ABDULLAH AL-SUBAIE, MBBS, FRCP ( C) PROFESSOR OF PSYCHIATRY

1. ABDULLAH AL-SUBAIE, MBBS, FRCP(C) PROFESSOR OF PSYCHIATRY Substance use/ Prof. Subaie

2. TYPES OF ABUSED SUBSTANCES • Anxiolytics and hypnotics • Opioids • Stimulants • Hallucinogens • Cannabis • Organic solvents Substance use/ Prof. Subaie

3. Prevalence: Substance use/ Prof. Subaie

4. Prevalence: Substance use/ Prof. Subaie

5. DSM-IV Criteria for Substance Intoxication • The development of a reversible substance-specific syndrome due to recent use of a substance. Different substances may produce similar or identical syndromes. • Clinically significant maladaptive behavioral or psychological changes that aredue to the effect of the substance on the central nervous system(eg, belligerence, mood lability, cognitive impairment, impaired judgment, impaired social or occupational functioning) and develop during or shortly after use of the substance. • The symptoms arenot due to a general medical condition and are not better accounted for by another mental disorder. Substance use/ Prof. Subaie

6. DSM-IV Criteria for Substance Withdrawal • The development of a substance-specific syndromedue to the cessation of (or reduction in) substance use that has been heavy and prolonged. • The substance-specific syndrome causes clinically significant distress or impairmentin social, occupational, or other important areas of functioning. • The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder. Substance use/ Prof. Subaie

7. DSM-IV Diagnostic Criteria for Substance Dependence - 1 • Maladaptive pattern of substance use,leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: • Tolerance, as defined by either of the following: (a) a need for markedly increased amountsof the substance to achieve intoxication or desired effect (b) markedly diminished effectwith continued use of the same amount of the substance • Withdrawal, as manifested by either of the following: (a) the characteristic withdrawal syndrome for the substance (refer to criteria ofwithdrawalof the specific substance) (b) the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms. Substance use/ Prof. Subaie

8. DSM-IV Diagnostic Criteria for Substance Dependence - 2 (3) the substance is often taken in larger amountsor over a longer periodthan was intended (4) there is a persistent desireorunsuccessful efforts to cut down or controlsubstance use (5) a great deal of timeis spent in activities necessary to obtainthe substance (eg, visiting multiple doctors or driving long distances), usethe substance (eg, chain-smoking), or recoverfrom its effects (6) important social, occupational, or recreational activities are given up or reducedbecause of substance use (7) the substance use is continueddespite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (eg, current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption) Substance use/ Prof. Subaie

9. DSM-IV Diagnostic Criteria for Substance Dependence - 3 Specify if: with physiological dependence: evidence of tolerance or withdrawal (i.e, either item 1 or 2 is present) without physiological dependence: no evidence of tolerance or withdrawal (i.e, neither item 1 nor 2 is present) Substance use/ Prof. Subaie

10. WHEN TO SUSPECT SUBSTANCE ABUSE / DEPENDENCE ? 1 • When medical or psychiatric problems may be related to alcohol or drugs. • If patient requests certain drugs for unsatisfactory reasons. • When needle tracks and thrombotic veins are found. • Finding scars of previous abscesses. • When forearms are concealed. Substance use/ Prof. Subaie

11. WHEN TO SUSPECT UBSTANCE ABUSE / DEPENDENCE ? 2 • In cases of self neglect, and school or occupational decline. • In history of former friends loss and joining the “drug culture.” • In history of thefts and prostitution. • When urine tests positive (except LSD and solvents). • When Gamma–Glutmyle–transferase (GGT) and MCV are elevated. Substance use/ Prof. Subaie

12. PREVALENCE ISSUES - 1 Availability: • Prescribed e.g. Benzodiazepines • Legal e.g. alcohol & nicotine • Illegal e.g. cocaine, hash Substance use/ Prof. Subaie

13. PREVALENCE ISSUES - 2 Personal characteristics: • Difficulty accepting authority, truancy and poor schooling in teenagers. • Disorganized families. • Unhappy childhood. • History of mental illness or personality disorder in family. • Personality disorder, disorganized life & unstable relationships. • Sexual promiscuity. Substance use/ Prof. Subaie

14. PREVALENCE ISSUES - 3 • Social Pressures: - especially in teenagers & school children. - unemployment. • Primary effect of the substance • Secondary effect of the substance (milieu). Substance use/ Prof. Subaie

15. MANGEMENT OUTLINES - 1 • Review history with the patient regarding: • Type of drug (s) and amount • I.V. usage and its dangers • Evidence of dependence • Complications of drugs (physical, psychological and social). • Personal and social resources and problems Substance use/ Prof. Subaie

16. MANGEMENT OUTLINES - 2 • Manage withdrawal symptoms • Treat urgent medical and psychiatric complications • Set attainable goals: • Abstaining from drug • Parting from drug culture • Dealing with personal and financial problems • Establishing new interests Substance use/ Prof. Subaie

17. MANGEMENT OUTLINES - 3 5. Set longer-term goals: • Individual or group counseling • Help for family • Rehabilitation 6. Self-help groups Substance use/ Prof. Subaie

18. PREVENTION Preventive measures Improved education Of availability Increased restrictions Ofadvertising Substance use/ Prof. Subaie

19. COMPLICATIONS • General medical complications e.g. AIDS, endocarditis • Local effects of I.V. injections e.g. thrombosis. • Frequent intoxication leading to poor functioning, failure of social relations, accidents, family problems and neglect. • Debts due to expensive illicit drugs leading to prostitution and crime. • Death. Substance use/ Prof. Subaie

20. ALCOHOL ABUSE / DEPENDENCE QUICK ASSESSMENT: • Cut down • Annoyed • Guilty • Eye opener Substance use/ Prof. Subaie

21. ALCOHOL ABUSE / DEPENDENCE 1 unit= 8 gm or 1 centiliter PREVALENCE: • In England, 6% of men & 1% of women admitted to consumption of >50 units/week. • Lifetime prevalence rate was 0.45% among Chinese in Shanghai & 23% among Native Mexican-Americans • Dependence is usually established in mid-forties for men and a few years later for women. • Dependence is also increasing in teenagers and women. • Dependence is generally more common in disadvantaged areas. • Age, sex: Young males but rate in females is rising. • Occupation: Executives, service men, journalists, Salesmen and movie industry. Substance use/ Prof. Subaie

22. ALCOHOL ABUSE / DEPENDENCE Stress leads to anxiety that is relieved by alcohol PERSONALITY TRAITS: • Self-indulgence • Anxiety • Painful reality is denied and pleasure is obtained by immediate oral gratification (drinking) • “Alcoholism is a conditioned behavioral response” • “Alcoholism is a series of transactions designed to obtain personal advantage or hide deficiencies” Substance use/ Prof. Subaie

23. ALCOHOL ABUSE / DEPENDENCE PHYSICAL COMPLICATIONS SUCH AS: • G.I.T.: Gastritis and peptic ulcer, esophageal varices, acute and Chronic pancreatitis, hepatitis and cirrhosis. • C.N.S.: Peripheral neuropathy, dementia, epilepsy. • Others: Anemia, episodes of hypoglycemia, obesity, Cardiomyopathy, Myopathy • Alcohol fetal syndrome: Facial abnormalities, low birth weight, low intelligence and over activity. Substance use/ Prof. Subaie

24. ALCOHOL ABUSE / DEPENDENCE NEUROPSYCHIATRIC COMPLICATIONS: • INTOXICATION STATES: • Blackouts: amnesia to events that occur during the period of intoxication. • Idiosyncratic intoxication: markedly changed behavior (usually aggressive) occurring within minutes of drinking a small amount of alcohol. • Other effects: • Mood: euphoria/dysphoria, irritability • Cognition: sedation, memory & judgment impairment • Behavior: disinhibition, aggression, violence, accident proneness. Substance use/ Prof. Subaie

25. ALCOHOL ABUSE / DEPENDENCE NEUROPSYCHIATRIC COMPLICATIONS: • TREATMENT OF WITHDRAWAL STATES: • Dehydration & correction of electrolytes • Sedation (Chlormethiazole & Benzodiazepines( • Multivitamins • Thiamine Substance use/ Prof. Subaie

26. ALCOHOL ABUSE / DEPENDENCE TOXIC AND NUTRITIONAL STATES: 1. Wernicke’s encephalopathy:due to thiamin deficiency leading to bilateral degeneration of the posterior hypothalamus, hippo- campus and mamillary bodies. Features include: delirium, ataxia and ophthalmoplegia. 2. Korsakov’s syndrome (alcohol amnestic syndrome): Features include: prominent disturbance of recent memory in the absence of generalized intellectual impairment (Immediate recall is good but recent memory is impaired). Confabulation and disorientation to time may occur. New learning is impaired. Occurs after prolonged use. On CT scan: Ventricles may be enlarged and sulci may be widened. CT changes may partially resolve on abstinence. Substance use/ Prof. Subaie

27. ALCOHOL ABUSE / DEPENDENCE ASSOCIATED COMORBIDITY & COMPLICATIONS: • Depression/ Suicide • Anxiety • Personality changes • Pathological jealousy • Sexual dysfunction • Hallucinations • Social damage • Crimes • Road traffic accidents • Occupational problems • Family conflicts and losses Substance use/ Prof. Subaie

28. ALCOHOL ABUSE / DEPENDENCE MANAGEMENT: 1. Assess:- Extent of drinking - Evidence of dependence - Alcohol related disability 2. Arrange for and treat withdrawal symptoms: - Sedation - Thiamin and Vitamin B supplements - Rehydration Substance use/ Prof. Subaie

29. ALCOHOL ABUSE / DEPENDENCE MANAGEMENT: 3. Treat urgent psychiatric or medical problems: 4. Arrange for rehabilitation and long term treatment: • Of medical and psychiatric disability • Resolving interpersonal problems • Social support ( work, law, finance, interests) • Individual and / or group counseling • Self help group e.g. alcohol anonymus • Help for family • Disulfiram (antabuse)- inhibits acetaldehyde dehydroginase… Substance use/ Prof. Subaie

30. ALCOHOL ABUSE / DEPENDENCE PROGNOSIS: • Generally poor: • At 6/12: 25% remain abstinent • At 18/12: 10% remain abstinent • Good prognostic factors include: • Good insight • Strong motivation • Supportive family • Stable job • Ability to form good relationship • Control of impulsivity and ability to defer gratification Substance use/ Prof. Subaie

31. OUTCOME Outcome depends more on the patient than on the treatment Substance use/ Prof. Subaie

32. CANNABIS • Derived from the plant Cannabis sativa • Effects vary with: dose, user’s expectation and social setting • Exaggerates the preexisting mood (euphoria or dysphoria) • Physical dependence and withdrawal symptoms do not occur • Acute intoxication may lead to psychosis while chronic use may lead to “amotivational syndrome” Substance use/ Prof. Subaie

33. ORGANIC SOLVENTS (INHALENTS) Due to: hepatorenal, brain & bone marrow toxicity, bronchial asthma & cardiorespiratory arrest, coma, asphyxiation with plastic bags, trauma … ADHESIVES, CLEANING FLUIDS, PETROL, AEROSOLS, BUTANE GAS. • Most common among teenagers. • Intoxication leads to drunkenness, delirium, uncoordinated gait, nausea, vomiting, and coma. • Visual hallucinations are common. • More psychological than physical dependence. • It has a neurotoxic effect leading to peripheral neuropathy and cerebellar dysfunction. • Over dosage may be fatal and chronic use may lead to psychosis. • Very cheap and easily obtained. Substance use/ Prof. Subaie

34. STIMULANTS Due to: hyperpyrexia, coma, CV shock, fits… AMPHETAMINES AND COCAINE • Lead to elevation of mood, over-activity, insomnia, over- talkativeness, and anorexia. • Cardiac arrhythmia and malignant hypertension may result from high doses. • Death • Prolonged use may result in paranoid psychosis resembling schizophrenia • Physical dependence is not severe • Withdrawal may lead to severe depression and suicide • Treatment includes abstinence, antidepressants and neuroleptics Substance use/ Prof. Subaie

35. HALLUCINOGENS LSD, DISMETHYL TRYPTAMINE AND ANTICHOLINERGIC DRUGS • Lead to distortion or intensification of perceptions or frank hallucinations. • Time moves slowly • Profound meaning of ordinary events. • Body image distortions and depersonalization may occur. • Experience may be pleasant, distressing, or frightening leading to dangerous unpredictable behavior. • Physical effects include hypertension • Flashbacks may occur • More psychological than physical dependence • Treatment is diazepam or phenothiazines (avoid in case of anticholinergic over-dose) Substance use/ Prof. Subaie

36. OPIOIDS HEROIN, MORPHINE, CODEINE AND PETHEDIN • Lead to immediate effects of euphoria, analgesia, reduced appetite, respiratory depression, drowsiness, gastrointestinal spasms, fits… • Tolerance develops rapidly • Withdrawal symptoms: craving, agitation, insomnia, pains and arthralgia, abdominal cramps, runny nose and eyes, sweating, diarrhea, piloerection, dilated pupils, tachycardia and disturbed temperature control. • Withdrawal starts within 6 hours, peaks in 24–48 hours and it is not life threatening • Short-term treatment includes: relief of withdrawal symptoms. • Long-term treatment includes: methadone replacement and rehabilitation • Treatment outcome remains poor in the best hands. • Death results in about: 10%-20% in 7 years. Substance use/ Prof. Subaie

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