SUBSTANCE ABUSE

BYDR. RABIE A. HAWARI

Consultant Psychiatrist Clinical Assistant Professor

W.H.O.1969-:

- A drug is any substance that , when taken , into the living organism, may modify one or more of its functions,

- Drug Abuse is the persistent or sporadic excessive use of a drug inconsistent with, or unrelated to, acceptable medical practice,

- Drug Dependence is a state – psychic and sometimes also physical – resulting from interaction between a living organism and a drug, characterized by behavioral and other responses that always include a compulsion to take the drug on a continuous or periodic basis in order to experience its psychic effect, and sometimes to avoid the discomfort of its absence. Tolerance may or may not be present, a person may be dependent on more than one drug.

Dependence-:

= Psychological :- overwhelming repetitive need to seek whatever ease, pleasure or stimulus is provided by a drug, is common to all drugs of dependent,

= Physical :- relates to the pharmacology of a drug, in the course of repeated administration of certain drug the body's metabolic processes adapt themselves to these drugs, if such a drug is suddenly withdrawn, the metabolic balance is upset and this lead to withdrawal symptoms.

= Tolerance :- diminishing response to repeated dose of a drug.

Dependence continue-:

=Withdrawal or Abstinence Symptoms :- symptoms occur after a sudden stoppage of a drug which are due to hyperactivity of those functions preciously depressed

by the drug , e.g. 1- convulsions and/or delirium tremens following a

rapid withdrawal of barbiturates or alcohol. 2 -vomiting, diarrhea, lacrimation, sweating,

sneezing, and restlessness following abrupt cessation of large morphine intake.

Elements of dependence-:

1- Withdrawal Symptoms :- e.g. fits2- Withdrawal relief :- need to get a relief from WDS.3- Tolerance :- diminished response to repeated dose.4- Subjective change :- sense of compulsiveness.5- Narrowing repertoire :- taking more.6- Salience :- important thing.7- Reinstatement :- back to drinking level fast.

Classes of drugs-:

1. Stimulants :- coffee , amphetamine , cocaine ,2. General Depressants :- alcohol , barbiturates ,3. Opiates :- pethidine , morphine , heroin,4. Hallucinogenic :- muscolain , L.S.D. ( lysergic acid diethylamide ),5. Others :- cannabis = sedative & stimulants. benzodiazepines = sedative & hypnotics. nicotine = stimulant & depressive. solvents = (glue, petrol, acetone) C.N.S. depressants.

Routes of Administration-:

a. Smoked = hash , tobacco , heroin,b. Sniffed = cocaine,c. Chewed = tobacco , ghat,d. Orally = tablets , alcohol , e. Injected = i.v. or i.m. – heroin , barbiturates.

Epidemiology-:

= age :- alcohol 40 – 54 drugs 20 – 39.= sex :- alcohol M : F - 2.5 : 1 drugs M : F - 4 : 1= social class :- all social classes.= urban / rural :- increased in urban areas.= general hospital patients :- 20% male – 4% female with alcohol problem.

Etiology-:

Multifactorial a) Genetics :- no conclusive evidence. For alcohol = parents & siblings 2&1/2 times that of general population,

= MZ : DZ 71% : 32%, = adoption 4 x control.b) Psychological theories :- * Behavioral :- 1. Modeling,

Etiology continue-:

Psychological theories – behavioral ( continue ) 2 .Primary direct reinforcement e.g. stimulus,

sedation reinforce abuse behavior. 3 .Secondary reinforcement e.g. the environment .

cues are linked with pharmacological effect of drugs i.e. advertisement on t.v. and newspapers.

* Analytic -: “ addicts considered fixed at or regressed to an oral

level of sexual development.

Etiology continue-:

c) Social & Family factors :- - peer group pressures, - demands of culture and subculture, - associated with parental disharmony & use of drugs & alcohol,d) Other factors :- - personality & attitudes :- * break rules, truancy , * grow before time, sexual promiscuity, * miserable and anxious.

Etiology continue-:

Other factors continue:- - supply and easy availability * prescribed Benzodiazepine, * legal alcohol & tobacco, * illegal cocaine & hash. - occupation risk :- * those involved in manufacture and sale of alcohol, * company directors and commercial travelers, * services, * journalists , entertainers , doctors , nurses.

Problem of dependence :-

a) Physical :- = over dose death, = contamination e.g. AIDS, = tissue damage e.g. ulcerative (stomach, nasal), perforation , thrombosis , cancer,

= dietary deficiency.b) Psychological :-= intoxication accidents, poor function, = WDS. e.g. hallucinations & delusions.c) Social :- = harm to self and other, = family problems e.g. divorce, battered wives, = crimes , prostitution.

Alcohol related psychiatric illness-:

- Blackout : amnesia with high blood level,- Fits : with heavily alcohol dependent,- Delirium Tremens : 2-4 days of sudden cessation

delirium, tremor, hallucination, delusion, dehydration, low bp, seizure, coma, death.,

- Alcohol Hallucination : auditory, 3rd. Person, conscious.- Agoraphobia, depression, suicide, morbid jealousy, low

sexual drive, impotence, - Anemia (B12, folate ), Fetal Alcohol Syndrome ( poor

growth, impaired intellect, craniofacial, cardiovascular defects ),

Alcohol related psy. Illnesses continue-:

- Wernicke – Korsakoff`s Syndromes : - ( degenerative changes in upper brain stem, thalamus hypothalamus, mammillary bodies),

* Wernicke’s Encephalopathy = neuropathy, confusion, nystagmus, staggering gait.

* Korsakoff’s Psychoses = dementia, impaired recent memory, confabulation, perseveration.,

- Dementia : following prolonged heavy intake and persist at least 3 wks. After cessation of alcohol ingestion.,

- Brain damage :- studies showed excess cerebral atrophy among alcoholics.

Management & Treatment-:

# Assessment :- - full Hx. + family Hx. of abuse, - drug Hx. = type(s), rout, amount, effect, last use, cast, - physical examination = general health, needle tracks, - social (isolation), psychiatric (hallcin., delusion) & criminal

(theft, jail) Hx., - urine tests ( except for LSD ,& solvents ), - evidence of dependent , - withdrawal signs & symptoms , - legal requirements.

Manage.& treatment continue-:

a) Opiate -: Methadone = cross - tolerance= in decrease dose regime, b) Alcoholism:- Detoxification = - sedation : chlormethiazone, benzodiazepine, - nutritional ; balanced diet, - rehydration : correct electrolytes imbalance, - vitamin : hi – potency parentrovite or thiamine inj. - anticonvulsant : for fits, - antabuse : for longer term aims ( Disulfiram )

Management & treatment continue:

c) Amphetamine Psychoses = phenothiazine , usually psychoses fades after 5 – 7 days., d) Barbiturates = - inpatient care & close observation, - short acting barbiturates to control WDS. e.g. pentobarbitone 4 – 6 hourly, - after stabilization a very gradual redaction , 10% of total dose each day, - phenytoin – as anticonvulsant cover .

Prognosis & Abstinence-:

Predictors of good prognosis= ( older , social support , motivated , first treatment,

adequate intelligence , absence of antisocial personality traits.)Abstinence = - mature – out , mid 30’s, - relationship with non-addict, - dramatic change in context of addiction, - intensive support : Alcohol Anonymous (AA) , self-

helped group , good rehabilitation.