Chapter 10 Substance Abuse

1. Chapter 10Substance Abuse Tolerance:increasing dose day by day to have the needed effect of substance. Withdrawal symptoms: If addict stops taking substance (usually within few hrs.) temporarily, withdrawal sxwill appear (psycho-somatic sx) which are very painful sx. -In Nicotine withdrawal sxit is mostly psychological sxas anxiety & irritability.

2. 1) Cannabis الحشيش -Marijuana (البانجو ) is one type of it . -Happy sx of taking Cannabis start after few min. if taken by smoking, & after 1/2 hr. if taken by mouth -Its effect (if taken by mouth) continues 5-12 hrs. -If big amount taken by mouth, respiratory center may stop&death will result during sleeping. -Wrongly cannabis is known as sex stimulus (longer sexual activity) which is not proved scientifically.

3. Sx of cannabis Abuse: -Feeling of well being. -Talkative with feeling of euphoria when talking. -Light head. -Hyperactivity. -Difficulty in orientation (esp. time). -If abuser moves up few steps in stair, will imagine that he is over biggest pyramid. -By increasing dose, hallucination will result.

4. Long-term using effect: -Respiratory diseases especially Bronchitis. -Cancer of lung. -Cardio-vascular diseases. N.B: Appetite to sweets will increase -Has negative effect on behavior & ethical manner as laughing in sad situation.

5. 2) Opiates (الأفيون) -Morphine, Heroin, Codeine, Pethedin, Crack. -Used in medical field as pain killer, cough relief. -If taken for few months, withdrawal sxwill appear (anxiety, irritability). -Each time amount will be increased. -Withdrawal sxwill appear after 3 hrs. of taking previous dose (Withdrawal sxwill reach its peak in 1-2days). -Usually it is white. -Used by IV, smoking or sniffing . -Heroin leads to mush happiness for abuser. -Abuser health: poor r/s. -Suffering of chronic constipation.

6. Withdrawal sx: 1-Increase urge to get substance, anxiety. 2- Condition like flue (Rhinitis), much sweating, lacrimation. 3-Pain in joints & muscle. 4-Vomiting, diarrhea, abdominal pain, appetite. 5-Difficulty in breathing.

7. Cocaine: -Cocaine is made from the leaves of the coca plant, which grows mainly in South America. -Stimulant drug . -White powder used by sniffing, or IV. -Addict may experience grandiosity (exaggerated belief in importance & abilities). Thiscan lead addict to take risks, particularly when driving, leading to accidents. -Usually feeling of anxiety will accompany cocaine use. -Effect of cocaine is very short. -Addict of cocaine may become criminal. -Withdrawal sxof cocaine less severity than opiates.

8. Complication of cocaine addiction: -Sleep disturbance. -Decrease appetite, decrease wt. -Skin itching. -Depression. -Criminal behavior. -Impotence.

9. Crack: -Crack is the street name for crystallized freebase cocaine. -It is most commonly smoked, which, due to lungs’ rapid absorption rate, means that more of drug gets into body faster than through injection or inhaling. -When smoked, it takes about 20 seconds or less for feelings of euphoria &pleasure to start, but along with this quick high comes the downside: the happy feelings fade just a few minutes later &resulting low can be dramatically dismal.

10. -Crack’s main course of action is to alter & work on autonomic nervous system of human body. -In normal functions, brain secretes dopamine, a chemical that, when bound to nerve cells in brain, produces feelings of pleasure in body. -Dopamine production normally occurs naturally, but crack speeds up this natural system by causing brain to release all of stored dopamine in one quick burst. -This produces feelings of intense pleasure & euphoria, but when settle down, & no dopamine left, this state means downswing of emotions & intense desire to get more crack at any cost.

11. Rx of addiction (dependence): Criteria (factors) help in Rx: 1-Short period b/w starting of taking substance & Rx. 2-Availability of intention of pt. to be treated. 3-Age of pt.'s. 4-Level of education. 4-Type of substance. 5-Acceptance of pt. to follow up Rx at home.

12. Stages of Rx: 1-Detoxification:l-2wks (weaning) should be in specialized hospital. 2-Rehabilitation: Trial to solve problem with cooperation of family, Reinforcement of positive behavior. 3-Follow up:Very important stage , could be more important than Rx itself. -If pt. is relapsed condition worse. **In some countries they use methadone with small doses. It is not Rx of addiction, but it is substitution by another type with less withdrawal sx.

13. Alcoholism -Effects if Alcohol : Alcohol is CNS depressant LevelEffect on the brain 0.05%Poor judgment 0.1%Clumsy motor actions slurred speech 0.2%Depressed motor area of brain, emotional lability 0.3%Confusion, stupor 0.4%Coma 0.5% Breathing & heart rate centers are affected,Death due to respiratory paralysis

14. -With chronic use: Alcoholic dementia -Social relation inhibition, marital problems, occupational problems, violence, legal problems increased accidents. -Medical problems. -Liver cirrhosis , fatty infiltration. -Gastritis, gastric ulcers. -Vitamin deficiency, especially Thiamin. -Peripheral neuropathy.

15. Epidemiology: -In many countries, alcohol is widely used & abused. -Some people take alcohol occasionally for social reasons or to relieve tension. -Prevalent in early 20-35 years age group. -Onset is in early 20s. -Sxof alcoholism start to appear in 30’s. -Alcoholism can coexist with other psychiatric disorders like: Depression, bipolar, anxiety, & personality disorders.

16. Etiology: -Alcoholism is not single disorder, it can have many causes. -Some alcoholics start to drink in an attempt to treat psychiatric problems: anxiety, depression, mania, etc. or physical disorder: pain. -Some people develop alcoholism & become dependent. -The short-term sedative effect of drinking alcohol is replaced by long term dysphoric mood & withdrawal sxwhich push alcoholic to drink more.

17. Biological Theory: -Some studies found genetic factor behind alcoholism. -In one study it was found that 25% of fathers of alcoholic pts. were alcoholic. -Concordance of alcoholism in monozygotic twins is twice as dizygotic twins.

18. 2. Psychoanalytic theory : -Individuals who abuse alcohol (or other substances) have undeveloped egos r/s, failure in completing tasks of separation-individuation. -Person retains highly dependent mature, with characteristics of poor impulse control, low frustration tolerance & low self-esteem. -Superego is weak, resulting in absence of guilt feelings for their behavior.

19. 3. Learning theory: Release of anxiety becomes reinforcement for further drinking as it results in temporary reduction of fear & conflict.

20. Clinical Picture: Alcoholic intoxication -Maladaptive behavior: sexual & aggressive behavior, labile impaired judgment, impaired social or occupation functions. -Somatic sx: slurred speech, in-coordination, unsteady gait, nystagmus, flushed face. c) Hematomas & contusions due to falls, hypothermia in cold weather. d) Other sx like liver cirrhosis, peripheral neuropathy & cerebral ataxia.

21. Alcohol withdrawal: -Syndrome observed after cessation or reduction of alcohol intake after prolonged period of use. Sx: -Nausea & vomiting. -Malaise of weakness, headache, insomnia. -Autonomic hyperactivity. - Anxiety, irritability or depression. - Seizures, especially if past hxof epilepsy. - Hallucinations or illusions.

22. 1) Delirium Tremens: -Occur in 5% of hospitalized alcoholics within 1 week after cessation or reduction of alcohol intake. -Withdrawal sxprogress to state of delirium. -Essential features are: -Delirium: Clouding of consciousness disorientation, hallucination visual or tactile. -Autonomic hyperactivity: Tachycardia, sweating, hypertension. -Fluctuating level of psychomotor activity:Pt. is sometimes hyperexcitable & sometimes lethargic. Rx: -Benzodiazepines 25 to 50 mg, chlordiazepoxide(librium) 2-4 hrs., adequate nutrition & hydration.

23. 2) Alcoholic hallucinosis: -In some pts. visual or auditory hallucinations occur within 48 hrs. after cessation of alcohol with no sxof delirium & continue after recovering from withdrawal sx. -Course is short, hallucinations disappear within several weeks or few months. Rx: -Like delirium, Benodiazepines, nutrition & adequate hydration. -If case is prolonged, anti-psychotics may be used.

24. 3) Alcohol Amnestic Disorder Encephalopathy: A) Wernick’sEncephalopathy: -Acute reversible neurological syndrome that results from prolonged heavy drinking of alcohol. -Etiology is due to Thiamin deficiency malnutrition that accompanies is predisposing factor. -Essential factors are: -Ataxia. -Opthalmoplegia: (cranial nerve paralysis). -Nystagmus. -Confusion. -Spontaneous recovery within few days or weeks. -It can progress to Alcohol Amnestic Disorder.

25. RX: -High doses of parenteral Thiamin & response is rapid. -If Rx delayed, irreversible damage occurs & respond to Rx. B)Alcohol Amnestic Disorder (Korsakoff’s Syndrome): -Chronic irreversible disorder resulting from heavy alcohol intake. -Irreversible impairment of memory occurs. Etiology: is also due to Thiamin deficiency. -Course is short & recovery occurs in only 20% of cases.

26. 4) Alcoholic Dementia: -Dementia that persists for longer than 3weeks after cessation of alcohol intake. -Usually occurs in heavy drinkers above 35 y/o who have been drinking for long period. Essential features: -Impairment of intellectual abilities. -Memory impairment. -Social & occupational impairment. -Condition is chronic & irreversible. -Rx is supportive.

27. Rx of Alcohol Dependence: I. Psychotherapy: -To explore the desire of alcoholic to be intoxicated (drinking is treated as a psychological defense). -Anxiety producing factors are discussed. -There should be supportive & active periods of depression are treated by psychotherapy& anti-depressants Behavioral Therapy: -Teaching alcoholic other ways to relieve anxiety like relaxation training & assertiveness skills. -Positive reinforcement is used to reinforce abstinence.

28. II. Medications: Disulfiram: (Antabuse):is drug used to produce undesirable side effects if alcohol is taken. -Given in dose of 25 only after last drink. -If pt. drinks alcohol while on disulfuram, he experiences nausea, palpitation, dizziness, hypotension, numbness in extremities. -These effect are toxic reactions due to accumulation of acetaldehyde in blood. Psychotropic medication:Anti-depressants or anxioloticsto treat depression, anxiety or irritability that may occur during abstinence.

29. III. Support Groups: -Some alcoholics who have bean treated form support groups to help other alcoholics. -These are voluntary organizations that may help pt. during his Rx. Ex: Alcoholics Anonymous (AA).