Ternopil State Medical University named I.Horbachevsky

1. Ternopil State Medical University named I.Horbachevsky Chair of neurology, psychiatry, narcology and medical psychology Prep. by Roksolana Hnatyuk M.D., Ph.D.

2. Alcoholism, NicotineAddiction, Cannabis Compound Abuse

3. Alcoholism • Alcoholism is the consumption of or preoccupation with alcoholic beverages to the extent that this behavior interferes with the alcoholic's normal personal, family, social, or work life. • The chronic alcohol consumption caused by alcoholism can result in psychological and physiological disorders. Alcoholism is one of the world's most costly drug use problems; with the exception of nicotine addiction, alcoholism is more costly to most countries than all other drug use problems combined.

5. While alcohol use is required to trigger alcoholism, the biological mechanism of alcoholism is uncertain. For most people, moderate alcohol consumption poses little danger of addiction. Other factors must exist for alcohol use to develop into alcoholism. These factors may include a person's social environment, emotional health and genetic predisposition. In addition, an alcoholic can develop multiple forms of addiction to alcohol simultaneously such as psychological, metabolic, and neurochemical. Each type of addiction must be treated individually for an alcoholic to fully recover.

6. What is alcoholism? • Alcoholism, also known as alcohol dependence, is a disease that includes the following four symptoms: • Craving--A strong need, or urge, to drink. • Loss of control--Not being able to stop drinking once drinking has begun. • Physical dependence--Withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety after stopping drinking. • Tolerance--The need to drink greater amounts of alcohol to get "high."

7. Epidemiology • Substance use disorders are the major public health problem facing many countries. In the United States today, more than 15 million Americans are estimated to suffer from alcoholism. "The most common substance of abuse/dependence in patients presenting for treatment is alcohol.” • In the United Kingdom, the number of 'dependent drinkers' was calculated as over 2.8 million in 2001.

8. In the US: These statistics are based on the US National Longitudinal Alcohol Epidemiologic Study. Alcoholism is prevalent in 20% of adult hospital inpatients. One in 6 patients in community-based primary care practices had problem drinking. The following apply to the US adult population: • Current drinkers - 44% • Former drinkers - 22% • Lifetime abstainers - 34% • Abuse and dependency in the past year - 7.5-9.5% • Lifetime prevalence - 13.5-23.5%

9. Four percent of the global burden of disease is attributable to alcohol. This figure rises to 7% in North America, Europe, Japan, and Australia and to 12% in Eastern Europe and Central Asia. Worldwide, alcohol is responsible for a percentage of a number of conditions, as follows: • Cirrhosis - 32% • Motor vehicle accidents - 20% • Mouth and oropharyngeal cancers - 19% • Esophageal cancer - 29% • Liver cancer - 25% • Breast cancer - 7% • Homicides - 24% • Suicides - 11% • Hemorrhagic stroke - 10%

10. Identification and diagnosis • Identification of alcoholism may be difficult because there is no detectable physiological difference between a person who drinks a lot and a person who can't control his or her drinking. Identification involves an objective assessment regarding the damage that imbibing alcohol does to the drinker's life compared to the subjective benefits the drinker perceives from consuming alcohol. While there are many cases where an alcoholic's life has been significantly and obviously damaged, there are still a large number of borderline cases that can be difficult to classify.

11. Genetic predisposition testing • At least one genetic test exists for an allele that is correlated to alcoholism and opiate addiction. Human dopamine receptor genes have a detectable variation referred to as the DRD2 TaqI polymorphism. Those who possess the A 1 allele (variation) of this polymorphism have a small but significant tendency towards addiction to opiates and endorphin releasing drugs like alcohol. Although this allele is slightly more common in alcoholics and opiate addicts, it is not by itself an adequate predictor of alcoholism.

12. Possible causes or contributors to alcohol-related psychosis include the following: • Chronic alcoholism • Thiamine deficiency (eg, diet, starvation, emesis, gastric tumor) • Alcohol-dependent withdrawal early-stage (8-24 h) or late-stage (36-72 h) (Monitor temperature at least every 4 h.) • Comorbid substance abuse (Therefore, do an extensive toxicology screen.) • Lack of psychosocial supports • Comorbid psychotic and mood disorders • Alcoholic idiosyncratic intoxication (pathological intoxication) • Impulse control disorder • Advanced age • Early onset of alcohol use

13. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria are required to make the diagnosis of alcohol dependence. The diagnosis requires 3 of the 8 criteria in the DSM-IV. The diagnosis of alcohol dependence relies more on the consequences of alcohol use and less on the amount of alcohol consumed. Thus, if one suspects alcohol problems from answers to screening questions, attempt to determine what consequences of alcohol abuse the patient has experienced. The following are diagnostic factors outlined by the DSM-IV: • Continued drinking despite physical or psychological consequences caused or exacerbated by alcohol • Neglect of other activities • Inordinate time spent drinking and recovering • Drinking more or over a longer period than intended • Inability to control drinking • Tolerance (defined as increased amounts needed for effect) • Withdrawal symptoms on cessation of alcohol • Drinking to relieve or avoid withdrawal symptoms

14. The following 5 reasons illustrate the importance of screening for alcohol and drug abuse: • Alcoholism is common and serious. • Failure to screen leads to misdiagnosis. Approximately 50-90% of alcohol problems are missed in the office. • Effective and simple screening tests are available. • Effective treatments are available, especially if the diagnosis is made early. • Early identification can prevent physical and psychosocial problems.

15. Physical: • The following are signs and symptoms of alcohol withdrawal: • Nausea and vomiting • Diaphoresis • Agitation and anxiety • Headache • Tremor • Seizures • Visual and auditory hallucinations: Many patients who are not disoriented, and who therefore do not have delirium tremens, have hallucinations.

16. The following are signs of delirium tremens (ie, alcohol withdrawal delirium): • Tachycardia and hypertension • Temperature elevation • Delirium

17. The following are signs of chronic alcoholism: • Gynecomastia • Spider angiomata • Dupuytren contractures (also may be congenital) • Testicular atrophy • Enlarged or shrunken liver • Enlarged spleen

18. Ataxia, ophthalmoplegia (usually lateral gaze palsy), and confusion indicate Wernicke encephalopathy. • Anterograde and retrograde amnesia, often with confabulation and preceded by Wernicke encephalopathy, indicates Korsakoff syndrome. • Asterixis and confusion suggest hepatic encephalopathy.

19. Causes: Patients commonly use a psychiatric disorder to deny alcohol abuse. Unless strong evidence indicates that the psychiatric disorder clearly precedes the alcoholism or is present during a long period of sobriety, the best plan is to proceed as if alcoholism is the primary diagnosis. Arrange a consultation with a psychiatrist for difficult cases because some patients who are treated for psychiatric conditions stop drinking and do very well.

20. Genetic psychiatric disorders, such as schizophrenia and bipolar disorder, are associated with alcoholism. The presence of both a serious, persistent mental illness and alcoholism is called dual diagnosis. The physician must address both. Family history commonly reveals members with bipolar disorder, alcoholism, or both. Despite this and despite an intensive search for a gene for alcoholism, study results remain inconclusive. Nevertheless, some evidence indicates that genetics plays a major role in alcohol abuse.

21. Treatment of alcoholism involves the following: • Brief physician advice makes a difference. • While a trial period of controlled drinking with careful follow-up might be appropriate for a diagnosis of alcohol abuse, this approach increases a physician's professional liability. Complete abstinence is the only treatment for alcohol dependence. Emphasize that the most common error is underestimating the amount of help that will be needed to stop drinking. The differential diagnosis between alcohol abuse and dependence can be a difficult judgment call. • Hospitalize patients if they have a history of delirium tremens or if they have significant comorbidity. Consider inpatient treatment if the patient has poor social support, significant psychiatric problems, or a history of relapse after treatment

22. Strongly recommend AA. • Encourage hospitalized patients to call AA from the hospital. AA will send someone to talk to them if the patient makes the contact. Patients need to attend meetings regularly (daily at first) and for a sufficient length of time (usually 2 y or more) because recovery is a difficult and lengthy process. • In the beginning of treatment, and perhaps ongoing, patients should remove alcohol from their homes and avoid bars and other establishments where strong pressures to drink may influence successful abstinence. • If the patient has an antisocial personality (ie, severe problems with family, peers, school, and police before age 15 y and before the onset of alcohol problems), recovery is less likely. If the patient has primary depression, anxiety disorder, or another potentially contributory disorder (The other disorder must antedate the problems with alcohol or it must be a significant problem during long periods of sobriety.), treat this primary problem aggressively.

24. Nicotine Addiction • Cigarette smoking is a major preventable cause of disease worldwide, and it is the major cause of premature death in North America. In 1912, Adler first suggested that inhalation of cigarette smoke might be a cause of lung cancer. Since then, knowledge about the adverse health effects of smoking has accumulated. • The important causes of mortality are atherosclerotic vascular disease, cancer, and chronic obstructive pulmonary disease (COPD). Smoking also can contribute to other diseases, eg, histiocytosis X, respiratory bronchiolitis, obstructive sleep apnea, idiopathic pneumothorax, low birth weight, and perinatal mortality.

25. Pathophysiology: Nicotine releases hormone noted in the following paragraphs that act on various receptors in the brain. Nicotine use results in more efficient processing of information and reduction of fatigue. In addition, nicotine has a sedative action, reduces anxiety, and induces euphoria. Nicotine effects are related to absolute blood levels and to the rate of increase in drug concentration at receptors. • Nicotine stimulates the hypothalamic-pituitary axis; this, in turn, stimulates the endocrine system. Continually increasing dose levels of nicotine are necessary to maintain the stimulating effects. With regards to dependence, some experts rank nicotine ahead of alcohol, cocaine, and heroin. A teenager who smokes as few as 4 cigarettes might develop a lifelong addiction to nicotine.

26. In the US: In 1965, 52% of men and 34% of women were cigarette smokers. Presently, the incidence of cigarette smoking has decreased to 28% and 24%, respectively. The incidence of smoking is highest in afro-americans, blue-collar workers, less-educated persons, and persons in the lower socioeconomic strata.

27. History: • Nicotine addiction is classified as nicotine use disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). The criteria for this diagnosis include any 3 of the following within a 1-year time span: • Tolerance to nicotine with decreased effect and increasing dose to obtain same effect • Withdrawal symptoms after cessation • Smoking more than usual • Persistent desire to smoke despite efforts to decrease intake • Extensive time spent smoking or purchasing tobacco • Postponing work, social, or recreational events in order to smoke • Continuing to smoke despite health hazards

28. Physical: • Physical effects of nicotine use include increased heart rate, accelerated blood pressure, and weight loss. • Physical effects of nicotine withdrawal and smoking cessation include weight gain due to increase in appetite, decreased heart rate, and improvement in the senses of taste and smell.

29. Opioid Abuse • Background: • Opioids are the most powerful known pain relievers. Their use and abuse date back to antiquity. The pain relieving and euphoric effects of opioids were known to Sumerians (4000 BC) and Egyptians (2000 BC). • International awareness of opioid abuse was stimulated early in the 20th century when President Theodore Roosevelt convened the Shanghai Opium Commission in 1909 to aid the Chinese empire in stamping out opioid addiction, especially opium smoking.

30. Cannabis Compound Abuse (marijuana) • Background: • The earliest references to marijuana include use by Chinese emperors in 1000 BC. In classical literature, Homer's Iliad records the gift of marijuana from Helen to Telemachus. • Marijuana was introduced to the Western Hemisphere in the early 1500s. African slaves brought marijuana plants with them to the Portuguese colony of Brazil, while the Spaniards began growing it in Chile. • Cannabis was introduced to the Virginia colony of Jamestown in 1611 and to the Massachusetts Bay Colony in 1629. Although primarily used as a source of fiber, cannabis occasionally was smoked. Cannabis began to be used medicinally and was grown by many American planters. By 1850, it was listed in the US Pharmacopoeia.

31. Frequency: In the US: Marijuana remains the most commonly used illicit drug in the United States. According to data from the 1998 National Household Survey on Drug Abuse (NHSDA), more than 72 million Americans (33%) aged 12 years and older have tried marijuana at least once in their lifetimes. Overall, rates of marijuana use appear to be increasing. Recent figures from the National Institute on Drug Abuse (NIDA, 1999) show that almost 50% of 12th-grade students have used marijuana.

32. The following symptoms may be prominent in acute intoxication of cannabis: • Euphoria • Relaxation • Subjective feelings of well-being or grandiosity • Perceptual changes (including visual distortions) • Drowsiness and sluggishness • Diminished coordination • Paradoxical hyperalertness • A subjective sense of slowing of the passage of time • Increased appetite (the "munchies")

33. Although commonly misperceived as universally resulting in a relaxed and euphoric state, cannabis intoxication can produce a dysphoric reaction. Carefully examine patients for evidence of suicidality and homicidality, document presence or absence thereof, and manage as indicated. • Feelings of panic • Disorientation and memory impairment (rare; usually occurs only after ingestion of high-potency cannabinoid preparations) • Paranoia • Mood lability • Altered perceptions (following heavy marijuana use) manifesting as illusions or frank hallucinations, most often visual in type • Depersonalization • Psychotic episodes • Dysphoria • Recurrence of psychosis in patients with schizophrenia

34. Physical: Physical signs and symptoms reflect the effects of marijuana on multiple organ systems and can be classified according to the system involved. • Effects on central and peripheral nervous systems: Cannabis-induced cerebral atrophy or neuropsychological impairment remains a controversial diagnosis. Chronic effects of long-term marijuana use may be related to marijuana's significant fat solubility resulting in high blood levels of the drug after extended use. Marijuana-induced seizures have been described. Studies using simulated driving and flying situations have shown that the use of cannabis has a profound effect on estimations of time and distance and causes impairment of attention and short-term memory. These effects are still discernible 24-48 hours after use of the drug.

35. Effects on respiratory system: Cannabis smoke contains carcinogens similar to those found in tobacco smoke, and chronic heavy marijuana use may predispose people to chronic obstructive lung disease. Some studies indicate that pulmonary neoplasms are more common among habitual marijuana users; however, confounding by cigarette smoking limits the interpretability of some of these reports.

36. Effects on cardiovascular system: Acute intoxication may induce tachycardia and orthostatic hypotension. • Effects on reproductive system: • Marijuana has been linked to infertility. In vitro studies have reported abnormal cell division and abnormal spermatogenesis resulting in decreased sperm counts; however, the effects of marijuana on human fertility remain unclear. In females, marijuana use may increase the number of anovulatory cycles. In males, marijuana use may cause a decrease in follicle-stimulating hormone, resulting in a decrease in testosterone production and, possibly, testicular atrophy. • Effects on gastrointestinal tract: Marijuana has known antinausea properties and the use of marijuana has been permitted for the treatment of nausea in some US states for this reason.

37. Causes: • Risk factors for use • Young age • Availability (may be affected by cultural and geographic factors, eg, urban environments) • Comorbid alcohol abuse and/or dependence • Comorbid drug abuse

38. Thank you for attention!