Substance abuse

Number of Self reported substance abuse cases

Alcohol:                                   13.4 M

Marijuana & hashish:               3.5 M

Opioids, sedatives                    1.4 M

Cocaine:                                  1    M

Heroine                                                0.2 M

Definition of Substance abuse: pattern of abnormal substance use which leads to

lOccupational

lPhysical

lOr social dysfunctioning

 Definition of Dependence = abuse plus

l presence of withdrawal symptoms

l increased tolerance

l Repetitive and increased use of the drug

Definition of Withdrawal: physical or psychological symptoms after reduction or cessation drug intake

Definition of Tolerance: need for increase amount of substance to achieve the same effect

Definition of Cross tolerance: tolerance to a substance because of regular use another substance

lBiology:

lImmediate effects:

lIncreased availability of neurotransmitters

lPleasure signaling in the nervous system by DA via VTA of mesolimbic system – median forebrain bundle – N. Accumbens – frontal cortex (pleasure pathway)

l Even Rats can be made addicts

lGlutamate role in maintenance of addictive behavior

 Blocking glutamate or NMDA receptors reduces drug cravings

lLong term effects

lChanges in receptors will lead to:

lDependence and tolerance

§  Classification of Substance abuse

1. Sedatives (benzodiazepine – barbiturate – alcohol type)

lEffect

lMood elevation

lDecreased anxiety

lSedation

lDisinhibition

lRespiratory depression

lWithdrawal symptoms:

lDepression, insomnia, anxiety

lEpileptic Seizures

lDelirium

Pharmacology of Sedatives

lCNS depressants

lGABA activity increased = reduce anxiety

lAlcohol

lAround 10% lifetime prevalence of alc dependency in western countries

lNative Americans 2x

lGenetic predispositions

lIn the history

lADHD

lConduct disorder

lConsequences

lFetal alcohol syndrome

lWernicke-Korsakoff encephalopathy

lUlcer, pancreatitis, cirrhosis, esophagus varix, haemorrhages

lAlcohol & sedatives withdrawal

lDelirium Tremens (DT)

lSeizures

lExplodes on 3^rd day of withdrawal

lMortality 20% without tretatment

lConfusion

lDisorientation is allopsychic and in place

lMassive hallucinations (visual + tactile + acoustic)

lDuration 1 week

lRecovery with Wernicke – Korsakoff syndrome

lTh:

lhospitalization

lFluid replacement

lCardiac support

lChlordiazepoxid, diazepam, lorazepam

2. Opioids (medical practitioners and nurses are at high risk)

·         Classification:

lMedical opioids

lHeroine

lMethadone

lPharmacologic Effects

lMood elevation

lDecreased anxiety

lSedation

lAnalgesia

lRespiratory depression

lConstipation

lPupillary constriction (pinpoint)

lWithdrawal

lDepression, anxiety

lAutonomic instability

lFlu-like symptoms

lPiloerection

lYawning

lStomach ache, diarrhea

lPupil dilation

3. Stimulants

Classification:

lAmphetamine

lCocaine

lCaffeine

lNicotine

lPharmacologic Effect

lMood elevation

lInsomnia

lDecreased appetite

lIncreased GI, cardiovascular neurological activity

lPsychosis

lPupillodilation

lTactile and other hallucinations

lWithdrawal

lDepression, lethargy

lIncreased appetite

lDecreased GI, cardiovascular, CNS activity

lFatigue

lHeadache

4. Hallucinogens

lMarijuana

lHashish

lLSD

lPCP

lPsilocybin

lMescaline

lEffects

lMood elation

lAltered perception

lCardiovascular, hyperthermia, sweating

lTremor

lNystamus (PCP)

lWithdraval

lFew of NO at al

Therapy of addictions and substance abuse

l Benzodiazepines, Barbiturates Alcohol,

lHospitalization

lSubstitution of long acting barbiturate (phenobarbital) or benzodiazepine (chlordiazepoxide) ‘weaning off’ in decreasing doses

lIv diazepam or lorazepam

lPhenobarbital if seizures occur

lThiamine & B vit in alcohol

lLong term th: Disulfiram (Antabuse) in alcohol dependency

lOpioids

lHospitalization

lNaloxone (Narcan) if acute overdose present

lClonidine (stabilize autonomic NS)

lSubstitution of long acting opioids (Methadone)

Long term therapy:

lMethadone

lNaloxone, Naltrexone, Buprenorphine to block opioid effects

lNarcotics anonymous

lStimulants (Amphetamine, Cocaine)

lBenzodiazepines

lAntipsychotics

lHallucinogens

l“Talking down” the patient

lBenzodiazepines

lAntipsychotics

lTreat “mentally ill + chemically addicted” group with dual diagnosis with targeting both treatment accordingly

Case Studies

v  A 46-year-old man is admitted to the emergency department acutely diaphoretic, tachycardic, hypertensive, tremulous, and agitated. He refuses to give a urine sample for toxicology studies. He is apparently hallucinating, judging from his insistence that he be allowed to “squash those bugs on the wall” (there are none). One would expect to most likely see this patient’s type of hallucinations in the context of which of the following?

(A) delirium

(B) delusional disorders

(C) schizophrenia

(D) conversion disorder

(E) brief psychotic disorder

(A) Any type of hallucinations can be seen in delirium. In schizophrenia-spectrum illness, including brief psychotic disorder, one rarely sees hallucinations other than auditory. Non-auditory hallucinations, then, as a general rule, suggest delirium of some cause. Delusions are thoughts (fixed false beliefs) and do not include sensory phenomena like hallucinations. Conversion disorder does not usually show hallucinations of any sort.

v  A 36-year-old man is brought to the emergency department in respiratory arrest. On examination, he is unresponsive, and the medical student rotating through the emergency department observes pinpoint pupils and antecubital track marks. There is suspicion that the patient’s condition may be the result of a drug overdose.

1.. The patient most likely has overdosed on which of the following drugs?

(A) cocaine

(B) phencyclidine (PCP)

(C) heroin

(D) alcohol

(E) inhalants

2. Which of the following would reverse the effects of the suspected drug?

(A) acetylcysteine

(B) naloxone

(C) deferoxamine

(D) methylene blue

(E) methadone

1. (C) Heroin overdose is most likely to have caused the clinical situation described. Cocaine use causes pupillary dilatation not constriction. PCP and alcohol intoxication may cause coma but both are associated with nystagmus rather than pupillary size changes. Inhalants are also known to cause coma but are not classically associated with pupillary constriction.

2. (B) Naloxone is used to reverse the acute effects of opiate overdose by blocking CNS opioid receptors. Acetylcysteine is administered in acetaminophen overdose, and deferoxamine is used in iron overdose. Methylene blue is used to treat methemoglobinemia. Methadone is used for the long-term maintenance of opiate addiction and would only worsen heroin overdose.