1. Dr. M. S. KABIR JEWEL
PSYCHIATRIST

2. OUTLINE
Definitions
Causes
Types of Substance
Mechanism of Action
Magnitude in Dhaka,Bangladesh
Consequences
Management

3. Substance :(means
psychoactive substance):
That can cause addiction,
a marked change in
mental status, or
psychological / physical
dependency.

4. DEPENDENCE
• Strong desire to take the drug
• Difficulties in controlling its use
• Persistent use despite harm
• Higher priority to drug rather than other activities
• Increased tolerance
• Withdrawal symptom after stoppage
(International Classification of Disease - 10)
• Recent concept : Drugs addiction is a chronic
disease of brain

5. Addiction
"a chronic relapsing disease characterized by compulsive
drug-seeking and abuse and by long-lasting chemical
changes in the brain" (NIDA-2002)
 Being abnormally tolerant & dependent on
something that is psychologically or physically
habit forming.
(WHO-2oo8)
(it is scientifically used for other than the Substances e .g:
TV, Money & Power, Cyber etc)
(WHO-1964)

6. Substance Abuse & Intoxication
Abuse: Recurrent use of Substances
despite of physiological hazards with social,
interpersonal and legal problems.
Intoxication: Clinically Significant
maladaptive behavioral or psychological
changes that are due to the effect of the
substance on the CNS and develop during
or transiently after use of the Substance.

7. Definition of Tolerance
 Need for markedly increased amounts of the
substance to achieve desired effect.
Or reversely we can consider it –
 Markedly diminished effect with continued use
of the same amount of
Substance.
Cross Tolerance:
Development of tolerance of
to one substance as the result
of using another one.
(i. e: Max pt. of our M/W)

8. Withdrawal
• Adaptive changes become fully apparent/focused
once drug exposure is terminated.
This state is called withdrawal and is observed to
varying degrees after chronic exposure to most
drugs of abuse or dependence.
(Globally w . syndrome has different panicky
Synonyms among the Abusers, i.e- Bera, Raadha)

10. Genetic component of
common traits
Trait Heritability
Type II (adult-onset) diabetes 0.31
Type I (insulin-dependent) diabetes 0.72
Hypertension 0.3 - 0.53
Peanut allergy 0.84
Cataract (age-related) 0.55
Alcoholism 0.66
Nicotine 0.5 – 0.67
Cocaine and stimulants( e. g.: Amphetamine) 0.4 – 0.88
Heroin and opiates 0.59
Marijuana 0.3 – 0.810

12. The “Gateway” or Stage
Theory
Related
With This theory comes from
Genetic epidemiological research.
Loading Adolescents engage in use of either
or alcohol or cigarettes (as legal and
Predisposition culturally accepted drugs) then
progress to marijuana, amphetamine
and then on to other illicit drugs, such
as heroin and cocaine. (Kandel, 1975
).

13. Problem Behavior Theory
• The theory proposes that there exists a
syndrome of adolescent problem
behaviours that may co-occur within
the same individual (Jessor, 1991).
Usually 3 types of problem
behaviours:-

14. Truancy
 Petty theft Delinquent • Risky and
precocious
Vandalism Behaviour sexual activity
Lying
 Running
away
Other
High Risk
Behaviour
Driving drunk , Drag racing

15. Patterson's Developmental Theory
• Patterson's theory was originally
proposed to explain the
development of “juvenile
delinquency”, and however
consistent with the observation.

16. Other Etiology
Psychodynamic Factors: Substance abuse is a
defense against anxious impulses (Freudian Defense Mechanism)
Personality Traits and disorders: Many traits are predisposed
with taking substances. Among the Personality disorders, Cluster –B
has profound relation specially Anti-social Personality is moved to the
highest position (Co-morbidity up to 60%)
Borderline P.D., Narcissistic
& also Anxious avoident personality,

17. According The
to the types Mechanistic
of Action Classification
upon CNS of Substance
According
to the
Mode of
Dependency.

18. According to the types of Action upon CNS
Nervous System Nervous System
Depressants Stimulants
Alcohol Amphetamines
(In BD- Yaba,Ind-Champa
Arab- Kreptagone,usa-Spd
Cannabis (Gaja) Cocaine, Anabolic Steroid
Opioids (phensidyl, heroin, Tobacco
pethedrine)
Benzodiazepines (Valium)
Barbiturates

19. TYPES
Drugs with physical & Drugs with psychological
psychological dependence dependence
Alcohol Cannabis (Hasis,Gaja)
Opioids (Phensidyl, Heroin) Amphetamines(YABA)
Barbiturates Cocaine
Benzodiazepines (Valium)
Tobacco
(Gelder et al, 2000)

20. The Mechanistic Classification of
Substance
Drugs activating G-Protein coupled receptors
Name Mode of Action Effect on
Dopamine (DA)
(Pharmacology) Neurons
Opioid & Agonist Disinhibition
Canabinoids
LSD, GHB Partial Agonist Disinhibition

21. Drugs That Bind to Ionotropic (Gaba.R, Ach.R,
NMDA.R) Receptors and Ion Channels
Name Mode of Action Effect on
Dopamine (DA)
(Pharmacology) Neurons
Nicotin Agonist Excitation
Alcohol Excit. &
Disinhibition
Benzodiazepine Partial Agonist Disinhibition
Ketamine

22. Drugs That Bind to Transporters of
Biogenic Amines
Name Mode of Action Effect on
Dopamine (DA)
(Pharmacology) Neurons
Amphetamine Reverses Blocks DA
Ecstasy transport uptake, synaptic
depletion
Inhibitor Blocks DA
Cocaine uptake

23. Volatile / Inhalant substances
Volatile / Mode of action Effect on NMDA receptors
Inhalant
substances
Spray Exhibits a variety of NMDA receptors antagonist,
paint,Cleaning Mechanism ,still not bind inside the ca-channels and
agent even well elucidated. outer surface of neuron.
Room
odorizers,Glue,
SISA

25. Normal Physiology

26. Substance (Amphetamine etc),
which areas are involved in Brain?

27. Molecular action of “Amphetamine”
(Gross view)

29. Circuits Involved In
Drug Abuse and Addiction
CONTROL PFC
INHIBITORY
CONTROL ACG
OFC Hipp
SCC REWARD
NAc
MOTIVATION/
c VP
DRIVE
Amy
g
MEMORY/
LEARNING

30. Magnitude

31. % Of Different Substances among Admitted patients
in our De-addiction Hospital/Clinics , Dhaka BD.
60% Ampheta
mine
50%
Canabin
40% oid
Inhalent(
30% Betix)
20% Alcohol
10% Benzodia
zepine
0%
1st 3rd Mixed
Qtr Qtr Abuser

32. ROUTES
• Oral - amphetamine (Yaba),
(Street Name- Champa,R etc)
Benzodiazepine(Ativan,Valim,Xanax)
Phensidyl(Codine phosphate).
Snifffing – Heroine (Chasing the dragon)
• Smoking - Cannabis (Hasish), Heroin .
• Inhalation/Volatile – Glue/SISA-spreading now fastly.
• Intravenous (IDU)- Pathedrine ,Morphine(e.g:TDJesic)
benzodiazepine

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la t
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35. REASONS
i. Availability of drugs
ii. Curiosity (From family & surroundings,just for thrill)
iii. Friends taking drugs (Peer pressure)
(Delinquent peer group highly influential on SA development)
iv. Pleasure Seeking (Lack of other recreation or amusements)
v. Frustration (From Unemployment /Distorted F.Sturcture)
vi. Disregard for values (Especially in Western culture)
vii. Some may think that they might be immune and the effects of
drugs won’t affect them.
viii. When some people are stressed and need something to get them
past their problems they may take drugs.

36. CYCLES OF ADDICTION
Drug intake Feels well (primary reward)
Conditioning Distress if not taken
(e.g. sour &
salivation)
Takes again to avoid distress
(2ndary reward)
Friends encouraging
drug taking
(social reward)

37. Diagnosis
• Evaluate medical condition including
complications (LFT, STDs)
• Generate differential diagnosis for
psychiatric/medical symptoms
• Utilize urine ,Blood and hair /nail (Prolong user)
for toxicology screening.( In our set up only
Urine, even all reagent not available,
i.e: Alcohol, Inhalants(SISA) etc)

38. CONSEQUENCES
Physical
• Hepatitis (HbsAg), AIDS-IDUs, cirhosis of liver-
Alcoholics,STDs,memory impairment-
Amp.,Hero,Cocaine,Volatiles…
Psychological
• Madness(Psychosis), depression, suicide, sexual
dysfunction-preferably E.D & Orgasmic Failure.
Social
o Academic failure, unemployment, job loss, prestige loss,
divorce, separation, In chaste
o Criminal involvement- snatching, hijacking, arms, illegal
sex.

39. Psychiatric Disorders due to
Substance Abuse
 Substance induced psychotic disorder.
Substance induced mood disorder
Substance induced anxiety disorder
 Substance induced sleep disorder
 Substance induced sexual disorder/perverted too.
 Substance induced dementia/delirium
 Substance induced other organic
B.syndrome

40. MANAGEMENT PLAN
• Early detection & motivation
• Hospitalization & detoxification
• Treatment of mental disorders
• Life style changes
• Counseling
• Follow up & rehabilitation

41. Management
• Prevention and Early Intervention
-- Aggressive psycho-education to parents and child
regarding SA (start <21yrs.)
-- Discussion of known risk factors (i.e. conduct
disorder)
-- Aggressive Tx of psychopathology
-- Close monitoring in high risk cases (tobacco use,
questionnaires, urine toxicology)

42. Management-Cont.
• Parent Works are the followings-
-- Need for involvement
-- Need for increased supervision
-- Behavioral management techniques
-- Need to monitor SA & Psych Treatment.
-- Establish additional supports
* AA/NA/AI-Anon (Self help group)
(In BD-Not exactly in the similar form but modified
S.H.G available in society.)

43. PREVENTION
1. Supply Reduction
- Control of air port, sea port, land port &
internal trafficking
- Control of illicit production
- Crush programme
2. Demand Reduction
- Drugs are available but people will not take
- Intervention with individual demand
3. Harm Reduction
- Early detection & treatment

44. Thanks a lot for attending me

46. Captagon (Amphetamine)
 History of Amphetamine
 Epidemiology & Routes
 Quantity & Quality,Derivatives
 Mechanism of Action of Amphetamine
 Sign & Symptoms of Amphetamine
 Misdiagnosis in our (Al-Jouf) OPD
 Management (Treatment)

47. History
• Amphetamine-first synthesized in1887 by Romanian
chemist Lazăr Edeleanu.
• OTC use of amphetamines were for- colds,
nasal congestion & as bronchodilator .
• The reinforcing effects of amphetamines were quickly
discovered, and the misuse of amphetamines started--
• During World War II, amphetamines were used by the
military to keep soldiers awake.
• The widespread misuse of amphetamines began in the post
war Japan and quickly spread to other countries.

48. Epidemiologic differences
of Amphetamine related Psychiatric Disorders
 Race
Amphetamine-related psychiatric disorders (ARPD)
most commonly occur in white individuals .
 Sex
With IV use, Psychiatric disorders commonly occur
in men, with a male-to-female ratio of 3-4:1.With
non-IV use -1:1.
 Age: Most frequently found around 20-
39 yrs at rave parties and dance clubs.
Also >40 to onwards available.

49. Routes of administration
Intravenous injection: is the fastest
mechanism, known as “Slamming”
methamphetamine salt 100mg -1gm
By
using a hypodermic needle.
o Smoking: By vaporizing it to inhale
the resulting fumes, not burning it to
inhale the resulting smoke
"chasing the white dragon"
 Insufflations (snorting): where a user crushes
the methamphetamine into a fine powder and
then sharply inhales it.

50. Quantity, Quality & Manufacture
 Purity: Overall range in purity for amphetamine is
up to 66%, and for methamphetamine up to 80%.
 Adulteration:--
 Caffeine : Amphetamine covered by caffeine.
 Fenethylline : Covered by fenethylline.
Available in Al-Jouf, UNODC reports that GULF regions
Captagone pills mix with the Caffeine, Fenethylline & others.
 Pseudo-ephedrine
Commonly marketed in
 Hypo-phosphorous Uk, Australia & USA

51. Common Derivatives of Amphetamine
• Amphetamine (α-methylphenylethylamine)
• Methamphetamine (N-methylamphetamine)
• Ephedrine pseudoephedrine
• Cathinone-β-Ketoamphetamine (Khat)
All above four are available in Al-Jouf .
• Methcathinone (ephedrone)
• MDA (3,4-methylenedioxyamphetamine)
• MDMA (3,4-methylenedioxymethamphetamine)
• MDEA (3,4-methylenedioxy-N-ethylamphetamine)

52. Various Types of Amphetamine Derivatives
with different colours & impressions with in it,
The Blueish and greenish ones are available in BD.

54. Major areas of brain usually Affected by
Amphetamine

55. Normal Brain molecular pathway

56. Normal Mechanisms
• In the normal operation, synaptic release of
catecholamines is carried out by exocytosis
of a vesicle which contain a
neurotransmitter. Then, the neurotransmitter
is reabsorbed from the synaptic cleft into
the cytoplasm of the neuron. From the
cytoplasm, the neurotransmitter penetrates
back into the vesicles via the action of the
vesicular monoamine transporter (VMAT).

58. Mechanism of amphetamine action. Left: Normal operation
of dopaminergic terminal. Right: Dopaminergic terminal in presence of
amphetamines showing the reversal of action of the dopamine transporter
(DAT) and the vesicular monoamine transporter (VMAT) and the decrease of
the standard vesicular neurotransmitter efflux.

59. Mechanism after taking
Amphetamine
• The stimulating effect of amphetamines is mainly
associated with an increased emissions ---of C
atecholamines Norepinephrine and Dopamine.
• Presence of amphetamine and its derivative inverts
the direction of the transport: neurotransmitter
moves from vesicles to the cytoplasm and then to
the synaptic cleft. As a result, vesicles are
emptied, vesicular release of neurotransmitter is
reduced, and the concentration of neurotransmitter
in the synaptic cleft increases.

60. Sign & Symptoms
• autonomic nervous system is mainly due to
emissions of norepinephrine. This enhances
stimulation of α-and β-adrenoreceptors that
can lead to tachycardia (increased heart
rate), elevated blood pressure, mydriasis
(dilated pupils), sweating and hyperthermia
(elevated body temperature)

61. The list of signs and symptoms mentioned in various sources for
Amphetamine abuse includes >70 symptoms with >5 phases --------
Stimulation
phase
Reaction
Addiction phase
Phase Withdrawal
(coming
Phase down)
Toxic Severe
Phase Phase

62. Stimulation phase symptoms may include
(symptoms vary greatly between people)
Raised blood
Important Symptoms
From ANS
– Alertness (Sleepless) pressure
– Energetic Dry mouth
– Exhilaration Pupil dilation
– Excitement Headaches
– General feeling of wellness Sweating
– Increased confidence Talkative
– Feeling of superiority Restlessness
– Reduced appetite Difficulty sleeping
– Raised pulse Anxiety
– Rapid breathing Irritability
Aggression

63. Reaction phase (coming down)
– Depressed mood
– Tiredness Mimics With
Canabinoids
– Violent behavior &MDD
Ie:A.R.M,H.Ayed
– Moodiness
– Mood swings
– Physical exhaustion
– Tension

64. Symptoms of amphetamine
addiction
– Paranoia – Suicidal thoughts
– Delusions – Suicide
– Hallucinations – Exhaustion
– Severe anxiety
– Weight loss
– Poor judgement
– Depression
• Malnutrition

65. S/S in a nutshell

66. Symptoms of amphetamine
withdrawal
– Irritability – Over-sleeping
– Hunger – Restless sleep
– Fatigue – Nightmares
– Anxiety – Panic
– Depressive
symptoms

67. DSM-IV-TR describes the following 10
amphetamine-related psychiatric disorders
• Amphetamine-induced anxiety disorder
• Amphetamine-induced mood disorder----------
• Amphetamine-induced psychotic disorder
with delusions---------------------------------- Common
• Amphetamine-induced psychotic disorder in our Al-
with hallucinations---------------------------- Jouf
• Amphetamine-induced sexual dysfunction OPD from
Lexis &
• Amphetamine-induced sleep disorder----------- Abu Hafera
• Amphetamine intoxication-------------------------
• Amphetamine intoxication delirium
• Amphetamine withdrawal –Few, due to lack of purity (up-to 35% mixed
with Caffeine-ie: Abu –Reeha, Lemis)
• Amphetamine-related disorder not otherwise specified

68. For a Amp. Dependent
On MSE specially in
Appearance & Behaviors ?

69. Mental status of a patient with amphetamine intoxication is as follows:
– Appearance and behavior: Unusually friendly,
scattered eye contact, buccal oral gyrations,
excoriations on extremities and face from picking at
skin, overly talkative and verbally intrusive
– Speech: Increased rate( in AIPD)
– Thought process: Tangential, circumstantial over
inclusive and disinhibited (Guarded in AIPD)
– Thought content: Occasional Paranoid; no suicidal
or homicidal thoughts usually
– Mood: Anxious, hypo manic
– Affect: Anxious and tense (Paranoid in AIPD)
– Insight and judgment: Poor
– Orientation: Alert to person, place, and purpose;
perspective of time is disorganized

70. Differential Diagnoses
 Opioid
• Cannabis Compound Abuse  Abuse Phencyclidine (PCP)Related
Psychiatric Disorders
• Cocaine-Related Psy.
Disorders  Schizophrenia
• Delirium  Adj.Disorder with cond prob
(common in our OPD ie K.md)
• Depression  Toxicity, Heroin
• Hallucinogens  Toxicity, Mushroom
• Hyperthyroidism  WernickeKorsakoff Syndrome
• Hypothyroidism
• Inhalant-Related Psy. Other problems--
Disorders  AIDS-related complex
• Insomnia  Thyrotoxicosis
 Syphilis

71. Investigations
 Laboratory Studies-
– CBC, RBS, LFT, RFT, Total protein, uric acid, Bilirubin
– Urinalysis Single Panel
Meth/Amphetamine
Drug Test tool
 Stat urine or serum toxicology screening
 HIV and Rapid Plasma Reagin (RPR) tests
Psychometric-BPRS, B.Dep.Scale, Viol & Sui.Assessm Scale,AIMS-for
AWS, MMSE-for cog imp in AIS, even TAT also for P. imp.
 Imaging Studies (Histological change)
• Neurologic impairments-By CT or MRI (Suba & ICH)

72. Vicious
Cycle of
Amphetamine length of
Dependence dendrites
From histological findings
Repeated
exposure
Psychosis to
amphetamines
tex al
Nu umb
acc
t
fron
cle ens
us
Pre
cor
Behavioural
.
cravings

74. Rx of
Amp Ind. Disorders
Intoxication With Anxiety
(neurotic)
With Psychotic
Symptoms
Syndrome Symptoms
Induced emesis by Ammonium Better to treat by
If few, we may wait
lavage,or charcoal, Chloride(Quelidrine) non-diazepines Anx
for Self limitation
Open i/v channel To Acidify urine Propanolol(<120-200)
500 mg every 2-3 hours.
(N.A in ouPharmacy,Expectorant)
Lorazepam, Cholordiazepoxide Anti-Depressants Anti-psychotic , Anti-manic
propanolol and also Naltrexone If need Benzodiazepines Even Naltrexone

75. Consultation
• Neurologist
• Internal medicine specialist
• Hepatologist
• Psychiatrist: Consult for inpatient substance abuse
treatment or further psychiatric stabilization.
• Social services: Social services coordinate
outpatient services, such as Narcotics Anonymous
meetings and sober houses.

76. Complications of Amp.
Ind. Disorders
– Psychosis
– Depression
– Anxiety disorder
– Sleep disturbance
– Memory impairment
– Medical complications
– Neurologic complications (i.e-Ayed Bashir)
– Abuse of another or several substances-Most
common in our Ward
– Psychosocial & pers. impairment ( also common-AA.K)

77. Prognosis
o The patient's prognosis depends on the severity of
psychiatric impairment and on the medical
complications.
o Overall, the prognosis is good if the patient abstains
from drug use after the initial psychiatric impairment
occurs.
o The prognosis worsens if personality disorders are
present.

79. Ghat / Khat
One of the popular Derivatives of
Amphetmine (Kreptagone) which is
basically Cathinone
• Natives of Yemen and Ethiopia have a long
tradition of chewing Ghat leaves to achieve
a stimulating effect. The active substances
of khat are cathinone and to a lesser extent
cathine