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ALCOHOL & SUBSTANCE ABUSE

ABDULLAH AL-SUBAIE, MBBS, FRCP (C)PROFESSOR OF PSYCHIATRY

@Prof_Subaie

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Disease Burden by Illness - DALY World, 2000, 15-44 year olds

HIV/AIDS

Unipolar depressive disorders

Road traffic accidents

Tuberculosis

Alcohol use disorders

Self inflicted injuries

Iron-deficiency anemia

Schizophrenia

Bipolar affective disorder

Violence

Comorbidity of Mental Disorders with Any Substance Abuse

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% with SubstanceOdds

Axis / Disorders Abuse or DependenceRatio

Bipolar I 61 7.9Bipolar II 48 4.7Schizophrenia 47 4.6Panic Disorder 36 2.9OCD 33 2.5Dysthymia 312.4Unipolar Depression 27 1.9Phobia 23 1.6

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What types of drugs do you know?

Anxiolytics and hypnotics

Opioids

Stimulants

Hallucinogens

Cannabis

Organic solvents

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GLOBAL TRENDS

Prevalence Issues

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Substance Abuse Costs Compared to Costs of Other

Health Problems Substance Abuse $660 billion

Alcohol $224 billion Illicit Drugs $181 billion Smoking $193 billion

Cancer $265 billion MVC $99 billion Diabetes $174 billion Cardiovascular Diseases $291 billion

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Global Drug Abuse

The global annual prevalence rate of all illicit drugs ranges from 3.3% to 4.1% of total world population

The most widespread illicit consumption is of cannabis products

About one third of the world’s population age 15 and over are tobacco smokers

Abuse spread relatively slowly in the 1980’s, but increased in a number of countries in the 1990’s

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About one third of the world’s population age 15 and over are tobacco smokers

Abuse spread relatively slowly in the 1980’s, but increased in a number of countries in the 1990’s

In the Americas, the second most widely abused drug is cocaine

Opiate use, while less prevalent, causes by far the greatest medical problems

Global Drug Abuse

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Local Figures

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Prevalence & Type

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Recent use

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Most commonly used substance?

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Most Risky age group?

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Trends over time

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Percentage of deaths over age 30 caused by tobacco,

2004

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Trends over time

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DEFINITIONS

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IntoxicationA. The development of a reversible

substance-specific syndrome due to recent use of a substance. Different substances may produce similar or identical syndromes.

B. Clinically significant maladaptive behavioral or psychological changes that are due to the effect of the substance on the central nervous system (eg, belligerence, mood lability, cognitive impairment, impaired judgment, impaired social or occupational functioning) and develop during or shortly after use of the substance.

C. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

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Withdrawal

A. The development of a substance-specific syndrome due to the cessation of (or reduction in) substance use that has been heavy and prolonged.

B. The substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

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Abuse

A maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by one (or more) of the following, occurring within a 12-month period:

1. Recurrent substance use resulting in a failure to fulfil major role obligations at work, school, or home (such as repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; or neglect of children or household).

2. Recurrent substance use in situations in which it is physically hazardous (such as driving an automobile or operating a machine when impaired by substance use)

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Abuse…

3. Recurrent substance-related legal problems (such as arrests for substance related disorderly conduct)

4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (for example, arguments with spouse about consequences of intoxication and physical fights).

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Dependence

A. Maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

1. Tolerance2. Withdrawal3. The substance is often taken in larger

amounts or over a longer period than was intended

4. There is a persistent desire or unsuccessful efforts to cut down or control substance use

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Tolerance

Defined by either of the following:

a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect

b) markedly diminished effect with continued use of the same amount of the substance

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Withdrawal

As manifested by either of the following:

a) the characteristic withdrawal syndrome for the substance (refer to criteria of withdrawal of the specific substance)

b) the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms.

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Dependence

5. A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects

6. Important social, occupational, or recreational activities are given up or reduced because of substance use

7. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

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Specify…

with physiological dependence: evidence of tolerance or withdrawal (i.e. either item 1 or 2 is present)

without physiological dependence: no evidence of tolerance or withdrawal (i.e. neither item 1 nor 2 is present)

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Which one is true?

Every dependent is an abuser !

Every abuser is a dependent !

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BE SMART!

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Be smart…

When medical or psychiatric problems may be related to alcohol or drugs.

When certain drugs are requested for unsatisfactory reasons.

When needle tracks and thrombotic veins are found.

Finding scars of previous abscesses.

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Needle tracks & abscesses

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Cont. to be smart…

When urine tests positive (except LSD and solvents).

When Gamma–Glutmyle–transferase (GGT) and MCV are elevated.

In cases of self neglect, and school or occupational decline.

In history of former friends loss and joining the “drug culture.”

In history of thefts and prostitution.

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Why Drugs?

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Seeking Stimulation Or Avoiding Pain

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Reasons Why College Students Use Drugs

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Many college students have false perception of how much their peers use marijuana.

In a recent survey, students estimated that 58% of their peers had used marijuana at least once in the past one month, and that 22.4% of them used it daily.

I fact, only 11.4% used marijuana in the pst month and only 1% had used daily

Did You Know?

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Quiz: Which group of drugs is most prevalent?

PrescribedBenzodiazepines

Legalalcohol & nicotine

Illegalcocaine, hash

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Other prevalence issues…

Personal characteristics: Difficulty accepting

authority, truancy and poor schooling in teenagers.

Personality disorder, disorganized life & unstable relationships.

Sexual promiscuity.

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Other prevalence issues…

Disorganized families.

Unhappy childhood.

History of mental illness or personality disorder in family.

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Other prevalence issues…

Social Pressures: especially in teenagers &

school children. unemployment. Primary effect of the

substance

Secondary effect of the substance (milieu).

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Management outlines

1. Review history with the patient regarding:

Type of drug (s) and amount I.V. usage and its dangers Evidence of dependence Complications of drugs (physical,

psychological and social). Personal and social resources and

problems

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Management outlines…

2 Manage withdrawal symptoms

3 Treat urgent medical / psychiatric complications

4 Set attainable goals: Abstaining from drug Parting from drug culture Dealing with personal and financial

problems Establishing new interests

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Management outlines…

5. Set longer-term goals: Individual or group

counseling Help for family Rehabilitation

6. Self-help groups

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Prevention

Of availability

Improve awareness

Increase restrictions

Of advertising

Through media

Through schools

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General Complications

General medical complications e.g. AIDS, endocarditis

Local effects of I.V. injections e.g. thrombosis.

Impaired functioning, failure of social relations, accidents, family problems and neglect.

Debts due to expensive illicit drugs Prostitution and crime. Death.

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ALCOHOLAbuse & dependence

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Screening Questions

Cut down

Annoyed

Guilty

Eye opener

CA

EG

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PREVALENCE:

In England, 6% of men & 1% of women admitted to consumption of >50 units/week.

Lifetime prevalence rate was 0.45% among Chinese in Shanghai & 23% among Native Mexican-Americans

Dependence is usually established in mid-forties for men and a few years later for women.

Dependence is generally more common in disadvantaged areas.

Occupation: Executives, service men, journalists, Salesmen and movie industry.

1 unit = 1 cl.

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Toxic & nutritional states

Blackouts amnesia to events that occur during the period

of intoxication

Idiosyncratic intoxicationmarkedly changed behavior (usually aggressive)

occurring within minutes of drinking a small amount of alcohol

Other effects euphoria/dysphoria, irritability

sedation, memory & judgment impairmentdisinhibition, aggression, violence, accident

proneness

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Toxic & nutritional states

Wernicke’s encephalopathyCause:Thiamin deficiency leading to bilateral

degeneration of the posterior hypothalamus, hippo- campus and mamillary bodies.

Features:Delirium, Ataxia and Ophthalmoplegia.

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Toxic & nutritional states

Korsakov’s syndrome (alcohol amnestic syndrome)

Features: Prominent disturbance of recent memory in the

absence of generalized intellectual impairment Immediate recall is good but recent memory is

impaired Confabulation and disorientation to time may

occur. New learning is impaired. Occurs after prolonged use On CT scan: Ventricles may be enlarged and

sulci may be widened. CT changes may partially resolve on abstinence

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ASSOCIATED COMORBIDITY & COMPLICATIONS

Depression/ Suicide Anxiety Personality changes Pathological

jealousy Sexual dysfunction Hallucinations

Social damage

Crimes Road traffic

accidents Occupational

problems Family

conflicts and losses

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MANAGEMENT

1. Assess: Extent of drinking

Evidence of dependence Alcohol related disability

2. Arrange for and treat withdrawal symptoms:

Sedation Thiamin and Vitamin B supplements

Rehydration

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MANAGEMENT

3. Treat urgent psychiatric or medical problems:

4. Long term treatment of: Medical and psychiatric disability Interpersonal problems Social problems ( work, law, finance, interests)

5. Arrange for rehabilitation: Individual and / or group counseling Self help group e.g. alcohol anonymous Help for family Disulfiram (antabuse)- inhibits acetaldehyde

dehydroginase…

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Prognosis

Generally poor:

At 6/12: 25% remain abstinent At 18/12: 10% remain abstinent

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Prognosis

Good prognostic factors include:

Good insight Strong motivation Supportive family Stable job Ability to form good relationship Control of impulsivity and ability

to defer gratification

OUTCOME

Outcome depends more on the patient than on the treatment

Hash or Marijuana

CANNABIS

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Derived from the plant Cannabis sativa

Effect varies according to dose, user’s expectation and social setting

Exaggerates the preexisting mood (euphoria or dysphoria)

Physical dependence and withdrawal symptoms do not occur

Acute intoxication may lead to psychosis while chronic use may lead to “amotivational syndrome

INHALENTS

ORGANIC SOLVENTS

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ADHESIVES, CLEANING FLUIDS, PETROL, AEROSOLS, BUTANE GAS

Most common among teenagers. Intoxication leads to drunkenness,

delirium, uncoordinated gait, nausea, vomiting, and coma.

Visual hallucinations are common. More psychological than physical

dependence. It has a neurotoxic effect leading to

peripheral neuropathy and cerebellar dysfunction.

Over dosage may be fatal and chronic use may lead to psychosis.

Very cheap and easily obtained.

Due to: hepatorenal, brain & bone marrow toxicity,

bronchial asthma & cardiorespiratory arrest, coma, asphyxiation with plastic bags, trauma …

AMPHETAMINES AND COCAINE

STIMULANTS

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حالوة , , , , , حمص قضوم قوسين أبو األبيض, لجج كبتي , , , طباشير داتسون ، ملف أبو لجة

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Lead to elevation of mood, over-activity, insomnia, over-talkativeness, and anorexia.

Cardiac arrhythmia and malignant hypertension may result from high doses.

Death Prolonged use may result in paranoid

psychosis resembling schizophrenia Physical dependence is not severe Withdrawal may lead to severe

depression and suicide Treatment includes abstinence,

antidepressants and neuroleptics

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METHAMPHITAMINE

LSD, DISMETHYL TRYPTAMINE AND ANTICHOLINERGIC

HALLUCINOGENS

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Lead to distortion or intensification of perceptions or frank hallucinations.

Time moves slowly Profound meaning of ordinary events. Body image distortions and

depersonalization may occur. Experience may be pleasant,

distressing, or frightening leading to dangerous unpredictable behavior.

Physical effects include hypertension Flashbacks may occur More psychological than physical

dependence Treatment is diazepam or

phenothiazines (avoid in case of anticholinergic over-dose)

HEROIN, MORPHINE, CODEINE AND PETHEDIN

OPIOIDS

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Lead to immediate effects of euphoria, analgesia, reduced appetite, respiratory depression, drowsiness, gastrointestinal spasms, fits…

Tolerance develops rapidly Withdrawal symptoms: craving, agitation,

insomnia, pains and arthralgia, abdominal cramps, runny nose and eyes, sweating, diarrhea, piloerection, dilated pupils, tachycardia and disturbed temperature control.

Withdrawal starts within 6 hours, peaks in 24–48 hours and it is not life threatening

Short-term treatment includes: relief of withdrawal symptoms.

Long-term treatment includes: methadone replacement and rehabilitation

Treatment outcome remains poor in the best hands.

Death results in about: 10%-20% in 7 years.

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SMOKING CIGARETTES

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وإعداد تصميم

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