ALCOHOL, OPIOIDS AND OTHER SUBTANCE-RELATED DISORDES

2ND GROUP

INTRODUCTION• Substances abuse problem causes significant disabilities for a relatively high percent-age of the population.• Substance-induced syndromes can mimic the full range of psychiatric illnesses, including mood, psychotic, and anxiety disorder.• Patient who are diagnosed with primary substance use disorder must be evaluated for another psychiatric disorder (dual diagnosis) that maybe contributing to the substance abuse or dependence. ClassificationThere are many classes of substances that are associated with these disorder : • Alcohol (ethanol); wood alcohol (methanol)• Amphetamine; Amphetamine-like substance• Caffeine + Cannabis• Coccaine + Halusinogen; Psychedelics• Inhalant + Nicotine• Opioids + Phencyclidine (PCP)• Sedatives, Hypnotics, and Anxiolytics• Prescribed drugs and over the counter (OTC) mediction• Anabolic-Androgenic Steroid Terminology• Dependence• Abuse• Misuse + Addiction• Intoxication + Withdrawal

• Tolerance + Cross-Tolerance• Neuroadaptation + Co-dependenceEVALUATION• Toxicology : Urine or blood test• Physical Examination• Diagnosisabuse is the chronic use and eventually produce dependence on the drug with tolerance and withdrawal symptoms• Treatment

The management of abuse or dependence involve abstinence and long-term treatment ALCOHOL RELATED DISORDER

The disorder of alcohol associated with alcoholism generally can be divide into three groups (1) disorder related to the direct effect of alcohol on the brain (2) disorder related to behavior associated with alcohol (3) disorder with persisting effects.

ALCOHOL DEPENDENCE AND ABUSE1. Definition

Pattern of compulsive alcohol use, defined in DSM-IV-TR by the presence of three or more major areas of impairment related to alcohol occurring within the same 12 months.2. Pharmacology

a. Pharmacokineticsb. Neuropharmacology

3. Epidemiology 10% of women and 25% of men have met the diagnostic

criteria for alcohol abuse during their lifetimes and 3% to 5% of women and 10% of men have met the diagnostic criteria for the more serious diagnosis of alcohol dependence.4. Etiology

(1) close family member(2) the identical twin of an alcoholic person(3) adopted-away chidren of alcoholic person

5. Diagnosis, Sign and Symptomsa. Alcohol Dependence

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Tolerance is the phenomenon in the drinker. The development of tolerance, especially marked tolerance, usually indicates dependence. Mild tolerance is common but severe tolerance is uncommonb. Alcohol Abuse

Chronic use of alcohol that leads to dependence tolerance or withdrawal

6.Evaluationthe proper evaluation of the alcohol user requires some

suspicion on the part of the evaluator.7.Treatment

the goal is the prolonged maintenance of total sobriety. Initial treatment requires detoxification and treatment of any withdrawal symptoms.8.Medical Complication

is a toxic to numerous organ system.

ALCOHOL INTOXICATION• Alcohol Intoxication1.Definition.

The recent ingestion of sufficient amount of alcohol to produce acute maladaptive behavioral changes.2.Diagnosis, Sign and Symptoms

Mild intoxication may produce a relaxed, talkative, euphoric or disinhibited person, severe intoxication often leads to more maladaptive changes. Severe intoxication can lead to withdrawn behavior, psychomotor retardation, blackouts, and eventually obtundation, coma, and death. 3.Evaluation

A through medical evaluation should be conducted; consider a possible subdural haematoma, or a concurrent infection. Always evaluate for possible intoxication with other substance. 4.Treatment

a. Ussualy only supportiveb. May give nutrients

c. Obsevation for complications may be requairedd. Alcoholic idiosyncratic intoxication is a medical

emergency.

ALCOHOL-INDUCED PSYCHOTIC DISORDER, WITH HALLUCINATION

The male to female ratio is 4:1. The condition usually requires at least 10 years of alcohol dependence. If the patient is agitated, possible treatment include benzodiazepine or low doses of high potency antipsychotic.

ALCOHOL WITHDRAWAL begins within several hours after cessation of or reduction in prolonged heavy alcohol consumption. At least 2 of following must be present: autonomic hyperactivity, hand tremor, insomnia, nausea or vomiting, transient illusions or hallucination, anxiety, grand mal seizures, and psychomotor agitation.

ALCOHOL WITHDRAWAL DELIRIUM1.Diagnosis, sign and symptoms a. Delirium b. Marked autonomic hyperactivity tachycardia, sweating fever, anxiety or insomnia. c. Associated feature d. Typical feature2.Medical workup

a. Complete history and physicalb. Laboratory test

3.Treatmenta. take vital sign every 6 hourb. observe the patient constantlyc. decrease stimulationd. correct electrolyte imbalancee. if the patient is dehydrated, hydratef. chlordiazepoxide, in the geriatric patient, give lorazepam.g. thiamineh. Folic acidi. One multivitamin dailyj. Magnesium sulfatk. After the patient is stabilized, taper chlordiazepoxide

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l. Provide medication for adequate sleep.m. Treat malnutrition if present.n. This regimen allows for a very flexible dosage of chlordiazepoxideo. Generally antipsychotic should be use cautiously because they can precipitate seizures.

ALCOHOL-INDUCED PERSISTING AMNESTIC DISORDERDisturbance in short-term memory resulting from prolonged heavy use of alcohol.1. Wernicke’s encephalopathy. An acute syndrome caused by thamin deficiency. Characterized by nystagmus,abducens and conjugated gaze palsies, ataxia and global confusion. Other symptoms may include confabulation, lethargy,indifference, mild delirium, anxious insomnia, and fear of the dark. Treat with thiamin until ophtalmoplegia resolves, may also require magnesium.2. Korssakof’s syndrome A chronic condition, ussualy related to alcohol dependence, wherein alcohol represent a large portion of the caloric intake for years. Cased by thiamin deficiency. Characterized by retrograde and anterograd amnesia. In addition of thiamine replacement, clonidine and propanolol may be of some limited use.

SUBSTANCES-INDUCED PERSISTING DEMENSIA This diagnosis should be made when other causes of dementia have been excluded and history of chronic heavy alcohol abuse is evident. Management is similar to that for dementia of other causes.OPIOID1.Introduction

Opioid include the natural drug opium and its derivatives. In addition to synthetic drug with similar action. The natural drug derived from opium include morphin and codein. The synthetic opioids include methadone, oxycodone,etc. heroin is concidered a semisynthetic drug an has the strongest euphoriant property, thus producing the most craving.

OPIOID2.Epidemiology the opioid drug most associated with abuse in heroin, with an estimated 600.000 heroin user reporterd in US.

3.Route of administration Depends on the drug. Opium is smoke. Heroin is typically injected or inhaled nasaly.4. Dosage Often difficult to determine by history for two reason : (1) the abuser has no way knowing the concentration of the heroin. He or she has bought and may underestimated the amount taken. (2) the abuser may over state the dosage an attempt to get more methadone.5.Intoxication• Objective sign and symptom CNS depression, decreased gastrointestinal motility, respiratory depression, analgesia, nausea and vomiting, slurred speech, hypotension, bradycardia, pupillary constriction, seizure (in overdose). Tolerant patient still have pupillary constriction and constipation. b. Subjective sign and symptoms Euphoria, decreased attention and memory, drowsiness, and psychomotor retardation.6.Treatment• ICU admission and support of vital functions.• Immediately administer 0,8 mg naloxone IV and wait 15 minutes• If no response give 1,6 mg IV• If still no response give 3,2 mg IV and suspect another diagnosis• If successful, continue at 0,4 mg/hour IV• Always consider possible polysubstance overdose.7.Tolerance, dependence, and withdrawal. Develop rapidly with long term opioid use. Withdrawal is seldom a medical emergency. Clinical signs are flulike and include drug craving, anxiety, lacrimation, rhinorrhea, sweating, insomnia,etc. The goal of detoxification is to minimize withdrawal symptoms.8.Detoxification if objective withdrawal signs are present give 10mg methadone, if withdrawal persist after 4-6 hour, give an additional 5-10mg, which may repeated every 2 to 6 hours. Total dose in 24 hours equals the dose for the second day (seldom>40mg). Give twice a day or every day decrease dosage by 5 mg/day for heroin withdrawal.

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9.Opioid substitutes Methadone maintenance program do decrease rates of heroin use. Levomethadyl is a longer acting opioid than methadone. Buprenorphine is a partial µ-opioid receptor agonist that is use for both detoxification and maintenance treatment.10.Therapeutic communities residential programs that emphasize abstinence and group therapy in a structured environment.11.Other interventions.

Education of HIV transmissions, free needle exchange program, individual and group psychotherapies, self-help groups and outpatient drug-free programs are also of benefit.

KRIS n ADAM

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