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1. SUBSTANCE RELATED D
ISORDER
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2. Learning Objectives:
 Define substance use disorder
 Describe the distribution and risk factors of substance
use disorder
 Identify common substance of dependence
 Manage substance abusers and dependants
 List and implement the prevention and control
strategies of substance abuse
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3. Terms used in substance-related
disorder
Behavioral dependence refers substance seeking activities
and related evidence of pathological use.
Physical dependence refers the physical effects of
multiple episode of substance use
Psychological dependence is characterised by continuous
craving
Co-dependency designate the behavioral pattern of
family members who have been affected by another
family member’s substance use
Enabling is a factor for co-dependency.
Denial is substance users behavior characterized by
behaving as if substance use has no problem.

4. Terms used in substance-related
disorder
 Intoxication: is a maladaptive behavior caused by
ingestion of an exogenous substance that can alter central
nervous system.
 Withdrawal: The development of a substance-specific
syndrome as result of cessation of (or reduction in) use of
a substance that has been heavy and prolonged.
 Tolerance: is increasing the amounts of substance to
achieve intoxication or desired effect.
 Cross-tolerance: is the ability of one substance to be
substituted for another.

5. Definition
 Psychoactive substances are chemical compounds
that produces emotional, cognitive or behavioral
changes when get in to the body.
 Some of the psychoactive substances are used as
medicines to relieve pain and for their calming effect.
 Some people also take substances to relieve
themselves from anxiety or other feelings of
discomfort in life.
 They can be drunk, chewed, swallowed, smoked,
inhaled, sniffed or injected

6. Definition
 Substance use disorder is a mal-adaptive pattern of
substance use resulting in adverse consequences.
 results in decreased work and school performance,
accidents, intoxication, absenteeism, violent crime,
and theft.
Prevalence:
 Substance abuse occurs in all segments of all
societies,
 highest in the 18-24 years of age, and M>F
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7. Conceptualization of substances
 Addictive substances change brain chemistry with
flooding the brain's so-called "reward circuit" with
dopamine, which occurred by: imitating brain
chemicals or stimulation .

8. Substance related disorder…
Substances most often affect the body by:
 Direct toxic effect on certain tissues such as liver
and the brain
 Decreasing appetite and poor diet leading to
protein and vitamin deficiencies
 Increasing risk of accidents
 Increasing vulnerability to infection
 Withdrawal effects
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9. Factors Associated with Substance Abuse and
Dependence
These variables can be organized in to 3 categories.
Agent / Drug Variables.
 The abuse liability of a substance is enhanced by its:
 Availability
 Cost
 Mode of administration
 Speed of onset
 Termination effect
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10. Host / Users variables.
 The likelihood of an individuals being abused depends
on:
 Genetic predisposition
 Psychiatric disorder
 Prior experience
 Propensity for risk taking behavior
Environmental Variables
 peer influence
 Paucity of other option for pleasure
 Low employment or educational opportunities
 Permissive society
 Homelessness
 Genetic factors 10

11. alcohols

12. Alcohol – harmful use
Ethanol (or alcohol) is a two-carbon molecule
Alcohol is a significant contributor to the global burden of
disease
It is listed as the third leading risk factor for premature
deaths and disabilities in the world.
It is estimated that 3.3 million people worldwide died of
alcohol-related causes per year in 2012.
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13. Alc…
 The harmful use of alcohol is a causal factor in more
than 200 disease and injury conditions.
 Worldwide, 3 million deaths every year result from
harmful use of alcohol. This represents 5.3% of all
deaths.
 Overall, 5.1% of the global burden of disease and
injury is attributable to alcohol, as measured in
disability-adjusted life years (DALYs).

14. Alc…
 Beyond health consequences, the harmful use of alcohol
brings significant social and economic losses to
individuals and society at large.
 Alcohol consumption causes death and disability
relatively early in life. In people aged 20–39 years,
approximately 13.5% of total deaths are attributable to
alcohol.
 There is a causal relationship between harmful use of
alcohol and a range of mental and behavioral disorders,
other non-communicable conditions and injuries.
 In Ethiopia, 24.21 % of high school and 25,27% of
college/ University students drink alcohol.

15. Gender Differences
Females have higher blood alcohol levels than males
Blood Alcohol Level – BAL
Behavioral Effects:
0.05%: Thought, judgment and restraint may be
loosened or disrupted
0.1%: Voluntary motor actions becomes clumsy
0.2%: Function of the entire motor area is depressed
0.3%: Person is usually confused or becomes
stuporous.
0.4 to 0.5%: Person is in a coma, live is endangered
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16. Effects of Alcohol on Reward Pathways
Indirectly increases dopamine levels in the
mesocorticolimbic system
Associated with positively reinforcing/rewarding effects
Indirect interaction with opioid receptors results in
activation of opioid system associated with reinforcing
effects via µ-receptors
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17. Increases the effects of GABA, the major inhibitory
neurotransmitter in the brain
Inhibits the effects of glutamate, the major excitatory
neurotransmitter in the brain
Contributes to decreased anxiety and increased sedation
during acute alcohol intake
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18. Positive reinforcement
Neural mechanisms:
 All natural reinforcers cause the release of Dopamin in the
Nucleus Accumbens (NA)
 Addictive drugs trigger the release of DA in the NA
 Some do this by increasing the activity of DA neurons in
mesolimbic system, some inhibit reuptake of DA by terminal
buttons
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19. Negative reinforcement
A behavior that stops or reduces and aversive stimulus
will be reinforced. This phenomenon is called
negative reinforcment
Punishment – the response must make the aversive
stimulus occur. (eg. withdrawal symptoms)
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20. 20
There is hazardous use if the person says yes to
any of the following questions
1. Consumed 5 or more standard drinks on any given
occasion in the last 12 months?
2. Drink on average more than two drinks per day?
3. Drink every day of the week?
4. Do you drink when
• driving or operating machinery?
• considering pregnancy?
• contra-indicated medical condition is present?
• using certain medications, such as sedatives,
analgesics and selected hypertensives?

21. mhGAP-IG base course - field test version 1.00 –
May 2012 21
There is hazardous use if the person says yes to
any of the following questions
1. Consumed 5 or more standard drinks on any given
occasion in the last 12 months?
2. Drink on average more than two drinks per day?
3. Drink every day of the week?
4. Do you drink when
• driving or operating machinery?
• considering pregnancy?
• contra-indicated medical condition is present?
• using certain medications, such as sedatives, analgesics
and selected hypertensives?

22. mhGAP-IG base course - field test version 1.00 –
May 2012 22
What is harmful use?
 Harmful use is a pattern of alcohol use which is causing
harm to health
 a physical or mental health problem caused by
alcohol, or they are pregnant
 AND
 continued alcohol use despite this health
problem/situation

23. Alcohol Use Disorder
A problematic pattern of alcohol use leading to clinically
significant impairment or distress, as manifested by at
least two of the following, occurring within a 12-month
period:
1. Alcohol is often taken in larger amounts or over a
longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to
cut down or control alcohol use.
3. A great deal of time is spent in activities necessary to
obtain alcohol, use alcohol, or recover from its effects.
4. Craving, or a strong desire or urge to use alcohol.
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24. Alcohol Use Disorder
5. Recurrent alcohol use resulting in a failure to fulfil major
role obligations at work, school, or home.
6. Continued alcohol use despite having persistent or
recurrent social or interpersonal problems caused or
exacerbated by the effects of alcohol.
7. Important social, occupational, or recreational activities
are given up or reduced because of alcohol use.
8. Recurrent alcohol use in situations in which it is
physically hazardous.
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25. Alcohol Use Disorder
9. Alcohol use is continued despite knowledge of
having a persistent or recurrent physical or
psychological problem that is likely to have been
caused or exacerbated by alcohol.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of alcohol to
achieve intoxication or desired effect.
b. A markedly diminished effect with continued use of
the same amount of alcohol.
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26. Alcohol Use Disorder
11. Withdrawal, as manifested by either of the
following:
a. The characteristic withdrawal syndrome for alcohol
b. Alcohol (or a closely related substance, such as a
benzodiazepine) is taken to relieve or avoid
withdrawal symptoms.
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28. Healthy Liver Alcoholic

32. Tobacco
 Nicotine is the principal constituent of tobacco
responsible for its addictive character.
 There more than 4000 chemicals have been identified
in tobacco smoke.
 The tobacco epidemic is one of the biggest public
health threats the world.
 Tobacco kills up to half of its users.

33. Tobacco
• Tobacco kills more than 8 million people each year.
• More than 7 million of those deaths are the result of
direct tobacco use while around 1.2 million are the
result of non-smokers being exposed to second-hand
smoke.
• Over 80% of the world's 1.3 billion tobacco users live
in low- and middle-income countries.
• In 2020, 22.3% of the global population used tobacco,
36.7% of all men and 7.8% of the world’s women.

34. Tobacco
Tobacco use is the single most preventable cause of death
in the world today
 Is estimated to kill more than tuberculosis, HIV/AIDS
and malaria combined.
By 2030, the death will exceed eight million a year,
unless urgent action is taken.
In Ethiopia, 8.30% high school and 9.80% college
/University students smoke cigarrete

35. How Does Tobacco Affect the Brain?
Nicotine is readily absorbed into the bloodstream
Upon entering it immediately stimulates the adrenal
glands to release the hormone epinephrine
(adrenaline).
Epinephrine stimulates the central nervous system and
increases blood pressure, respiration, and heart rate.

36. Tobacco
Glucose is released into the blood while nicotine
suppresses insulin output from the pancreas, which
means that smokers have chronically elevated blood
sugar levels.
It increases levels of the neurotransmitter dopamine,
which affects the brain pathways that control reward
and pleasure.

37. How Does Tobacco Affect the Brain?
For many tobacco users, long-term brain changes
induced by continued nicotine exposure result in
addiction.
A number of studies indicate that adolescents are
especially vulnerable to develop an addiction to
tobacco.

38. What Adverse Effects Does Tobacco Have on Health?
Cancers
Cigarette smoking accounts for about one-third of
all cancers, including 90 percent of lung cancer
cases.
Smokeless tobacco (such as chewing tobacco and
snuff) also increases the risk of cancer, especially
oral cancers.
On average, smoker die 14 years earlier than

39. What are the benefits of quitting to smoke?
The health benefits of smoking cessation are
immediate and substantial—including reduced risk for
cancers, heart disease, and stroke.
A 35-year-old man who quits smoking will, on
average, increase his life expectancy by 5 years.

40. Behavioral Treatments
 Behavioural treatments employ a variety of methods to assist
smokers in quitting, ranging from self-help materials to
individual counselling.
 These interventions teach individuals to recognize high-risk
situations and develop coping strategies to deal with them.
Nicotine Replacement Treatments
 Nicotine replacement therapies (NRTs), such as nicotine gum
and the nicotine patch,

42. Khat
 Khat is a flowering evergreen shrub that is abused for its
stimulant-like effect.
 It has two active ingredients, cathine and cathinone.
 The stimulant effect of Khat is related to the cathinone.
 Is metabolized rapidly to cathine and norephedrine.
 In Ethiopia, 13.82% of high school abd 17.30%
college/University students chew khat.

43. Adverse effects of khat
 Cardiovascular system
 Respiratory system
 Gastro-intestinal system
 Hepatobiliary system
 Genito-urinary system
 Obstetric effects
 Metabolic and endocrine effects
 Ocular effects
 Periodontal effects
 Central nervous system

44.  The best measure against substance dependence is
never start
Congratulations to you, you are a good example to
others regarding not using substance.

45. Problems associated with substance abuse/dependence
 Health related problems: (liver damage, coronary heart
disease, psychiatric problems and lung cancer)
 Economic problems: (Un employment, Economic
crisis, Decrease work performance)
 Social consequence: (Divorce, Crime (theft, hijack/
seize, rape),Violence, Accident and Dangerous vagrancy)
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46. Management of substance abuse and dependence
a) Early detection and intervention
 Gradual withdrawal
 Substitution of less addictive
 Symptomatic treatment
 Pharmacotherapy (to prevent relapse)
b) Psychotherapy and counseling
 Rx designed to produce a response by mental rather
than by physical effects
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47. c) Long term Rx and rehabilitation include
 education
 family / friend support
 self – help group or treatment allies
 vocation rehabilitation
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48. Prevention and control strategies
Prevention:
Primary prevention
 Identifying and avoiding substances used by the
community
 Information and education about substance abuse to
the community.
Secondary prevention
 Early detection and management before complication
Tertiary prevention
 To avoid further disabilities & to reintegrate in to
society
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49. Control methods:
Control of production, supply and availability
 stopping the supply process
 eradication and crop substitution
 control of distribution & access
Demand reduction
 reducing consumption
 increase price
 control of advertisement and promotion
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