Psychoactive substance use Psychoactive substance use disordersdisorders

Dr.Dr. Erika SzilyErika Szily16. 10. 2013.16. 10. 2013.

Basic conceptionsBasic conceptions

Psychoactive substance: compound Psychoactive substance: compound that can alter one’s state of mindthat can alter one’s state of mind

Reinforcer: that causes pleasant or Reinforcer: that causes pleasant or stops unpleasant conditions stops unpleasant conditions

Categories of drugsCategories of drugs

CNS DepressantsCNS Depressants AlcoholAlcohol Sedatives, hypnotics, and Sedatives, hypnotics, and

anxiolyticsanxiolytics

OpiatesOpiates StimulantsStimulants Heroin Amphetamines Heroin Amphetamines Meperidine MethylphenidateMeperidine Methylphenidate Codeine CocaineCodeine Cocaine Hydromorphone Hydromorphone CannabisCannabis HallucinogensHallucinogens

LSD LSD InhalantsInhalants

Designer drugsDesigner drugs

Synthetic cathinons and other amphetamine derivatives, opioids, THC-analogues

DSM-IV-TR substance-related mental disorders

1. Substance use disorders:

- Substance abuse

- Substance dependence

2. Substance -induced disorders:

- Substance intoxication

- Substance withdrawal with or without delirium

- Substance -induced amnestic disorder / dementia

- Substance -induced psychotic disorder (e.g. delusion of

jealousy and hallucinations)

- Substance -induced mood, personality, anxiety, sexual, and

sleep disorder

Basic definitions: Basic definitions: substance substance abuseabuse

Maladaptive pattern of substance use:Maladaptive pattern of substance use:– Failure to fulfill role obligations at work, school Failure to fulfill role obligations at work, school

or homeor home– Physically hazardous situationsPhysically hazardous situations– Legal problems Legal problems – Continued use despite serious social and Continued use despite serious social and

interpersonal problemsinterpersonal problems

Basic definitions: Basic definitions: substance substance dependencedependence

(Heavy and prolonged substance use);(Heavy and prolonged substance use);Tolerance (need for increase amounts; diminished Tolerance (need for increase amounts; diminished effect of the same amount)effect of the same amount)Withdrawal (certain symptoms when stop substance Withdrawal (certain symptoms when stop substance use, alcohol cures the syndrome)use, alcohol cures the syndrome)Persistent desire or unsuccessful efforts to cut down Persistent desire or unsuccessful efforts to cut down substance usesubstance useGreat amount of time is spent on activity related to Great amount of time is spent on activity related to the substancethe substanceSocial, work or recreational activities are given upSocial, work or recreational activities are given upContinued use despite of knowledge of serious Continued use despite of knowledge of serious social, psychological,and physical problemssocial, psychological,and physical problems

DependenceDependenceWhen the substance use is reduced or ceasedWhen the substance use is reduced or ceased

withdrawal symptoms developwithdrawal symptoms develop

lack of withdrawal symptoms lack of withdrawal symptoms Level of dependence Level of dependence ----------------------------- -----------------------------

withdrawal symptomswithdrawal symptoms

Two typesTwo typesphysiological dependencephysiological dependence (Alcohol, BZDs, Opioids – drug-specific effects on certain (Alcohol, BZDs, Opioids – drug-specific effects on certain receptors: e.g. GABA receptors)receptors: e.g. GABA receptors)

psychological dependencepsychological dependence(Most of the psychoactive substances – dopaminergic (Most of the psychoactive substances – dopaminergic

effects, effects, reward and motivationreward and motivation systems (striatum, n. systems (striatum, n. accumbens)accumbens)

ToleranceTolerance

The dose of the drug has to be The dose of the drug has to be increased in order to reach the desired effectincreased in order to reach the desired effect

(pharmacokinetic (enzym induction) and (pharmacokinetic (enzym induction) and pharmacodynamic (receptor downregulation)pharmacodynamic (receptor downregulation)

effect of effect of drug developsdrug developsLevel of tolerance ------------------------- Level of tolerance -------------------------

effect of effect of drug doesn’t developdrug doesn’t develop

AddictionAddiction

Compulsive behavioural pattern of seeking Compulsive behavioural pattern of seeking drugs, consumption of drugsdrugs, consumption of drugs

Characterized by Characterized by strong dsesire towards the drugs, and strong dsesire towards the drugs, and

strong tendency to the relapse after the strong tendency to the relapse after the withdrawalwithdrawal

Alcohol consumption in the World

Neuropsychiatric disorders due Neuropsychiatric disorders due to alcohol consumptionto alcohol consumption

Withdrawal without or with delirium tremensWithdrawal without or with delirium tremens

Alcoholic hallucinatory stateAlcoholic hallucinatory state

Alkoholic delusive disorderAlkoholic delusive disorder

Alcoholic personality changes

Alcohol-induced Persisting DementiaAlcohol-induced Persisting Dementia

Wernicke’s encephalopathyWernicke’s encephalopathy

Korsakoff syndromeKorsakoff syndrome

Alcohol withdrawal - clinical Alcohol withdrawal - clinical presentationpresentation

Minor withdrawalMinor withdrawal (5-10 hours) (5-10 hours) – Autonomic hyperactivity: tremulousness, Autonomic hyperactivity: tremulousness,

hyperhydrosis, tachycardia, hypertension, GI upset;hyperhydrosis, tachycardia, hypertension, GI upset;– Anxiety, insomnia, and vivid dreamsAnxiety, insomnia, and vivid dreams

Major Withdrawal (12-72 hours)Major Withdrawal (12-72 hours)– Hallucinations (visual, tactile) – 10-25%Hallucinations (visual, tactile) – 10-25%– SeizuresSeizures (generalized tonic-clonic seizures ) – 10% (generalized tonic-clonic seizures ) – 10%

Delirium tremens (48-72 hours) – 5%Delirium tremens (48-72 hours) – 5%– Disordered consciousnessDisordered consciousness– Life threatening state – medical emergency!!!!Life threatening state – medical emergency!!!!

Delírium tremensDelírium tremens

Most severe form of alcohol withdrawal Most severe form of alcohol withdrawal

Untreated delirium has a mortality rate ofUntreated delirium has a mortality rate of20 %20 %

Occurs after prolonged and heavy alcohol Occurs after prolonged and heavy alcohol consumption at cease or reduction of alcohol use consumption at cease or reduction of alcohol use

Provoking factors can often be seenProvoking factors can often be seen(fever, internal disturbance)(fever, internal disturbance)

Symptoms of deliriumSymptoms of delirium

Psychopathological symptoms:Psychopathological symptoms:

- - Disordered Disordered conscioussnessconscioussness, confusion, confusion- Impaired - Impaired attentionattention, distractibility, distractibility- - DisorientationDisorientation in relation to time, place and person in relation to time, place and person- - HallucinationsHallucinations and illusions (complex, visual, tactile, and illusions (complex, visual, tactile,

auditory)auditory)- - DesorganisedDesorganised behaviour, agitation, violence behaviour, agitation, violence

Vegetative and somatic symptomsVegetative and somatic symptoms::Autonomic hyperactivity: tremulousness, hyperhydrosis, tachycardia, Autonomic hyperactivity: tremulousness, hyperhydrosis, tachycardia,

hypertension, feverhypertension, feverGI upsetGI upsetInversion of sleepingInversion of sleepingConvulsionsConvulsions

Treatment of deliriumTreatment of delirium

PreventionPrevention

BenzodiazepinesBenzodiazepines

ThiamineThiamine

Ensure fluid and electrolite ballanceEnsure fluid and electrolite ballance

High calorie, high-carbohydrate diet suplemented High calorie, high-carbohydrate diet suplemented by multivitaminsby multivitamins

Treatment of internal disorders, infections, etc.Treatment of internal disorders, infections, etc.

Alcoholic hallucinatory stateAlcoholic hallucinatory state

At prolonged and heavy alcohol-At prolonged and heavy alcohol-consumption, consumption,

after alcohol-abuse or cease of alcohol after alcohol-abuse or cease of alcohol consumptionconsumption

Alcoholic hallucinatory stateAlcoholic hallucinatory state

Symptoms:Symptoms: HallucinationsHallucinations

Clear conunsciousnessClear conunsciousness, kept orientation, kept orientationSevere anxietySevere anxiety

Persecutory delusionsPersecutory delusionsDelusions of referenceDelusions of reference

Altered behaviour by the psychotic contentsAltered behaviour by the psychotic contentsSuicidal dangerSuicidal danger

Alcoholic delusive disorderAlcoholic delusive disorder

Delusions of jealousy (most often)Delusions of jealousy (most often)

persecutorypersecutory reference reference

Alcoholic personality changes

Slowly progressing chronic psychic

distrubance involving all parts of personality

after prolonged alcohol consumption

Symptoms

Changeable mood, superficial emotions, bursts of angerSuperficial attachment to the familyLack of inhibitions, lack of ethicDecreased critical sense, unconscientiousnessIrritability, agressivityDecreased adapting to the societyDecreased judgementDeterioration of intelelctual functions

Alcohol-induced DementiaAlcohol-induced Dementia

ReasonReason::Direct neurotoxic effect of alcoholDirect neurotoxic effect of alcohol

and thiamine deficiencyand thiamine deficiency

Symptoms:Symptoms:Deterioration of intelelctual functionsDeterioration of intelelctual functions

Impaired memory, Impaired ability of abstractionImpaired memory, Impaired ability of abstractionImpaired judgement, Impaired problemsolving Impaired judgement, Impaired problemsolving

thinkingthinkingImpaired orientationImpaired orientation

Alcohol-related nutritional disordersAlcohol-related nutritional disorders

Nutritional and absorption problems: Nutritional and absorption problems: thiamine (vitamin B1) thiamine (vitamin B1) deficiency in chronic alcohol dependencedeficiency in chronic alcohol dependence

Lesions: mammilary body, fornix, thalamus, cerebellum and Lesions: mammilary body, fornix, thalamus, cerebellum and brainstembrainstem

Korsakoff’s syndrome: Korsakoff’s syndrome: short-term memory impairment, short-term memory impairment, confusion, and confabulationconfusion, and confabulationWernicke’s encephalopathy: Wernicke’s encephalopathy: gait ataxia, confusion, gait ataxia, confusion, oculomotor problems - horizontal nystagmus and gaze palsy oculomotor problems - horizontal nystagmus and gaze palsy (Wernicke’s encephalopathy is reversible but can progress to Korsakoff’s (Wernicke’s encephalopathy is reversible but can progress to Korsakoff’s syndrome, coma or death; avoid rapid glucose administration BEFORE syndrome, coma or death; avoid rapid glucose administration BEFORE thiamine)thiamine)

--- --- Lack of folic acid: macrocytaer anaemiaLack of folic acid: macrocytaer anaemia

Rare: pellagra and beri-beri-like conditionsRare: pellagra and beri-beri-like conditions

ThiamineThiamine

Reason of thiamine deficiency:Reason of thiamine deficiency:

Poor nutritionPoor nutrition

MalabsorptionMalabsorption

Thiamine is a cofactor for several Thiamine is a cofactor for several important enzymesimportant enzymes

It’s involved in the conduction of the axon It’s involved in the conduction of the axon potential along the axon and in synaptic potential along the axon and in synaptic

transmissiontransmission

Effects and consequences of Effects and consequences of illegal drug useillegal drug use

Effects of opiate useEffects of opiate use

- flushing - orgasmic sensation in the flushing - orgasmic sensation in the abdomen abdomen

- euphoria - calmness- euphoria - calmness

Withdrawal symptoms of opiatesWithdrawal symptoms of opiates

lacrimation rhinorrhealacrimation rhinorrhea

sweating yawningsweating yawning

hot and cold flashes insomniahot and cold flashes insomnia

muscle and joint pain nausea muscle and joint pain nausea

vomiting abdominal vomiting abdominal

crampscramps

sever anxiety irritability sever anxiety irritability

Effects of stimulantsEffects of stimulants

elevated mood increasd energy elevated mood increasd energy

increased alertness transient psychosisincreased alertness transient psychosis

decreased appetitedecreased appetite

autonomic hyperarousal:autonomic hyperarousal:

- tachicardia- tachicardia

- elevated blood pressure- elevated blood pressure

Effects of cocainEffects of cocain

euphoria euphoria

disinhibitiondisinhibition

enhanced sense of masteryenhanced sense of mastery

sexual alertness sexual alertness

improved self esteem improved self esteem

rush (rapid onset of euphoria)rush (rapid onset of euphoria)

tactile hallucinations (coke bugs)tactile hallucinations (coke bugs)

Stimulant withdrawalStimulant withdrawal

fatigue fatigue

depressiondepression

nightmaresnightmares

headacheheadache

sweatingsweating

muscle crampsmuscle cramps

hungerhunger

HallucinogensHallucinogens

Agents, that induce psychotic-like Agents, that induce psychotic-like experiences, hallucinations, perceptual experiences, hallucinations, perceptual

disturbances, feeling of unrealitydisturbances, feeling of unreality

HallucinogensHallucinogens

LSD (lysergic acid diethylamide)LSD (lysergic acid diethylamide)peyotle peyotle

mescalinemescaline MDMAMDMA

Effects of HallucinogensEffects of Hallucinogens

Alterations in perception: Alterations in perception:

hallucinations, illusionshallucinations, illusions

synthesias synthesias

(e.g. colors are brighter and more intense or (e.g. colors are brighter and more intense or

colors may be heared and sounds seen) colors may be heared and sounds seen)

Emotions become intense and labileEmotions become intense and labile

Introspection Introspection

Depersonalisation, DerealizationDepersonalisation, Derealization

Bad tripsBad trips

Patient develop marked anxiety and Patient develop marked anxiety and

paranoia paranoia

Flashback: a brief reoccurrence of a drug Flashback: a brief reoccurrence of a drug induced experience induced experience

that occurs in situations unrelated to that occurs in situations unrelated to taking the drugtaking the drug

CannabisCannabis

Cannabis derivatives are produced Cannabis derivatives are produced from the hemp Cannabis sativa. from the hemp Cannabis sativa. The active ingredient is the THC (delta-The active ingredient is the THC (delta-9-tetrahydrocannabinol).9-tetrahydrocannabinol).The illicit psychoactive compound The illicit psychoactive compound (marijuana) is probably the most widely (marijuana) is probably the most widely used.used.

EffectsEffects

- euphoria - euphoria - drowsiness- drowsiness

- feeling of calm feeling of calm - feeling that time has slowedfeeling that time has slowed

- improved self coinfidence- improved self coinfidence- perceptual distortions- perceptual distortions

- paranoia (suspiciosness)paranoia (suspiciosness)- decreased motor coordinaton decreased motor coordinaton

CosequencesCosequences

Amotivation syndromeAmotivation syndrome

Memory disturbanceMemory disturbanceMarijuana impairs the transfer ofMarijuana impairs the transfer of

material from mediate to long term material from mediate to long term memorymemory

InhalantsInhalants

Chemicals, that produces psychoactive Chemicals, that produces psychoactive vapoursvapours

airplane glueairplane gluepaint thinnerpaint thinner

nail-polish removernail-polish removergasolinegasoline

many substances in aerosol cansmany substances in aerosol cans

Active substances:Active substances: Toluane, acetone, benzene, other organic Toluane, acetone, benzene, other organic

hydrocarbonshydrocarbons

EffectsEffects

excitation disinhibitionexcitation disinhibition

euphoria dizzinesseuphoria dizziness

slurred speech ataxiaslurred speech ataxia

delirium hallucinationsdelirium hallucinations

delusions nystagmusdelusions nystagmus

double visiondouble vision

At higher doses: stupor, comaAt higher doses: stupor, coma

Consequences Consequences

Neuromuscular and brain damage, Neuromuscular and brain damage,

damage to the kidneys, liver damage to the kidneys, liver

due to high concentrations of heavy due to high concentrations of heavy metalsmetals

Therapy of addictive disordersTherapy of addictive disorders

Connected therapeutic chain from Connected therapeutic chain from detixification to resocialisation and detixification to resocialisation and

rehabilitationrehabilitation

Aim of treatment:Aim of treatment:Improve ability to community and social Improve ability to community and social

functioningfunctioning

Therapy of addictive disordersTherapy of addictive disorders

Different methods in treatmentDifferent methods in treatment

since drug abuse issince drug abuse is

a medicala medical- a psychological anda psychological and- sociological problemsociological problem

TherapyTherapy

PharmacotherapyPharmacotherapy

(Opioids - methadone, naltrexon(Opioids - methadone, naltrexonAlcohol - nalmefene, disulfiram)Alcohol - nalmefene, disulfiram)

PsychoterapyPsychoterapy

Relapse preventionRelapse prevention

Long-term Long-term managementmanagement of of substancesubstance dependence: psyhosocial treatment and dependence: psyhosocial treatment and

rehabilitationrehabilitation

Confrontation with reality and Confrontation with reality and motivating motivating according to according to individual needs and capacity to changeindividual needs and capacity to change

Focusing on and treatment of Focusing on and treatment of co-morbid co-morbid mood and anxiety mood and anxiety disorders (30-40%)disorders (30-40%)

Family-level Family-level interventionintervention

CounselingCounseling and community-level intervention: and community-level intervention:

- - mmotivation to maintain abstinence and prevent relapse – otivation to maintain abstinence and prevent relapse – showingshowing the consequencesthe consequences

- - ccope with everyday stressope with everyday stress

- - sstimulus control and cravingtimulus control and craving

- - bbuild-up alternative lifestyleuild-up alternative lifestyle

Self-help groups Self-help groups

Alcoholics AnonymousAlcoholics Anonymous, Narcotics Anonymous, Narcotics Anonymous- SSober peer group, 12-step treatment from confrontationober peer group, 12-step treatment from confrontation to to

spiritual awakening spiritual awakening - RRole modeling of social functioning without drinkingole modeling of social functioning without drinking- PPeer help available 24 hourseer help available 24 hours- SStrong group coherence („we-ness”)trong group coherence („we-ness”)- RReligion and spiritualityeligion and spirituality

potential problems: confrontation with the medical model, may potential problems: confrontation with the medical model, may be dogmatic, requires changes in view of life be dogmatic, requires changes in view of life

Other organizations: LifeRing Secular Recovery, Rational Other organizations: LifeRing Secular Recovery, Rational Recovery, SMART Recovery Recovery, SMART Recovery