Substance Related Disorders

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Substance Related Disorders

• Dr. Anurag Mishra M.D.
• Coordinator- Psychoanalytical Wing
• Max Hospitals- Delhi

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Substance vs Drug

• Drug- Manufactured chemical
• Many substances associated with abuse patterns
  
• Occur Naturally- opium, cannabis
• Not meant for human consumption- petrol, solvents
• Illegal - cocaine
• Legal but obtained by illegal means or for non
  prescribed purposes- morphine

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Addiction

• Describes the degree to which drug
  use pervades an individuals life
• Possible to be dependent without being addicted-
  individuals life is not organized around finding
  using drug e.g. those who become addicted to
  drugs used in prolonged medical treatment
• Possible to be addicted without being physically
  dependent
• 1964- WHO substituted Dependence

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Substance Use Disorders

• Substance Dependence
• Substance Abuse
• Codependence

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Substance Dependence

• Impairment or distress because of 3 or more of
  the following at any time in a year
• Tolerance increased amount of substance to
  produce same effect / decreased effect with same
  amount
• Withdrawal typical withdrawal syndrome/
  substance or related compound used to relieve or
  avoid withdrawal
• Use of substance in greater amounts or for a
  longer time than originally intended
• Unsuccessful attempts or wishes to cut down
• Significant time spent in obtaining, using,
  recovering
• Giving up social, occupy, recreational activities
• Continued use despite knowledge of physical/
  mental problems

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Substance Dependence

• Physiological Dependence presence of withdrawal
  or tolerance
• Psychological Dependence (Habituation)
  continuous intermittent craving for substance to
  avoid dysphonic state (difficulty in speaking)
  dysphoria
• anxiety

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Substance Abuse

• Pt. not meeting criteria for Dependence with any
  one of following in a year
• Failure to fulfill major role obligations
• Recurrent use of substance in hazardous
  situations
• Recurrent legal problems resulting from substance
  use
• Continued use of substance despite social or
  interpersonal problems caused by substance

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Codependence

• Behavioral patterns of family members who have
  been significantly affected by another family
  members substance use or addiction
• Enabling
• Unwillingness to accept addiction as disease,
  voluntary behavior, responsibility shifted to
  family
• Denial

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Substance Induced Disorders

1. Intoxication Reversible substance specific
   syndrome
2. Substance withdrawal
3. Substance induced delirium
4. Substance withdrawal delirium
5. Substance induced persisting dementia
6. Substance induced persisting Amnestic disorder
7. Substance induced psychotic disorder
8. Substance induced mood disorder
9. Substance induced anxiety disorder
10. Substance induced sexual dysfunction
11. Substance induced sleep disorder

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Alcohol Intoxication

• Mild
• Overconfidence
• Mood swings, emotional outbursts, euphoria
• Nausea, vomiting
• Restlessness
• Severe
• Stupor or coma
• Hypothermia
• Slow respiration
• Tachycardia
• Increased I C T
• Dilated pupils
• Death

• Diagnosis
• Slurred speech
• Loss of coordination
• Unsteady gait
• Nystagmus
• Impaired attention/ memory
• Stupor/ coma
• T/t (treatment)
• Conscious pt.- wait!
• Agitation- BZD, anti psychotic
• 2. Unconscious pt.- keep warm
• Prevent aspiration
• Increased ICT- mannitol
• Hemodialysis in extremes

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Sedative, Hypnotic, Anxiolytic Intoxication

• T/t
• Protect airway
• Oxygen
• Ventilation
• Prevent further body heat loss
• I.v. fluids and BP maintenance with Dopamine
• Forced diuresis
• Hemodialysis

• BZD, Barbiturates
• Mild
• Euphoria
• Sedation
• Paradoxical excitement
• Nystagmus, dysarthria, impaired attention
  memory
• Postural hypotension
• Severe (suicide attempts, overdose)
• Coma
• Respiratory depression
• Low BP
• Low cardiac output
• Low temp.
• Coma
• Death

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Stimulant Intoxication

• Amphetamines, methamphetamine, cocaine
• Mild
• Elevated mood
• Increased energy alertness
• Decreased apppetite
• Talkativeness
• Anxiety irritability
• Insomnia
• Increased/ decreased heart rate BP
• Nausea/ vomiting
• Loss of appetite weight

• Severe
• Psychotic symptoms- visual, auditory tactile
  hallucinations, delusions, mania
• Fighting
• Dilated pupils
• Increased BP pulse
• Arrhythmias
• Seizures
• Exhaustion
• Coma I C Hemorrhage
• T/t hypertension hyperthermia
• Psychosis- antipsychotics

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Hallucinogen Intoxication

• LSD, PCP, Mescaline
• Most hallucinogens
• Dilated pupils
• Increased pulse BP
• Increased temp
• Delusions hallucinations
• Anxiety
• Distortion of time sense
• Inappropriate affect

• PCP Intoxication
• Violence hyperactivity
• Increased hearing
• Mutism
• Echolalia
• Muscular rigidity
• Seizures, coma, IC hemorrhage
• T/t Quiet setting
• Antipsychotic/ BZD

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Hallucinogen Intoxication
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Cannabis Intoxication

• Marijuana, hash, ganja, bhang

• Euphoria
• Anxiety
• Increased appetite
• Increased suggestibility
• Distortion of time space
• Red conjunctiva
• No change in pupils
• Dry mouth
• Tachycardia
• T/t Quiet setting, BZD

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Opioid Intoxication

• Opium
• Morphine
• Heroin
• Crack
• Brown sugar
• Codeine
• Pethidine
• Fortwin (pentazocin)

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Opioid Intoxication

• Mild- Moderate
• Analgesia without loss of consciousness
• Drowsiness
• Nausea vomiting
• Apathy lethargy
• Euphoria
• Itching
• Constricted pupils
• Constipation
• Flushed warm skin
• Impaired attention memory
• Illusions

• Severe
• Miosis
• Respiratory depression
• Hypotension or shock
• Pulmonary edema
• Seizures Coma
• T/t
• Supportive care
• Naloxone- narcotic antagonist, reverses coma
  apnea but also produces severe withdrawal

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Inhalant Intoxication

• Erasex, petrol, glue, paint thinner, solvents

• Dizziness, confusion
• Euphoria
• Confusion, nystagmus, ataxia, dysarthria
• Tremors
• Muscle weakness
• Blurred vision
• Delirium
• Chronic use- Dementia
• T/t prevent access to drug

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Anticholinergic Drug Intoxication

• Cough syrups, imipramine, pacitane
• Confusion
• Memory loss
• Delirium
• Hallucinations
• Amnesia
• Drowsiness
• Tachycardia

• Decreased peristalsis
• Fever
• Warm dry skin
• Fixed dilated pupils
• Coma
• T/t
• Protect pt wait for drug to be metabolized
• Physostigmine

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Alcohol Withdrawal

• The Shakes
• Tachycardia
• Tremors
• Sweating
• Nausea
• Hypotension
• Weakness
• Anxiety, irritability
• T/t Thiamine, BZD

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Alcohol Withdrawal

• Motor Seizures (Rum fits)
• Seizure inlt48 hrs after stopping
• T/t I.v. BZD
• Alcohol withdrawal delirium
• Delirium
• Autonomic hyperactivity
• Agitation, hallucinations, tremors
• T/t Hydration
• Thiamine, BZD, antipsychotic

• Psychosis
• Hallucinations in clear sensorium - threatening
  or derogatory
• T/t Anti psychotics
• Wernicke-Korsakoff Syndrome
• Wernickes Encephalopathy/ Alcoholic
  encephalopathy- ataxia, giddiness, eye signs
• Korsakoffs Syndrome/ Chronic Amnestic Syndrome
  Impaired memory
• T/t thiamine

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Sedative, Hypnotic, Anxiolytic Withdrawal

• Anxiety, agitation
• Low BP
• Weakness tremors
• Fever
• Sweating
• Delirium
• Seizures
• Cardiovascular collapse

• T/t
• Withdrawal can be life threatening
• Hospitalization
• BZD substitution
• Other drugs

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Stimulant Withdrawal ( Crash )

• Increased sleep
• Nightmares
• Fatigue
• Lassitude
• Increased appetite
• Depression ( cocaine blues)
• Suicide attempts
• Intense drug craving

• Hospitalization if suicidal
• Antidepressants

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Hallucinogen Withdrawal

• Dr. Albert Hoffman discovered/ invented LSD!

• Flashbacks 15- 80
• Spontaneous transitory occurrences of substance
  induced experience visual distortion,
  hallucinations, trails of images, micro/
  macropsia, time expansion, relived intense
  experience
• T/t Reassurance, BZD

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Opioid Withdrawal

• Watering from nose and eyes
• Sweating
• Restlessness sleepiness
• Gooseflesh
• Dilated pupils
• Irritability
• Yawning
• Insomnia
• Craving

• Substitution with medicinal opioid and gradual
  withdrawal
• Clonidine to control BP and other autonomic
  symptoms
• BZD
• Non opioid pain killers
• Symptomatic t/t

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Anti Cholinergic Withdrawal

• Influenza like syndrome
• Depression
• Seizures
• Mania

• T/t Atropine
• Reintroduction and gradual discontinuation of
  drug

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Nicotine Withdrawal

• Malaise
• Irritability
• Anxiety
• Craving for tobacco
• T/t Nicotine patches
• Nicotine gum
• SSRI

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Treatment

• Five Stages
• Pre contemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Treatment approach tailored to pt.s stage of
  readiness

• Pharmacological agents
• Alcohol disulfiram, naltrexone, acamprosate,
  gabapin
• Opioid Naltrexone
• Nicotine Nicotine gum, patches

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Treatment

1. Detoxification
2. Insistence on abstinence
3. Avoidance of other substance associated with
   dependence or abuse
4. Involvement of family

• Toxicology screens
• Self help groups
• 7. Treat complications
• Psychotherapy
• Treat co morbidities
• Treat complications

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