Substance disorder include different type of drug use and abuse

1. SUBSTANCE
RELATED
DISORDERS

2. Substance:
 Refers to a drug of abuse, a medication or a toxin.

3. Substance related disorder
1.Substance use disorders
Substance dependence
Substance abuse
2.Substance induced disorders
Substance intoxication
Substance withdrawal
Substance induced persisting dementia
Substance induced persisting amnesia

4. Substance dependence
A maladaptive pattern of substance use leading to
clinically significant impairment or distress
Manifested by three or more of the following
occurring at any time in 12months

5. 1)Tolerance:
a. Need for markedly increased amounts of the
substance to achieve intoxication or desired effect
b. Markedly diminished effect with continued use
of the same amount of the substance

6. 2) Withdrawal :
A substance specific syndrome that occurs
after stopping or reducing the amount of the drug
or substance that has been used regularly over a
prolonged period of time
3)Substance is taken in larger amounts or over a
longer period than was intended

7. 4)There is a persistent desire or unsuccessful efforts
to cut down or control substance use
5)A great deal of time is spent in activities necessary
to obtain the substance.
6) Important social ,occupational or recreational
activities are given up or reduced because of
substance use

8. 7)The substance use is continued despite knowledge
of having a persistent or recurrent physical or
psychological problem
 Substance abuse: a maladaptive pattern of
substance use leading to clinically significant
impairment or distress, as manifested by one or
more of the following occurring within a 12 month
period

9. 1) Recurrent substance use resulting in failure to fulfill major
role obligations
2) recurrent substance use in situations in which it is
physically hazardous
3)recurrent substance related legal problems
4)Continued substance use despite having persistent
or recurrent social or interpersonal problems

10. Alcohol related disorders

11. Alcohol related disorders
Alcohol use disorder
Alcohol dependence
Alcohol abuse
Alcohol-induced disorders
Alcohol intoxication
Alcohol withdrawal
Alcohol delirium
Alcohol induced persisting dementia

12.  Alcohol induced persisting amnesia
 Alcohol induced psychotic disorder
 Alcohol induced mood disorder
 Alcohol induced anxiety disorder
 Alcohol induced sexual dysfunction
 Alcohol induced sleep disorder

13.  Epidemiology:
3rd largest health problem in U.S.A
 Prevalence
90% of the population in the united states drinks,
with most people beginning their alcohol intake in
the early to middle teens
By the end of high school, more than 60% have
been intoxicated.

14.  Gender
Men are much more likely than women to be
binge drinkers and heavy drink
 Educational level
About 70% of adults with college degrees are
current drinkers
 Socioeconomic class
persons of all socioeconomic classes

15.  Co morbidity:
 Other substance related disorder
 Antisocial personality disorder
 Mood disorders 30-40%
High daily consumption of
alcohol and family history of alcohol abuse

16. Anxiety disorder 25-50%
 Use to alleviate anxiety
 Phobias and panic disorder are frequent co morbid
diagnoses in these patients
Suicide is common 10-15%
MDD, weak psychosocial support
unemployment, living alone, serious coexisting
medical condition

17. Etiology
Genetic factors
 Evidence support the conclusion that alcoholism is
genetically influenced
 3-4 fold increased risk for severe alcohol problems
is seen in close relatives of alcoholic people
 Twin studies: Identical twin of an alcoholic
person is at higher risk than a fraternal twin

18.  Adoption studies : children of alcoholic person
who are adopted away have a fourfold higher risk .
Sociocultural factors
 Environmental events, presumably including
cultural factors, account for as much as 40% of the
alcoholisms risk.

19.  Absorption
 10% stomach
 15-20%mg/dl metabolaization 1hr
 Peak blood concentration 30-90min.
 Usually 45-60minutes

20.  Metabolism
 90% in the liver through oxidation
 10% excreted unchanged in the lung and
kidney
 It is metabolized by two enzymes alcoho
dehydrogenase(ADH) and aldehyde
dehydrogenase

21.  ADH catalyzes the conversion of alcohol into
acetaldehyde, which is a toxic compound
 Aldehyde dehydrogenase catalyzes the conversion
of acetaldehyde into acetic acid
 Aldehyde dehydrogenase is inhibited by
disulfiram, often used in the treatment of alcohol
related disorders.

22. Alcohol level Behavioral effect
0.05% Thought, judgment and restraints are
loosened and sometimes disrupted
0.1% Voluntary motor actions usually
become perceptibly clumsy
0.2% The function of the entire motor area
of the brain is measurably depressed,
and the parts of the brain that control
emotional behavior are also affected

23. 0.3% a person is commonly confused or
may become stuporous
0.4-0.5% Coma
> Centers of the brain that control
breathing and heart rate are
affected, and death ensues
secondary to direct respiratory
depression

24. Sleep effect
 Ease of falling asleep
 Decrease in rapid eye movement sleep and
deep sleep
 Fragmentation of sleep

25. Physiological effect
 Liver:
 Accumulation of fat and protein
 Association between fatty infiltration of the liver
and serious liver damage remains unclear
 Associated with alcoholic hepatitis and cirrhosis

26. Gastrointestinal system
 Long term heavy drinking is associated with
development of esophagitis,gastritis, achlorhydria,
gastric ulcers and esophageal varices
 Pancreatitis, pancreatic insufficiency and
pancreatic cancer

27.  Interfere with the normal processes of food
digestion and absorption as a result consumed
food is inadequately digested
 Inhibit the intestine’s capacity to absorb various
nutrients such as vitamins and amino acids

28.  Poor dietary habits of those with alcohol related
disorders, can cause serious vitamin deficiencies
particularly of the B vitamins

29. Other bodily systems
 Increased blood pressure,dysregulation of
lipoprotein and triglycerides, increase risk of
myocardial infarction
 Increased risk of cancer of the head, neck
esophagus,stomach,colonic and lung cancer

30.  Hypoglycemia which could be the cause of death in
some person who are intoxicated
 Increase in estradiol level in women

31. Laboratory tests
 Increase in gamma glutamyl transpeptidase and
mean corpuscular volume
 Increase in SGOT,SGPT,uric acid , and triglyceride
level

32.  Symptoms of Alcohol intoxication
 Slurred speech , Incoordination
 Unsteady gait ,Nystagmus
 Impairment in attention or memory
 Stupor or coma

33.  Symptoms of alcohol withdrawal
 Autonomic hyperactivity
 Increased hand tremor
 Insomnia
 Nausea or vomiting

34. Transient visual,tactile,or auditory hallucinations
or illusions
Psychomotor agitation
Anxiety
Grand mal seizures

35.  Aggravating and predisposing
factors
 Malnutrition
 depression
 fatigue
 physical illness

36. Clinical feature of alcohol withdrawal
Tremulousness 6-8hours
Psychotic and
perceptual disturbance
8-12hours
Seizures 12-24hours
Delirium tremens 72hours

37. Withdrawal seizures
 Are stereotyped,generalized,and tonic-clonic in
character.
 Patients often have more than one seizure 3-6
hours after the first seizure.
 Status epilepticus is relatively rare and occurs in
less than 3% of patients

38. DDX:
 Head injury
 CNS neoplasm's and other vascular disease
 Hypoglycemia, Hypomagnesaemia,

39. Treatment
Benzodiazepines
 Diazepam and chlordazepoxide
 Titrate the dosage of the benzodiazepine starting
with a high dosage and lowering the dosage as the
patient recovers.

40.  Carbamazepine 800mg daily effective as
benzodiazepines and has the added benefit of
minimal abuse liability

41. Delirium Tremens
 Occurs within one week of cessation or reducing
alcohol
 30s-40s after 5-15 years of heavy drinking typically
of the binge type
 5% of admitted patients with alcohol related
disorders develop DT.

42.  Mortality rate is 20%
 Physical illness e.g. hepatitis or pancreatitis
predispose to the syndrome ; rare in good physical
health
 Death is secondary to intercurrent pneumonia
renal disease hepatic insufficiency

43. Treatment
 A high calorie, high carbohydrate diet
supplemented by multivitamins
 Dehydration can be corrected with fluids given by
mouth or iv
 Warm, supportive psychotherapy
 Skillful verbal support is imperative for, patient
bewildered, frightened, and anxious

44.  Prevention is best:
 Benzodiazepines :
 25-50 mg of chlordiazepoxide q 2-4 hrs until they
seem to be out of danger
 DTs : 50- 100mg chlordiazepoxide q 4hrs po or
lorazepam iv 0.1mg/kg at 2mg/min
 vitamins (thiamine 100mg iv/po tid)

45. Alcohol induced persisting
amnestic disorder
 Diagnoses and clinical features
 A disturbance in short term memory
 The disorder usually occurs in persons who have
been drinking heavily for many years
 The disorder is rare in persons younger than age
35

46. Wernicke-korsakoff syndrome
 Set of acute symptoms
 Secondary to thiamine deficiency
 Wernick’s encephalopathy is characterized by
ataxia , vestibular dysfunction , confusion,

47.  Ocular motility abnormalities (horizontal
nystagmus,lateral orbital palsy and gaze palsy)
 Wernicke’s encephalopathy is completely
reversible with treatment

48. Treatment
 Respond rapidly to large doses of parenteral
thiamine which is believed to be effective
(thiamine in IV bag)
OR
 Thiamine 100mg BID or TID p.o 1-2 weeks

49. Korsakoff’s syndromes
 Caused by thiamine deficiency
 Onset is gradual is often associated with
Wernicke’s encephalopathy.
 Most commonly associated with the poor
nutritional habits of people with chronic alcohol
abuse.

50. TREATMENT
 Thiamine 100mg 3-4 months
 With treatment patients may remain amnestic
for 3 months and then gradually improve over
the ensuing year.
 Administration of thiamine may prevent the
development of additional amnestic symptoms.

51.  Approximately one third to one fourth of all
patients recover completely
 Approximately on fourth of all patient have no
improvement of their symptoms

52. Alcoholic Blackouts
 Characteristically these persons awake in the
morning with a conscious awareness of being
unable to remember a period the night before
during which they were intoxicated
 Can perform complicated tasks and appear normal
to casual observers

53. Alcohol induced psychotic
disorder
 most common auditory hallucination
 After the episode most patients realize the
hallucinatory nature of the symptoms

54. Treatment and rehabilitation
 Three general steps
 Intervention
 detoxification
 rehabilitation

55.  Intervention: The goal is to break through
feelings of denial and help the patient recognize
the adverse consequences likely to occur if the
disorder isn't treated
 Is a process aimed at maximizing the motivation
for treatment and continued abstinence

56. Motivational interviewing
 Precontemplation stage
does not recognize the need for change or is not
actively considering change
 Contemplation
recognizes problem and is considering change
 Preparation action has initiated change

57.  Maintenance is adjusting to change and is
practicing new skills and behaviors to sustain change
 Relapse has relapsed to drug use

58.  Detoxification
 The first step in detoxification is a thorough
physical examination
 The second step is to offer rest, adequate nutrition.
And multiple vitamins, especially those containing
thiamine

59.  Mild or moderate withdrawal
 Treatment is the administration of 25mg of
chlordiazepoxide by mouth three or four times a
day on the first day gradual reduction in dose
 With a notation to skip a dose if the patient is
asleep or feeling sleepy

60.  Severe withdrawal
 First step is to ask why such a severe and relatively
uncommon withdrawal syndrome has occurred
 The answer often relates to a severe concomitant
medical problem that needs immediate treatment
 Withdrawal symptoms can then be minimized
through the use of either benzodiazepines.

61. Diazepam
 Day 1 and 2 10mg tid
 Day 3 and 4 10mgbid
 Day 5 and6 5mg bid
 Day 7 5mg at bed time
 Thiamine 50-100mg/day

62. Rehabilitation
 Components
 Continued efforts to increase and maintain high
levels of motivation for abstinence
 Work to help the patient readjust to a lifestyle free
of alcohol
 Relapse prevention

63.  First identify situations in which the risk for
relapse is high
 The counselor must help patient develop modes of
coping to be used when the craving for alcohol
increases
 or when any event or emotional state makes a
return to drinking likely

64.  Important aspect of recovery involves helping
family members and close friends understand
alcoholism and realize that rehabilitation lasts for
6-12 or more months
Follow up
 Monitor liver function tests periodically

65.  Disulfiram 250mg daily before the patient is
discharged from intensive first phase of outpatient
rehabilitation or from inpatient care
 The goal is to place the patient in a condition in
which drinking alcohol precipitates an
uncomfortable physical reaction including nausea
vomiting and a burning sensation

66.  Naltrexon
 Opioid antagonist decrease the craving for alcohol
or blunt the rewarding effects of drinking
 Using of this drug had potentially promising
results

67. Opiate
related
disorders

68.  Opioid dependence is a cluster of physiological
behavioral and cognitive symptoms
 which together indicates repeated and
continuing use of opioid drugs despite significant
problems related to such use

69.  Opioid abuse a pattern of maladaptive use of an
opioid drug leading to clinically significant
impairment or distress and occurring within a 12
month period.
 but one in which the symptoms have never met
the criteria for opioid dependence

70.  Neuropharmacology
 Endorphins are involved in neural transmission
and pain suppression
 Opoid also have significant effects on the
dopaminergic and noradrenergic neurotransmitter
system

71.  Addictive rewarding properties of Opioids are
mediated through activation of the ventral
tegmental area dopaminergic neurons that project
to the cerebral cortex and the limbic

72.  Comorbidity
 90% of persons with opioid dependence have an
additional psychiatric disorder
 Most common comorbid psychiatric diagnoses are
major depressive disorder, alcohol use disorders,
antisocial personality disorder, and anxiety
disorders.

73.  Crosses the blood brain barrier faster and has a more
rapid onset than morphine.
 One effect of all Opioids is decreased cerebral blood
flow in selected brain regions in persons with opioids
dependence (PET study)
 Peak of the withdrawal syndrome is during the second
or third day and subsides during the next 7 to 10 days,
but some symptoms may persist for 6 months or long.

74.  Morphine and heroin
 Morphine and heroin withdrawal syndrome begins
6 to 8 hours after the last dose
 usually after a 1to2 week period of continuous use
or after the administration of a narcotic antagonist.
 Heroin is the most commonly abused opioid and is
more potent and lipid soluble than morphine.

75.  Etiology
 Social factors
 children of single or divorced parents
 Children from families in which at least one other
member has a substance related disorder

76.  Biological and genetic factors:
 Monozygotic twins are more likely than dizygotic
twins to be concordant for opioid dependence .

77.  Opioid intoxication
 initial euphoria followed by apathy,
dysphoria,psychomotor agitation/retardation
drowsiness or coma
Slurred speech
Impairment in attention or memory
 Pupillary constriction or dilation.

78. Opioid withdrawal
Dysphoric mood
Nausea or vomiting
Muscle aches
Lacrimation or rhinorrhea
Pupillary dilation,piloerection,sweating
Diarrhea, Fever
Insomnia,Yawning

79.  Clinical features
 Route of administration
p.o, snorting intranasally and i.v
 Adverse effects
 The most common and serious
Hepatitis and HIV through the use of
contaminated needles by more than one person.

80.  Persons can experience idiosyncratic allergic
reactions to opioids,
 which result in anaphylactic shock, pulmonary
edema, and death if they do not receive prompt
and adequate treatment.

81.  Opioid overdose
 Death from an overdose of an opioid is usually
attributable to respiratory arrest from the
respiratory depressant effect of the drug.
 Symptoms of overdose
 Marked unresponssiveness,coma slow
respiration, hypothermia ,hypotension and
bradycardia

82.  Suspect opioid overdose when you meet the
clinical triad of coma, pinpoint pupils, and
respiratory depression.
 Inspect the patient’s body for needle tracks in the
arms,legs,ankles,groin and even the dorsal vein of
the penis

83. TREATMENT
 Overdose treatment
 First task
Ensure adequate airway
Tracheopharangeal secretion should be aspirated
Airway may be inserted

84.  Naloxene i.v slow rate
 Sign of improvement
Increased respiratory rate
Pupillary dilation
Medically supervised withdrawal and detoxification
Opioid agents for treating opioid withdrawal

85.  Education and needle exchange
Attention to education on transmission of HIV
Users of i.v/s.c must be taught available safe sex
practice
Free needle exchange program where allowed
should be made available to persons with opioid
dependence

86. THANK
YOU!!!