A presentation on different psychoactive substances and the disorders caused by dependence and addiction on them. And what can social workers do about it. - by Tasmin Kurien Subject: Mental Health and Social Work

1. Psychoactive
Substance Use
Disorders
TASMIN KURIEN
MENTAL HEALTH & SOCIAL WORK

2. Jens
Martensson
Breaking Down The Basics
• Psychoactive drug – Commonly used to refer to mind-
altering drugs, but also includes alcohol, that can
impair mental functioning.
• Alcohol – Any type of fermented or distilled liquor
containing alcohol, such as whiskey or beer.
• Drug – A wide range of materials that alter mood or
consciousness when ingested, or may modify the
functions of a person.

3. Jens
Martensson
Situation in India
‘Magnitude of Substance Use in India’
Report 2019
• Among drug users, 72 lakh need treatment for
cannabis, 60 lakh for opioids and 11 lakh for
sedatives
• 1800-110-031 national drug de-addiction
helpline – offers telephonic counselling and
referrals to de-addiction centres & treatment
facilities
• Helpline witnessed a spike in calls from April –
June – over 9,400 calls – for moderate to
severe withdrawal symptoms & suicidal
thoughts due to inability to access drugs

4. Redefining Addiction
• Substance
Dependence &
Abuse
• Included Gambling
ICD 10
1990
• Substance Use
Disorder – 2
criteria
• Adds Tobacco,
Gambling, Gaming
DSM 5
2013 • Maintains
substance
dependence
• Gaming disorder
added
ICD 11
2018

5. Redefining Addiction
• “Substance Abuse” or “Addiction” – a maladaptive pattern of
substance use manifested by recurrent and significant adverse
consequences.
[Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR),
APA, 2000, p. 198-199]
• “Substance Dependence”– the recurring use of a substance, either
out of one’s own choice or for medication purposes, sometimes
leading to abuse

6. Redefining Addiction
• Substance Use Disorder (DSM V) - cluster of cognitive,
behavioural, physiological symptoms where the
individual continues using the substance despite the
consequences
• Must meet at least 2 of the 11 criteria
• Severity of substance use disorder divided into:
1. Mild (2-3 criteria)
2. Moderate (4-5 criteria)
3. Severe (above 6 criteria)

7. Diagnostic Criteria (DSM)
A. Evidence of impaired control
(Criteria 1-4)
 Increasing intake of substance
or over a longer period than
planned
 Multiple unsuccessful efforts
to discontinue
 Spend a lot of time using
substance & recovering from it
 Craving - via classical
conditioning
B. Social impairment (Criteria 5-7)
 Failure to fulfill roles at work,
school, home
 Continuing to use it despite
social/interpersonal problems
 Giving up past social,
occupational, recreational
activities

8. Diagnostic Criteria (DSM)
C. Risky patterns of use
(Criteria 8-9)
 Recurrent use in dangerous
situations
 Continuing use despite
knowing the problems it is
causing
D. Pharmacological criteria
(Criteria 10-11)
 Developing tolerance
 Withdrawal syndrome

10. Acute Intoxication
• High blood levels of the drug
• If low threshold, even small
doses can lead to intoxication
• Effects eventually wear off
unless there is tissue damage
Transient condition following the administration of a psychoactive
substance leading to disturbances in level of consciousness, cognition,
perception, affect or behaviour, other physiological responses
Complications:
 Trauma or bodily injury
 Medical complications (like inhalation of
vomitus)
 Delirium
 Perceptual distortions
 Coma, Convulsions
 Pathological intoxication or dipsomania

11. Withdrawal Syndrome
Short-lasting syndrome (few hours to few days) developing on total or
partial withdrawal of drug, usually after repeated/high dose use
• Symptoms are relieved with
further substance use
• Differ with specific drug use
• Not seen for some substances
e.g. cannabis, inhalants,
hallucinogens, PCP
ICD 10 coding:
i. Uncomplicated
ii. With convulsions
iii. With delirium

12. Dependence Syndrome
A desire (often strong and overpowering) to take substances which
are not medically prescribed.
Diagnosis can be made with 3+ symptoms:
 Sense of compulsion to ingest
 Difficulties in controlling substance-taking
behaviour
 Physiological withdrawal state, or taking
another substance to relieve withdrawal
symptoms
 Evidence of increased tolerance to take more
substance
 Progressive neglect of alternate pleasures and
activities
 Persisting with substance use despite harmful
consequences
ICD 10 coding:
i. Currently abstinent
ii. Abstinent in a protected environment
(hospital, prison)
iii. Clinically supervised maintenance or
replacement regime (using nicotine patch
or methadone)
iv. Abstinent but receiving treatment with
blocking drugs (disulfiram, naltrexone)
v. Active dependence (using)
vi. Continuous use
vii. Dipsomania (episodic use)

13. Harmful Use
Actual damage should have been caused to the mental or physical
health of a user because of use
Characteristics:
Continued drug use despite
awareness of harmful
medical/social effects
Pattern of physically hazardous
use of drug (drunk driving)
• Not diagnosed if dependence
is already there
• DSM-IV-TR uses term
“substance abuse”
• All 4 patterns can overlap
Other ICD 10 syndromes – psychotic disorder, amnesic syndrome,
residual and late-onset psychotic disorder

14. Contoso
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AetiologicalFactorsinSubstanceUseDisorders
BIOLOGICAL FACTORS
• Genetic vulnerability
• Co-morbid psychiatric
disorder or personality
disorder
• Co-morbid medical
disorders
• Reinforcing effects of
drugs
• Withdrawal effects &
cravings
• Biochemical factors
PSYCHOLOGICAL FACTORS
• Curiosity or novelty-
seeking
• Rebelliousness or social
non-conformity
• Early initiation of alcohol
& tobacco
• Poor impulse control
• Sensation-seeking (high)
• Low self-esteem,
personal autonomy
• Psychological distress
• Childhood trauma or loss
• Relief from fatigue or
boredom
SOCIAL FACTORS
• Peer pressure
• Modelling other’s
behaviour
• Ease of availability
• Intrafamilial conflicts
• Religious or tribal rituals
• Poor social/familial
support
• Permissive social
attitudes
• Rapid urbanization
• Poor drug law
enforcement

15. Contoso
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AlcoholUse
Disorders
F10-MentalandBehavioural
DisordersduetoUseofAlcohol

16. Jens
Martensson
Administration: Oral
Dependence is more common in
men, insidious course
Tolerance: Mild
In India, legal drinking age is
different in different states:
1. Goa - 18+
2. Noida, UP, Chennai, Bangalore -
21+
3. Delhi, Haryana - 25+
4. Maharashtra - 21+ for beer and
wine, 25+ for other drinks
Characteristics
BAC* (mg%) Behavioural Effects
25 - 100
Excitement, euphoria,
relaxation, clumsiness
80
Noisy, moody, impaired
judgement, impaired driving
ability
100 - 200
Serious intoxication, slurred
speech, incoordination,
nystagmus, aggression
200 - 300 Amnesia or blackout
300 - 350
Hypothermia, dysarthria, cold
sweats
350 - 400 Coma, respiratory depression
> 400 Death may occur
*Blood Alcohol Concentration

17. Jens
Martensson
Classification
Factors Type I Type II
Synonym Milieu-limited Male-limited
Gender Both sexes Mostly in males
Age of onset > 25 years < 25 years
Family history May be positive
Parental alcoholism, antisocial
behaviour usually present
Loss of control Present No loss of control
Other features
Psychological dependence,
guilt present
Drinking followed by
aggressive behaviour,
spontaneous alcohol seeking
Pre-morbid
personality traits
Harm avoidance, high reward
dependence Novelty-seeking

18. Jens
Martensson
Acute Intoxication
Ethanol is absorbed through the mucosal lining of the
digestive tract
• Relief from anxiety
• Slowed thinking & poor judgement
• Slurred speech & uncoordinated movements
• Alcohol myopia - reacting more strongly to emotion-
arousing cues due to impairment of long-term thinking
• Amnesia or blackouts
• Pathological intoxication or dipsomania

19. Jens
Martensson
Withdrawal Syndrome
1. Delirium tremens - starts 8-20 hours after alcohol is cleared
from body
• frightening hallucinations (visual, auditory, tactile)
• fever, sweating, hypertension
• muscle tremors
• sweating, tachycardia (high heart rate)
• insomnia, dehydration
2. Alcoholic seizures (rum fits) - 12-48 hours after - usually
multiple seizures
3. Alcoholic hallucinosis – recovery in one month
• Auditory hallucinations

20. Contoso
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ComplicationsofAlcoholDependence
MEDICAL
Gastrointestinal System:
• Liver cirrhosis, hepatitis
• Pancreatitis, Gastritis,
Mallory-Weiss Syndrome
Central Nervous System:
• Peripheral neuropathy,
Cerebellar degeneration
• Alcoholic jealousy,
Alcoholic dementia
• Wernicke-Korsakoff
psychosis
• Marchiafava-Bignami
disease
• Suicide
SOCIAL
• Accidents
• Marital disharmony
• Divorce
• Occupational problems
• Increased drug
dependence
• Criminality
• Financial difficulties
MISCELLANEOUS
• Acne rosacea, Alcohol
Myopathy
• Foetal Alcohol Syndrome
• Cardiomyopathy,
Anaemia, Accidental
hypothermia
• Risk for coronary artery
disease, Malnutrition
• Infertility in men, Sexual
dysfunction
• Decreased immunity,
proneness toTB

21. Contoso
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Prognosis
A client can approach general practitioner, crisis clinic, mental
health agency, family service agency, public assistance agency
presenting the following symptoms:
Medical
Setting
• Pancreatitis, Liver/Kidney
Disease,Traumatic
Injury/Broken Bones
Mental
Health
Setting
• Depression, Suicidal
Thoughts, Self-
destructive Behaviour,
Anxiety, Psychotic
Symptoms

22. Contoso
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CAGEQuestionnaire
A score of 2 or more identifies problem drinkers:
i. Have you ever had to Cut down on alcohol?
ii. Have you ever been Annoyed by people’s criticism of alcoholism?
iii. Have you ever felt Guilty about drinking?
iv. Have you ever needed an Eye opener drink (early morning drink)?

23. Jens
Martensson
Effective Professional Attitudes
• An alcoholic can recuperate & improve.
• Alcoholism is a disease, out of the client’s control.
• Be alert to symptoms of an alcoholic problem.
• Understand that alcoholics have lost control.
• Use motivational interviewing.
• Teach alcoholic to take responsibility for own behaviour.
• Entire family is part of the problem.
• Know what resources are available.
• Avoid placing labels on the addict.

24. Jens
Martensson
Treatment
There are at least 7 resources for treatment:
1. Detoxification (using benzodiazepines like Chlordiazapoxide,
Diazepam)
2. Outpatient Services
3. Intensive Outpatient Rehabilitation (Halfway Homes, Personal
Care Homes)
4. Inpatient Treatment
5. Specialty Programs & Tracts
6. Mutual Self-Help Groups or Group Therapy (AA groups)
7. Deterrent Agents (Disulfiram), Anti-craving Agents
(Naltrexone)

25. Opioid Use
Disorders
F11 - Mental and Behavioural
Disorders due to Use of Opioids

26. Jens
Martensson
Administration: Oral, Parenteral,
Smoking
Dependence, Tolerance: Severe
UN declared India Asia’s biggest
consumer of heroin
Golden Triangle (Burma-Thailand-Laos) &
Golden Crescent (Ira-Afghanistan-
Pakistan)
• Derived from poppy plant
• Street names: chasing the dragon
(smoked), smack or brown sugar
(injected)
• Morphine & Heroin are the worst
Characteristics
Opioid Derivatives
Natural Alkaloids
1. Morphine
2. Codeine
3. Thebaine
4. Noscapine
5. Papaverine
Synthetic
Compounds
1. Heroin
2. Nalorphine
3. Hydromorphone
4. Methadone
5. Dextropropoxyphene
6. Meperidine
7. Cyclazocine
8. Levallorphan
9. Diphenoxylate

27. Jens
Martensson
Acute Intoxication
• Heroin is derived from morphine and extracted from the
poppy plant to create a powdery substance
• Adulterated heroin (brown sugar) created by mixing drug
with talcum powder, powdered milk, sugar, etc. - more
dangerous
Symptoms:
 Apathy, hypotension, respiratory depression, bradycardia (slow heartbeat),
subnormal body temperature, pin-point pupils
Overdose can cause delayed reflexes, thready pulse, coma
Severe intoxication can lead to mydriasis (pupil dilation)

28. Jens
Martensson
Withdrawal Syndrome
• Heroine withdrawal is more severe than morphine
withdrawal
• Flu-like symptoms peak 24-72 hours after use
Symptoms:
• Lacrimation (tears), Pupillary dilation, Sweating,
Diarrhoea, Tachycardia, Mild Hypertension (high blood
pressure)
• Insomnia, Yawning, Raised body temperature, Muscle
cramps, Anxiety, Piloerection (goosebumps), Nausea,
Vomiting, Anorexia

29. Jens
Martensson
Complications of Chronic Use
1. Due to illicit drugs (contaminants): Parkinsonism,
degeneration of globus pallidus, Peripheral
neuropathy, Amblyopia, Transverse Myelitis
2. Due to intravenous use: AIDS, Skin infections,
Thrombophlebitis, Pulmonary embolism, Septicaemia,
Viral hepatitis, Tetanus, Endocarditis
3. Social Complications: Drug peddling and involvement
in criminal activities

30. Jens
Martensson
Treatment
1. Treatment of Overdose – narcotic
antagonists (naloxone, naltrexone) to be
injected every 2 hours
2. Detoxification & Maintenance Therapy where
withdrawal can be handled by:
i. Substitution drugs like methadone which are
less addictive
ii. Clonidine to sedate user
iii. Naltrexone with Clonidine to make the
opioid experience lose pleasure
iv. Other drugs like Buprenorphine, LAAM
3. Individual psychotherapy, CBT, group therapy
(Narcotics Anonymous)
4. Psychosocial Rehabilitation

31. YourEmotionalOneRing
a.k.a.
HedonisticHotspots

32. • Pleasure centers of brain or ‘reward
centres’
• Music, art, food, read, get drunk,
have sex – your response comes from
the mesolimbic cortex
• Not just for pleasure but for 3 main
functions – pleasure, learning,
motivation (enjoying, expecting,
eagerness)
1. Enjoying – assesses hedonic impact
of stimulus – sweet taste, high of
drug, joy of love, thrill of winning
2. Expecting – linking ‘now’ to what
should come next (implicit learning)
3. Eagerness – generic gas pedal of the
emotional brain

33. 1. Enjoying
2. Expecting
3. Eagerness
All three work in context.

34. CANNABIS
USE
DISORDER
F12 - Mental and Behavioural Disorders due to use
of Cannabinoids

35. Characteristics
◦ Derived from the hemp plant, Cannabis Sativa (or sativa indica
in India)
◦ Tetrahydrocannabinol, or THC, is the primary psychoactive
component of marijuana
◦ Administration: Smoking (weed, hash, ganja), Oral (bhang,
hash oil, pot brownie)
◦ Street names: marijuana, grass, hash or hashish or charas,
weed, pot, ganja, 420
◦ Dependence & Tolerance: Little to none, marked
psychological dependence (compulsive)
* Mild withdrawal symptoms

36. ACUTE
INTOXICATION
◦ Mild impairment of consciousness &
orientation, light-headedness, tachychardia,
euphoric dream-like state, tremors, dry
mouth, increased appetite, feeling of time
slowing down, splitting of consciousness
◦ Increased sensitivity to sound, physical
touch & light
◦ Perceptual disturbances like
depersonalization, synaesthesia (seeing the
music)
◦ Visual hallucinations only in severe
intoxication
◦ Flashback phenomenon

37. COMPLICATIONS
◦ Transient or short psychiatric disorders:
anxiety, paranoid psychosis, suicidal
ideation, schizophrenia-like state
(persecutory delusions, hallucinations) or
Indian hemp insanity
◦ Amotivational syndrome: lethargy, apathy,
lack of ambition, reduced drive
◦ Others: memory impairment, relapse in
schizophrenia or mood disorder, chronic
obstructed airway, decreased fertility &
virility
(after chronic use)

38. TREATMENT
Psychotherapy, psycheducation
In rare cases, psychotropic medication &
hospitalisation

39. Sedative-
Hypnotic Use
Disorders
F13 - Mental and Behavioural
Disorders due to use of Sedatives or
Hypnotics

40. Jens
Martensson
Barbiturates commonly used as
sedatives, hypnotics, anticonvulsants,
anaesthetics, tranquilisers
Benzodiazepines have taken over to
treat insomnia and anxiety
Act on benzodiazepine receptors,
increasing GABA action receptor,
which is the chief inhibitor
Administration: Oral, Parenteral
Dependence: Mild to Moderate
Tolerance: Mild to Severe
Can cause withdrawal symptoms
Characteristics
Sedative-
Hypnotics
Barbiturates Benzodiazepines

41. Jens
Martensson
Intoxication Withdrawal Treatment
Barbiturates
• Episodic & resembles
alcohol intoxication
• Intravenous use can
cause infections
• Can be severe
• Marked
restlessness,
delirium
tremens,
seizures, coma,
death
• Should treat the
symptoms
• Pentobarbital
Substitution
therapy
• Treatment of
depression
Benzodiazepines
• Acute intoxication
resembles alcohol
intoxication, chronic
intoxication creates
tolerance
• After end of 4-6
weeks of
moderate to
heavy doses
• Anxiety,
depression,
transient
psychotic
episodes
• Symptomatic
management
• Can use
flumazenil in case
case of overdose

42. Cocaine Use
Disorder
F14 - Mental and Behavioural
Disorders due to use of Cocaine

43. Jens
Martensson
 Alkaloid derived from coca
bush found in Bolivia & Peru
Street names: crack, coke, liquid
lady, blow, rock
 CNS stimulant which increases
dopamine, norepinephrine,
serotonin production
 Typically had in cocaine ‘runs’
(binges) followed by ‘crashes’
 Sometimes mixed with heroin
(speedball) or amphetamines
Administration: Inhalation, Oral,
Smoking, Parenteral
Dependence & Tolerance:
Moderate
Characteristics

44. Contoso
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Acute Intoxication
• Pupil dilation,
tachycardia, sweating,
nausea
• Grandiosity, elation of
mood, judgement
impaired
Withdrawal Symptoms
• Triphasic withdrawal
syndrome:
• 1. Phase I (Crash Phase)
• 2. Phase 2 (Normal sleep,
mild craving)
• 3. Phase 3 (Extinction Phase
– no withdrawal but higher
chance of relapse)
Complications
• Acute anxiety,
uncontrolled
compulsive behaviour
• Perforation of nasal
septum, lung damage,
seizures,
hallucinations
• Overdose & chronic
use will require
treatment
PatternsofUse
page 44
* Cocaine is seen as a “status symbol” drug in India
as only “Thin Upper Crust” can afford it

45. Caffeine&Nicotine
UseDisorders
F15 - Mental and Behavioural Disorders due
to use of other Stimulants, including Caffeine
F17 - Mental and Behavioural Disorders due
to use ofTobacco

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• Caffeinism or caffeine intoxication
(DSM-IV-TR)
• Consumption of caffeinated beverages
exceeding 250 mg in a day along with 5
or more criteria
• Restlessness, flushed face, insomnia,
flow of thought and speech, muscle
twitching
Caffeine
Nicotine/Tobacco
• Nicotine (through smoking) more
common in schizophrenia, depression
• Withdrawal can happen 12-14 hours
after smoking
• Nicotine replacement therapy (patch,
gum use) & certain medication

51. INHALANTS OR
VOLATILE SOLVENT
USE DISORDER
F18 - Mental and Behavioural Disorders due to use of Volatile Solvents

52. Characteristics
COMMON VOLATILE
SOLVENTS INCLUDE
GASOLINE, GLUES,
AEROSOLS, THINNERS,
VARNISH REMOVER,
INDUSTRIAL SOLVENTS
MORE COMMON AMONG
ADOLESCENTS, LOW
SOCIOECONOMIC STATUS
(SLUMS IN MUMBAI, DELHI)
NO SPECIFIC TREATMENT,
PROGNOSIS IS USUALLY
GUARDED

53. Gaming & Gambling
Disorders
ICD 11 6C50 - Gambling Disorder
ICD 11 6C51 - Gaming Disorder

55. Multiple Drug
Use Disorders
F19 - Mental and behavioural
disorders due to multiple drug use

56. Jens
Martensson
Multiple Drug Use
Gateway Drug Theory
Soft drugs, such as tobacco, alcohol and marijuana,
serve as a gateway towards the use of other illicit
drugs.
Alcohol & tobacco are legal and socially acceptable,
making it a gateway. Marijuana is also a party drug.
The normalization & prevalence of them allows
people to experiment with their limits before
moving on to other substances.
Dual Diagnosis Behavioral & Mood Disorders - A drug
or alcohol addiction combined with a behavioral or
mood disorder
1. Eating Disorders including anorexia, bulimia, and
binge eating disorder
2. Depression
3. Anxiety
4. Sleep Disorders
5. Fibromyalgia
6. Panic Disorder
7. PTSD (Post Traumatic Stress Disorder)
8. Sex & Love Addiction

57. SOCIAL WORK &
SUBSTANCE USE
DISORDERS

58. Scope for Social Workers
1. Substance Abuse is on the rise
2. Can work in many different settings:
hospitals, outpatient clinics, schools, nonprofit & local advocacy
organizations, courts, police departments
3. Higher salary on the spectrum
4. Offer professional independence and growth with a lot of exposure

59. Roles of a Clinical Social Worker
◦ Provide psychotherapy & counseling
◦ Case managers for individuals with complex needs
◦ Discharge planners in hospital settings
◦ Help create treatment plans for patients with co-occurring mental
illness
◦ Addressing socioeconomic issues like homelessness
◦ Navigating the justice system for clients who are in conflict with the
law

60. Contoso
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ThankYou
Tasmin Kurien
kurien.tasmin2@gmail.com