SUBSTANCE RELATED DISORDERS

SUBSTANCE RELATED DISORDERS
Owondo Thomas
Bwindi Community Hospital

INTRODUCTION
• Since the beginning of human history and before, people have
found ways to alter their bodies and their consciousness by taking
substances such as herbs, alcohol, and drugs.
• Some people are able to keep using drugs on an occasional
basis. Many other people are not so lucky. For these unlucky
others, their use of drugs begins (gradually in some cases,
abruptly in others) to increase, and the amount of attention they
spend thinking about getting high, purchasing drugs, preparing
drugs and taking drugs increases until it becomes the center of
their lives.
© 2017 Thomas Owondo. All rights reserved. 2

INTRODUCTION
• As their consumption of drugs rises, users may become
physically dependent on their drug to the extent that if
they do not take it on a particular day, they get sick.
• As dependence increases, tolerance to the drugs
increases as well - meaning that it takes more and more
of the drug to get the same 'high' or 'buzz' effect.

INTRODUCTION
• Substance-related disorders are diagnosed when use of
any substance, whether recreational or prescribed,
becomes excessive and leads to significant impairment or
distress.
• Substance-related disorders are generally divided into two
groups:
➢ Substances-induced disorders and
➢ Substance-use disorders.

INTRODUCTION
➢Substances-induced disorders include;
▪ Intoxication,
▪ Withdrawal,
▪ Other mental disorders that can be caused by
substances, such as psychotic disorders and sleep
disorders.
➢ Substance-use disorders include;
▪ Dependence and abuse.

CATEGORIES OF SUBSTANCES
• There are three main types of psychoactive drugs that people
take to change how they feel or behave.
• They include
➢ Depressants,
➢ Stimulants,
➢ Hallucinogens. In addition to these,
➢ Other drugs of abuse – Include inhalants, anabolic steroids, medications.

Depressant drugs
• Depressant drugs slow down or depress the functions of the central
nervous system.
• This doesn’t mean they make you depressed; rather the quantity,
concentration, environment and mood of the user all contribute to the
effects.
• In small quantities they can cause a person to feel more relaxed and
less inhibited.
• In larger quantities they may cause unconsciousness, vomiting, and in
some cases, death.
• Depressants affect concentration and coordination.
• They slow down a person’s ability to respond to unexpected situations.

Depressant drugs
• Alcohol, opiates and opioids (including heroin, opium,
morphine, codeine, methadone, pethidine and palfium);
• Cannabis (marijuana, hashish);
• Tranquillisers and hypnotics (including Rohypnol, Valium,
Serepax, Mogodon, Eupynos, Ativan, Ketamine).
• Some solvents and inhalants (petrol, glue, paint thinners,
lighter fluid).

Stimulant drugs
• They speed up or stimulate the central nervous system and can make the
user feel more awake, alert, or confident.
• Stimulants increase heart rate, body temperature and blood pressure.
Depending on the dose, other physical effects include loss of appetite,
dilated pupils, talkativeness, agitation and inability to sleep.
• Higher doses can ‘over stimulate’ the user and cause anxiety, panic,
seizures, headaches, stomach cramps, aggression and paranoia.
• Prolonged use of stimulants can also cause these effects.
• Strong stimulants can ‘mask’ the effects of depressants such as alcohol,
and this can increase the potential for aggression, or pose problems for
driving.

Stimulant drugs
• Mild stimulants include: tea, coffee, cola drinks,
tobacco/nicotine and ephedrine (used in cough
medicines).
• Stronger stimulants include: amphetamines, cocaine,
ecstasy (also classified as an hallucinogen), slimming
tablets (Duromine, Tenuate, Dospan and Ponderax).

Hallucinogenic drugs
• They distort perceptions of reality. Users may see or hear
things that do not actually exist, or that are exaggerated in
relation to normal sensory experience (Alter sensory
perception).
• The effects of hallucinogens are not easy to predict – they
often depend on the mood of the user and the context of use.
• The main physical effects are dilation of the pupils, loss of
appetite, increased activity, talking or laughing, jaw clenching,
sweating, stomach cramps and nausea.

Hallucinogenic drugs
• Hallucinogenic drugs include: LSD (lysergic acid
diethylamide), magic mushrooms (psilocybin), mescalin
(peyote cactus), ecstasy (MDMA – methylene
dioxymethylamphetamine), cannabis (in higher
concentrations, as well as being a depressant).

Anabolic steroids
• Anabolic steroids are one type of performance-enhancing drug or
medication. They mimic testosterone in the body to enhance
performance by making muscle cells larger and by allowing the body
to recover more quickly from the stress of exercise.
• Some people use anabolic steroids to enhance performance in sport
and for body-building.
• Side effects or consequences of anabolic steroid use include:
dependence and tolerance, depression (in withdrawal), organ
disease or cancer, increased blood pressure, auto-immune
suppression, decreased libido, breast tissue changes in men and
women, growth of facial hair and deepening of the voice in women.

Anabolic steroids
• Testosterone (Axiron, Androgel, Fortesta,
Testopel, Striant, Delatestryl, Testim, Androderm)
• Androstenedione
• Stanozolol (Winstrol)
• Nandrolone (Deca-Durabolin)
• Methandrosteolone (Dianabol)

WHY PEOPLE USE SUBSTANCE

EFFECTS OF SUBSTANCE USE
• Different patterns of drug use result in different types of
problems.

Psychoactive drug that depresses the
nervous system.

ALCOHOL
• Alcohol is commonly used to celebrate, relax, or socialize with
others, and drinking in moderation is typically seen as a
reasonable behavior.
• Individuals have different genetic make ups and early
experiences, they may respond differently to alcohol and other
drugs and have a different risk for drug abuse and dependence.
• Moderate alcohol consumption does not generally cause any
psychological or physical harm. However, if who enjoy social
drinking increase their consumption or regularly consume more
than is recommended, Alcohol Use disorder may eventually
develop.

Categorization of alcohol use disorders
• Like other substances, alcohol use can be categorized as
follows;
➢ Alcohol Use Disorders;
⚫ Alcohol Dependence
⚫ Alcohol Abuse
➢ Alcohol-Induced Disorders;
⚫ Alcohol Intoxication
⚫ Alcohol Withdrawal
⚫ Alcohol -Induced Psychiatric Syndromes (E.g; Psychosis, Mania etc)

ALCOHOL USE DISORDER (AUD)
• Alcoholism, now known as alcohol use disorder, is a condition in
which a person has a desire or physical need to consume alcohol,
even though it has a negative impact on their life.
• A person with this condition does not know when or how to stop
drinking. They spend a lot of time thinking about alcohol, and they
cannot control how much they consume, even if it is causing
serious problems at home, work, and financially.
• Alcohol use disorder is defined by a cluster of behavioral and
physical symptoms, which can include withdrawal, tolerance, and
craving.

SUB CLASS OF AUD
1. Alcohol Dependence;
A maladaptive pattern of alcohol use, leading to clinically significant impairment
or distress, as manifested by 3+ of the following, at any time in a 12-month
period:
➢ Tolerance
⚫ A need for markedly increased amounts of substance to achieve
intoxication or desired effect
⚫ Markedly diminished effect with continued use of the same amount of
substance
➢ Withdrawal
⚫ Characteristic withdrawal syndrome for substance
⚫ The same or a closely related substance taken to relieve or avoid
withdrawal symptoms
➢ Substance taken in larger amounts or over longer period than intended.
21

Alcohol Dependence
➢ Craving for alcohol is indicated by a strong desire to drink that makes it
difficult to think of anything else and that often results in the onset of drinking.
➢ Persistent desire or unsuccessful efforts to cut down or control substance
use.
➢ A great deal of time is spent in activities necessary to obtain or use the
substance or recover from its effects.
➢ Important social, occupational, or recreational activities are given up or
reduced because of substance use.
➢ Substance use is continued despite having a persistent or recurrent physical
or psychological problem that is likely to have been caused or exacerbated
by the substance.
Specifiers:
•With Physiological Dependence – evidence of tolerance or withdrawal.
•Without Physiological Dependence – no evidence of tolerance or withdrawal

SUB CLASS OF AUD
2. Alcohol Abuse;
• Maladaptive pattern of alcohol use, leading to clinically significant impairment
or distress, as manifested by 1 or more of the following, occurring in a 12-
month period:
➢ Recurrent alcohol use resulting in a failure to fulfill major role obligations at
work, school, or home
➢ Recurrent alcohol use in situations in which it is physically hazardous (e.g.
driving while impaired)
➢ Recurrent alcohol use -related legal problems (e.g. disorderly conduct)
➢ Recurrent alcohol use despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of the alcohol
(e.g. arguments with significant other about substance use, physical fights)

ALCOHOL USE DISORDE (AUD)
• Alcoholism, or alcohol dependence, used to
be considered the most severe form of alcohol abuse.
The DSM-V integrates alcohol abuse and alcohol
dependence, into a single disorder called alcohol use
disorder (AUD) with mild, moderate, and severe sub-
classifications.
• Mild: The presence of two to three symptoms
• Moderate: The presence of four to five symptoms
• Severe: The presence of six or more symptoms.

Differential Diagnosis of Substance
Dependence & Abuse
• Continuum of Substance Use: Recreational Use → Problematic Use →
Substance Abuse → Substance Dependence
• Substance Dependence: adverse consequences & tolerance, withdrawal,
compulsive use.
• Substance Abuse: adverse consequences, but absence of tolerance,
withdrawal, or compulsive use.
• Consider factors such as age, sex, culture, and health.
• Once person has met criteria for Substance Dependence for a substance,
they can never be given diagnosis of Substance Abuse for that substance.

ALCOHOL INDUCED DISORDERS
• Some of the disorders are:
➢Alcohol intoxication
➢Alcohol withdrawal,
➢Alcohol-induced persisting dementia,
➢Alcohol-induced persisting amnestic disorder,
➢Alcohol-induced psychotic disorder,
➢Alcohol-induced mood disorder
➢ Alcohol-induced etc…….

ALCOHOL INTOXICATION
• Alcohol intoxication is a harmful physical condition caused when you
drink more alcohol than your body can handle. It is also called ethanol
poisoning, or being drunk.
• Alcohol intoxication results as the amount of alcohol in your
bloodstream increases. The higher the blood alcohol concentration is,
the more impaired you become.
• The development of a reversible substance-specific syndrome, due to
recent ingestion of, or exposure to, a substance.
• Clinically significant maladaptive behavioral or psychological changes
develop during or shortly after use of the substance due to the effect of
the substance on the central nervous system.
• Intoxication is not diagnosed when someone simply ingests a
substance that has the desired effect and no undesired side effects. 27

Signs and symptoms of Alcohol
Intoxication
Physical
• Breath that smells like alcohol
• Blackouts or seizures
• Enlarged pupils
• Eye movements that are faster than
normal for you
• Fast heartbeats and slow breaths
• Loss of balance, or no ability to
walk straight or stand still
• Nausea and vomiting
• Slurred or loud speech
Behavioral
• Quick mood changes: You feel
happy and quickly become angry,
or you easily become sad. You may
act out violently.
• Risky sexual behavior: You have
sex that is not protected, or you
have sex with many people.
• Work or school trouble: You have
many absences or do not finish
your work.

ALCOHOL WITHDRAWAL
• If you drink alcohol heavily for weeks, months, or years, you
may have both mental and physical problems when you stop or
seriously cut back on how much you drink. This is called alcohol
withdrawal. Symptoms can range from mild to serious.
• Alcohol withdrawal syndrome is the clinical syndrome that occurs
when people who are physically dependent upon alcohol stop
drinking or reduce their alcohol consumption.
• The substance-specific syndrome causes clinically significant
distress or impairment in social, occupational, or other important
areas of functioning.

Clinical Information
• Current substance use
• History of substance use
• History of substance use
emergencies & treatment
• Cognitive impairment, e.g.
confusion, disorientation, impaired
attention, rambling thoughts,
drowsiness
• Physiological signs, e.g.
tachycardia, hypertension,
hypotension, dilation or constriction
of pupils
• Neurological signs, e.g. slurred
speech, lack of coordination, ataxia,
dystonia, tremor, seizure, etc.
• Psychomotor agitation or
retardation
• Changes in personality, mood,
anxiety
• Urine drug screening, blood alcohol
level
• Changes in social or family life
• Current and past legal problems

Alcohol withdrawal syndrome
• During the first several days after you quit drinking, you may
experience withdrawal symptoms. Over time, your body
becomes dependent on your drinking frequency and patterns.
However, when you abruptly stop drinking, your body requires
time to figure out what chemicals it’s missing. This phase is
what produces the painful side effects.
• Alcohol withdrawal syndrome can occur when you quit
drinking and may trigger life-threatening health
complications.

• Alcohol withdrawal syndrome (AWS) is the name for the
symptoms that occur when a heavy drinker suddenly
stops or significantly reduces their alcohol intake.
• Alcohol withdrawal syndrome is divided into 4 categories:
➢Minor withdrawal
➢Major withdrawal
➢Withdrawal seizures
➢Delirium tremens (DTs)

• Minor withdrawal (withdrawal tremulousness);
➢Occurs within 6-24 hours following the patient’s last drink
and is characterized by tremor, anxiety, nausea, vomiting,
and insomnia.
• Major withdrawal (alcoholic hallucinosis);
➢Major withdrawal (hallucinations) occurs 10-72 hours after
the last drink. The signs and symptoms include visual and
auditory hallucinations, whole body tremor, vomiting,
diaphoresis, and hypertension.

Withdrawal seizures (rum fits);
➢ Occur within 6-48 hours of alcohol cessation; they are major
motor seizures that take place during withdrawal in patients who
normally have no seizures and have normal
electroencephalograms (EEGs).
➢ These seizures are typically generalized and brief. In the absence
of treatment, multiple seizures occur in 60% of patients, but the
duration between the first and last seizure is usually less than 6
hours.
➢ Only 3% of patients go on to develop status epilepticus.

Withdrawal seizures (rum fits) conti
• An alcohol withdrawal seizure is frequently the first sign of alcohol
withdrawal, and no other signs of withdrawal may be present after
the seizure abates. About 30-40% of patients with alcohol
withdrawal seizures progress to DTs.
• Alcohol withdrawal seizures usually occur only once or recur only
once or twice, and they generally resolve spontaneously. If a
patient has seizures that are not typical of alcohol withdrawal
seizures (such as partial or focal seizures, prolonged seizures, or
seizures with a prolonged postictal state) or has signs of
significant head trauma, then the underlying cause of the seizure
should be investigated.

DELIRIUM TREMENS
• DTs is the most severe manifestation of alcohol
withdrawal.
• It occurs 3-10 days following the last drink.
• Clinical manifestations include; Agitation, Global
confusion, Disorientation, Hallucinations (Tactile and
visual), fever, hypertension, diaphoresis, and autonomic
hyperactivity (tachycardia and hypertension). Profound
global confusion is the hallmark of delirium tremens.

DELIRIUM TREMENS
• The "symptoms are characteristically worse at night".
• Other common symptoms include intense perceptual disturbance
such as visions of insects, snakes, or rats. These may be
hallucinations or illusions related to the environment, e.g.,
patterns on the wallpaper or in the peripheral vision that the
patient falsely perceives as a resemblance to the morphology of
an insect, and are also associated with tactile hallucinations such
as sensations of something crawling on the subject—a
phenomenon known as formication.

Management of DTs
• It is a psychiatric/medical emergency with a high mortality
rate, making early recognition and treatment essential..
• Admission is a priority.
• Treatment in a quiet intensive care unit with sufficient light
is often recommended.
• Benzodiazepines are the medication of choice.
• The vitamin thiamine is recommended.
• The antipsychotic haloperidol may also be used.

GENERAL MANAGEMENT OF AUD
• SEARCH FOR IT

SUBSTANCE RELATED DISORDERS

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