The document discusses substance use disorders and alcoholism. It defines key terms like tolerance, dependence, withdrawal, and provides the ICD-10 classification for mental and behavioral disorders due to substance use. It explores the etiology of substance abuse, including biological factors like genetics and gender, and social factors like family, peers, and culture. It focuses on alcoholism, defining it and describing the clinical types and stages of alcoholism. It also discusses tools for assessing problem drinkers like CAGE, MAST, AUDIT, and PAT questionnaires.

1. SUBSTANCE
USE
DISORDERS
Prof Sathish Rajamani
DSCON - CUTTACK

2. Basic terms to know in this chapter
● Tolerance – Increase in the level of substance use in order to get the same desired effect.
● Dependence – Compulsive and repeated use of substance, which results in tolerance
towards the substance and also leads to withdrawal symptoms when it is commenced to quit
or decrease the dosage of the substance.
● Psychological dependence – Continuous craving for substance to avoid dysphoria
(unpleasant mood)
● Physiological dependence – Physical effects are seen and withdrawal symptoms
appear if one quits a drug.

3. Basic terms to know in this chapter
● Behavioural dependence – Drug seeking activities and pathological uses are seen.
● Abuse – Maladaptive pattern of substance use leading to clinically significant distress or
impairment with one or more of the following.
○ Recurrent substance use results in failure to perform well in home, school and at work.
○ Recurrent substance use in situation which is physically hazardous (e.g,. Driving
vechicle)
○ Recurrent legal problems related to substance usage.
○ Continued substance use might leads to recurrent interpersonal problems.

4. Basic terms to know in this chapter
● Harmful use – A pattern of psychoactive substance use which harms the physical health
(cirrhosis of liver) or psychological use (depression).
● Withdrawal – Symptoms occurs when blood level of abused drugs gets decreased and
symptoms cease when that substance has been taken by the individual.
● Intoxication – Substance related syndrome occurs due to the strong exposure to the
substance.
● Detoxification – It is the process of eliminating or neutralizing the toxins from the human
body.

5. Basic terms to know in this chapter
● Codependency – It is an excessive emotional or psychological reliance on other people
for support. It is a behavioural problem and mostly it is affected due to substance abuse
by a family member
● Cross Tolerance – Effect of one drug produces tolerance to another drug that usually
happens between two drugs with same function.

6. COMMON SUBSTANCE ABUSE IN INDIA
Alcohol
1 2 3
4 5 6
Cannabis
Hypnotics,Sedatives and
Anti – anxiety drugs
Amphetamine Barbiturates Cocaine

7. COMMON SUBSTANCE ABUSE IN INDIA
Hallucinogens
7 8 9
10 11 12
Inhalants Nicotine
Opioids – Heroin, Morphine Phencyclidine Polysubstances

8. ICD – 10 Classification
F10 – F19: Mental and Behavioural disorders due to osychoactive substance use and mental
and behavioural disorder due to the use of
● F10 – Alcohol
● F11 – Opioids
● F12 – Cannabinoids
● F13 – Hypnotics and Sedatives
● F14 – Cocaine
● F16 - Hallucinogens

9. ETIOLOGY
Etiology and Risk factors of Substance Abuse /
Dependency

10. 1
Heredity, Genetics, Physiological vulnerability,
Gender
Biological Factors

11. Heredity Factors
 The exact causes of substance abuse are
unclear. Psychological and coping factors
plays an important role in causation. Substance
addiction runs in families.
 Children who grow up seeing their parents
using drugs may have a high risk of
developing substance use problem later in life
for both environmental and genetic reasons.

12. Genetics Factors
 Genes account for 40 – 60 % of the risk factor for addiction
development.
 The genetic connection to addiction comes through inherited
levels of dopamine, a neurotransmitter made in your brain.
 High levels of dopamine can fuel poor impulse control and tilt
someone toward addictive behaviors.

13. Physiological Vulnerability
 Differences in metabolic variations by
different races. For examples polymorphism
of liver enzymes.

14. GENDER
 Males are more likely than females to
develop a substance use disorders.

15. 2
Family, Peer and Other factors
Social Factors

16. Family Factors
 Having a parent or sibling that has a substance
use disorders
 Poor quality of the parent – child relationship.
 Family disruptions such as divorce.
 Social isolation.
 Abuse (Physical, Verbal and Sexual)

17. Peer Factors
 Poor social skills
 Excessive time spending with substance using
peers.
 Substance uses during birthday and college
parties.

18. Socio-Cultural Factors
 Media influences
 Social and legal policies
 Low SES
 Community drug use norms
 Accessibility and availability of drugs

19. Other Factors
 Exposure to physical, sexual and emotional
abuse.
 Religious rituals, modernization and rapid
urbanization.

20. 3
Family, Peer and Other factors
Psychological Factors

21. Psychological Factors
 Sensation Seeking Behaviour
 High Impulsivity
 Anti – Social Personality

22. Mental Health Disorders
 Major depression
 ADHD
 PTSD
 Anxiety disorders
 Schizophrenia

23. ALCOHOLISM

24. WHAT IS ALCOHOLISM?
● Alcohol (ethyl alcohol or ethanol) is the most commonly used
psychoactive substance world wide.
● Alcohol – CNS Depressant
● Alcohol affects a person’s emotions, thinking processes, motor
function and behaviour.
● Blood Alcohol Concentration (BAC) leads to all these changes in
an individual who consumes alcohol.

25. DEFINITION OF ALCOHOLISM
● Alcoholism is a state where person is powerless to stop the
drinking that seriously alters his normal living pattern.
○ National Council on Alcoholism (USA)

26. 3 – 6 % Alcohol
16 – 24 % Alcohol
14 – 16 % Alcohol
36 – 50 % Alcohol
36 – 50 % Alcohol 36 – 50 % Alcohol
Beer Wine Whisky
Rum Scotch
COMMON ALCOHOLIC BEVERAGES
Gin
40 – 45 % Alcohol
Vodka
40 – 95 % Alcohol

29. BLOOD ALCOHOL CONCENTRATION
● What is the normal blood alcohol concentration in the body? At a blood
ethanol level of less than 50 mg/dL, or 0.05% concentration, an individual is
not considered to be intoxicated.
● How do you calculate blood alcohol concentration?

30. BLOOD ALCOHOL CONCENTRATION & ITS EFFECTS
BAC Mg / dl Effects of Alcohol in Body
20 – 30 Slow motor activity
30 – 80 Decline in Cognition
80 – 200 Lack of coordination, Decline in cognition,
Poor judgement
200 – 300 Alcohol blackout, Slurring of speech,
Nystagmus
300 – 350 Hypothermia, Dysarthria
350 – 400 Coma Respiratory depression
> Than 400 Death might occur

31. Physical dependence, psychological
dependence tolerance, inability to
control and withdrawal symptoms
are present
GAMA
CLINICAL TYPES OF ALCOHOLISM
ALPHA
Increased consumption of alcohol to
come out of physical or emotional pain.
BETA
Increased consumptions of alcoholism
lead to physical consumptions but no
dependence to alcohol.
DELTA
Inability to stop alcohol
completely but it can
be controlled.
EPSILON
Dipsomania
(Uncontrollable
craving of alcohol)

32. STAGES
OF
ALCOHOLISM

34. STAGE – 1: EXPERIMENTATION
● Most people have their first taste of alcohol when they
are teenagers, but some may try it at an even younger age.
● At this point, they may decide whether or not they like
the taste or how drinking makes them feel. Some young
people drink even if they don’t like the effects.
● This is usually because of peer pressure or fear of missing
out.

35. STAGE – 2: INCREASED TOLERANCE
● If a person continues to drink alcohol regularly, they will
build up a tolerance.
● This means the effects are reduced each time they drink.
If they are seeking to achieve a particular feeling, they
will need to consume more and more alcohol each time.

36. STAGE – 3: ADVERSE EFFECTS
● With continued misuse of alcohol, the substance may
begin to have a negative impact on the user’s life.
● Excessive drinking can damage relationships with
relatives and friends and impact the individual’s work
performance. It can also lead to financial problems.

37. STAGE – 4: DEPENDENCE
● Over time, the brain and body get used to
the presence of alcohol and they become
physically dependent.
● When you’re not drinking, you will
experience withdrawal symptoms like
nausea, vomiting, sweating, shaking and
headaches.

38. STAGE – 5: ADDICTION
● When you develop an alcohol addiction, you lose all control over your consumption.
● You will drink to reduce the physical symptoms of withdrawal or because you feel
anxious when you’re not drinking.
● You won’t be able to stop drinking even if you want to. You could also start to
experience more health problems including heart, liver or kidney disease, paranoia,
and dementia.

40. Diagnosis of Alcohol Abuse
Blood Alcohol Concentration – Normal level
in India is < 30 mg / dl or 0.03 % g/dl.
Gama Glutamyl Transferase (GGT) - > 40
IU/L.
Mean Corpuscular Value (MCV) - > 92fL /
red cell.
Liver Function Test (LFT) – Increased
SGOT, SGPT, ALT and Ammonia.
Haematologic Studies – Anaemia,
Thrombocytopenia, Raised PT and Partial PTT.

41. Diagnosis of Alcohol Abuse (Cont)
Serum Glucose Level– Decreased in case of
severe liver disease.
Urine Toxicology- To screen out other
diseases
Serum Electrolyte Analysis – To screen out
the electrolyte imbalances due to alcohol abuse
ECG – Cardiac problems due to alcoholism are
screened out.

42. ASSESSMENT TOOLS
FOR
PROBLEM DRINKERS
CAGE Questionnaire, MAST, AUDIT, PAT

43. CAGE QUESTIONNAIRE

44. MICHIGAN ALCOHOLISM SCREENING TEST (MAST)
● MAST is a tool for assessment of problem drinkers and to screen
individuals who met alcohol related offences.
● It is a tool which consisted of 24 items and the client has to answer it
in ‘yes or no’ format.

45. Alcohol Use Disorders Identification Test (AUDIT)
● Alcohol Use Disorders Identification Test (AUDIT) The AUDIT
(Alcohol Use Disorders Identification Test) is a simple and effective
method of screening for unhealthy alcohol use, defined as risky
or hazardous consumption or any alcohol use disorder.
● The AUDIT-C is scored on a scale of 0-12 (scores of 0 reflect no
alcohol use). In men, a score of 4 or more is considered positive; in
women, a score of 3 or more is considered positive. Generally, the
higher the AUDIT-C score, the more likely it is that the patient's
drinking is affecting his/her health and safety.

46. PADDINGTON ALCOHOL TEST (PAT)
● The Paddington Alcohol Test (PAT) has developed
pragmatically for emergency department (ED) staff to
give patients brief advice (BA) about alcohol.
● The Paddington Alcohol Test, designed to screen for
alcohol related problems amongst those attending
Accident and Emergency Departments

47. ALCOHOL
RELATED
DISORDERS

48. Alcohol
related
Disorders
Alcohol
Amnestic
Syndrome
Alcoholic
Psychosis
Delirium
Tremens
Alcohol
Withdrawal
Syndrome

49. Alcoholic Amnestic Syndrome
(Wernicke Korsakoff’s Syndrome)
“A mental disorder associated with
chronic ethanol abuse (ALCOHOLISM)
and nutritional deficiencies
characterized by short term memory
loss, confabulations, and disturbances of
attention.”

50. Wernicke – Korsakoff Syndrome
Korsakoff syndrome (also called Korsakoff's
amnesic syndrome) is a memory disorder that
results from vitamin B1 deficiency and is
associated with alcoholism.
Korsakoff's syndrome damages nerve cells and
supporting cells in the brain and spinal cord, as
well as the part of the brain involved with
memory.

51. Alcoholic Amnestic Syndrome
Wernicke encephalopathy (WE) is an acute
neurological condition characterized by a clinical
triad of ophthalmoparesis with nystagmus,
ataxia, and confusion. This is a life-threatening
illness caused by thiamine deficiency, which
primarily affects the peripheral and central nervous
systems.
Treatment: 50 – 100 mg Thiamine Hydrochloride

52. Wernicke – Korsakoff’s Psychosis
COAT RACK
Wernicke’s
Encephalopathy
• C – Confusion
• O – Opthalmoplegia
• A – Ataxia
• T – Thiamine Deficiency
Korsakoff’s
Psychosis
• R – Retrograde Amnesia
• A – Anterograde Amnesia
• C – Confabulation
• K – Korsakoff’s Psychosis

53. ALCOHOL
WITHDRAWAL

54. Stage - 1
Mild Symptoms
6 to 12 Hours
Stage - 2
Moderate Symptoms
12 to 48 Hours
Stage - 3
Severe Symptoms
48 to 72 Hours
1 2 3
STAGES OF ALCOHOL WITHDRAWAL

58. Alcoholic Psychosis
“Alcohol-related psychosis is a secondary psychosis that
manifests as prominent hallucinations and delusions
occurring in a variety of alcohol-related conditions. For
patients with alcohol use disorder, previously known as
alcohol abuse and alcohol dependence, psychosis can occur
during phases of acute intoxication or withdrawal, with or
without delirium tremens.”

59. DELIRIUM TREMENS
“Delirium tremens (DTs) is the most severe form of ethanol withdrawal, manifested
by altered mental status (global confusion) and sympathetic overdrive (autonomic
hyperactivity), which can progress to cardiovascular collapse.
Minor alcohol withdrawal is characterized by tremor, anxiety, nausea, vomiting,
and insomnia.
Major alcohol withdrawal signs and symptoms include visual hallucinations and
auditory hallucinations, whole body tremor, vomiting, diaphoresis, and
hypertension (high blood pressure).”

60. Treatment of alcohol dependency and be divided into
three stages.:
Stages
● Medical Stabilization
● Detoxification
● Long-term abstinence rehabilitation
MANAGEMENT OF ALCOHOLISM

61. This includes treatment of associated medical
conditions as alcohol withdrawal and alcoholic
ketoacidosis
1
MEDICAL STABILIZATION

62. Oral or IV Hydration
Benzodiazepines
Diazepam, Chlordiazepoxide
& Lorazepam
Vitamin B12

63. This stage involves stopping alcohol consumption.
2
DETOXIFICATION

64. Benzodiazepines
Vitamin
Supplements
Thiamine
Disulfiram
Antabuse

65. Naltrexone and
Acamprosate
Calcium
Carbimide
Works like disulfiram
Ondansetron

66. Short and long – term residential programs aim
to build a recovery support system and for
replapse.
3
Rehabilitation

67. Short – term programs
Last less than 4 weeks. These are structured programs that p
therapy, education, skills training and help to develop a long – t
to prevent relapsing.

68. Out-patient counselling
Outpatient counselling can provide education on alcoholism
recovery. It can help the person to learn skills not to drink an
early signs of potential relapse.

69. Self Help Groups
A well known self – help group is “Alcoholic
Anonymous” (AA).
Founded by Bill Wilsonn and Dr Bob Smith (1935)
The primary purpose of the AA is to stay Sober (Self –
disciplined) and help other alcoholics to attain sobriety.

70. VARIOUS APPROACHES TO QUIT ALCOHOL
1 2 3 4
Group
Therapy
Cognitive
Therapy
Behaviour
Therapy
Motivational
EnhancementTherapy
(MET)

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