Substance Related Disorders

1. Substance Related Disorders Dr. Anurag Mishra M.D. Coordinator- Psychoanalytical Wing Max Hospitals- Delhi

2. Substance vs Drug • Drug- Manufactured chemical • Many substances associated with abuse patterns : • Occur Naturally- opium, cannabis • Not meant for human consumption- petrol, solvents • Illegal - cocaine • Legal but obtained by illegal means or for non prescribed purposes- morphine

3. Addiction • Describes the degree to which drug use pervades an individual’s life • Possible to be dependent without being addicted- individual’s life is not organized around finding & using drug e.g. those who become addicted to drugs used in prolonged medical treatment • Possible to be addicted without being physically dependent • 1964- WHO substituted Dependence

4. Substance Use Disorders • Substance Dependence • Substance Abuse • “Codependence”

5. Substance Dependence • Impairment or distress because of 3 or more of the following at any time in a year: • Tolerance: increased amount of substance to produce same effect / decreased effect with same amount • Withdrawal: typical withdrawal syndrome/ substance or related compound used to relieve or avoid withdrawal • Use of substance in greater amounts or for a longer time than originally intended • Unsuccessful attempts or wishes to cut down • Significant time spent in obtaining, using, recovering • Giving up social, occupy, recreational activities • Continued use despite knowledge of physical/ mental problems

6. Substance Dependence • Physiological Dependence: presence of withdrawal or tolerance • Psychological Dependence (Habituation) : continuous intermittent craving for substance to avoid dysphonic state (difficulty in speaking) dysphoria = anxiety

7. Substance Abuse • Pt. not meeting criteria for Dependence with any one of following in a year: • Failure to fulfill major role obligations • Recurrent use of substance in hazardous situations • Recurrent legal problems resulting from substance use • Continued use of substance despite social or interpersonal problems caused by substance

8. Codependence • Behavioral patterns of family members who have been significantly affected by another family member’s substance use or addiction • Enabling • Unwillingness to accept addiction as disease, voluntary behavior, responsibility shifted to family • Denial

9. Substance Induced Disorders • Intoxication: Reversible substance specific syndrome • Substance withdrawal • Substance induced delirium • Substance withdrawal delirium • Substance induced persisting dementia • Substance induced persisting Amnestic disorder • Substance induced psychotic disorder • Substance induced mood disorder • Substance induced anxiety disorder • Substance induced sexual dysfunction • Substance induced sleep disorder

12. Mild Overconfidence Mood swings, emotional outbursts, euphoria Nausea, vomiting Restlessness Severe Stupor or coma Hypothermia Slow respiration Tachycardia Increased I C T Dilated pupils Death Diagnosis Slurred speech Loss of coordination Unsteady gait Nystagmus Impaired attention/ memory Stupor/ coma T/t (treatment) Conscious pt.- wait! Agitation- BZD, anti psychotic 2. Unconscious pt.- keep warm Prevent aspiration Increased ICT- mannitol Hemodialysis in extremes Alcohol Intoxication

13. BZD, Barbiturates Mild Euphoria Sedation Paradoxical excitement Nystagmus, dysarthria, impaired attention & memory Postural hypotension Severe (suicide attempts, overdose) Coma Respiratory depression Low BP Low cardiac output Low temp. Coma Death T/t Protect airway Oxygen Ventilation Prevent further body heat loss I.v. fluids and BP maintenance with Dopamine Forced diuresis Hemodialysis Sedative, Hypnotic, Anxiolytic Intoxication

14. Amphetamines, methamphetamine, cocaine Mild Elevated mood Increased energy & alertness Decreased apppetite Talkativeness Anxiety & irritability Insomnia Increased/ decreased heart rate & BP Nausea/ vomiting Loss of appetite & weight Severe Psychotic symptoms- visual, auditory & tactile hallucinations, delusions, mania Fighting Dilated pupils Increased BP & pulse Arrhythmias Seizures Exhaustion Coma & I C Hemorrhage T/t: hypertension & hyperthermia Psychosis- antipsychotics Stimulant Intoxication

15. LSD, PCP, Mescaline Most hallucinogens Dilated pupils Increased pulse & BP Increased temp Delusions & hallucinations Anxiety Distortion of time sense Inappropriate affect PCP Intoxication Violence & hyperactivity Increased hearing Mutism Echolalia Muscular rigidity Seizures, coma, IC hemorrhage T/t: Quiet setting Antipsychotic/ BZD Hallucinogen Intoxication

16. Hallucinogen Intoxication

17. Marijuana, hash, ganja, bhang Euphoria Anxiety Increased appetite Increased suggestibility Distortion of time & space Red conjunctiva No change in pupils Dry mouth Tachycardia T/t: Quiet setting, BZD Cannabis Intoxication

18. Opioid Intoxication • Opium • Morphine • Heroin • Crack • Brown sugar • Codeine • Pethidine • Fortwin (pentazocin)

19. Mild- Moderate Analgesia without loss of consciousness Drowsiness Nausea & vomiting Apathy & lethargy Euphoria Itching Constricted pupils Constipation Flushed & warm skin Impaired attention & memory Illusions Severe Miosis Respiratory depression Hypotension or shock Pulmonary edema Seizures & Coma T/t Supportive care Naloxone- narcotic antagonist, reverses coma & apnea but also produces severe withdrawal Opioid Intoxication

20. Erasex, petrol, glue, paint thinner, solvents Dizziness, confusion Euphoria Confusion, nystagmus, ataxia, dysarthria Tremors Muscle weakness Blurred vision Delirium Chronic use- Dementia T/t: prevent access to drug Inhalant Intoxication

21. Cough syrups, imipramine, pacitane Confusion Memory loss Delirium Hallucinations Amnesia Drowsiness Tachycardia Decreased peristalsis Fever Warm dry skin Fixed dilated pupils Coma T/t Protect pt & wait for drug to be metabolized Physostigmine Anticholinergic Drug Intoxication

22. “The Shakes” Tachycardia Tremors Sweating Nausea Hypotension Weakness Anxiety, irritability T/t: Thiamine, BZD Alcohol Withdrawal

23. Motor Seizures (Rum fits) Seizure in<48 hrs after stopping T/t: I.v. BZD Alcohol withdrawal delirium Delirium Autonomic hyperactivity Agitation, hallucinations, tremors T/t: Hydration Thiamine, BZD, antipsychotic Psychosis Hallucinations in clear sensorium - threatening or derogatory T/t: Anti psychotics Wernicke-Korsakoff Syndrome Wernicke’s Encephalopathy/ Alcoholic encephalopathy- ataxia, giddiness, eye signs Korsakoff’s Syndrome/ Chronic Amnestic Syndrome: Impaired memory T/t: thiamine Alcohol Withdrawal

24. Anxiety, agitation Low BP Weakness & tremors Fever Sweating Delirium Seizures Cardiovascular collapse T/t Withdrawal can be life threatening Hospitalization BZD substitution Other drugs Sedative, Hypnotic, Anxiolytic Withdrawal

25. Increased sleep Nightmares Fatigue Lassitude Increased appetite Depression ( cocaine blues) Suicide attempts Intense drug craving Hospitalization if suicidal Antidepressants Stimulant Withdrawal ( Crash )

26. Dr. Albert Hoffman discovered/ invented LSD! Flashbacks: 15- 80% Spontaneous transitory occurrences of substance induced experience: visual distortion, hallucinations, trails of images, micro/ macropsia, time expansion, relived intense experience T/t : Reassurance, BZD Hallucinogen Withdrawal

27. Watering from nose and eyes Sweating Restlessness & sleepiness Gooseflesh Dilated pupils Irritability Yawning Insomnia Craving Substitution with medicinal opioid and gradual withdrawal Clonidine to control BP and other autonomic symptoms BZD Non opioid pain killers Symptomatic t/t Opioid Withdrawal

28. Influenza like syndrome Depression Seizures Mania T/t :Atropine Reintroduction and gradual discontinuation of drug Anti Cholinergic Withdrawal

29. Malaise Irritability Anxiety Craving for tobacco T/t: Nicotine patches Nicotine gum SSRI Nicotine Withdrawal

31. Five Stages Pre contemplation Contemplation Preparation Action Maintenance Treatment approach tailored to pt.’s stage of readiness Pharmacological agents: Alcohol: disulfiram, naltrexone, acamprosate, gabapin Opioid: Naltrexone Nicotine: Nicotine gum, patches Treatment

32. Detoxification Insistence on abstinence Avoidance of other substance associated with dependence or abuse Involvement of family Toxicology screens Self help groups 7. Treat complications Psychotherapy Treat co morbidities Treat complications Treatment