Addiction/dependence

A state of periodic or chronic intoxication, produced by

repeated consumption of a drug/substance

Characteristics Preoccupation/anticipation-

constant craving & effort to obtain the substance Binge/intoxication-

consuming the substance with its deleterious effects Tolerance-

requiring increasing amount of substance for similar effect

Withdrawal- reducing/stopping consumption associated with psychological & physical manifestations like insomnia, irritability, anger, depression, loss of appetite

Affects health, occupation, family, society

Target

Nearly all addictive drugs target the brain’s reward circuit, the mesolimbic system

Main neurotransmitter- dopamine Drugs- CNS depressants- alcohol, opioids,

benzodiazepines CNS stimulants- nicotine, amphetamine, cocaine

Nicotine Tobacco use, smoked or chewed,

releases nicotine- half-life ~2 hours Nicotine activates receptors

in CNS releasing dopamine & in SNS/adrenal medulla releasing epinephrine

Benefits of nicotine/smoking- Less revascularization required after PCI Reduces risk of ulcerative colitis, Kaposi sarcoma,

breast cancer in women with BRCA gene, pre-eclampsia

Delays onset of Parkinson’s disease Improve schizophrenia & ADHD

Health effects of tobacco Single greatest cause of preventable death Nicotine causes dependence Carcinogens- benzopyrene, acrolein,

nitrosamines Diseases caused- COPD CAD, CVA, HT Cancers- oral, larynx, lung,

esophagus, stomach, pancreas, kidney, bladder

Alcohol Screening- CAGE questionnaire- ≥2

felt need to Cut down, felt Annoyed on being asked, felt Guilty, need for an Eye-opener?

Long-term effects- cirrhosis, pancreatitis, dementia, epilepsy, polyneuropathy, nutritional deficiencies, sexual & ovulatory dysfunction

Anxiety & depression are common Social effects- increased crime- theft, child abuse,

rape, domestic violence, accidents, loss of job/occupation Withdrawal- anxiety, delirium tremens, seizures,

hallucinations

Cannabis- marijuana/bhaang

Commonest illicit drug usedRepeated use leads to

dependence

Opioids

Morphine/afeem, heroin, codeine, oxy/hydrocodone, buprenorphine etc.

High addiction potential Withdrawal symptoms- x 2 days-6 weeks Insomnia, anxiety, panic attacks, depression Leg & abdominal cramps Vomiting, diarrhea Rhinitis, lacrimation

Benzodiazepines Commonest cause of therapeutic drug

dependence Frequent if taken for >4 weeks & with

use of potent short-acting benzodiazepines

Withdrawal symptoms- Anxiety, depression, insomnia Tremors, twitches Muscular pain. Headache Hypersensitivity to touch & pain Suicidal tendency

Cocaine Snorted, smoked or injected;

with increasing addiction potential Causes CNS stimulation leading to

euphoria, insomnia, erratic behaviour Withdrawl leads to ‘comedown’/crash-

dysphoria, exhaustion, craving CNS depressants- alcohol/opioids-

commonly used together to dull crash

Amphetamine CNS stimulant Commonly ingested Causes euphoria & insomnia Tolerance develops rapidly leading to

increasing use of drug Withdrawl causes dysphoria, exhaustion Alcohol, opioids, benzodiazepines

commonly used together to blunt withdrawl effects

Management- principles Addiction is a mental disease Needs treatment that is- Readily available Tailored Comprehensive Options- Detoxification Medications Counseling-individual/group & behavioural therapy Regular follow-up- to ensure abstinence &

compliance

Drugs used

Tobacco/nicotine- nicotine replacement- patch, gum,spray,lozenges bupropion, varenicline

Alcohol- naltrexone, acamprosate, disulfiram, calcium carbimide, topiramate

Opioid- methadone, buprenorphine, naltrexone