Substance abuse prof. fareed minhas
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Transcript of Substance abuse prof. fareed minhas
Prof. Fareed A.Minhas
Head,
Institute of Psychiatry
Rawalpindi Medical College
Rawalpindi
Substance use disorder (DSM IV)
Disorders due to psychoactive drug use (ICD 10)
Conditions arising from the abuse of alcohol, psychoactive drugs and other chemicals such as volatile solvents
DSM IV ICD 10Intoxication
AbuseDependenceWithdrawal
Withdrawal deliriumPsychotic disorders
DementiaAmnestic Disorder
Mood disordersAnxiety disorders
Sexual dysfunctionsSleep disorders
IntoxicationHarmful useDependence
syndromeWithdrawal stateWithdrawal with
deliriumPsychotic disorder
Amnestic syndromeResidual and late--onset psychotic
disorderOther mental and
Behavioral disorders
INTOXICATION – transient syndrome due to recent substance ingestion that produces clinically significant psychological and physical impairment
ABUSE – maladaptive patterns of substance use that impair health
DEPENDENCE – certain physiological and psychological phenomena induced by repeated taking of a substance (strong desire, neglect to other sources of satisfaction, development of tolerance and a physical withdrawal state)
TOLERANCE – state in which, after repeated administration, a drug produces a decreased effect or increasing doses are required to produce the same effect
WITHDRAWAL – state is a group of symptoms and signs occurring when a drug is reduced in amount or withdrawn, lasting for a limited time
ESCALATION – refers to a phenomenon when a person taking so called softer drugs moves on to harder drugs
DSM IV ICD 10Alcohol
AmphetaminesCaffeineCannabisCocaine
HallucinogensInhalentsNicotineOpioids
PhencyclidineSedatives/Hypnotics
Polysubstance /Others
AlcoholOther stimulants such as caffeine
CannabinoidsCocaine
HallucinogensVolatile solvents
TobaccoOpioids
Sedatives/Hypnotics
Multiple drug use
Availability ofdrugs
AdverseSocial
circumstancesA vulnerablepersonality
EXTENT OF THE PROBLEM –
- Atleast 300,000 ppl in UK have this problem - Ppl with drinking problems have a 2 to 3 percent greater chance of dying - 1 in 5 admissions in acute medical wards in UK is directly or indirectly related to alcohol
- Admissions to psychiatric hospitals for this purpose have increased 25 fold
TERMINOLOGY OF DRINKING -
HEAVY
DRINKERS
PROBLEM
DRINKERSBINGE
DRINKERS
DETECTION – History
Absenteeism from workUnexplained dyspepsia or GI bleedsAdmissions for accidentsFits, turns or falls
SignsPlethoric face with/without
telangiectasesBlood shot conjuctivaeSmell of stale alcoholFacial resemblance to Cushing’s
SyndromeMarked tremors and other signs of
disease
‘At risk’ factorsMarital discordDays off workAn affected relative having similar
problemsHigh-risk occupations eg. SalesmenAssociated physical/mental conditions
MarkersGamma-glutamyl transpeptidaseMean corpuscular volume (MCV)Carbohydrate-deficient transferrin HDL CholesterolBlood/Urinary Alcohol
The subjective Awareness of a
Compulsion to drink
A narrowing of theDrinking repertoire
Primacy of drinkingOver other activitiesIncreased tolerance
To alcohol. Need forMore to achieve
Same results
Withdrawal symptoms
Relief from withdrawalBy further drinking
Rapid reinstatementOf syndrome on drinking
After a period ofabstinence
ALCOHOL
DEPENDENCE
SYNDROME
SYMPTOMS OF ALCOHOL DEPENDENCE –Unable to keep a drink limit/Difficulty avoiding getting drunkSpending considerable time drinkingMissing meals/Memory lapses, blackoutsRestless without drink/Trembling after drinkingOrganizing day around drink Morning retching and vomitingSweating at night/Withdrawal fitsMorning drinking/Increased toleranceHallucinations/ frank delirium tremens
DIAGNOSTIC CRITERIA OF ALCOHOL WITHDRAWAL
Any THREE of the following :
Tremor of outstretched hands, tongue or eyelidsSweatingNausea / retching/ vomitingTachycardia or hypertensionAnxietyPsychomotor agitationHeadacheInsomniaMalaise or weaknessTransient visual, auditory or tactile hallucinations/illusionsGrandmal convulsions
TREATMENT – Raise awareness of the problemIncrease motivation to changeWithdraw alcohol (controlled drinking)Support and adviceCBT (Social skills, relapse prevention)Marital therapyMedication (Diazepam/chlormethiazole/Disulfiram or Acamprosate)
Psychological dependence Glue-sniffing – adolescents. Tolerance develops in weeks or months Intoxication characterized by euphoria, excitement, floating sensation, dizziness, slurred speech and ataxia Acute intoxication – amnesia + visual hallucinations There is risk of tissue damage including that to bone marrow, brain, liver and kidneys which can prove fatal
Derived directly from opium poppy: Morphine/Codeine Semi-synthetic Heroine / DiacetylmorphineSynthetic Methadone/Meperidine/Dihydrocodeine Uses Pain relief; suppression of cough; treatment of acute myocardial infarction and also diarrhea Effects Pleasant mood and a euphoric detachment Causes of death in narcotics addicts
Heart disease (including infective endocarditis)TuberculosisGlomerulonephritisTetanus/Malaria/Hepatitis B
NARCOTIC ABSTINENCE SYNDROME –
Yawning/Rhinorrhea/LacrimationPupillary dilatationSweating/Piloerection/Restlessness
Muscle twitches/Aches and painsAbdominal
cramps/Vomiting/DiarrheaHypertensionInsomnia/Anorexia/AgitationProfuse sweating/Weight loss
12 – 16HRS AFTERDOSE
24 – 72 HRS AFTER
LAST OPIATE DOSE
Abrupt withdrawal is highly dangerous. May result in a mental disorder, similar to alcohol withdrawal, may lead to seizure & sometimes to death. Withdrawal symptoms may not appear for several days. Anxiety, restlessness, and disturbed sleep anorexia, nausea. May progress to vomiting, hypotension, pyrexia, tremulousness, major Seizures, disorientation & hallucinations.
Elevate mood, increase wakefulness, give an enhanced sense of mental and physical energy
Pleasurable stimulation & excitement potential of misuse
Cocaine, amphetamines, Synthetic (Phenmetrazine diethylpropon), Khat, Caffeine
Effects similar to these Amphetamines
Strong Psychological dependence
Excitation,dilated pupils, tremulousness
Dizziness and sometimes convulsions
Confusion, depression, paranoid psychosis and formication
Chlordiazepoxide (Librium), Diazepam (Valium),
Lorazepam (Ativan) and Nitrazepam (Mogadon)
Cause: Sedation, anxiety relief and Muscle relaxation
Withdrawal Symptoms:Anxiety, restlessness, tachycardia and sensory disturbances
Produce strange, intense, & transcendental effects,which gives them ‘recreational’ popularity
Peyote, mescaline, ‘Magic mushroom’
LSD:lysergic acid diethyl-amide
Do not give rise to dependence in true sense, nonetheless use is intensely hazardous
Effects vary with dose, persons expectation , mood, & social setting
Exaggerates pre-existing mood: exhilaration, depression or anxiety
Increased enjoyment of aesthetic experience & distortion of time & space
Reddening of the eyes, dry mouth, irritation of respiratory treat & coughing
No definite withdrawal Syndrome
No evidence of Tolerance. No serious side effects amongst intermittent users
No evidence of teratogenecity. Not safe in first trimester
Psychosis: disagreement
PRE-COMTEMPLATION:Misuser doesn’t see the problem; others recognize it
ACTION USER:Choose necessary strategy for change
DECISION POINT:Where the decision is made to act on this issue
CONTEMPLATION:Individual weighs pros/cons. Considers change is needed
MAINTENANCE GAINS:Are maintained and consolidated
RELAPSE:Return to previous pattern of behavior
1.DETOXIFICATION
2.INSISTENCE ON ABSTINENCE
3.INVOLVEMENT OF FAMILY
4.TOXICOLOGY SCREENS (periodic urine screens are often essential in identifying relapse and noncompliance)
5.SELF-HELP GROUPS
6. SANCTIONED TREATMENT (patient forced to remain in therapy by a legal sanction e.g. drivers/professional
license)7. CONTINGENCY CONTRACTING
(This approach provides a powerful negative contingency for leaving treatment or relapsing or a positive contingency
for remaining drug free)