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![The DSM, both in its revision of the third
edition (DSM–III–R; American Psychiatric
Association [APA] 1987) and in its most recent
edition (DSM– IV; APA 1994 and DSM-IV-TR;
2000), avoids the term addiction, preferring
instead to use the diagnoses of substance
abuse and dependence, collectively referred
to as substance use disorders.
Ref: APA: 1987, 1994, 2000](https://image.slidesharecdn.com/substanceusedisorder-171219150256/85/Substance-use-disorder-7-320.jpg)
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Substance use disorder
- 1.
- 3. Substance use disorders haveworld wide distribution. It affects both gender and all races. Pattern and type of substance use depends on several factors.
- 4. Epidemiology As per National HouseholdSurvey, current prevalence of • Alcohol is 21.4% • Cannabis is 3.0% • Opioid is 0.6%
- 5.
- 6. Definition - TheWorld Health Organization's 1957 Expert Committee on Addiction-Producing Drugs offered the following definition : Drug addiction is a state of periodic or chronic intoxication produced by repeated consumption of a drug (natural or synthetic). Its characteristics include: (1) An overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means; (2) A tendency to increase the dose; (3) A psychic (psychological) and generally a physical dependence on the effects of the drug; (4) Detrimental effect on the individual and society. Ref : WHO,1957
- 7. The DSM, bothin its revision of the third edition (DSM–III–R; American Psychiatric Association [APA] 1987) and in its most recent edition (DSM– IV; APA 1994 and DSM-IV-TR; 2000), avoids the term addiction, preferring instead to use the diagnoses of substance abuse and dependence, collectively referred to as substance use disorders. Ref: APA: 1987, 1994, 2000
- 8. • It isa cluster of physiological, behavioural and cognitive phenomenon in which the use of substance takes on much higher priority for a given individual than other behaviours that once had greater values. • Characterized by • Strong desire or sense of compulsion to consume substance; • Impaired capacity to control taking substance • Withdrawal state when substance is reduced or ceased • Tolerance • Preoccupation with substance, • Persistent substance use despite clear evidence of harmful consequences Dependence syndrome
- 9. Why is itdifficult to quit substance? Pleasure effect Regular long term use leads to dependence (addiction) Tolerance Stopping substance produces withdrawal symptoms
- 10. Causes of substanceuse Psychological – substance has calming effect Stress Socio-cultural Environmental - parent (s) alcoholic Biological – genetic Psychiatric illnesses
- 12.
- 13. Alcoholic beverages • World’soldest consumed alcoholic beverage • Third most popular drink overall ( 1st – Water, 2nd – Tea) • On an average it contains 4 – 6% absolute alcohol.Beer • Involves a longer fermentation process and long aging process. • Contains 9 – 16% absolute alcoholWine • Unsweetened, distilled alcoholic beverages • Contains absolute alcohol at least 20% • Eg- Whiskey, Rum, Gin, Vodka, BrandySpirits
- 14. Alcoholic beverages Alcohol beverageswith lower concentration of alcohol ( Beers/ Wines) are produced by fermentation of sugar or starch where as that with higher concentration of alcohol are produced by fermentation followed by distillation.
- 15. Country wise consumptionof alcohol Alcohol consumption per capita (age 15 or older), per year, by country, in liters of pure alcohol
- 16. Scenario Alcohol contributes to1.8 million deaths each year (worldwide). In US 22,000 deaths and 2 million non-fatal injuries each year are due to alcohol. In US 90% of population drink alcohol at sometime during their life.
- 17. In India thedata available is just tip of the ice berg. After nicotine, most commonly psychotropic substance of use in India • National House Hold Survey (NHS)- Prevalence in general population (above 15 yrs) 21.4% (National survey, 2004) • Drug Abuse Monitoring Survey (DAMS)- Prevalence in treatment seekers 43.9% (National survey, 2004)
- 19. PROPERTIES OF ALCOHOL Ethanolis well absorbed through the mucosal lining of the digestive tract in the mouth, esophagus, stomach and intestine. The most common site of absorption is in the proximal small intestine, which is also the site of absorption of many of the B vitamins.
- 20. Intoxication with alcohol One(or more) of the following signs, developing during, or shortly after, alcohol use: Slurred speech, Inco-ordination, Unsteady gait, Nystagmus, Impairment in attention or memory and Stupor or coma
- 21. BAC (mg/dl) Effects <80 Euphoria, feelingof relaxation and talking freely, clumsy movements of hands and legs, reduced alertness but believes himself to be alert >80 Noisy, moody, impaired judgement, impaired driving ability 100-200 Electroencephalographic changes begin to appear, Blurred vision, unsteady gait, gross motor in-coordination, slurred speech, aggressive, quarrelsome, talking loudly. 200-300 Amnesia for the experience – blackout 300-350 Coma 350-600 May cause or contribute to death
- 22.
- 23. Complications of alcoholism Complicationscan be subdivided into Acute • Physiological • Psychological Chronic • Physiological • Psychological
- 24. Complications of alcoholism-acute effects Mental & Behavioural Effects Drowsiness Impaired attention Impaired memory Impaired judgement Impulsive behaviour Inappropriate sexual behaviour Aggressive behaviour Inappropriate social conduct Impaired occupational performance Mood lability(rapid changes) Stupor/Coma
- 25. Complications of alcoholism– acute effects Physical Effects Flushed face Rapid pulse Headache Stomach ache Diarrhoea Sweating Slurred speech Motor in coordination Unsteady gait Nystagmus Respiratory depression
- 26. Complications of alcoholism-in long term • Gastrointestinal system - Fatty liver, Alcoholic Hepatitis, Cirrhosis, Esophagitis, Gastritis, Peptic ulcer Pancreatitis, Malabsorption • Nutritional deficiencies - Thiamine, Pyridoxine, Vitamin A, Folic acid, Ascorbic acid • Haematological disorders- Anaemia, Leucopenia, Thrombocytopenia • Cardiovascular system - Cardiomyopathy, Hypertension Physical consequences of long term alcohol use
- 27. Complications of alcoholism-in long term • Central nervous system - Wernicke- Korsakoffs syndrome, Dementia, Cerebellar degeneration, Peripheral neuropathy, Myopathy, Head injury • Metabolic disorders- Ketoacidosis, Hypoglycaemia, Hypocalcemia, Hypomagnesemia • Miscellaneous- Fetal alcohol syndrome, Osteoporosis, Tuberculosis, Psoriasis,Domestic & traffic accidents • Cancers -Oral, Esophagus, Colon, Hepatocellular, Breast (women) Physical consequences of long term alcohol use
- 28. Complications of alcoholism-inlong term Psychiatric complications of long term alcohol use: • Dependence syndrome • Withdrawal syndrome • Delirium tremens • Alcoholic hallucinosis • Withdrawal seizures • Psychotic disorders • Schizophrenia like • Manic / depressive / mixed affective symptoms • Anxiety disorders • Amnestic syndrome (Korsakoff’s psychosis) • Personality disorders • Dementia
- 29. Complications of substanceuse- in long term • Gastrointestinal system - Fatty liver,Hepatitis, Cirrhosis, Esophagitis, Gastritis, Peptic ulcer Pancreatitis, Malabsorption • Nutritional deficiencies - Thiamine, Pyridoxine, Vitamin A, Folic acid, Ascorbic acid • Haematological disorders- Anaemia, Leucopenia, Thrombocytopenia • Cardiovascular system - Cardiomyopathy, Hypertension Physical consequences of substance use
- 30. Complications of substanceuse- in long term • Central nervous system - Wernicke- Korsakoffs syndrome, Dementia, Cerebellar degeneration, Peripheral neuropathy, Myopathy, Head injury • Metabolic disorders- Ketoacidosis, Hypoglycaemia, Hypocalcemia, Hypomagnesemia • Miscellaneous- Fetal alcohol syndrome, Osteoporosis, Tuberculosis, Psoriasis, Domestic & traffic accidents • Cancers -Oral, Esophagus, Colon, Hepatocellular, Breast (women) Physical consequences of substance use
- 31. Complications of substanceuse Psychiatric complications of substance use: • Acute intoxication • Harmful use • Dependence syndrome • Withdrawal syndrome • Uncomplicated withdrawal (tremor, insomnia, hang over) • Complicated withdrawal (Delirium, Alcoholic hallucinosis, Withdrawal seizures) • Psychotic disorders • Schizophrenia like • Manic / depressive / mixed affective symptoms • Anxiety disorders • Amnesic syndrome (Korsakoff’s psychosis) • Personality disorders • Dementia
- 32. The patients mayseek treatment for different reasons like – Heavy intake of substance Dependence Physical complications due to use of substance Occupational impairment Financial crisis Social crisis Legal problems
- 34. THE GENERAL PRINCIPLESOF SUBSTANCE USE DISORDER AT PRIMARY CARE LEVEL SCREENING ASSESS ADVICE AGREE MONITOR
- 35. Screening Ask for •Any formof substance use •Frequency / Quantity /Duration /Abstinence •Withdrawal symptoms , if any •Any complications
- 36. Assess Assess • Physical condition(By doing detailed systemic examination) • Psychological condition (By history taking and mental status examination) • Occupational condition • Legal issues • Socio – economic condition • Level of motivation # Assessment can be done using structured screening questionnaires (eg- CAGE questionnaire for alcoholism) # Laboratory investigations help in assessing the degree of damage to body
- 37. Motivation • Not ready PRE- CONTEMPLATION • Unsure CONTEMPLATION •Ready PREPARATION • Changing ACTION • Changed MAINTENANCE
- 38. Advice Brief intervention (self – efficacy, responsibility, feedback about physical hazards, advice) In brief intervention Self efficacy-The patient is motivated to be optimistic. Responsibility- To be responsible for own health, family and society. Feedback about physical hazards-He/she is to be educated to avoid risky situations, consequences of substance use is to be explained Advice- Clear advice should be given to reduce drinking
- 39. Agree To convince (make agree) theperson for de-addiction
- 40. Monitor Monitor • For withdrawalsymptoms • During detoxification • Treatment
- 42. Non pharmacological Management ofsubstance use disorder is done with abstinence, motivation of the patient for quitting substance and by brief intervention.
- 43. Specific lab. Investigationsrequired •Hemogram •X-ray chest •sputum examination Nicotine •Hemogram •MCV •GBP •LFT Alcohol •Hemogram •X-ray chest •sputum examination Cannabis •Hemogram •X-ray chest •sputum examination Opioids •LFT Benzodiazepines
- 44. Specific pharmacotherapy • Nicotinechewing gum • Bupropion Nicotine • Long acting benzodiazepines • Anticraving agents (Acamprosate) • Trazodone • Thiamine Alcohol • Long acting benzodiazepines Cannabis • Fixed dose combination of Buprenorphine and naloxone • Clonidine Opioids • Long acting benzodiazepines Benzodiazepines
- 45. Specific non- pharmacologicalintervention Common to all substances •Counseling •Motivational interview •Brief intervention Effective modes of non- pharmacological intervention
- 47. Considering the demographic profileof developing countries like India, where majority of population reside in rural areas, the focus should be at primary care level.
- 48. Pharmacological management is specificfor each substance of abuse
- 49. Alcohol dependence is managedwith • Supplementation of heavy dose of thiamine along with vitamins and nutrients • Long acting benzodiazepines like diazepam/ chlorodiazepoxide • Anticraving agents-Acamprosate • Trazodone (in low doses)-For sleep
- 50. Delirium, withdrawal seizures are treated with benzodiazepines. Ifstatus epilepticus develops then only antiepileptics are recommended along with benzodiazepines .
- 51.
- 52. Opioid dependence can be better dealtwith fixed dose combination of Buprenorphine and Naloxone or Clonidine.
- 53. Anxiety due to substance withdrawalcan be dealt with long acting benzodiazepines which needs to be tapered gradually over time.
- 54. Sleep disturbances associated with substanceuse can be treated with low doses of trazodone (50 - 200mg) or benzodiazepines.
- 55. Harm minimization (eg: cuttingdown the amount / number of cigarettes) and replacement regimen (eg: nicotine chewing gum) can be used in nicotine users.
- 56. Co-morbid physical illness should be treated withequal importance.