substance related disorder

1. SUBSTANCE RELATED DISORDES

2. Substance-Related Disorder:
 Substance Abuse: Is a pattern of substance use leading to
impairment or distress for at least 1 year.
 Criteria: Manifestations 1 or more:
1. Failure to fulfill obligations at work, school, or home
2. Use in dangerous situations (i.e. driving a car)
3. Recurrent substance-related legal problems
4. Continued use despite social or interpersonal problems due
to the substance use.

3. Substances:
1. Alcohol
2. Cocaine
3. Amphetamines
4. Sedatives-hypnotics
5. Opioids
6. Hallucinogens
7. Phencyclidine (PCP)
8. Marijuana
9. Inhalants
10. Caffeine
11. Nicotine

4. Substance-related disorder:
 Substance dependence: Is substance use leading to
impairment o distress manifested by at least 3 of the
following within a 12-months period:
1. Tolerance:
2. Withdrawal
3. Using substance more than originally intended
4. Persistence desire or unsuccessful efforts to cut down on use
5. Significant time spent in getting, using, or recovering from a
substance
6. Decreased social, occupational, or recreational activities
because of substance use
7. Continued use despite subsequent physical or psychological
problem (e.g. drinking despite worsening liver problems)

5. Cont.
 Epidemiology: Lifetime prevalence 17%, more common in men,
most common substance: caffeine, alcohol and nicotine, depressive
symptoms are common.
 Withdrawal and Tolerance:
Withdrawal: the development of a substance-specific syndrome due
to the cessation of substance use that has been heavy and prolonged.
Tolerance: the need for increased amounts of substance to achieve the
desire effect or diminished effect if using the same amount of the
substance.
 Acute intoxication and withdrawal: the intoxicated patient, or one
experiencing withdrawal, can present several problems in both
diagnosis and treatment. The clinical presentation is often confuse
due to the addicts abuse several drugs at once, and
signs/symptoms may be atypical.

6. Alcohol:
 Alcohol activates gamma-aminobutyric acid (GABA) and
serotonin receptors in the CNS and inhibits glutamate
receptors. GABA receptors are inhibitory, and thus alcohol has
a sedating effect.
 Most common abused substance about 7 to 10%
 Screening for abuse: the CAGE questionnaire.
 Alcohol intoxication: The effects of the alcohol depends on
the blood alcohol level (BAL).
Effects: BAL
1. Decreased fine motor control 20-50 mg/dl
2. Impaired judgment and coordi- 50-100 mg/dl
nation
3. Ataxic gait and poor balance 100-150 mg/dl
4. Lethargic, difficulty sitting upright 150-250 mg/dl
5. Coma in the novice drinker 300 mg/dl
6. Respiratory depression 400 mg/dl

7. Cont. Alcohol:
• DD: Hypoglycemia, hypoxia, mixed alcohol-dug, overdose,
ethylene glycol or methanol poisoning, hepatic
encephalopathy, psychosis, and psychomotor seizures.
• Diagnostic evaluation: Serum alcohol level or an expired air
breathalyzer can determine the extent of intoxication. Head
CTScan to rule out subdural hematoma or other brain injury.
• Treatment:
 Acute Intoxication: Ensure adequate airway, breathing, and
circulation. Monitor electrolytes and acid-base status.
• Hypoglycemia: Bolus of dextrose (D 50) is given.
• Thiamine (to prevent or treat Wernicke’s encephalopathy)
• Naloxone (to reverse the effects of any opioids ingested)
• Intubation if severe intoxication
• Gastrointestinal evacuation (gastric lavage and charcoal).

8. Cont. Alcohol
• Dependence (Long term): AA- self-help group, Disulfiram
(Antabuse)- aversive therapy, inhibits aldehyde
dehydrogenase, causing nausea when the person drinks,
Psychotherapy and SSRIs, and Naltrexone (thought and opioid
antagonist, help reduce cravings for alcohol.
• Alcohol Withdrawal: It begins between 6 and 24 hours after
the patient’s last drink and depend on the duration and
quantity of alcohol consumption, mild withdrawal the patient
may be irritable and complain of insomnia, in severe
experience fever, disorientation, seizures or hallucinations.
Signs and symptoms of alcohol withdrawal syndrome:
insomnia, anxiety, tremor, irritability, anorexia, tachycardia,
hyperreflexia, hypertension, fever, seizures, hallucinations, and
delirium.

9. Alcohol
• Delirium Tremens: Is the most serious form of alcohol
withdrawal and often begins within 72 hours od cessation of
drinking, symptoms may include: visual or tactile
hallucinations, gross tremor, autonomic instability, and
fluctuating levels of psychomotor activity.
• Diagnostic evaluation: Assessment of vital signs is essential,
attention to the level of consciousness and possible trauma,
signs of hepatic failure (e.g. ascites, jaundice, caput medusae,
coagulopathy).
• DD: Alcohol-induced hypoglycemia, acute schizophrenia,
drug- induced psychosis, encephalitis, thyrotoxicosis,
anticholinergic poisoning and withdrawal from other sedative-
hypnotic type drugs.
• Treatment: Tapering dose of benzodiazepines (Lithium,
lorazepam), Thiamine, folic acid, and multivitamin,
magnesium sulfate for post withdrawal seizures.

10. Alcohol
• Long-term complications of alcohol intake: Wernicke’s-
Korsakoff syndrome is caused by thiamine (vitamin B1)
deficiency resulting from poor diet alcoholics. Wernicke’s
encephalopathy is acute and can reversed with thiamine
therapy: ataxia, confusion, ocular abnormalities (nygtasmus,
gaze palsies), if left untreated may progress into Korsakoff’s
syndrome, which is chronic and often irreversible: impaired
recent memory, anterograde amnesia and confabulation
(making up answers when memory failed).

11. Marijuana:
 Main active component is cannabis. Cannabinoid receptors in
the brain inhibit adenylate cyclase, effects are increased when
used with alcohol.
 No dependence or withdrawal syndrome has been shown.
 Intoxication: Causes euphoria, impaired coordination, mild
tachycardia, conjunctival injection, dry mouth and increased
appetite.
 Treatment: Supportive and symptomatic.
 Diagnostic evaluation: urine drug screen (positive for up ot 4
weeks in heavy users)
 Withdrawal: no withdrawal syndrome, but mild irritability,
insomnia, nausea, and decreased appetite in heavy users.
 Treatment: Supportive and symptomatic.

12. Cocaine:
 Cocaine blocks dopamine reuptake from the synaptic cleft,
causing a stimulant effect.
 Intoxication: Euphoria, increased or decreased blood
pressure, tachycardia, or bradycardia, nausea, dilated pupils, r
weight lose, psychomotor agitation or depression, seizures,
arrhythmias, and hallucinations (especially tactile).
 Cocaine’s vasoconstrictive effect may result in myocardial
infarction (MI) or cerebrovascular accident.(CVA)
 DD: Amphetamine or phencyclidine (PCP) intoxication,
sedative withdrawal.
 Diagnostic evaluation: Urine drug screen (positive for 3 days,
longer in heavy users)
 Treatment: Intoxication:
• For mild to moderate agitation: benzodiazepines
• For fever agitation or psychosis: Haloperidol
• Symptomatic support (control hypertension, arrhythmias)

13. Cocaine:
• Dependence: Psychotherapy, group therapy, Tryciclic
Antidepressants (TCAs), Dopamine agonist (amantadine,
bromocriptine)
• Withdrawal: Abrupt abstinence is not life threatening but
produces a dysphonic crash” malaise, fatigue, depression,
hunger, constricted pupils, vivid dreams, psychomotor
agitation or retardation.
• Treatment: Usually supportive, let patient sleep off crash.

14. Amphetamines:
• Intoxication causes symptoms similar to those of cocaine
• DD: Cocaine or PCP intoxication, chronic use in high dose may
cause a psychotic state that is similar to schizophrenia.
• Diagnostic evaluation: urine drug screen (positive for 1 to 2
days). A negative drug screen can never completely rule out
substance abuse or dependence.
• Treatment: Similar to cocaine.
• Withdrawal: Similar to cocaine.

15. Sedatives-hypnotics:
 Intoxication: Drowsiness, slurred, speech, incoordination,
ataxia, mood liability, impaired , nygtasmus, respiratory
depression, and coma or death in overdose (especially
barbiturates), symptoms augmented when combined with
alcohol, log term sedative use causes dependence.
 DD: Alcohol intoxication, generalized cerebral dysfunction (i.e.
delirium)
 Diagnostic evaluation: Urine or serum drug screen (positive
for 1 week), electrolytes, electrocardiogram
 Treatment: Maintain airway, breathing, and circulation;
activated charcoal to prevent further gastrointestinal
absorption.
• For barbiturates: alkalinize urine with sodium bicarbonate to
promote renal excretion, Flumazil in overdose; supportive
care: improve respiratory status, control hypotension.

16. Cont.
• Withdrawal: Abrupt abstinence after chronic use can be life
threatening.
• Clinical presentation: symptoms of autonomic hyperactivity
(tachycardia, sweating), insomnia, anxiety, tremor,
nausea/vomiting, delirium, and hallucinations, seizures.
• Treatment: Administration of a long-acting benzodiazepine
such as Chlordiazepoxide or diazepam, with tapering of the
dose, Tegretol or valproic acid for seizure control.