.
• Opiates e.g. heroin, methadone, codeine,
buprenorphine , pethidine.
• Hallucinogens e.g. LSD, PCP, mushrooms,
• Others e.g. cannabis, volatile substances,
• These drugs potentiate neuro-transmission and
increase cortical excitability producing effects of
increased alertness and endurance, diminished
need for sleep, and a subjective sense of wellbeing.
• Include cocaine (and crack cocaine),
amphetamines, MDMA or (ecstasy), and
Cocaine blocks dopamine reuptake from the
synaptic cleft, causing a stimulant effect.
Dopamine plays a role in behavioral
reinforcement (“reward” system of the
Cocaine intoxication often produces
euphoria, increased or decreased blood
pressure, tachycardia or bradycardia,
nausea, dilated pupils, weight loss,
psychomotor agitation or depression,
chills, and sweating.
It may also cause respiratory depression,
seizures, arrhythmias, and hallucinations
Since cocaine is an indirect sympathomimetic,
intoxication mimics the fight-or-flight response.
• Cocaine’s vasoconstrictive effect may result in
myocardial infarction (MI) or cerebrovascular
• Chronic harmful effects include necrosis of nasal
septum, foetal damage, panic and anxiety disorders,
persecutory delusions, and psychosis.
• No tolerance.
• No physical dependence.
Amphetamine or phencyclidine (PCP)
intoxication, sedative withdrawal
Urine drug screen (positive for 3 days,
longer in heavy users)
1. For mild-to-moderate agitation: Benzodiazepines
2. For severe agitation or psychosis: Haloperidol
3. Symptomatic support (i.e., control hypertension,
1. Psychotherapy, group therapy
2. Tricyclic antidepressants (TCAs)
3. Dopamine agonists (amantadine, bromocriptine)
Abrupt abstinence is not life threatening but
produces a dysphoric “crash”: malaise, fatigue,
depression, hunger, constricted pupils, vivid
dreams, psychomotor agitation or retardation .
Usually supportive—let patient sleep off crash.
Classic amphetamines: Dextroamphetamine (Dexedrine),
methylphenidate (Ritalin), methamphetamine (Desoxyn, ice,
speed, “crystal meth,”“crack”)
Substituted (“designer”) amphetamines: MDMA (ecstasy),
Classic amphetamines release dopamine from nerve endings,
causing a stimulant effect. They are used medically in the
treatment of narcolepsy, attention deficit hyperactivity
disorder (ADHD), and depressive disorders.
Designer amphetamines release dopamine and serotonin
from nerve endings and have both stimulant and
Amphetamine intoxication causes symptoms
similar to those of cocaine.
Cocaine or PCP intoxication. Chronic use in
high doses may cause a psychotic state
that is similar to schizophrenia.
Urine drug screen (positive for 1 to 2 days). A negative
routine drug screen does not rule out amphetamine use,
since most assays are not of adequate sensitivity.A
negative drug screen can never completely rule out
substance abuse or dependence.
Similar to cocaine
Similar to cocaine withdrawal
• Drugs of this group produce their effects by
generalised or specific cortical depression.
• They include the benzodiazepines, alcohol, and
• They are taken for their anxiolytic and relaxant
properties alone, or as a way of counteracting
unpleasant side-effects of other drugs of abuse.
• These drugs are highly abused in the United
States since they are more readily available than
other drugs such as cocaine or opioids.
Benzodiazepines (BDZs) are commonly used in the
treatment of anxiety disorders and are therefore
obtained easily via prescription. They potentiate the
effects of GABA by increasing the frequency of
chloride channel opening.
Barbiturates are used in the treatment of epilepsy
and as anesthetics, and they potentiate the effects
of GABA by increasing the duration of chloride
channel opening. At high doses they act as direct
GABA agonists and have a lower margin of safety
relative to BDZs.
In combination BDZs and barbiturates are
synergistic due to their complementary
effect on GABA channel opening.
Respiratory depression can occur as a
• Intoxication with sedatives produces drowsiness,
slurred speech, incoordination, ataxia, mood lability,
impaired judgment, nystagmus, respiratory
depression, and coma or death in overdose
(especially barbiturates). Symptoms are augmented
when combined with EtOH.
Long-term sedative use causes dependence.
• Tolerance develops rapidly (with cross tolerance to all
drugs in the benzodiazepine group & with
barbiturates), so requiring increasing doses to achieve
Alcohol intoxication, generalized cerebral
dysfunction (i.e., delirium)
Urine or serum drug screen (positive for 1
week), electrolytes, electrocardiogram
Maintain airway, breathing, and circulation.
Activated charcoal to prevent further gastrointestinal
• For barbiturates only: Alkalinize urine with sodium
bicarbonate to promote renal excretion.
• For benzodiazepines only: Flumazenil in overdose
• Supportive care—improve respiratory status, control
Abrupt abstinence after chronic use can be life threatening.
While physiological dependence is more likely with shortacting agents, longer-acting agents can also cause withdrawal
Symptoms of autonomic hyperactivity (tachycardia, sweating,
etc.), insomnia, anxiety, tremor, nausea/vomiting, delirium,
and hallucinations. Seizures may occur and can be life
Administration of a long-acting benzodiazepine such as
chlorodiazepoxide or diazepam, with tapering of the dose
Tegretol or valproic acid may be used for seizure control.
Examples: Heroin, codeine, dextromethorphan,
morphine, methadone, meperidine (Demerol).
These compounds stimulate opiate receptors
(mu , kappa, and delta), which are normally
stimulated by endogenous opiates and are
involved in analgesia, sedation, and
dependence. Opiates also have effects on the
dopaminergic system, which mediates their
addictive and rewarding properties. Endorphins
and enkephalins are endogenous opiates.
Opiate intoxication causes drowsiness, nausea/vomiting, constipation,
slurred speech, constricted pupils, seizures, and respiratory
depression, which may progress to coma or death in overdose.
Meperidine and monoamine oxidase inhibitors taken in combination
may cause the serotonin syndrome: Hyperthermia, confusion,
hyper- or hypotension, and muscular rigidity.
Sedative-hypnotic intoxication, severe EtOH intoxication
Rapid recovery of consciousness following the administration of
intravenous (IV) naloxone (opiate antagonist) is consistent with
opiate overdose. Urine and blood tests remain positive for 12 to 36
Ensure adequate airway, breathing, and circulation.
Administration of naloxone or naltrexone (opiate antagonists) will
improve respiratory depression but may cause severe
withdrawal in an opiate-dependent patient. Ventilatory support
may be required.
Oral methadone once daily, tapered over months to years
Psychotherapy, support groups (Narcotics Anonymous, etc.)
While not life threatening, abstinence in the opiatedependent individual leads to an unpleasant withdrawal
syndrome characterized by dysphoria, insomnia,
lacrimation, rhinorrhea, yawning, weakness, sweating,
piloerection, nausea/vomiting, fever, dilated pupils, and
Moderate symptoms: Clonidine and/or buprenorphine
Severe symptoms: Detox with methadone tapered over 7
• Hallucinogens (or psychedelics) are a
heterogeneous group of natural and synthetic
substances which produce altered sensory and
• They include: lysergic acid diethylamide (LSD),
phenylcyclidine (PCP), ketamine, mescaline and
Pharmacological effects vary, but LSD is
known to act on the serotonergic system.
Tolerance to hallucinogens develops
quickly but reverses rapidly after
cessation. Hallucinogens do not cause
physical dependence or withdrawal.
Hallucinogens cause perceptual changes,
papillary dilation, tachycardia, tremors,
incoordination, sweating, and palpitations.
Guidance and reassurance (“talking down”
the patient) are usually enough. In severe
cases, antipsychotics or benzodiazepines
may be used.
No withdrawal syndrome is produced, but
patients may experience “flashbacks” later
in life (recurrence of symptoms due to
reabsorption from lipid stores).
PCP, or “angel dust,” is a hallucinogen that
(NMDA) glutamate receptors and activates
Ketamine is similar to PCP. Both were
developed as anesthetic agents.
Intoxication with PCP causes recklessness,
impulsiveness, impaired judgment, assaultiveness,
rotatory nystagmus, ataxia, hypertension,
tachycardia, muscle rigidity, and high tolerance to
pain. Overdose can cause seizures or coma.
• Monitor blood pressure, temperature, and
• Acidify urine with ammonium chloride and ascorbic
• Benzodiazepines or dopamine antagonists to
control agitation and anxiety
• Diazepam for muscle spasms and seizures
• Haloperidol to control severe agitation or psychotic
Acute psychotic states, schizophrenia
Urine drug screen (positive for > 1 week). Creatine
phosphokinase (CPK) and aspartate
aminotransferase (AST) are often elevated.
No withdrawal syndrome, but “flashbacks” may
The main active component in marijuana, or
cannabis, is THC (tetrahydrocannabinol).
Cannabinoid receptors in the brain inhibit
adenylate cyclase. Effects are increased
when used with EtOH.
Marijuana has been shown to successfully treat
nausea in cancer patients and to increase
appetite in AIDS patients
No dependence or withdrawal syndrome has
Marijuana causes euphoria, impaired coordination, mild
tachycardia, conjunctival injection, dry mouth, and
Marijuana can be smoked or eaten.
Supportive and symptomatic
Urine drug screen is positive for up to 4 weeks in heavy
users (released from adipose stores).
No withdrawal syndrome, but mild irritability,
insomnia, nausea, and decreased appetite
may occur in heavy users.
Supportive and symptomatic
Examples: Solvents, glue, paint thinners, fuels, isobutyl
nitrates (“rush,” “locker room,” “bolt”). Inhalants generally
act as CNS depressants. User is typically an adolescent
Inhalants may cause impaired judgment, belligerence,
impulsivity, perceptual disturbances, lethargy, dizziness,
nystagmus, tremor, muscle weakness, hyporeflexia, ataxia,
slurred speech, euphoria, stupor, or coma. Overdose may
be fatal secondary to respiratory depression or
arrhythmias. Long-term use may cause permanent
damage to CNS, peripheral nervous system (PNS), liver,
• Monitor airway, breathing, and circulation.
• Symptomatic treatment as needed
• Psychotherapy and counseling for dependent patients
Serum drug screen (positive for 4 to 10 hours)
A withdrawal syndrome does not usually occur, but
symptoms may include irritability, nausea, vomiting,
tachycardia, and occasionally hallucinations.
Caffeine is the most commonly used
psychoactive substance in the United
States, usually in the form of coffee or tea.
Caffeine acts as an adenosine antagonist,
causing increased cyclic adenosine
monophosphate (cAMP) and a stimulant
effect via the dopaminergic system.
Intoxication may occur with consumption of over 250
mg of caffeine. Signs and symptoms include
anxiety, insomnia, twitching, rambling speech,
flushed face, diuresis, gastrointestinal disturbance,
and restlessness. Consumption of more than 1
gram of caffeine may cause tinnitus, severe
agitation, and cardiac arrhythmias. In excess of 10
g, death may occur secondary to seizures and
Supportive and symptomatic
Withdrawal symptoms resolve within 1 week and
include headache, nausea/vomiting, drowsiness,
anxiety, or depression.
Taper consumption of caffeine-containing
products. Use analgesics to treat headaches.
Rarely, a short course of benzodiazepines may
be indicated to control anxiety.
Nicotine is derived from the tobacco plant and
stimulates nicotinic receptors in autonomic
ganglia of the sympathetic and parasympathetic
Cigarette smoking poses many health risks, and
nicotine is rapidly addictive through its effects on
the dopaminergic system.
Nicotine acts as a CNS stimulant and may cause
restlessness, insomnia, anxiety, and increased
gastrointestinal motility. Tobacco users report
improved attention, improved mood, and
Withdrawal causes intense craving, dysphoria,
anxiety, increased appetite, irritability, and
Smoking cessation with the aid of:
1. Behavioral counseling
2. Nicotine replacement therapy (gum, transdermal
3. Zyban—antidepressant that helps reduce
Relapse after abstinence is common.
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HD, eds. Textbook of Substance Abuse Treatment. 3rd ed. Washington,
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