Disorders Due to Psychoactive Substances

1. Disorders Due to Psychoactive Substances as. MUDr. Olga Pecinovská Department of Psychiatry, First Faculty of Medicine, Charles University and General University Hospital in Prague

2. Disorders Due to Psychoactive Substances • Mental disorders due to substance abuse • Intoxication • Abuse • Addiction • Withdrawal syndrom • Psychotic disorders due to addiction • Physical complications of substance abuse

3. Abused Psychoactive Substances • Alcohol (F10) • Opioids (F11) • Cannabinoids (F12) • Sedatives/hypnotics and benzodiazepins (F13) • Cocaine (F14) • Other stimulants (F15) • Hallucinogens(F16) • Tobacco (F17) • Inhalants (F18) • Other substances or combinations (F19)

4. Mental Disorders due to Substance (ab)use F 1x.0 Intoxication F 1x.1 Substance abuse F 1x.2 Addiction (syndrome of dependence) F 1x.3 Withdrawal syndrome F 1x.4 Delirium F 1x.5 Psychosis F 1x.6 Amnestic disorder F 1x.7 Residual psychotic disorder

5. Psychoactive Substance Abuse Continuing to use substance even though the person knows there are reoccurring physical or psychological problems being caused by using the substance

6. Psychoactive Substance Dependence • Craving (strong desire or sense of compulsion to take a drug) • Change of tolerance (needing increased amounts to achieve the same effect) • Difficulties in controlling drug-taking behavior (onset, termination, levels of use) • Progressive neglect of alternative pleasures or interests because of drug use (increasing time for drug) • Withdrawal symptoms • Persisting with drug use despite clear evidence of harmful consequences

7. Alcohol Intoxication Alteration in behavior depending on the amount of used alcohol and individual variation and tolerance (impaired judgment, mood lability,disinhibition of aggressive impulses, social dysfunction) 0,3g/l euphoric effect 0,5g/l cognitive deficits, motor coordination problem 2,5g/l significant confusion, decreased state of consciousness 4g/l coma, death

8. Alcohol Withdrawal Syndrome Uncomplicated • Tremor, hyperreflexia • Anxiety • Increased heart rate and blood presure • Sweating • Nausea, vomiting • insomnia • Alcohol withdrawal seizure

9. Alcohol Withdrawal Delirium • Disorientation • Fluctuating consciousness • Vivid hallucinations • Agitation • Mild hyperpyrexia • Onset 48-72hours after the last drink (up to 7 days) • Mortality: 10-15% (untreated)

10. Alcohol Psychotic Disorders • Alcoholic paranoid psychosis • Heresy jealous, persecute • Alcoholic hallucinosis • Auditory hallucinations without clouding of sensorium • Alcohol amnestic disorder(Korsakoff‘s psychosis) • Memory defect, confabulations, intellectual function is preserved • Alcoholic dementia

11. Physical Complications of Alcohol Abuse/dependence • Alcoholic peripheral neuropathy • Alcoholic encephalopathy • Alcoholic liver disease (steatosis, hepatitis, cirrhosis) • Cardiovascular disorders (dilated cardiomyopathy, hypertension, hemorrhagic stroke, „holiday heart syndrome“) • Hematological disorders (anemia, macrocytosis, leukopenia, thrombocytopenia, abnormalities of homeostasis)

12. Physical Complications of Alcohol Abuse/dependence • GIT complications (gastritis, peptic ulcer, esophagitis, esophageal varices, diarrhea, malabsorption, acute or chronic pancreatitis) • Malnutrition (thinning of the hair, ecchymosis, glossitis,peripheral oedema, abdominal distension, neuropathy, tetany) • Endocrinological Disease (amenorrhoea, hypogonadism, virilisation/feminization) • Acute or chronic alcoholic myopathy • Osteoporosis • FAS

13. Orofacial Consequencies of Alcohol Addiction • Parotid gland enlargement • Neglected teeth, early loss of teeth • Gingivitis, parodontitis • Stomatitis, glossitis, cheilitis • Cancer of the mouth • Carcinoma of the pharynx

14. Sedatives/hypnotics/benzodiazepins Addiction • Most often: Alprazolam, bromazepam, clonazepam, diazepam, zolpidem • High doses (multiple LD) • Signs of intoxication and withdrawal as alcohol addiction, withdrawal often complicated by seizure or delirium • Consequences: seizures, memory impairment, dementia, accidents! • Combinations with alcohol or replacement of alcohol

15. Opioids • Illegal drugs (heroin=diacetylmorphine, brown=codeine) • Subutex (buprenorphine), methadone • Opioid analgetics (morphine, dihydrocodeine, hydromorphone, oxycodone) • Opioid-like analgetics (pethidine, tramadol, fentanyl) • Medicaments with contents of codeine • Alnagon, Korylan, Spasmoveralgin, Spasmopan • Pleumolysin, Talvosilen

16. Opioid Intoxication • Euphoria immediately after use, then apathy and psychomotor retardation • Miosis • Slow regular respiration • Slurred speech • Impairment of judgment, attention, concentration, memory • analgesia

17. Opioid Withdrawal • Craving • Lacrimation,rhinorrhea, yawning, sweating • Mydriasis, piloerection • Anorexia, tremor, irritability, insomnia • Weakness • Nausea, vomiting, diarrhoea • Muscle spasms, restless lower extremities • Abdominal pain • Flushing, fever

18. Medical Complications of Opioid Abuse/addiction Mental: depression, dementia, personality dis. Physical: • illness of dirty needles: abscesses, lymphadenopathy, osteomyelitis, endocarditis, glomerulonephritis, septicemia, memingitis, septic emboli • Infective diseases: hepatitis (C,B,A), AIDS, tbc, syphilis • Pneumonia, pulmonary hypertension • Consequences of overdoses (paralysis, dementia, blindness, acute transverse myelitis) • Consequences of analgesia (peritonitis, osteomyelitis etc)

19. Stimulants • Cocaine, pervitin, phentermine, ephedrine • Intoxication • Anxiety, irritability, agitation, paranoia, confusion, hallucinations, sympathomimetic effects (dizziness, tremor, mydriasis, tachycardia, hypertension, hyperpyrexia) • Withdrawal • Dysphoria, insomnia/hypersomnia, hyperphagia • Risks • Convulsions, heart attack, psychosis, accidents

20. Marihuana • Intoxication: • Tachycardia, conjunctival injection,dry mouth, increased appetite, • Impaired short-term memory,labile affect, altered time perception, enhanced sociability • Withdrawal: • Craving, insomnia, dysphoria, irritability • Medical and psychological consequences: • Bronchitis, impaired sexual function, chromosomal damage • Panic attacks, amotivational syndrome, cannabis psychosis, dementia

21. Inhalants • Abused inhalants: alkyl-nitrites, toluene and toluene mixtures – glues, paints, thinners, gasoline, ketones – nail polish remover, printing ink, halogenated hydrocarbons – halothane, trichloroethylene,ethylene glycol… • Clinic similar to alcohol, high toxicity!!, high risk of overdoses!! • Consequences: hepatopathia, neuropathia, nefropathia, cardiopathia, pneumonia, organic mental syndrome, pulmonary and brain oedema

22. Addicts at the Doctor´s • Abstining addicts • Good collaboration • Valid anamnesis including information about addiction in an. • Carefully asking for used medication • CAVE: no psychoactive substances excluding vital indication (benzodiazepines, tramadol etc.)

23. Addicts at the Doctor´s • Active addicts • Poor collaboration, not valid anamnesis • Come in intoxication or withdrawal syndrome • Often come even with inflammatory complications • Irritability, manipulative • Asking for psychoactive substances • CAVE: • alcohol: vomiting reflex, seizure • IUD: infection!!, analgesia or hypersensitivity • Cave combination therapy with abused substances • Cave high tolerance to psychoactive substances