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 • “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 • What of the following causes pupillary dilation (mydriasis) • Cholinergics • Opiates • Organophosphates • Crystal met • Clonidine
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 • 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 • 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 3 • Based on the history above what is the most likely diagnosis? • Opiod abuse • Fibromyalgia • Dependent personality disorder • Opiod dependence • Addictive personality disorder
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 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 3 • What pharmacologic options are suitable for opiodtapering? • Buprenorphine • Naloxone • Methadone • Topamax • Depot injectable naltrexone
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 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 4 • What is the most likely substance abused? • Amphetamines • Cocaine • Speak K • PCP • LSD
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 5 • Which of the following is the most addictive method of abuse • Inhalation • Free basing • IV injection • Oral • Subcutaneous
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 • 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 • 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 • 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?
ECA Lifetime prevalenceRegier et al. JAMA 1990 Substance Abuse % w Psych illness, O.R. Alcohol 37%, 2.3 THC 50%, 3.8 Cocaine 76%, 11.3 Opiods 65%, 6.7 Psych illness and % w substance abuse SCZ 47% Affective 32% Anxiety 24% Antisocial 84%
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? • 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 Disorders • Substance Abuse > 1 at anytime over a 12 month period C continued use despite interpersonal problems O obligations, missed L legal problems, recurrent D dangerous related behaviour
Substance Dependence • > 3/7 at anytime over a 12 month period T Tolerance W Withdrawal I Increased amount than intended S Substance use despite symptoms (physical or psychological) T Time spent E Essential social occupational dysfxn D Desire 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? • Probability of becoming dependent when you have tried the substance at least once: • Tobacco 33% • Heroin 23% • Cocaine 17% • Alcohol 15% • Stimulants 11% • Anxiolytics 9% • Cannabis 9% • Analgesics 8% • Inhalants 4% Stahl’s Psychopharm
Specific Substances • Stimulants • Cocaine • Amphetamines • Caffeine • Nicotine • Sedatives • ETOH • Benzos • Barbiturates • Opiods • Heroin • Codeine • morphine • Others • Hallucinogens • LSD • Ecstasy • shrooms • PCP • Cannabinoids
Specific Substances • Alcohol • Benzos • Opiods • THC • Cocaine • Others • Amphetamines • Hallucinogens • PCP • Inhalents Physiological dependence with prolonged withdrawal sx Downers Uppers
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).
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?
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?
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
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.
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 • Naltrexone • NEJM 2008 • Small effect size, variable results in multi-centered trials
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 Dependence • Topiramate • JAMA Oct 2007
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 • 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