2nd part

1. Substance Use Disorder
Addiction (DSM 5)
By
Soheir H. ElGhonemy
Assist. Professor of Psychiatry- Ain Shams University- Egypt
Member of International Society of Addiction Medicine
Member of European and American Psychiatric Associations
Trainer Approved by NCFLD

3. Dopamine Pathways
Functions
•reward (motivation)
•pleasure,euphoria
•motor function
(fine tuning)
•compulsion
•perserveration
•decision making
Serotonin Pathways
Functions
•mood
•memory
processing
•sleep
striatum
hippocampus
nucleus
accumbens
frontal
cortex
substantia
nigra/VTA
raphe

4. Medial Forebrain Bundle
 Ventral tegmental area (VTA)
 (Lateral) hypothalamus (LH)
 Nucleus accumbens (NAc)
 Frontal cortex (FC) - key portions
 Prefrontal cortex (pfc)
 Orbitofrontal cortex (ofc)

5. Drugs Associated wth
Neurotransmitters
 Why do people have “drugs of choice”?
 Dopamine - amphets, cocaine, alcohol
 Serotonin - LSD, alcohol
 Endorphins - opioids, alcohol
 GABA - benzos, alcohol
 Glutamate -alcohol
 Acetylcholine - nicotine, alcohol

6. A Brain Chemistry Disease!
 Addicting drugs seem to “match” the
transmitter system that is not normal
 A chronic, relapsing, medical disease
 There are mild, moderate, and severe forms
 Detox is traditionally the first step in the
total treatment process
 Methadone and nicotine maintenance is
evidence that some people require a
chemical to overcome the non-normal
transmitter system

7. Figure 5

8. The combination of neuroadaptations in the brain
circuitry for the three stages of the addiction cycle
that promote drug-seeking behavior in the
addicted state.
Activation of the ventral striatum/dorsal
striatum/extended amygdala driven by cues
through the hippocampus and basolateral
amygdala and stress through the insula.
The frontal cortex system is compromised,
producing deficits in executive function and
contributing to the incentive salience of drugs
compared to natural reinforcers.
Dopamine systems are compromised, and brain
stress systems such as CRF are activated to
reset further the salience of drugs and drug-related
stimuli in the context of an aversive
dysphoric state

10. Common Underlying Neurobiological
Factors Can Be
 Neurochemical (imbalance of
neurotransmitters)
 Structural/anatomical (same
regions and pathways)
 Genetic (inherited factors that
compromise function)

11. Drug Disorder
Cocaine and Methamphetamine Schizophrenia, paranoia,
anhedonia, compulsive
behavior
Stimulants Anxiety, panic attacks, mania
and sleep disorders
LSD, Ecstasy & psychedelics Delusions and hallucinations
Alcohol, sedatives, sleepaids
& narcotics
Depression and mood
disturbances
PCP & Ketamine Antisocial behavuor

12. DRUG USE
(Self-Medication)
What Role Does Stress Play
CRF
Anxiety
In Initiating Drug Use?
STRESS
CRF
Anxiety

13.  Consequence: There is no “cure”…
 To be successful, treatment is a Lifetime
Process
 Science is helping to improve our
strategies and successes

14. History Taking

15. The history is the chronological story of the
patient’s life from birth to present
Personal data:
Name, age, sex, marital status, religion,
address, occupation, education.
n.b.; source of referral could be mentioned
here if the patient won’t cooperate

16. Personal History:
Birth and developmental milestones, family
atmosphere, school performance and general
conduct in school, educational achievement,
occupational history, sexual and marital history.
Attempt to correlate social problems with
evolving drug problems. Enquire about impact
of drug use on lifestyle.

17. Family History:
Brief vignette of father, mother and other
siblings should include age, occupation
and relation with the client. History of
psychiatric problems or problems
resulting from alcohol, drugs or nicotine.

18. Drug History:
This section should attempt to give a clear picture of
initiation of drug use accounting for each specific
drug. The evolution of drug use with the
development of personal and social problems as a
consequences of drug use.
Type, quantity, and route of use of each individual
drug. Alcohol consumption should be checked as a
routine part of drug history taking.

19.  Drug use in the past 24 hr.:
Detailed and sensitive questioning around this will not
only provide data about drug use and drug
dependence but should give a clear picture of the
client’s lifestyle and daily stresses and strains.
 Drug use in the past month:
Should try to draw a picture of drug use over the past
4 weeks.
 History of abstinence:
Number of trials , how , duration of each and reason
for relapse.

20. Legal History:
Charges, convictions, imprisonments and
violent incidents.
Sexual and Marital History:
Sexual behavior and marital relation and if
extramarital relationships. Relation of sexual
or marital problems to drug use.
Occupational History:
Relationships of jobs and relations to drug
use. Current employment status.

21. Present life situation:
Family and social support. Non drug use
friends, leisure activities and
occupational prospects, financial status
and accommodations.

22. Mental state examination:
 On admission:
Describe relevant features. Positive and
negative findings regarding both physical
and mental condition of the client. Focus
on physical signs of drug withdrawal, liver
diseases signs and any neurological
dysfunctions. Sites of injections and any
infections.

23. Mental state should include level of
consciousness, alertness and orientation and as
well as level of cooperativeness. Ability to give
history will provide data about their intelligence,
cognitive state and level of insight into their
condition.
General state of dress and grooming as well as
evidence of agitation, calmness or detachment
from problem should be checked.

24. Pattern of sleep, appetite, energy level,
mood state and suicidal ideations giving
data about special and general
psychological state.
Any delusions or hallucinations should
be considered and relation to client
intoxication or withdrawal states

25.  Follow up setting is meant for better
elaboration of the client’s condition and
allow building rapport for setting
management plan.
A thorough history is the substrate for a
considered opinion about the client. What is
the best for the client. History is cornerstone
in the substance abuse field.

26. Patient with treatment program:
Substance is being used.
Recent regular use.
Psychiatric status.
Medical condition.
Social network.
Legal aspects.

27. Goals of treatment:
A.Help the individual to be drug
free( detoxification).
B.Help to maintain drug free state (
relapse prevention)
C.Long term Rehabilitation.

28. Classification of substance:
I. CNS depressants:
 Alcohol
 Opiates
 Sedative hypnotics
II.CNS stimulants:
 Amphetamines
 Cocaine
III.CNS hallucinogens:
 Cannabis
 LSD
 Anticholinergics

29. Stimulation : Depression :
a. Anxiety .
b. Insomnia.
c. Twitches.
d. Convulsions.
e. Hyperthermia.
f. Tachycardia.
g. Irritability.
h. Excitement.
i. Tremors.
j. Hypertension.
k. Tachypnea
a. Apathy.
b. Retardation.
c. Inattentive.
d. Stupor.
e. Hypotension.
f. Bradypnea.
g. Ataxia.
h. Lethargy.
i. Drowsiness.
j. Confusion.
k. Hypothermia
l. Bradycardia &Coma.

30. Drugs of abuse that can be tested in urine:
Alcohol: 7-12 hrs.
Amphetamine : 48 hrs.
Barbiturate ; short: 24 hrs. , long acting:
3 wks.
Benzodiazepine: 3 days.
Cannabinoides : 3 days ---4 wks “ depending on
the use; chronic use leads to lengthening of
period”
Cocaine : 6- 8 hrs.
Codeine : 48 hrs.
Heroin : 36—72 hrs.
Methadone : 3 days.
Morphine : 48 – 72 hrs

31. The Neuropharmacology of Drugs of
Abuse
Psychoactive drugs alter normal neurochemical
processes . This can occur at any level of activity
including :
a. mimicking the action of a neurotransmitter .
b. altering the activity of a receptor .
c. acting on the activation of second messengers
d. directly affecting intracellular processes that control
normal neuron functioning.

32. Routes of administration:
It affects how quickly a drug reaches the
brain ,also ,chemical structure of a drug
plays an important role in the ability of a drug
to cross from the circulatory system into the
brain.
Four routes:
oral.
nasal.
Intravenous.
inhalation.

33. alcohol
Mild and moderate intoxication:
1.Impaired attention , poor motor coordination.
2.Dystharthria- ataxia , nystagmus, slurred
speech.
3.Prolonged reaction time, flushed face
orthostatic hypotension.
4.Hematemesis and stupor.
Pathological intoxication:
1.Excited , psychotic state following min.
consumption in susceptible individuals.
Intoxication associated with belligerence.

34. Uncomplicated Withdrawal:
 Coarse tremors of hands, tongue, eyelids and
at least one of the following:
 Nausea or vomiting.
 Malaise or weakness.
 Autonomic hyperactivity.
 Anxiety, Depressed mood or irritability.
Transient hallucination or illusions.
 Headache , insomnia.
Withdrawal complication:
 Seizures.
 Hallucination.
Delirium.

35. Management:
I. Avoid aspiration by placing patient’s face down or on one
side. Hospitalization is usually necessary.
II. Parenteral sedatives or physical restrains.
III. Low dose sedative ; Lorazepam 1-2 mg, physical
restrains or further sedation by Haloperidol IM 5 mg.
IV. Parenteral dose of Thiamine 100 mg.
V. Benzodiazepine tapering.
VI. Thiamine 50 mg PO.
VII. Multivitamin PO.
VIII.Folate 1 mg PO.
Over a week for uncomplicated withdrawal.

36. Opiate:
Patients rarely seek treatment for intoxication.
Overdose :
I. Respiratory and CNS depression.
II. Depression.
III.Gastric hypomotility with ileus.
IV. Non-cardiogenic pulmonary edema.
Withdrawal:
I. Lacrimation, rhinorrhea.
II. Diaphoresis, yawing, sneezing.
III. Malaise, irritability, nausea and vomiting.
IV. Diarrhea, myalgia, arthralgia, bone ache.

37. Management of Opiate overdose:
I. Respiratory depression : air way support
II. Cardiopulmonary suppression: Naloxone
Hydrochloride 0.4 mg or 0.01 mg kg IV,
repeated dose of Naloxone infusion
0.4 mg hr. for 12 hrs. subsequent to the
initial boluses.
III. Pulmonary edema : Intubation and pressure
ventilation ;ICU admission.
IV. Gastric lavage or induced emesis followed
by activated Charcoal for orally ingested
overdose.