Substance use disorders
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Substance Use Disorders. REVIEW OF PSYCHIATRY. T. Lau, MD, FRCPC [psych], Director of Undergraduate Education Faculty of Medicine, Department of Psychiatry, UNIVERSITY OF OTTAWA. NOTEABLE QUOTABLES. “ It's easy to quit smoking. I've done it hundreds of times. ” Mark Twain, 1835-1910

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Substance use disorders

Substance Use Disorders

REVIEW OF PSYCHIATRY

T. Lau, MD, FRCPC [psych], Director of Undergraduate Education

Faculty of Medicine, Department of Psychiatry, UNIVERSITY OF OTTAWA


Noteable quotables

NOTEABLE QUOTABLES

  • “It's easy to quit smoking. I've done it hundreds of times.”

    Mark Twain, 1835-1910

  • “It provokes the desire but it takes away the performance.”

    William Shakespeare

  • “I'm not so think as you drunk I am.”

    John Squire


Pre test questions

Pre-Test Questions

  • What of the following causes pupillary dilation (mydriasis)

    • Cholinergics

    • Opiates

    • Organophosphates

    • Crystal met

    • Clonidine


Case 1

CASE 1

  • 35 year old man whose alcohol consumption started in his teens. For many years, he drank alcohol mostly on social occasions.

  • He is not sure what happened first but he began having problems with his wife and his work. It was during this time that his alcohol consumption increased.

  • Although he doesn’t drink everyday he often drives to work somewhat intoxicated and his coworkers have noticed that he has not been himself lately.

  • He has been having problems with intimacy with his wife and she had been wondering if it was related to alcohol he had been consuming more of.

  • What is the diagnosis?

  • What treatment options exist?


Case 2

CASE 2

  • 58 year old divorced man with alcohol problems who drinks everyday, needing an “eye opener” to get going in the morning and to avoid feeling shakey. He sometimes consumes more than 10 drinks at a time.

  • He has lost several jobs over the years and is estranged from his wife and 3 children largely because of his drinking and behaviour.

  • He has had a heart attack, has hypertension and is obese. He saw his family physician who tells him his bloodwork and MRI abdomen is consistent with cirrhosis.

  • What is the diagnosis?

  • What blood work would be consistent with this picture?

  • What treatment options would you offer?


Case 3

CASE 3

  • 38 year old female who lives with her husband and 3 year old daughter. She suffers from chronic pain following a MVA 2 years ago.

  • She was treated at that time with Percocet, however her GP “cut her off” after 6 months of medications and now will only prescribe her NSAIDs.

  • She works as a purchasing agent in the civil service but is getting in trouble at work for repeated work absences.

  • She is currently using 2x80 mg oxycontin which she gets from a friend who refers to them as “oxys”. She is paying $80 per day for these narcotics and can’t really afford to continue like this.


Case 31

CASE 3

  • Based on the history above what is the most likely diagnosis?

    • Opiod abuse

    • Fibromyalgia

    • Dependent personality disorder

    • Opiod dependence

    • Addictive personality disorder


Case 32

CASE 3

  • You ask her when her last “oxy” was and she states 2h ago. Which of the following are symptoms of opiod intoxication?

    • Hypotension

    • Miosis

    • Lacrimation

    • Respiratory depression

    • euphoria


Case 33

CASE 3

  • She states that when she doesn’t take the pills she feels sick. Which of the following are symptoms of opiod withdrawal.

    • Nausea or vomiting

    • Seizures

    • Myalgias

    • Yawning

    • Rhinorrhea


Case 34

CASE 3


Case 35

CASE 3

  • What pharmacologic options are suitable for opiodtapering?

    • Buprenorphine

    • Naloxone

    • Methadone

    • Topamax

    • Depot injectable naltrexone


Case 4

Case 4

  • The patient was a 20-year-old man who was brought to the hospital, trussed in ropes, by his four brothers. This was his seventh hospitalization in the last 2 years, each for similar behavior.

  • One of his brothers reported that he “became home crazy,” threw a chair through a window, tore a gas heater off the wall, and ran into the street. The family called the police, who apprehended him shortly thereafter as he stood, naked, directing traffic at a busy intersection.

  • He punched two of the officers and appeared to have no pain. He assaulted the arresting officers, escaped from them, and ran home screaming threats at his family. There, his brothers were able to subdue him.

  • One of his brothers also suggested that “he gets dusted every day.”


Case 41

Case 4

  • On admission, the patient was observed to be agitated, with his mood fluctuating between anger and fear. He had slurred speech and staggered when he walked. He had visible nystagmus, tachycardia, was hypertensive, and febrile. He was particularly sensitive to noise.

  • He remained extremely violent and disorganized for the first several days of his hospitalization, then began having longer and longer lucid intervals, still interspersed with sudden, unpredictable periods in which he displayed great suspiciousness, a fierce expression, slurred speech, and clenched fists.

  • After calming down, the patient denied ever having been violent or acting in an unusual way (“I’m a peaceable man”) and said he could not remember how he got to the hospital. DSM IV Case Manual.


Case 42

Case 4

  • What is the most likely substance abused?

    • Amphetamines

    • Cocaine

    • Speak K

    • PCP

    • LSD


Case 5

CASE 5

  • 38year old male advertising executive, who presents with a history of altered behaviour. His girlfriend who accompanied him describes that he has been behaving like Jeckyl and Hyde.

  • Lately she has been hearing a crackling sound when he is in the bathroom and strange smells that linger afterwards. He sometimes acts like he’s energized, outgoing, hypervigilant, talkative and becomes interpersonally sensitive.

  • These periods that last several hours are often followed by intense and unpleasant feelings of lassitude and depression with increased appetite generally requiring several days of recuperation. During this crash, he sleeps much more and often has nightmares and vivid dreams. He has also expressed feeling suicidal during these lows.

  • What is the most likely offending substance?


Case 51

CASE 5

  • Which of the following is the most addictive method of abuse

    • Inhalation

    • Free basing

    • IV injection

    • Oral

    • Subcutaneous


Case 6

CASE 6

  • 23 year old student who began using diet pills to stay awake to study. This helped him stay up for days at a time. He later found a friend of a friend who offered other pills that were more potent.

  • He called some of these pills: Black Beauties, Glass, Bikers Coffee, Chicken Feed, Shabu, Stove Top, Trash, Go-Fast, Yaba, and Yellow Bam.

  • After he took them orally and found that his wakefulness improved as did his energy level but his appetite went down. The next day however he would feel irritable, unhappy and paranoid.

  • Over time these runs of energy where followed by increasing paranoia, visual and auditory hallucinations, and out-of-control rages that can be coupled with extremely violent behavior.

  • What is the most likely substance?


Case 7

CASE 7

  • 17 year old female who was at a party. Her friends pressured her into trying some strange drug. Shortly after consuming them she started seeing radiant colors and she felt that some of the things she was looking at appeared to ripple or “breathe”. She described seeing colored patterns behind her closed eyelids. She also started describing a sense that time was stretching, repeating itself, or changing speed and stopping.

  • Her friends then described that she started to freak out and have “a bad trip”. She felt she was going insane and became intensely anxious, depressed, and suicidal. After a week the depressive symptoms subsided but she continued to periodically have “flashbacks of the same symptoms she had during her “bad trip”.

  • What is the most likely substance?


Case 8

CASE 8

  • 25 year old female university student who went to a party. Somebody slipped something in her drink and her personality changed. Although she had always been a chronic worrier she suddenly became more relaxed and euphoric.

  • She began touching people and described feeling very close to everyone stating that she had compassion for all of mankind and was willing to forgive everyone.

  • She went with some of her new friends to a club where loud electronic music was being played. Eventually she passed out from heat exhaustion.

  • Over the next few days she felt depressed, irritable, tired with a loss of appetite. She continued for awhile afterwards to feel a sense of closeness to others. She had problems sleeping as well with aches, pains and jaw tightness.

  • What is the drug that someone slipped her?


Case 9

CASE 9

  • 24 year old female medical student. Drinks 6 cups of starbucks each day. When she gets up in the morning she feels a bit shakey and needs coffee to think clearly. The coffee clears her head and calms her but at the same time wakens her up.

  • How much caffeine is in a Starbuck’s Verona or a Pepsi MAX?

  • Are you one of us that needs coffee everyday?


What is the connection between substance abuse and mental illness

What is the connection between substance abuse and mental illness?


Eca lifetime prevalence regier et al jama 1990

ECA Lifetime prevalenceRegier et al. JAMA 1990

Substance Abuse % w Psych illness, O.R.

Alcohol37%, 2.3

THC50%,3.8

Cocaine76%,11.3

Opiods65%, 6.7

Psych illness and % w substance abuse

SCZ47%

Affective32%

Anxiety 24%

Antisocial84%


Classification

classification

  • DSM IV

  • Substance use disorders

    • Abuse (COLD) & dependence (TWISTED)

  • Substance induced disorders

    • Intoxication & withdrawal

    • Mood / Anxiety / Psychotic / Sexual dysfxn / Sleep disorder / Delirium / Persisting dementia / amnestic disorder / Hallucinogen persisting perception disorder


What is the difference between abuse and dependence

What is the difference between abuse and dependence?

  • Which of the following is the most true?

    • Abuse is more harmful to the person

    • Dependence means physiological dependence

    • Clinically significant impairment or distress is part of dependence not abuse

    • Dependence is a more severe problem

    • Criteria for both can be met simultaneously


Substance use disorders1

Substance Use Disorders

  • Substance Abuse > 1 at anytime over a 12 month period

    Ccontinued use despite interpersonal problems

    Oobligations, missed

    Llegal problems, recurrent

    Ddangerous related behaviour


Substance dependence

Substance Dependence

  • > 3/7 at anytime over a 12 month period

    TTolerance

    WWithdrawal

    IIncreased amount than intended

    SSubstance use despite symptoms (physical or psychological)

    TTime spent

    EEssential social occupational dysfxn

    DDesire to cut down or unsuccessful attempts to Diminish

  • Epid

    • Generally M>F, low SES, unemployed, minority. THC most common illicit drug

    • ETOH, nicotine, caffeine common

    • Suicide risk inc 20x

  • Etiology

    • Bio- ML VTA-NA (reward pathway), LC (NA somatic sx). Family studies

    • Psy- dynamic fixation @ oral stage,

    • Soc- codependence, learned social behaviour, cues from environment trigger relapse

  • Comorbidity

    • Other substance M 76%, F 67%

    • ASPD, SP, MDD, Dysthymia

  • Treatment goals

    • Abstinence, physical/emotional wellbeing

  • Modifiers:

    • Early >1<12, partial remission = abuse, full no abuse/dependence. Full > 12 months

    • with and without physiological dependence


How addicting

How addicting?

  • Probability of becoming dependent when you have tried the substance at least once:

    • Tobacco33%

    • Heroin23%

    • Cocaine17%

    • Alcohol15%

    • Stimulants11%

    • Anxiolytics9%

    • Cannabis9%

    • Analgesics8%

    • Inhalants4%

Stahl’s Psychopharm


Specific substances

Specific Substances

  • Stimulants

    • Cocaine

    • Amphetamines

    • Caffeine

    • Nicotine

  • Sedatives

    • ETOH

    • Benzos

    • Barbiturates

    • Opiods

      • Heroin

      • Codeine

      • morphine

  • Others

    • Hallucinogens

      • LSD

      • Ecstasy

      • shrooms

    • PCP

    • Cannabinoids


Specific substances1

Specific Substances

  • Alcohol

  • Benzos

  • Opiods

  • THC

  • Cocaine

  • Others

    • Amphetamines

    • Hallucinogens

    • PCP

    • Inhalents

Physiological dependence with prolonged withdrawal sx

Downers

Uppers


Pleasure pathway

Pleasure pathway

  • Mesolimbic dopaminergic tract from the ventral tegmental area to the nucleus accumbens

  • VTA releases dopamine not only into the nucleus accumbens, but also into the septum, the amygdala, and the prefrontal cortex. The nucleus accumbens then activates the individual’s motor functions, while the prefrontal cortex focuses his or her attention.

  • Mesocortical/limbic median forebrain bundle MFB forms pleasure reward bundle whose activation leads to the repetition of the gratifying action to strengthen the associated pathways of the brain (Olds and Milner)

  • All drugs of abuse have either receptors directly on (eg mu opiods) or indirectly through interneurons (GABA).


Substance use disorders

CASE

  • 35 year old man who has been drinking since he was in his teens. He usually had alcohol on mostly social occasions. He began having problems with his wife and his work and his alcohol consumption increased. Although he doesn’t drink everyday he often drives to work somewhat intoxicated. He has been having problems with intimacy with his wife and she had been wondering if it was related to alcohol he had been consuming more of.

  • What is the diagnosis?


Substance use disorders

CASE

  • 58 year old divorced man with alcohol problems who drinks everyday, needing an “eye opener” to get going in the morning. He consumes more than 10 drinks at a time. He has lost several jobs and is estranged from his wife and 3 children largely because of his drinking and behaviour. He has had a heart attack, has hypertension and is obese. He saw his family physician who tells him his bloodwork and MRI abdomen is consistent with cirrhosis.

  • What is the diagnosis?

  • What blood work would be consistent with this picture?


Substance use disorders

ETOH

  • Low-Risk Drinker:

    • Men: 3-4/day max & 15/wk. max

    • Women: 2-3/day max & 10/wk. max

    • "1 drink"

    • = 12-oz beer

    • = 5-oz wine

    • = single mixed drink

  • Clues of problem drinking

    • Hypertension

    • Liver dysfunction

    • Sleep disorders

    • Sexual dysfunction

    • Depression

    • Blackouts

    • Trauma, falls, MVAs

    • Prescription drug abuse

    • Chronic abdominal pain

    • Tobacco use

    • Illicit drug use


Substance use disorders

ETOH


Substance use disorders

ETOH

  • Epid

    • 5% F, 10% M dependence. 10% F, 20% M abuse.

    • Inc ETOH w education (differs from illicit drugs)

    • Inc risk of ASPD, MDD (30-40%), anxiety: phobias&PD (25-50%), suicide 10-15%

  • Etiology

    • Bio-genetics: 3-4x inc risk & inc severe use w 1st degree relative. MZ 60%, MZ>DZ. Adoption studies support genetic link.

    • Psychol- neuro deficits Dec P300, EEG abn, fixated @ oral stage

    • Social- reward, social learning theory

  • Subtypes of dependency:

    • Type A late onset, dec childhood RF’s, few problems. B: early onset, severe dependency, strong FHx, poly, severe psychopathology, inc # stressors

  • Labs:

    • GGT sensitive, not specific. MCV (60%, F>M), TG, UA, AST/ALT also CHO-deficient transferrin. γ-glutamyltransferase

  • Sleep effects:

    • dec sleep latency, dec REM, dec stage 4, inc # of awakenings.


Substance use disorders

ETOH

  • Intoxication (GAS-IN)

    • Gait abnormality, attentional, stupor/coma (risk of asp pneum), slurred speech, incoordination, nystagmus. Also mood lability, dec judgement, inappropriate physical/sexual fxn

  • Withdrawal (PINT ASA)

    • Perceptual abn, insomnia, nausea, tremor, onset (hrs-days), facial flushing, agitation, seizures, anxiety (ANS hyperactivity: inc HR, HTN)

    • Shakes 6-12h, hallucinations 8-12, sz 12-24, DT’s >72h

    • Inc risk w malnutrition, physical illness, depression, fatigue

  • Short term Complications

    • Withdrawal, sz’s, blackouts, DT’s, psychotic sx, depression, suicide, coma / pneumonia

  • Long term Complications:

    • Medical: cirrhosis, CHAOS, malnutrition, ETOH persisting amnestic disorder (Wernicke’s-ataxia, confusion, nystagmus: Rx thiamine, Korsakoff’s: 20% irreversible anterograde amnesia due to thiamine deficiency in the mammilary bodies) / ETOHlic dementia.


Alcohol dependence

Alcohol Dependence

  • Naltrexone

    • NEJM 2008

    • Small effect size, variable results in multi-centered trials


Alcohol dependence tx ajp editorial june 2010

Alcohol dependence txAJP Editorial June 2010

  • Identification of at-risk drinkers:

    • Alcohol Use Disorders Identification Test (AUDIT) recommended by the National Institute on Alcohol Abuse and Alcoholism Clinicians Guid.

  • For at-risk drinkers, a more detailed history about the pattern of drinking, associated medical and psychiatric comorbidities, family history, and sufficient clinical information to make a DSM–IV diagnosis should be obtained.

  • In the case of the middle-aged man who has severe chronic alcohol dependence with regular and frequent heavy drinking and medical complications, a trial with topiramate (25–300 mg/day with a target dose of ≥100 mg/day) is recommended.

  • For the young adult man with early-onset drinking, antisocial behavior, binge drinking, and emerging alcohol dependence, low-dose ondansetron (4 μg/kg) or oral naltrexone, up to 100 mg/day, along with brief intervention is considered appropriate.

  • Finally, for an elderly, recently retired woman who feels gloomy and is drinking to alleviate her low mood, long-acting injectable naltrexone, 380 mg once a month for 4 months, is recommended along with brief intervention.


Alcohol dependence1

Alcohol Dependence

  • Topiramate

    • JAMA Oct 2007


Substance use disorders

Case

  • 23 year old student who began using diet pills to stay awake to study. This helped him stay up for days at a time. He later found a friend of a friend who offered other pills that were more potent. He called some of these pills: Black Beauties, Glass, Bikers Coffee, Chicken Feed, Shabu, Stove Top, Trash, Go-Fast, Yaba, and Yellow Bam.

  • After he took them orally and found that his wakefulness improved as did his energy level but his appetite went down. The next day however he would feel irritable, unhappy and paranoid.

  • Over time these runs of energy where followed by increasing paranoia, visual and auditory hallucinations, and out-of-control rages that can be coupled with extremely violent behavior.

  • What is the most likely substance?


Amphetamines

Amphetamines

  • AKA:

    • Speed, Meth, Ice, Crystal, Chalk, Crank, Tweak, Uppers, Black Beauties, Glass, Bikers Coffee, Methlies Quick, Poor Man's Cocaine, Chicken Feed, Shabu, Crystal Meth, Stove Top, Trash, Go-Fast, Yaba, and Yellow Bam

  • Intoxication like cocaine (24-48 h)

    • As a powerful stimulant, methamphetamine, even in small doses, can increase wakefulness and physical activity and decrease appetite. A brief, intense sensation, or rush, is reported by those who smoke or inject methamphetamine. Oral ingestion or snorting produces a long-lasting high instead of a rush, which reportedly can continue for as long as half a day.

  • Withdrawal (see cocaine-peak 2-4d-wk)

    • Less addictive than cocaine

    • no physical manifestations of a withdrawal syndrome

    • Other sx include depression, anxiety, fatigue, paranoia, aggression, and an intense craving for the drug.

  • Methamphetamine has toxic effects. In animals, damages nerve terminals in the dopamine-containing regions of the brain. High doses can elevate body temperature to dangerous, sometimes lethal, levels, as well as cause convulsions


Amphetamines1

Amphetamines

  • Chronic Use

    • Tolerance can develop. Abusers sometimes forego food and sleep in a form of binging known as a “run,” injecting as much as 1 gm q 2-3 hrs over several days until the user runs out of the drug or is too disorganized to continue.

    • Chronic abuse can lead to psychotic behavior, characterized by intense paranoia, visual and auditory hallucinations, and out-of-control rages that can be coupled with extremely violent behavior.

    • As much as 50 percent of the dopamine-producing cells in the brain can be damaged after prolonged exposure to relatively low levels of methamphetamine. Serotonin-containing nerve cells may be damaged even more extensively. Whether this toxicity is related to the psychosis is unknown

  • Psychotic syndrome

    • Similar (paranoia, perceptual abn) to SCZ except increased VHs, appropriate affect, hyperactivity, hypersexuality, confusion/incoherent but usually no thought disorder

    • Rx: haldol


Amphetamines2

Amphetamines

  • Psychopharmacology

    • D and L enantiomers have different effects. Direct and indirect sympathomimetics (mostly cause vesicular release of DA or NA).

  • Adverse effects

    • CVA, cardiac (MI, HTN), GI ischemic colitis, HIV/hepatitis

  • Designer amphetamines (which also have 5HT properties) inc use

  • Rx indications

    • ADHD, narcolepsy, depression +/- augmentation


Caffeine

Caffeine

  • Intoxication

    • >250 mg/d

    • Restlessness, nervousness, twitching, excitement, dec sleep, periods of inexhaustion, nausea, diuresis, tachy, arrhythmia, flushed face, rambling thoughts

    • At > 1g tinnitis, light flashes, >10g sz, resp failure

  • Withdrawal (not formally recognized DSM IV)

    • 50-75%, H/A, fatigue, anxiety, irritability, psychomotor retardation, N/V, craving. Onset 12-24h, peak 24-48h.

  • Epid: most widely used substance

  • Pharmacology

    • Methylxanthine

    • T ½ 3-10 h (peak 30-60 min)

    • Blocks adenosine R->CAMP

    • Theoxanthane and caffeine are adenosine antagonists.

    • Through adensine blockade, these substances activate DA in the nucleus accumbens and NA in the locus coeruleus.

  • Comorbidity

    • Sedative hypnotic abuse

  • Adverse effects

    • Cardiac arrhythmias, fibrocystic disease, ?birth defects, panic attacks


Substance use disorders

CASE

  • 38year old male advertising executive, who presents with a history of altered behaviour. His girlfriend who accompanied him describes that he has been behaving like Jeckyl and Hyde. Lately she has been hearing a crackling sound when he is in the bathroom and strange smells that linger afterwards. He sometimes acts like he’s energized, outgoing, hypervigilant, talkative and becomes interpersonally sensitive.

  • These periods that last several hours are often followed by intense and unpleasant feelings of lassitude and depression with increased appetite generally requiring several days of recuperation. During that time he sleeps much more and often has nightmares and vivid dreams. Sometimes he also feels like committing suicide during these lows.

  • What is the most likely diagnosis?


Cocaine

Cocaine

  • AKA

    • Blow, nose candy, snowball, tornado, wicky stick, Perico, crack

  • Epidemiology

    • M=F

  • Forms:

    • Powdered, HCl salt form of cocaine can be snorted or dissolved in water and injected. Crack (free base) is cocaine that has not been neutralized by an acid to make the hydrochloride salt. This form of cocaine comes in a rock crystal that can be heated and its vapors smoked. The term “crack” refers to the crackling sound heard when it is heated

  • Concomitant use of other drugs

    • The combination of cocaine with alcohol (some studies report up to 70% of cocaine consumers) produces cocaethylene (ethylbenzoylecgonine), which has more potent proconvulsant and cardiotoxic properties than cocaine itself, coupled with a longer half-life. Heroin is also commonly used with cocaine as a "speedball" in an effort to combine a cocaine high (initial phase) with a heroin high (latter phase) of intoxication. Furthermore, nicotine dependence is reported in up to 88% of patients who use cocaine, thus adding to cocaine cardiovascular risk factors.


Cocaine1

Cocaine

  • Comorbidity

    • Mood, ASPD, Anxiety d/o, BAD-II, cyclothymia, ?ADHD

  • Psychopharm

    • Blocks DA reuptake, T ½ 30-60 min

    • Urine screen – lasts 10 days

  • Tolerance

    • Physiologic and psychologic tolerance to cocaine emerges between the first and second dose. In other words, the psychologic high and the physiologic body response (eg, pulse, blood pressure) do not increase with additional doses of cocaine once the initial effect is reached.

  • Treatment

    • B- abstinence (alone, OP, assisted, residential, DP, inpatient), consider beta blocker, clonidine, NDRI, or Nefazadone for withdrawal sx. Tx underlying psych comorbidity

    • P- supportive, CBT, relapse prevention

    • S- family therapy, psychoeducation, vocation, residential support


Cocaine2

Cocaine

  • Intoxication (MAGIC)

    • Maladaptive behavioral or psychological changes + 2 of

    • ANS: dilated pupils, sweating, chills, HR inc/dec, HTN

    • GI: N/V

    • Inc muscle weakness, resp depression

    • Cardiac: chest pain, arrhythmia

    • CNS: psychomotor change, confusion, sz, dystonia, dyskinesia

  • Withdrawal (FASTD)

    • Fatigue

    • Appetite change

    • Sleep change

    • Too fast/slow :[psychomotor changes]

    • Dysphoric mood, Dreams


Cocaine3

Cocaine

  • Adverse effects

    • Non-hemorrhagic CVA, TIA, MI, arrhythmia, cardiomyopathy, Sz 3-8%, inc risk w preexisting sz d/o (the chicken). IVDU: HIV/HCV, HBV

  • Acute cocaine abstinence syndrome:

    • depression, irritability, lethargy, amotivation, hypersomnolence, confusion, and drug craving


Cocaine4

Cocaine

  • Hyperthermia:

    • Temperatures as high as 114°F . Rapid cooling important through conduction and evaporation. Benzodiazepines may be used generously in order to control psychomotor agitation and shivering.

  • Psychomotor agitation:

    • Benzodiazepines, such as diazepam and lorazepam until sedated. Avoid physical restraints in patients with psychomotor agitation because they may interfere with heat dissipation. Likewise, avoid neuroleptic agents because they interfere with heat dissipation and, perhaps, lower the seizure threshold.


Cocaine5

Cocaine

  • Convulsions:

    • Aggressively treat recurrent seizures because they may worsen hyperthermia, rhabdomyolysis, hypoxia, and acidosis. Seizures may also be a manifestation of an acute intracerebral complication. Imaging studies and, when indicated, cerebrospinal fluid (CSF) analysis should follow immediate seizure control.

    • Phenytoin may be ineffective in this circumstance and may be part of the street additives to cocaine bulk. Incremental doses of benzodiazepines, such as diazepam (0.1-0.3 mg/kg, intravenously) and lorazepam, are the preferred but if ineffective barbiturates anesthesia with ventilatory support and neuromuscular blockade should be considered.


Cocaine6

Cocaine

  • Hypertension:

    • due to alpha-mediated vasoconstriction, secondary to norepinephrine from CNS.

    • Commonly responds to benzodiazepines.

    • Vasodilators, such as nitroprusside and nitroglycerin, are effective.

    • If a contraindication to nitrate therapy exists, alpha-blockers, such as phentolamine, which block the vasomotor effect of norepinephrine, may be used.

    • Beta-blockers are best avoided in the setting of cocaine toxicity because they may result in unopposed alpha effects of cocaine. Beta-blockers have been reported to increase the blood pressure, reduce coronary blood flow, reduce left ventricular function, accentuate vasoconstriction and reduce the cardiac output and tissue perfusion in patients with cocaine toxicity


Substance use disorders

Case

  • 38 year old female who lives with her husband and 3 year old daughter. She suffers from chronic pain following a MVA 2 years ago. She was treated at that time with Percocet, however her GP “cut her off” after 6 months of medications and now will only prescribe her NSAIDs.

  • She works as a purchasing agent in the civil service but is getting in trouble at work for repeated work absences.

  • She is currently using 2x80 mg oxycontin which she gets from a friend who refers to them as “oxies”. She is paying $80 per day for these narcotics and can’t really afford to continue like this.


Substance use disorders

Case

  • Based on the history above what is the most likely diagnosis?

    • Opiod abuse

    • Fibromyalgia

    • Dependent personality disorder

    • Addictive personality

    • Opiod dependence


Substance use disorders

Case

  • You ask her when her last “oxy” was and she states 2h ago. Which of the following are symptoms of opiod intoxication?

    • Hypotension

    • Miosis

    • Lacrimation

    • Respiratory depression

    • euphoria


Substance use disorders

CASE

  • She states that when she doesn’t take the pills she feels sick. Which of the following are symptoms of opiod withdrawal.

    • Nausea or vomiting

    • Seizures

    • Myalgias

    • Yawning

    • Rhinorrhea


Substance use disorders

CASE

  • What pharmacologic options are available for opiodtapering?

    • Buprenorphine

    • Naloxone

    • Methadone

    • Topamax

    • Depot injectable naltrexone


Heroin

Heroin

  • AKA

    • Smack, thunder, hell dust, big H, nose drops

  • Most abused and the most rapidly acting of the opiates.

  • Forms

    • Processed from morphine, a naturally occurring substance extracted from the seed pod of certain varieties of poppy plants. Sold as a white or brownish powder or as the black sticky substance known on the streets as “black tar heroin.”

    • Although purer heroin is becoming more common, most street heroin is “cut” with other drugs or with substances such as sugar, starch, powdered milk, or quinine. Street heroin can also be cut with strychnine, fentanyl or other poisons.

  • Patterns of use

    • Heroin can be injected, smoked, or sniffed/snorted. Injection is the most efficient way to administer low-purity heroin. The availability of high-purity heroin, however, and the fear of infection by sharing needles has made snorting and smoking the drug more common.

  • Dangers

    • Because heroin abusers do not know the actual strength of the drug or its true contents, they are at risk of overdose or death.

    • Heroin also poses special problems because of the transmission of HIV and other diseases that can occur from sharing needles or other injection equipment.


Hallucinogens

hallucinogens

  • The general group of pharmacological agents can be divided into three broad categories:

    • Psychedelics,

    • Dissociatives,

    • Deliriants.

  • These classes of psychoactive drugs have in common that they can cause subjective changes in perception, thought, emotion and consciousness.

  • The term "hallucinogen" is a misnomer because these drugs do not cause hallucinations at typical doses. Alters normal perceptions; therefore are more illusions.

  • Deliriants, such as diphenhydramine and atropine, may cause hallucinations in the proper sense.


Hallucinogens psychedelic

Hallucinogens: PSYCHEDELIC

  • Perception altering. The term "psychedelic" is used interchangeably with "psychotomimetic" and "hallucinogen"

  • The word psychedelic was coined to express the idea of a drug that makes manifest a hidden but real aspect of the mind.

  • It is commonly applied to any drug with perception-altering effects such as LSD, psilocybin, DMT, 2C-B, mescaline and DOB as well as a panoply of other tryptamines, phenethylamines and yet more exotic chemicals.

  • It can refer to a large number of drugs such as classical hallucinogens (LSD, psilocybin, mescaline, etc.), entactogens (e.g. MDMA), cannabinoids and dissociative drugs (e.g. ketamine). The classical hallucinogens are considered to be the representative psychedelics and LSD is generally considered the prototypical psychedelic.


Hallucinogens dissociative

Hallucinogens: dissociative

  • Dissociative drugs produce analgesia, amnesia and catalepsy at anesthetic doses.

  • They also produce a sense of detachment from the surrounding environment, hence "the state has been designated as dissociative anesthesia since the patient truly seems disassociated from his environment.”

  • Dissociative symptoms include the disruption or compartmentalization of "...the usually integrated functions of consciousness, memory, identity or perception.”

  • Dissociation of sensory input can cause derealization, the perception of the outside world as being dream-like or unreal. Other dissociative experiences include depersonalization (eg. not recognizing yourself in a mirror)


Hallucinogens dissociative1

Hallucinogens: dissociative

  • The primary dissociatives are similar in action to PCP (angel dust) and include ketamine (an anaesthetic) and DXM (dextromethorphan, though evidence suggests that its metabolite dextrorphan DXO, is mostly responsible for its PCP-like effects.

  • Also included are nitrous oxide, muscimol, and from the Amanita muscaria (fly agaric) mushroom.

  • Also, dissociation is remarkably administered by Salvinorin A's potent κ-Opioid receptor agonism


Hallucinogens deliriants

Hallucinogens: deliriants

  • The deliriants (or anticholinergics) are a special class of dissociative which are antagonists for the acetylcholine receptors (unlike muscarine and nicotine which are agonists of these receptors). Deliriants are sometimes called true hallucinogens, because they do cause hallucinations in the proper sense.

  • While dissociatives can produce effects similar to lucid dreaming (during which one is consciously aware of dreaming), the deliriants have effects akin to sleepwalking (during which one does not remember the experience).


Hallucinogens deliriants1

Hallucinogens: deliriants

  • Included in this group are such plants as deadly nightshade, mandrake, henbane and datura, as well as a number of pharmaceutical drugs, when taken in very high doses, such as the first-generation antihistamines diphenhydramine (Benadryl), its close relative dimenhydrinate (Dramamine or Gravol) and hydroxyzine, to name a few.


Hallucinogens other classifications

HallucinogensOther classifications

  • Psychedelics (5-HT2A receptor agonists)

    • Tryptamines

      • Lysergamides

    • Phenethylamines

      • Amphetamines

    • Piperazines

  • Cannabinoids (CB-1 receptor agonists)

  • Dissociatives

    • NMDA receptor antagonists

    • κ-Opioid receptor agonists

  • Deliriants (anticholinergics)


Hallucinogens1

Hallucinogens

  • Chemical Classification

    • Ergots:LSD

    • Phenylakylamines(amphetamine derivatives):

      • Mescaline (Peyote Cactus), MMDA (nutmeg/mace), TMA, MDA, STP, MDMA (ecstasy)

    • Indole alkaloids (serotonin activity):

      • Psilocybin (magic mushrooms)

      • DMT (cohaba snuff) (IV)

      • Befotenine (skins of toads)

    • Anticholinergic drugs

      • Hyoscyamine, atropine, scopolamine, gravol

LSD


Hallucinogens2

Hallucinogens

  • Intoxication

    • Behavioural or psychological change: depression / anxiety / ideas of reference, paranoia, impaired judgement

    • Perceptual changes ( intensification, depersonalization, derealization, illusions, hallucinations, synthesthesias)

    • Associated physical si/sx (PTSD)

      • Pupillary dilation/ Blurred vision

      • Tremor, Tachycardia

      • Sweating (hyperthermia)

      • Dizziness/in-coordination

    • Death by hyperthermia, HTN

  • Tolerance develops/reverses quickly

  • Hallucinogen Persisting Perceptual Disorder

    • Flashbacks

    • prev 15-80%, can be after single use. DDx: migraine, PTSD, sz’s, visual changes


Hallucinogens3

Hallucinogens

Ecstacy

  • Patterns of use

    • Limited to a few times per week to prevent tolerance (also cross tolerance)

  • Pharmacology

    • Post synaptic 5 HT-2 receptor antagonists

    • Rapid tolerance to euphoria and psychedelic effects but not to autonomic effects (mydriasis, hyperreflexia, HTN, pyrexia, piloerection, tachycardia)

    • Many have long half life/duration of action

      • MDMArapid onset, peak 30 min, lasts 4-6h

      • LSD onset minutes, peaks 2-4 h, lasts 12-14 hrs

  • Adverse effects

    • “bad trips” usually panic attacks/flashbacks

    • Hangover effects w MDMA (insomnia, fatigue, drowsiness, sore jaw muscles, loss of balance, H/A’s)

    • Dangerous behavioural reactions

      • Jumping out of windows due to lack of insight while intoxicated

    • MDMA causes hyperthermia, which is exacerbated by such excessive activity as wildly dancing in a crowded, hot room (ie. RAVE). Deaths reported. MDMA causes damage to serotonergic neurons.

    • MDMA (less disorientation and perceptual distortion cf LSD) but more a sense of closeness, personal comfort and increased luminescence of objects


Substance use disorders

Case

  • The patient was a 20-year-old man who was brought to the hospital, trussed in ropes, by his four brothers. This was his seventh hospitalization in the last 2 years, each for similar behavior.

  • One of his brothers reported that he “became home crazy,” threw a chair through a window, tore a gas heater off the wall, and ran into the street. The family called the police, who apprehended him shortly thereafter as he stood, naked, directing traffic at a busy intersection. He punched two of the officers and appeared to have no pain. He assaulted the arresting officers, escaped from them, and ran home screaming threats at his family. There, his brothers were able to subdue him.

  • One of his brother reported that thought “he gets dusted every day.”


Substance use disorders

Case

  • On admission, the patient was observed to be agitated, with his mood fluctuating between anger and fear. He had slurred speech and staggered when he walked.

  • He remained extremely violent and disorganized for the first several days of his hospitalization, then began having longer and longer lucid intervals, still interspersed with sudden, unpredictable periods in which he displayed great suspiciousness, a fierce expression, slurred speech, and clenched fists.

  • After calming down, the patient denied ever having been violent or acting in an unusual way (“I’m a peaceable man”) and said he could not remember how he got to the hospital. DSM IV Case Manual.


Substance use disorders

Case

  • What is the most likely substance abused?

    • Amphetamines

    • Cocaine

    • Speak K

    • PCP

    • LSD


Pcp angel dust

PCP (angel dust)

  • Intoxication PCP-Hardens

    • P Psych/Beh changes: belligerent/assaultive, unpredicatable, agitated

    • C coma/sz

    • P pain sensitivity dec

    • H hyperacusis

    • A ataxia

    • R rigidity

    • D dysarthia

    • E elevated BP/HR

    • N nystagmus

    • S S-GMC other d/o exclusion

  • Psychopharm

    • Blocks NMDA-R of glutamate, activates DA via VTA-NA

    • Tolerance but no withdrawal

  • Delirium in 25% (in DDx for NMS but usually no fever)

  • Urine x 1 wk

  • Adverse effects

    • Hyperthermia (looks like NMS), rhabdo, CK

  • Tx:

    • BDZ+/- haldol (not talking down), supportive monitor VS, dec sensory stimulation.


Phencyclidine dependence dsm iv p 307

Phencyclidine Dependencedsm iv p 307

  • Some of the generic criteria for Substance Dependence do not apply to phencyclidine. Although "craving" has been reported by individuals with heavy use, neither tolerance nor withdrawal symptoms have been clearly demonstrated in humans (although both have been shown to occur in animal studies).

  • Phencyclidine is usually not difficult to obtain, and individuals with Phencyclidine Dependence often use it at least two to three times per day, thus spending a significant proportion of their time using the substance and experiencing its effects. Phencyclidine use may continue despite the presence of psychological problems (e.g., disinhibition, anxiety, rage, aggression, panic, flashbacks) or medical problems (e.g., hyperthermia, hypertension, seizures) that the individual knows are caused by the substance. Individuals with Phencycldine Dependence can manifest dangerous behavioral reactions due to lack of insight and judgment while intoxicated.

  • Aggressive behavior involving fighting-probably the result of disorganized thinking, agitation, and impaired judgment has been identified as an especially problematic adverse effect of phencyclidine. As with hallucinogens, adverse reactions to phencyclidine may be more common among individuals with preexisting mental disorders.


Cannabis

Cannabis


Cannabis1

cannabis

  • Cannabis, from the Indian hemp plant Cannabis sativa, is a hardy, aromatic annual herb. The cannabis plant has been used in China, India and the Middle East for approximately 8,000 years for its fiber and as a medicinal agent. It is the most commonly used illicit drug in the United States and, by most estimates, around the world as well.

  • All parts of Cannabis sativa contain psychoactive cannabinoids, of which delta9-tetrahydrocannabinol (delta-9-THC) is most abundant. At least 66 other cannabinoids are also present in cannabis, including cannabidiol (CBD), cannabinol (CBN) and tetrahydrocannabivarin (THCV) among many others, which are believed to result in different effects than those of THC alone

  • The most potent forms of cannabis come from the flowering tops of the plants or from the dried, black-brown, resinous exudate from the leaves, which is referred to as hashish or hash.

  • The cannabis plant is usually cut, dried, chopped, and rolled into cigarettes (commonly called “joints”), which are then smoked.


Cannabis2

cannabis

  • Common names

    • marijuana, grass, pot, weed, tea, and Mary Jane. Other names, which describe cannabis types of various strengths, are hemp, chasra, bhang, ganja, dagga, and sinsemilla. The potency of marijuana preparations has increased in recent years because of improved agricultural techniques used in cultivation so that plants may contain up to 15 or 20 percent THC.

  • Prevalence and Recent Trends

    • Based on the 2003 National Surveys on Drug Use and Health (NSDUH), an estimated 90.8 million adults (42.9 percent) aged 18 years or older had used marijuana at least once in their lifetime. Among this group, about 2 percent used the drug before age 12, about 53 percent between 12 and 17 and about 45 percent after age 18.

    • According to the text revision of the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), there is a 5 percent lifetime rate of cannabis abuse or dependence, but that figure may be too low according to NSDUH surveys.


Miscellaneous notes on substance use disorders

Miscellaneous Notes on Substance use disorders

  • Death by hyperthermia with MDMA

  • Inhalants a common cause of cognitive impairment

  • PCP commonly presents with catatonia

  • No withdrawal w PCP according to the DSM IV


Reasons to suspect an underlying psychiatric disorder

Reasons to suspect an underlying psychiatric disorder…

  • Sx precede use of substance

  • Sx persist after discontinuation (eg. One month)

  • Sx out of proportion or unusual for offending substance

  • Cross sectional, longitudinal, epidemiology, FHx and past tx responsiveness suggest a specific axis 1 pathology


Treatment

Treatment

  • 2 approaches

    • Abstinence

    • Harm reduction

  • Treatment settings

    • Outpatient

    • Residential tx programs

  • Psychotherapy


Substance use disorders

WHO 2006


Treatment1

Treatment

  • Motivational Interviewing

  • Cognitive Behavioural Therapy

  • Social Skills Training

  • Contingency Management

  • Pharmacological therapy - A number of medications have been approved for the treatment of substance abuse. These include replacement therapies such as buprenorphine and methadone as well as antagonist medications like disulfiram and naltrexone in either short acting, or the newer long acting form (under the brand name Vivitrol).

  • Several other medications, often ones originally used in other contexts, have also been shown to be effective including bupropion (Zyban or Wellbutrin), Modafinil (Provigil) and more.


Change theory

Change theory

Prochaska & DiClemente

STAGES OF CHANGE

Precontemplation

Contemplation

Preparation

Action

Maintenance


Psychotherapy

Psychotherapy

  • Motivational Interviewing

    • Focuses on the present interests, concerns and perspectives of the individual

    • Focuses on the resolution of ambivalence

    • Elicits and selectively reinforces change talk

    • Is a method of communicating rather than a set of techniques

    • It is fundamentally a way of being with and for people- “facilitative approach to communication that evokes natural change”.

    • Illicits the persons intrinsic motivation for change.


Motivational interviewing

Motivational interviewing

  • Four General Principles

    • Express Empathy

      • Acceptance facilitates change

    • Develop Discrepancy

      • Between behaviour and personal goals

    • Roll with resistance

      • Patient primary resource for solutions

      • Signal to respond differently

    • Support self-efficacy

      • Patient responsible for choosing and carrying out change


Cbt for substance

CBT for substance

  • Cognitive Behavior Therapy for substance has two main components: functional analysis and skills training.

  • Functional Analysis: Working together, the therapist and the patient try to identify the thoughts, feelings and circumstances of the patient before and after they drank or used drugs. This helps the patient determine the risks that are likely to lead to a relapse.

  • Functional analysis can also give the person insight into why they drink or use drugs in the first place and identify situations in which the person has coping difficulties.

  • Skills Training: If someone is at the point where they need professional treatment for their alcohol or drug dependence, chances are they are using alcohol or drugs as their main means of coping with their problems. The goal of cognitive behavior therapy is to get the person to learn or relearn better coping skills.


Substance use disorders

WHO 2006


Substance use disorders

WHO 2006


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