6. A Brain Chemistry Disease!
Addicting drugs seem to ―match‖ the
transmitter system that is not normal
A chronic, relapsing, medical disease
There are mild, moderate, and severe forms
Detox is traditionally the first step in the
total treatment process
Methadone and nicotine maintenance is
evidence that some people require a
chemical to overcome the non-normal
transmitter system
8. The combination of neuroadaptations in the brain
circuitry for the three stages of the addiction cycle
that promote drug-seeking behavior in the
addicted state.
Activation of the ventral striatum/dorsal
striatum/extended amygdala driven by cues
through the hippocampus and basolateral
amygdala and stress through the insula.
The frontal cortex system is
compromised, producing deficits in executive
function and contributing to the incentive salience
of drugs compared to natural reinforcers.
Dopamine systems are compromised, and brain
stress systems such as CRF are activated to
reset further the salience of drugs and drug-
related stimuli in the context of an aversive
dysphoric state
9.
10. Common Underlying Neurobiological
Factors Can Be
Neurochemical (imbalance of
neurotransmitters)
Structural/anatomical (same
regions and pathways)
Genetic (inherited factors that
compromise function)
11. Drug Disorder
Cocaine and Methamphetamine Schizophrenia, paranoia,
anhedonia, compulsive
behavior
Stimulants Anxiety, panic attacks, mania
and sleep disorders
LSD, Ecstasy & psychedelics Delusions and hallucinations
Alcohol, sedatives, sleepaids
& narcotics
Depression and mood
disturbances
PCP & Ketamine Antisocial behavuor
13. Consequence: There is no “cure”…
To be successful, treatment is a Lifetime
Process
Science is helping to improve our
strategies and successes
15. The history is the chronological story of the
patient’s life from birth to present
Personal data:
Name, age, sex, marital
status, religion, address, occupation, educ
ation.
n.b.; source of referral could be
mentioned here if the patient won’t
cooperate
16. Personal History:
Birth and developmental milestones, family
atmosphere, school performance and
general conduct in school, educational
achievement, occupational history, sexual
and marital history.
Attempt to correlate social problems with
evolving drug problems. Enquire about
impact of drug use on lifestyle.
17. Family History:
Brief vignette of father, mother and
other siblings should include
age, occupation and relation with the
client. History of psychiatric
problems or problems resulting from
alcohol, drugs or nicotine.
18. Drug History:
This section should attempt to give a clear
picture of initiation of drug use accounting for
each specific drug. The evolution of drug use
with the development of personal and social
problems as a consequences of drug use.
Type, quantity, and route of use of each
individual drug. Alcohol consumption should be
checked as a routine part of drug history
taking.
19. Drug use in the past 24 hr.:
Detailed and sensitive questioning around this
will not only provide data about drug use and drug
dependence but should give a clear picture of
the client’s lifestyle and daily stresses and
strains.
Drug use in the past month:
Should try to draw a picture of drug use over the
past 4 weeks.
History of abstinence:
Number of trials , how , duration of each and
reason for relapse.
20. Legal History:
Charges, convictions, imprisonments
and violent incidents.
Sexual and Marital History:
Sexual behavior and marital relation and
if extramarital relationships. Relation of
sexual or marital problems to drug use.
Occupational History:
Relationships of jobs and relations to
drug use. Current employment status.
21. Present life situation:
Family and social support. Non drug
use friends, leisure activities and
occupational prospects, financial
status and accommodations.
22. Mental state examination:
On admission:
Describe relevant features. Positive
and negative findings regarding both
physical and mental condition of the
client. Focus on physical signs of drug
withdrawal, liver diseases signs and
any neurological dysfunctions. Sites of
injections and any infections.
23. Mental state should include level of
consciousness, alertness and orientation and
as well as level of cooperativeness. Ability to
give history will provide data about their
intelligence, cognitive state and level of
insight into their condition.
General state of dress and grooming as well
as evidence of agitation, calmness or
detachment from problem should be checked.
24. Pattern of sleep, appetite, energy
level, mood state and suicidal
ideations giving data about special
and general psychological state.
Any delusions or hallucinations
should be considered and relation to
client intoxication or withdrawal states
25. Follow up setting is meant for better
elaboration of the client’s condition
and allow building rapport for setting
management plan.
A thorough history is the substrate for a
considered opinion about the client. What
is the best for the client. History is
cornerstone in the substance abuse field.
26. Patient with treatment program:
Substance is being used.
Recent regular use.
Psychiatric status.
Medical condition.
Social network.
Legal aspects.
27. Goals of treatment:
A.Help the individual to be drug
free( detoxification).
B.Help to maintain drug free
state ( relapse prevention)
C.Long term Rehabilitation.
29. Stimulation : Depression :
a. Anxiety .
b. Insomnia.
c. Twitches.
d. Convulsions.
e. Hyperthermia.
f. Tachycardia.
g. Irritability.
h. Excitement.
i. Tremors.
j. Hypertension.
k. Tachypnea
a. Apathy.
b.Retardation.
c. Inattentive.
d.Stupor.
e. Hypotension.
f. Bradypnea.
g.Ataxia.
h. Lethargy.
i. Drowsiness.
j. Confusion.
k. Hypothermia
l. Bradycardia &Coma.
30. Drugs of abuse that can be tested in urine:
Alcohol: 7-12 hrs.
Amphetamine : 48 hrs.
Barbiturate ; short: 24 hrs. , long acting:
3 wks.
Benzodiazepine: 3 days.
Cannabinoides : 3 days ---4 wks ― depending on
the use; chronic use leads to lengthening of
period‖
Cocaine : 6- 8 hrs.
Codeine : 48 hrs.
Heroin : 36—72 hrs.
Methadone : 3 days.
Morphine : 48 – 72 hrs
31. The Neuropharmacology of Drugs of
Abuse
Psychoactive drugs alter normal neurochemical
processes . This can occur at any level of activity
including :
a. mimicking the action of a neurotransmitter .
b. altering the activity of a receptor .
c. acting on the activation of second messengers
d. directly affecting intracellular processes that
control normal neuron functioning.
32. Routes of administration:
It affects how quickly a drug reaches the
brain ,also ,chemical structure of a drug
plays an important role in the ability of a
drug to cross from the circulatory system
into the brain.
Four routes:
oral.
nasal.
Intravenous.
inhalation.
33. alcohol
Mild and moderate intoxication:
1.Impaired attention , poor motor
coordination.
2.Dystharthria- ataxia , nystagmus, slurred
speech.
3.Prolonged reaction time, flushed face
orthostatic hypotension.
4.Hematemesis and stupor.
Pathological intoxication:
1.Excited , psychotic state following min.
consumption in susceptible individuals.
Intoxication associated with belligerence.
34. Uncomplicated Withdrawal:
Coarse tremors of hands, tongue, eyelids
and at least one of the following:
Nausea or vomiting.
Malaise or weakness.
Autonomic hyperactivity.
Anxiety, Depressed mood or irritability.
Transient hallucination or illusions.
Headache , insomnia.
Withdrawal complication:
Seizures.
Hallucination.
Delirium.
35. Management:
I. Avoid aspiration by placing patient’s face down or on
one side. Hospitalization is usually necessary.
II. Parenteral sedatives or physical restrains.
III. Low dose sedative ; Lorazepam 1-2 mg, physical
restrains or further sedation by Haloperidol IM 5 mg.
IV. Parenteral dose of Thiamine 100 mg.
V. Benzodiazepine tapering.
VI. Thiamine 50 mg PO.
VII. Multivitamin PO.
VIII.Folate 1 mg PO.
Over a week for uncomplicated
withdrawal.
36. Opiate:
Patients rarely seek treatment for intoxication.
Overdose :
I. Respiratory and CNS depression.
II. Depression.
III.Gastric hypomotility with ileus.
IV. Non-cardiogenic pulmonary edema.
Withdrawal:
I. Lacrimation, rhinorrhea.
II. Diaphoresis, yawing, sneezing.
III. Malaise, irritability, nausea and vomiting.
IV. Diarrhea, myalgia, arthralgia, bone
ache.
37. Management of Opiate overdose:
I. Respiratory depression : air way support
II. Cardiopulmonary suppression: Naloxone
Hydrochloride 0.4 mg or 0.01 mg kg
IV, repeated dose of Naloxone infusion
0.4 mg hr. for 12 hrs. subsequent to the
initial boluses.
III. Pulmonary edema : Intubation and
pressure ventilation ;ICU admission.
IV. Gastric lavage or induced emesis
followed by activated Charcoal for orally
ingested overdose.
38.
39. 26 year old heroin addict. He has all the symptoms of
withdrawal. He has a runny nose, stomach cramps, dilated
pupils, muscle spasms, chills despite the warm weather,
elevated heart rate and blood pressure, and is running a
slight temperature. Aside from withdrawal symptoms, this
man is in fairly good physical shape. He has no other
adverse medical problem and no psychological problems.
At first he is polite and even charming to the staff. He’s
hoping you can just give him some “meds” to tide him over
until he can see his regular doctor. However, he becomes
angry and threatening to you and the staff when you tell
him you may not be able to comply with his wishes.
40. He complains about the poor service he’s been
given because he’s an addict. He wants a bed
and “meds” and if you don’t provide one for
him you are forcing him to go out and steal and
possibly hurt someone, or, he will probably just
kill himself “because he can’t go on any more
in his present misery.” He also tells you that he
is truly ready to give up his addiction and turn
his life around if he’s just given a
chance, some medication, and a bed for
tonight.
41. The 26 year old is a heroin addict in
withdrawal. His signs and symptoms all
indicate opiate withdrawal. He has a runny
nose, stomach cramps, dilated
pupils, muscle spasms, chills, despite the
warm weather, elevated heart rate and
blood pressure, and is running a slight
temperature. He may or may not have other
drug issues. A urine analysis may provide
some answers to this question.
42. The second patient is an older man in his late sixties and
is a bit disheveled in appearance. He is accompanied by
his lady. The lady tells you that she found him earlier this
evening trying to enter his apartment door. He was
sweaty, his eyes where dilated, and his hands were
trembling so badly that he could not get the key in the
door. He kept calling her by another name and saying he
was trying to get into his office to do some work. She
says he retired years ago. His blood/alcohol level is low
and his speech is not slurred.
43. He can correctly identify himself but, also appears
confused. He is unable to tell you the month or season.
His nose and cheeks are red with tiny spider veins and his
stomach distended and when he extends his hands out in
front of him they are very tremulous. His demeanor is
polite and apologetic to you and the staff. He tells you he
has never had a problem with alcohol. He then admits to
an occasional drink
every now and then. He did have a few drinks earlier
today but can’t say exactly when. However, he is willing to
come into the hospital for a brief stay if really thought it
was necessary.
44. late 50’s and has all the signs and symptoms of a late stage
alcoholic starting to go into alcohol withdrawal. He was
sweaty, his eyes were dilated and his hands were trembling so
badly that he could not get the key in the door. He kept calling
his lady by another name . His blood/alcohol level is low and his
speech is slurred, but appears confused. His nose and cheeks
are red with tiny spider veins, he has a distended abdomen and
when he extends his hands out in front of him they are very
tremulous. He probably does not have other drugs in his
system like benzodiazepines. They would act as a stabilizer in
his condition and these drugs are often given to treat Alcohol
withdrawal.
45. Delirium tremors or “DT’s”. The symptoms are
as follows: they begin with anxiety attacks,
increasing confusion, poor sleep, marked
sweating, and fleeting hallucinations or
nocturnal illusions which arouse fear. Some
patients may suffer grand mal seizures,
several in short succession. There is a
trembling of the hands at rest, sometimes
extending to the head and trunk. Walls are
falling, floors are moving, and rooms will be
rotating.
46. Injuries often occur because patients are
unable to maintain their balance at this stage.
These falls can cause severe head and neck
injuries. Animal hallucinations are frequent
and often incite terror. It is also typical that in
these delirious, confused, states the person
will return to a habitual activity usually work
related.
In this case he is imagining himself back at
work and trying to get into his office.
