Amit Anand CT-3 Psychiatry

1. Amit Anand CT-3 Psychiatry

2. Problem Definition UK among the highest recorded use of illegal drugs in Europe High rate of heroin and crack cocaine. Mortality risk is nearly 12% in heroin addicts. 2/3rd reported cannabis in a major problem in <18 years with alcohol. 34 % Hep B, 90% Hep C and 5.6% of HIV due to IDU ( HPA 2006) 7 % acute drug related death among aged 15-39 years (EMCDDA 2006)

3. Psychiatry of substance Misuse Assessment and treatment of problems arising from substance misuse Alcohol, illegal drugs, pharmaceutical drugs Management of acute states- intoxication, withdrawal Long term effects, dependency, relapsing chronic course Psychiatric co-morbidities. Physical disease Psychological interventions- MIT, CBT Pharmacological- substitutes- methadone, adjunct treatments (adversive-disulfiram, anti-craving- acamprosate, naltrexone), antidepressants, BDZ

4. Neurobiology Reinforcing properties of most drugs are due to direct or indirect release of dopamine in nucleus accumbens.

5. Terminology Tolerance and withdrawal To increase the dose of psychoactive substance are required in order to get to achieve effects originally produced by lower doses. Physiological vs Psychological dependence Physiological is ch by tolerance and dependence and Psychological dependence mainly relates to continuous or intermittent cravings. Remission Remission is interval of time elapsed since last drug use. Lapse vs Relapse Relapse is resumption of drug use to pre-existing pattern after a period of remission. And Lapse is use of drugs in small amount during recovery. Lapses are common

7. Stimulants Feelings of alertness, endurance, decreased need for sleep, well being Caffeine-legal, widespread, 1 in 10 withdrawal symptoms Cocaine (made from coca leaves) Freebase (crack) cocaine Amphetamine MDMA (ecstacy)

8. Opiates Opiates Derived from poppy Analgesic and widespread legitimate use Anxiolytic, induces euphoria and widely abused, often leading to dependency Heroin- white/brown powder Smoked, snorted, iv or sc use Overdose- nausea, vomiting, respiratory depression and sedation (risk of aspiration) Pharmaceutical- dihydrocodeine, pethidine, methadone, morphine, codeine.

9. Hallucinogens Sensory and perceptual experiences with euphoria Wide group of substances Lysergic acid diethyalmide (LSD), found by Albert Hoffham in 1944. High up to 6 hours. Derealisation, euphoria, depersonalisation, visual illusions, misperceptions, synaesthesia. Mescaline, Phenylcyclidine (PCP), Magic Mushrooms (�Liberty Cap�), Ketamine

10. Cannabis Cannabis salvia Most widely abused drug THC is principle active compound Resin, dried Skunk Intoxication-euphoria, derealisation, depersonalisation, visual illusions, sedation, tachycardia, increase appetite Withdrawal- mild- irritability, insomnia

11. Assessment of drug and Alcohol Use Reasons for presentation In Crisis Court Case On probation Own concern about drug use Family�s concerned. Developed mental illness Pregnant Drugs not available.

12. contd Current Usage ( What, How often, how many, Typical day) Longitudinal History ( First drink, age, progress to daily and current level) Dependence Syndrome ( Edwards and Gross Criteria, ICD-10) CAGE Injecting drug use and unsafe sexual practices: Why injecting Sharing? Site and route of injection Safe practice Knowledge of blood borne viral diseases Commercial sex to fund drug use.

14. Contd Medical Hx Injection site complications� Abscess BBV illness status STDs Accident, falls etc. Neuro, GIT, Cardio-resp etc Psychiatry Hx Screen for psychiatric illness Past hsitory of overdoses or admissions ? Use of drugs to treat underlying mental illness.

15. Contd Forensic Hx: Past and present contact with criminal justice system Probation order Association of drug s to offences Social Hx Family situation and Employment, Accommodation and Debts

16. Contd Number and duration of abstience attempts Kind of intervention used. Any treatment in inpatient rehab setting

17. Examination Assess motivation ****** Appearance & Behaviour- well kempt/malnourished? Intoxicated? Agitated/hostile/aggressive/sedated? Evidence of drug use? Mood- generalised anxiety, panic, low mood, hopelessness. Thoughts- persecutory ideation, guilt, helplessness. Suicide (increased in substance misuse) Psychotic phenomena- persecutory delusions, auditory, visual and tactile hallucinations. Insight**- into dependency, effects on mental state Cognition- confusion, impairment, dementia

18. Substance Misuse Syndromes Acute intoxication Harmful Use Dependence Withdrawal Substance-induced psychotic disorders Cognitive impairment syndromes Dual diagnosis

19. Acute Intoxication Reversible physical and mental abnormalities caused by direct effects of substance. Alcohol-disinhibition, aggression, lability, ataxia, slurred speech, impaired judgement and attention, nystagmus, decreased consciousness. Opioids- apathy, sedation, disinhibition, psychomotor retardation, pupillary constriction, respiratory depression. Cannabinoids- Euphoria, anxiety/agitation, suspiciousness, temporal slowing, impaired judgement and attention, auditory/visual/tactile illusions, hallucinations, depersonalisation, derealisation, dry mouth, increased appetite, conjunctival injection, tachycardia Cocaine- euphoria, increased energy, hypervigilance, grandiose beliefs/actions, argumentativeness, lability of mood, illusions, hallucination, paranoid ideation, tachycardia, cardiac arrhythmias, chest pain, convulsions, agitation.

20. Harmful USe A pattern of psychoactive substance use that is causing damage to health. Physical or mental health consequences Pattern of use must have existed for at least a month or occurred repeatedly in a year Look out for denial- ask about effects on work attendance, interpersonal relationships, finances, mental state

21. Dependence Syndrome �A cluster of behavioural, cognitive and physiological phenomena that develop after repeated substance exposure, leading to strong desire to take the drug.� Primacy of drug seeking behaviour Narrowed spectrum of use Tolerance Loss of control of consumption Signs of withdrawal on abstinence Drug taking in avoidance of withdrawal Continued use despite harm Relapsing course after abstinent periods.

22. Withdrawals Pattern of physiological and psychological symptoms experienced on acute abstinence from a substance Alcohol, opiates, BDZ, Alcohol: uncomplicated alcohol withdrawal syndrome, seizures, delirium tremens. Opiate withdrawal: with in a day of last dose, lasting 5-7 days, peaking at 2 days. Symptoms- sweating, tachycardia, hypertension, dilated pupils, abdominal cramps, �goose flesh�, yawning, nausea, vomiting, diarrhoea, tremor, muscle cramps. Symptomatic treatment- analgesia, loperamide, anti-emetics, lofexidine (alpha-adrenergic agonist) Substitute prescribing- methadone- long-acting synthetic opiate- daily dosing. Oral dosing. Long term management and reduction regimes in community.

23. Alcohol Withdrawal Synd Risk of dependency, history of withdrawal, heavy recent drinking, currently symptomatic Uncomplicated: course tremor, sweating, tachycardia, insomnia, agitation, nausea, vomiting, generalised anxiety May have transient illusions or hallucinations Cravings for alcohol Start after 4-12 hours, peaking at 48 hours. May occur in up to 15% with grand mal seizures. Prophylaxis: chlordiazepoxide reducing regimen. Titrate to history and symptoms Delirium Tremons Acute confusional state secondary to alcohol withdrawal 5% of withdrawal, peaks at 48 hrs after last consumption confusion, amnesia, disorientation, psychomotor agitation, anxiety, auditory, tactile and visual hallucinations (Lilliputian), delusions. Fluctuating confusional state. Sweating, fevers, cardiovascular collapse. 5-10% mortality.

24. Psychiatric Disorders Common co-existence of psychotic phenomena and substance misuse Psychosis is a potential feature of: Acute intoxication (alcohol, hallucinogens, stimulants) Withdrawal state (alcohol, BDZ, cocaine) Drug-induced psychosis ( Amphetamines� Paranoia**) Underlying psychosis maintained/exacerbated by substance use (dual diagnosis)

25. Cognitive Impairment 50-60% of heavy drinkers show cognitive impairment when tested while sober STW, LTM recall. MRI reveals cortical atrophy and widened ventricles Wernicke-Korsakoff�s Syndrome- neuronal degeneration secondary to thiamine deficiency. Wernicke�s encephalopathy- acute confusional state, nystagmus and ataxia- prescribe Pabrinex in susceptible individuals Korsakoff�s- Impairment or absence of the ability to form new memories, reduced recall for LTM (confabulating), no clouding of consciousness, no global intellectual decline.

26. Co-existence of major mental illness and substance misuse Is individual self medicating? Opiates for auditory hallucinations, alcohol to aid sleep, agitation etc.. Diagnostic uncertainty (drug-induced psychosis) Time course helpful Higher rate of relapse- cannabis in schizophrenia

27. Take Home message If you only remember a few things� Drug, including alcohol, use is common If you don�t ask, they won�t necessarily tell you Take a thorough history Seek collateral history if possible Be aware of acute intoxication states (head injuries, infection, encephalopathy, withdrawal) Always think of withdrawal Delirium tremens can kill

28. Any Burning Questions From Amit Anand