Prof. Fareed A.Minhas
Head,
Institute of Psychiatry
Rawalpindi Medical College
Rawalpindi
Substance use disorder (DSM IV)
Disorders due to psychoactive drug use
(ICD 10)
Conditions arising from the abuse of
alcoh...
DSM IV

ICD 10

Intoxication

Intoxication

Abuse

Harmful use

Dependence

Dependence syndrome

Withdrawal

Withdrawal st...
INTOXICATION – transient syndrome due to recent
substance ingestion that produces clinically significant
psychological and...
TOLERANCE – state in which, after repeated
administration, a drug produces a decreased effect
or increasing doses are requ...
DSM IV

ICD 10

Alcohol

Alcohol

Amphetamines
Caffeine

Other stimulants such
as caffeine

Cannabis

Cannabinoids

Cocain...
Availability of
drugs

A vulnerable
personality

Adverse
Social
circumstances
EXTENT OF THE PROBLEM –
- Atleast 300,000 ppl in UK have this problem
- Ppl with drinking problems have a 2 to 3
percent g...
DETECTION –

History
Absenteeism from work
Unexplained dyspepsia or GI bleeds
Admissions for accidents
Fits, turns or fall...
‘At risk’ factors
Marital discord
Days off work
An affected relative having similar problems
High-risk occupations eg. Sal...
Rapid reinstatement
Of syndrome on drinking
After a period of
abstinence
Relief from withdrawal
By further drinking
Withdr...
SYMPTOMS OF ALCOHOL DEPENDENCE –
Unable to keep a drink limit/Difficulty avoiding getting drunk
Spending considerable time...
Any THREE of the following :
Tremor of outstretched hands, tongue or eyelids
Sweating
Nausea / retching/ vomiting
Tachycar...
TREATMENT –
Raise awareness of the problem
Increase motivation to change
Withdraw alcohol (controlled drinking)
Support an...
 Psychological dependence
 Glue-sniffing – adolescents. Tolerance develops in
weeks or months
 Intoxication characteriz...
 Derived directly from opium poppy: Morphine/Codeine
 Semi-synthetic  Heroine / Diacetylmorphine
Synthetic  Methadone...
 NARCOTIC ABSTINENCE SYNDROME –
Yawning/Rhinorrhea/Lacrimation
Pupillary dilatation
Sweating/Piloerection/Restlessness

1...
Abrupt withdrawal is highly dangerous. May
result in a mental disorder, similar to alcohol
withdrawal, may lead to seizure...
 Elevate mood, increase wakefulness, give an
enhanced sense of mental and physical energy
 Pleasurable stimulation & exc...
 Effects similar to these Amphetamines
 Strong Psychological dependence
 Excitation,dilated pupils, tremulousness
 Diz...
 Chlordiazepoxide (Librium), Diazepam (Valium),
Lorazepam (Ativan) and Nitrazepam (Mogadon)
 Cause:
Sedation, anxiety re...
Produce strange, intense, & transcendental
effects,which gives them ‘recreational’ popularity
Peyote, mescaline, ‘Magic mu...
Effects vary with dose, persons expectation ,
mood, & social setting
Exaggerates pre-existing mood: exhilaration,
depressi...
 No definite withdrawal Syndrome
 No evidence of Tolerance. No serious side
effects amongst intermittent users

 No evi...
PRE-COMTEMPLATION:
Misuser doesn’t see the problem; others recognize it

CONTEMPLATION:
Individual weighs pros/cons. Consi...
MAINTENANCE GAINS:
Are maintained and consolidated

RELAPSE:
Return to previous pattern of behavior
1.DETOXIFICATION
2.INSISTENCE ON ABSTINENCE
3.INVOLVEMENT OF FAMILY
4.TOXICOLOGY SCREENS (periodic urine
screens are often...
6. SANCTIONED TREATMENT
(patient forced to remain in therapy by a legal
sanction e.g. drivers/professional license)
7. CON...
Substance abuse prof. fareed minhas
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Substance abuse prof. fareed minhas

  1. 1. Prof. Fareed A.Minhas Head, Institute of Psychiatry Rawalpindi Medical College Rawalpindi
  2. 2. Substance use disorder (DSM IV) Disorders due to psychoactive drug use (ICD 10) Conditions arising from the abuse of alcohol, psychoactive drugs and other chemicals such as volatile solvents
  3. 3. DSM IV ICD 10 Intoxication Intoxication Abuse Harmful use Dependence Dependence syndrome Withdrawal Withdrawal state Withdrawal delirium Withdrawal with delirium Psychotic disorders Psychotic disorder Dementia Amnestic Disorder Amnestic syndrome Mood disorders Residual and late- Anxiety disorders -onset psychotic disorder Sexual dysfunctions Other mental and
  4. 4. INTOXICATION – transient syndrome due to recent substance ingestion that produces clinically significant psychological and physical impairment ABUSE – maladaptive patterns of substance use that impair health DEPENDENCE – certain physiological and psychological phenomena induced by repeated taking of a substance (strong desire, neglect to other sources of satisfaction, development of tolerance and a physical withdrawal state)
  5. 5. TOLERANCE – state in which, after repeated administration, a drug produces a decreased effect or increasing doses are required to produce the same effect WITHDRAWAL – state is a group of symptoms and signs occurring when a drug is reduced in amount or withdrawn, lasting for a limited time ESCALATION – refers to a phenomenon when a person taking so called softer drugs moves on to harder drugs
  6. 6. DSM IV ICD 10 Alcohol Alcohol Amphetamines Caffeine Other stimulants such as caffeine Cannabis Cannabinoids Cocaine Cocaine Hallucinogens Hallucinogens Inhalents Volatile solvents Nicotine Tobacco Opioids Opioids Phencyclidine Sedatives/Hypnotics Sedatives/Hypnotics Multiple drug use
  7. 7. Availability of drugs A vulnerable personality Adverse Social circumstances
  8. 8. EXTENT OF THE PROBLEM – - Atleast 300,000 ppl in UK have this problem - Ppl with drinking problems have a 2 to 3 percent greater chance of dying - 1 in 5 admissions in acute medical wards in UK is directly or indirectly related to alcohol - Admissions to psychiatric hospitals for this purpose have increased 25 fold TERMINOLOGY OF DRINKING HEAVY BINGE DRINKERS PROBLEM DRINKERS DRINKERS
  9. 9. DETECTION – History Absenteeism from work Unexplained dyspepsia or GI bleeds Admissions for accidents Fits, turns or falls Signs Plethoric face with/without telangiectases Blood shot conjuctivae Smell of stale alcohol Facial resemblance to Cushing’s Syndrome Marked tremors and other signs of disease
  10. 10. ‘At risk’ factors Marital discord Days off work An affected relative having similar problems High-risk occupations eg. Salesmen Associated physical/mental conditions Markers Gamma-glutamyl transpeptidase Mean corpuscular volume (MCV) Carbohydrate-deficient transferrin HDL Cholesterol Blood/Urinary Alcohol
  11. 11. Rapid reinstatement Of syndrome on drinking After a period of abstinence Relief from withdrawal By further drinking Withdrawal symptoms The subjective Awareness of a Compulsion to drink ALCOHOL DEPENDENCE SYNDROME Increased tolerance To alcohol. Need for More to achieve Same results A narrowing of the Drinking repertoire Primacy of drinking Over other activities
  12. 12. SYMPTOMS OF ALCOHOL DEPENDENCE – Unable to keep a drink limit/Difficulty avoiding getting drunk Spending considerable time drinking Missing meals/Memory lapses, blackouts Restless without drink/Trembling after drinking Organizing day around drink Morning retching and vomiting Sweating at night/Withdrawal fits Morning drinking/Increased tolerance Hallucinations/ frank delirium tremens DIAGNOSTIC CRITERIA OF ALCOHOL WITHDRAWAL
  13. 13. Any THREE of the following : Tremor of outstretched hands, tongue or eyelids Sweating Nausea / retching/ vomiting Tachycardia or hypertension Anxiety Psychomotor agitation Headache Insomnia Malaise or weakness Transient visual, auditory or tactile hallucinations/illusions Grandmal convulsions
  14. 14. TREATMENT – Raise awareness of the problem Increase motivation to change Withdraw alcohol (controlled drinking) Support and advice CBT (Social skills, relapse prevention) Marital therapy Medication (Diazepam/chlormethiazole/Disulfiram or Acamprosate)
  15. 15.  Psychological dependence  Glue-sniffing – adolescents. Tolerance develops in weeks or months  Intoxication characterized by euphoria, excitement, floating sensation, dizziness, slurred speech and ataxia  Acute intoxication – amnesia + visual hallucinations  There is risk of tissue damage including that to bone marrow, brain, liver and kidneys which can prove fatal
  16. 16.  Derived directly from opium poppy: Morphine/Codeine  Semi-synthetic  Heroine / Diacetylmorphine Synthetic  Methadone/Meperidine/Dihydrocodeine  Uses  Pain relief; suppression of cough; treatment of acute myocardial infarction and also diarrhea  Effects  Pleasant mood and a euphoric detachment  Causes of death in narcotics addicts  Heart disease (including infective endocarditis) Tuberculosis Glomerulonephritis Tetanus/Malaria/Hepatitis B
  17. 17.  NARCOTIC ABSTINENCE SYNDROME – Yawning/Rhinorrhea/Lacrimation Pupillary dilatation Sweating/Piloerection/Restlessness 12 – 16 HRS AFTER DOSE Muscle twitches/Aches and pains Abdominal cramps/Vomiting/Diarrhea Hypertension Insomnia/Anorexia/Agitation Profuse sweating/Weight loss 24 – 72 HRS AFTER LAST OPIATE DOSE
  18. 18. Abrupt withdrawal is highly dangerous. May result in a mental disorder, similar to alcohol withdrawal, may lead to seizure & sometimes to death.   Withdrawal symptoms may not appear for several days. Anxiety, restlessness, and disturbed sleep anorexia, nausea.   May progress to vomiting, hypotension, pyrexia, tremulousness, major Seizures, disorientation & hallucinations.
  19. 19.  Elevate mood, increase wakefulness, give an enhanced sense of mental and physical energy  Pleasurable stimulation & excitement potential of misuse  Cocaine, amphetamines, Synthetic (Phenmetrazine diethylpropon), Khat, Caffeine   
  20. 20.  Effects similar to these Amphetamines  Strong Psychological dependence  Excitation,dilated pupils, tremulousness  Dizziness and sometimes convulsions  Confusion, depression, paranoid psychosis and formication
  21. 21.  Chlordiazepoxide (Librium), Diazepam (Valium), Lorazepam (Ativan) and Nitrazepam (Mogadon)  Cause: Sedation, anxiety relief and Muscle relaxation Withdrawal Symptoms: Anxiety, restlessness, tachycardia and sensory disturbances
  22. 22. Produce strange, intense, & transcendental effects,which gives them ‘recreational’ popularity Peyote, mescaline, ‘Magic mushroom’ LSD:lysergic acid diethyl-amide Do not give rise to dependence in true sense, nonetheless use is intensely hazardous
  23. 23. Effects vary with dose, persons expectation , mood, & social setting Exaggerates pre-existing mood: exhilaration, depression or anxiety Increased enjoyment of aesthetic experience & distortion of time & space Reddening of the eyes, dry mouth, irritation of respiratory treat & coughing
  24. 24.  No definite withdrawal Syndrome  No evidence of Tolerance. No serious side effects amongst intermittent users  No evidence of teratogenecity. Not safe in first trimester  Psychosis: disagreement
  25. 25. PRE-COMTEMPLATION: Misuser doesn’t see the problem; others recognize it CONTEMPLATION: Individual weighs pros/cons. Considers change is needed DECISION POINT: Where the decision is made to act on this issue ACTION USER: Choose necessary strategy for change
  26. 26. MAINTENANCE GAINS: Are maintained and consolidated RELAPSE: Return to previous pattern of behavior
  27. 27. 1.DETOXIFICATION 2.INSISTENCE ON ABSTINENCE 3.INVOLVEMENT OF FAMILY 4.TOXICOLOGY SCREENS (periodic urine screens are often essential in identifying relapse and noncompliance) 5.SELF-HELP GROUPS
  28. 28. 6. SANCTIONED TREATMENT (patient forced to remain in therapy by a legal sanction e.g. drivers/professional license) 7. CONTINGENCY CONTRACTING (This approach provides a powerful negative contingency for leaving treatment or relapsing or a positive contingency for remaining drug free)
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