Amit Anand

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• Amit Anand
• CT-3 Psychiatry

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Problem Definition

• UK among the highest recorded use of illegal
  drugs in Europe
• High rate of heroin and crack cocaine.
• Mortality risk is nearly 12 in heroin addicts.
• 2/3rd reported cannabis in a major problem in lt18
  years with alcohol.
• 34 Hep B, 90 Hep C and 5.6 of HIV due to IDU
  ( HPA 2006)
• 7 acute drug related death among aged 15-39
  years (EMCDDA 2006)

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Psychiatry of substance Misuse

• Assessment and treatment of problems arising from
  substance misuse
• Alcohol, illegal drugs, pharmaceutical drugs
• Management of acute states- intoxication,
  withdrawal
• Long term effects, dependency, relapsing chronic
  course
• Psychiatric co-morbidities.
• Physical disease
• Psychological interventions- MIT, CBT
• Pharmacological- substitutes- methadone, adjunct
  treatments (adversive-disulfiram, anti-craving-
  acamprosate, naltrexone), antidepressants, BDZ

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Neurobiology

• Reinforcing properties of most drugs are due to
  direct or indirect release of dopamine in nucleus
  accumbens.

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Terminology

• Tolerance and withdrawal
• To increase the dose of psychoactive substance
  are required in order to get to achieve effects
  originally produced by lower doses.
• Physiological vs Psychological dependence
• Physiological is ch by tolerance and dependence
  and Psychological dependence mainly relates to
  continuous or intermittent cravings.
• Remission
• Remission is interval of time elapsed since last
  drug use.
• Lapse vs Relapse
• Relapse is resumption of drug use to pre-existing
  pattern after a period of remission. And Lapse is
  use of drugs in small amount during recovery.
  Lapses are common

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Stimulants

• Feelings of alertness, endurance, decreased need
  for sleep, well being
• Caffeine-legal, widespread, 1 in 10 withdrawal
  symptoms
• Cocaine (made from coca leaves)
• Freebase (crack) cocaine
• Amphetamine
• MDMA (ecstacy)

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Opiates

• Opiates

• Derived from poppy
• Analgesic and widespread legitimate use
• Anxiolytic, induces euphoria and widely abused,
  often leading to dependency
• Heroin- white/brown powder
• Smoked, snorted, iv or sc use
• Overdose- nausea, vomiting, respiratory
  depression and sedation (risk of aspiration)
• Pharmaceutical- dihydrocodeine, pethidine,
  methadone, morphine, codeine.

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Hallucinogens

• Sensory and perceptual experiences with euphoria
• Wide group of substances
• Lysergic acid diethyalmide (LSD), found by Albert
  Hoffham in 1944. High up to 6 hours.
• Derealisation, euphoria, depersonalisation,
  visual illusions, misperceptions, synaesthesia.
• Mescaline, Phenylcyclidine (PCP), Magic Mushrooms
  (Liberty Cap), Ketamine

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Cannabis

• Cannabis salvia
• Most widely abused drug
• THC is principle active compound
• Resin, dried
• Skunk
• Intoxication-euphoria, derealisation,
  depersonalisation, visual illusions, sedation,
  tachycardia, increase appetite
• Withdrawal- mild- irritability, insomnia

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Assessment of drug and Alcohol Use

• Reasons for presentation
• In Crisis
• Court Case
• On probation
• Own concern about drug use
• Familys concerned.
• Developed mental illness
• Pregnant
• Drugs not available.

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contd

• Current Usage ( What, How often, how many,
  Typical day)
• Longitudinal History ( First drink, age, progress
  to daily and current level)
• Dependence Syndrome ( Edwards and Gross Criteria,
  ICD-10)
• CAGE
• Injecting drug use and unsafe sexual practices
• Why injecting
• Sharing?
• Site and route of injection
• Safe practice
• Knowledge of blood borne viral diseases
• Commercial sex to fund drug use.

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Contd

• Medical Hx
• Injection site complications Abscess
• BBV illness status
• STDs
• Accident, falls etc.
• Neuro, GIT, Cardio-resp etc
• Psychiatry Hx
• Screen for psychiatric illness
• Past hsitory of overdoses or admissions
• ? Use of drugs to treat underlying mental illness.

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Contd

• Forensic Hx
• Past and present contact with criminal justice
  system
• Probation order
• Association of drug s to offences
• Social Hx
• Family situation and Employment,
• Accommodation and Debts

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Contd

• Number and duration of abstience attempts
• Kind of intervention used.
• Any treatment in inpatient rehab setting

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Examination

• Assess motivation
• Appearance Behaviour- well kempt/malnourished?
  Intoxicated? Agitated/hostile/aggressive/sedated?
  Evidence of drug use?
• Mood- generalised anxiety, panic, low mood,
  hopelessness.
• Thoughts- persecutory ideation, guilt,
  helplessness.
• Suicide (increased in substance misuse)
• Psychotic phenomena- persecutory delusions,
  auditory, visual and tactile hallucinations.
• Insight- into dependency, effects on mental
  state
• Cognition- confusion, impairment, dementia

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Substance Misuse Syndromes

• Acute intoxication
• Harmful Use
• Dependence
• Withdrawal
• Substance-induced psychotic disorders
• Cognitive impairment syndromes
• Dual diagnosis

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Acute Intoxication

• Reversible physical and mental abnormalities
  caused by direct effects of substance.
• Alcohol-disinhibition, aggression, lability,
  ataxia, slurred speech, impaired judgement and
  attention, nystagmus, decreased consciousness.
• Opioids- apathy, sedation, disinhibition,
  psychomotor retardation, pupillary constriction,
  respiratory depression.
• Cannabinoids- Euphoria, anxiety/agitation,
  suspiciousness, temporal slowing, impaired
  judgement and attention, auditory/visual/tactile
  illusions, hallucinations, depersonalisation,
  derealisation, dry mouth, increased appetite,
  conjunctival injection, tachycardia
• Cocaine- euphoria, increased energy,
  hypervigilance, grandiose beliefs/actions,
  argumentativeness, lability of mood, illusions,
  hallucination, paranoid ideation, tachycardia,
  cardiac arrhythmias, chest pain, convulsions,
  agitation.

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Harmful USe

• A pattern of psychoactive substance use that is
  causing damage to health.
• Physical or mental health consequences
• Pattern of use must have existed for at least a
  month or occurred repeatedly in a year
• Look out for denial- ask about effects on work
  attendance, interpersonal relationships,
  finances, mental state

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Dependence Syndrome

• A cluster of behavioural, cognitive and
  physiological phenomena that develop after
  repeated substance exposure, leading to strong
  desire to take the drug.
• Primacy of drug seeking behaviour
• Narrowed spectrum of use
• Tolerance
• Loss of control of consumption
• Signs of withdrawal on abstinence
• Drug taking in avoidance of withdrawal
• Continued use despite harm
• Relapsing course after abstinent periods.

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Withdrawals

• Pattern of physiological and psychological
  symptoms experienced on acute abstinence from a
  substance
• Alcohol, opiates, BDZ,
• Alcohol uncomplicated alcohol withdrawal
  syndrome, seizures, delirium tremens.
• Opiate withdrawal with in a day of last dose,
  lasting 5-7 days, peaking at 2 days.
• Symptoms- sweating, tachycardia, hypertension,
  dilated pupils, abdominal cramps, goose flesh,
  yawning, nausea, vomiting, diarrhoea, tremor,
  muscle cramps.
• Symptomatic treatment- analgesia, loperamide,
  anti-emetics, lofexidine (alpha-adrenergic
  agonist)
• Substitute prescribing- methadone- long-acting
  synthetic opiate- daily dosing. Oral dosing. Long
  term management and reduction regimes in
  community.

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• Alcohol Withdrawal Synd

• Delirium Tremons

• Risk of dependency, history of withdrawal, heavy
  recent drinking, currently symptomatic
• Uncomplicated course tremor, sweating,
  tachycardia, insomnia, agitation, nausea,
  vomiting, generalised anxiety
• May have transient illusions or hallucinations
• Cravings for alcohol
• Start after 4-12 hours, peaking at 48 hours.
• May occur in up to 15 with grand mal seizures.
• Prophylaxis chlordiazepoxide reducing regimen.
• Titrate to history and symptoms

• Acute confusional state secondary to alcohol
  withdrawal
• 5 of withdrawal, peaks at 48 hrs after last
  consumption
• confusion, amnesia, disorientation, psychomotor
  agitation, anxiety, auditory, tactile and visual
  hallucinations (Lilliputian), delusions.
• Fluctuating confusional state.
• Sweating, fevers, cardiovascular collapse.
• 5-10 mortality.

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Psychiatric Disorders

• Common co-existence of psychotic phenomena and
  substance misuse
• Psychosis is a potential feature of
• Acute intoxication (alcohol, hallucinogens,
  stimulants)
• Withdrawal state (alcohol, BDZ, cocaine)
• Drug-induced psychosis ( Amphetamines
  Paranoia)
• Underlying psychosis maintained/exacerbated by
  substance use (dual diagnosis)

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Cognitive Impairment

• 50-60 of heavy drinkers show cognitive
  impairment when tested while sober
• STW, LTM recall.
• MRI reveals cortical atrophy and widened
  ventricles
• Wernicke-Korsakoffs Syndrome- neuronal
  degeneration secondary to thiamine deficiency.
• Wernickes encephalopathy- acute confusional
  state, nystagmus and ataxia- prescribe Pabrinex
  in susceptible individuals
• Korsakoffs- Impairment or absence of the ability
  to form new memories, reduced recall for LTM
  (confabulating), no clouding of consciousness, no
  global intellectual decline.

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• Co-existence of major mental illness and
  substance misuse
• Is individual self medicating? Opiates for
  auditory hallucinations, alcohol to aid sleep,
  agitation etc..
• Diagnostic uncertainty (drug-induced psychosis)
  Time course helpful
• Higher rate of relapse- cannabis in schizophrenia

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Take Home message If you only remember a few
things

• Drug, including alcohol, use is common
• If you dont ask, they wont necessarily tell you
• Take a thorough history
• Seek collateral history if possible
• Be aware of acute intoxication states (head
  injuries, infection, encephalopathy, withdrawal)
• Always think of withdrawal
• Delirium tremens can kill

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• Any Burning Questions
• From
• Amit Anand