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Substance Abuse
Alison Freeland MD FRCPC
Schizophrenia Program
Royal Ottawa Hospital
Definitions
Dependence: the repeated use of a drug
Abuse: Use of any drug in a manner that deviates from approved social or medical patterns
Addiction: the repeated and increased use of a substance, the deprivation of which gives rise to symptoms of distress and an irresistible urge to use again
Definitions
Intoxication: a reversible syndrome caused by a specific substance that effects 1 or more of the following – memory, orientation, mood, judgment, and level of functioning Withdrawal: a substance specific syndrome that occurs after stopping or reducing the amount of the substance used
Definitions
Tolerance: phenomenon in which, after repeated administration, a given dose of a substance produces a decreased effect
Cross tolerance: ability of one drug to be substituted for another each usually producing the same physiologic and psychologic effects
Drugs that can be tested in the urine
Alcohol: 7-10 hours
Benzodiazepine : 3 days
Cocaine : 6-8 hrs (metabolites 2-3 days)
Marijuana: 3 days to 4 weeks ( depending on use)
Codeine: 48 hours
Heroin: 36-72 hours
Alcohol
90% absorbed through the stomach
Peak blood concentrations in 30-90 mins
Rapid consumption and consumption on an empty stomach enhance absorption and decrease time to peak blood levels
Intoxication more pronounced as blood levels are rising
90% metabolized by hepatic oxidation
Alcohol
Body metabolizes approx one moderately sized drink per hour (ie one 12 oz beer, 4 oz wine, 1 oz liquor)
Alcohol: epidemiology
10% women and 20% men meet criteria for alcohol abuse
5% women and 10% men have met criteria for alcohol dependence
60% alcohol abusers are men
Caucasians have highest rates of alcohol abuse ( 60%)
Alcohol: Etiology
Genetic: close family members of alcoholics have 4x increased risk
Cultural: Asians show increased acute toxic effects, Native Americans and Inuit have higher rates
Alcohol: comorbidity
Anxiety
Depression
Insomnia
Schizophrenia
Other substance disorders
Alcohol related disorders
DependenceAbuseIntoxication (delirium)Withdrawal (delirium)Persisting dementiaPersisting amnestic disorderPsychotic disorderDepressionAnxietySexual dysfunctionSleep disorder
Subtypes of Alcohol Dependence
A: late onset, mild dependence, few alcohol related problems, little psychopathology
B: severe dependence, early onset, strong family history, life stressors, severe psychopathology
Alcohol Withdrawal
Begins within several hours of alcohol cessation
2 of the following: autonomic hyperactivity, tremor, insomnia, nausea/vomiting, transient illusions/hallucinations, anxiety, grand mal seizures, agitation
Rx: benzodiazepines
Alcohol Withdrawal delirium
1-3% of alcohol dependent patients
Symptoms: delirium, marked autonomic hyperactivity (tachycardia, sweating, agitation, anxiety), vivid hallucinations, agitation tremor, fever, seizures
Tx: monitor vitals, decrease stimulation, hydrate, benzodiazepines, thiamine, Folic acid, multivite, mag sulphate as needed for seizures
Alcohol induced amnestic disorder
Wernickes encephalopathy: acute syndrome caused by thiamine deficiency (nystagmus, ataxia, confusion). Treat with thiamine –symptoms may resolve
Korsakoffs syndrome: chronic condition result of thiamine deficiency, amnesia, confabulation, disorientation, polyneuritis, Rx with thiamine, 25% patients fully recover
Alcohol induced psychotic disorder
Vivid persistent hallucinations following a decrease in alcohol consumption in an alcohol dependent person
May persist and progress into a more chronic psychotic presentation
Condition usually requires at least 10 years of alcohol dependence
Tx: benzodiazepines +/- antipsychotic med
Opioids
Natural derivatives of opium: codeine, morphine
Synthetic opioids: methadone, oxycodone, dilaudid, talwin, demerol
Semisynthetic opioids: heroin
Opioids
Heroin most commonly associated with abuse
600,000 heroin users in the US
Lifetime rate of heroin abuse is 2%
Male to female ratio is 3 :1
Most users in their 30s and 40s
Dependance on other opioids most commonly seen in patients who are prescribed as part of medical treatment
Opiate Overdose
Can be a medical emergency
Often accidental
Often results from combined use with other CNS depressants ( alcohol, benzodiazepines)
Clinical signs: pinpoint pupils, respiratory and CNS depression
Rx: naloxone ( antagonist)
Opiate Withdrawal
Seldom a medical emergency
Symptoms include flu like sx, craving, lacrimation, rhinorrhea, yawning, sweating, insomnia, abdominal cramps, dilated pupils, piloerection, N/V/D
Treatment: methadone, clonidine, supportive
Cocaine Epidemiology
10% of US population has tried it
Lifetime rate for use/dependence is 2%
Most commonly used in 18 to 25 year old range
Male to female ratio of 2:1
Delusions and hallucinations may occur in 50% of those who use
Cocaine
Intoxication: restlessness, agitation, anxiety, pressured speech, paranoid ideation, aggressivity, increased sexual interest, tachycardia, hypertension, pupillary dilation, chills, anorexia, insomnia, stereotypic movementsTreatment:supportive, benzos, antipsychotics
Cocaine Withdrawal
Most prominent sign is craving
Symptoms include fatigue, lethargy, guilt, anxiety and feelings of helplessness
Withdrawal symptoms usually peak in several days but can last for weeks
Treatment: supportive, SSRIs
Sedative hypnotics
Benzodiazepines
Barbiturates
Methaqualone
Meprobamate
About 6% of general population have used these illicitly
Female: male 3:1
Sedative and Hypnotic Intoxication
Slurred speech
Uncoordination
Unsteady gait
Impaired attention
Respiratory depression, particularly if used with other sedative agents (ie alcohol)
Sedative and Hypnotic Withdrawal
Nausea, vomiting
Malaise, weakness
Autonomic hyperactivity
Anxiety, irritability
Increased sensitivity to light and sound
Tremor
Insomnia
seizures
Hallucinogens
Natural and synthetic substances
Produce hallucinations, loss of contact with reality, experience of heightened consciousness
Egs: psilocybin (mushrooms), mescaline (peyote), MDMA, LSD
Hallucinogens
Act as sympathomimeticsCause hypertension, tachycardia, hyperthermia and dilated pupilsTolerance develops rapidly and remits within several days of abstinencePhysical dependence and withdrawal do not occurOften contaminated with anticholinergic drugs
Hallucinogen Intoxication
Maladaptive behavioral changes (anxiety, paranoia)
Changes in perception (hallucinations)
Sympathomimetic changes
Panic reactions (bad trips)
Duration variable (shrooms 4-6 hrs, LSD 6-12 hrs)
Phencyclidine (PCP)
“angel dust”A dissociative anaesthetic and hallucinogenCommonly causes paranoia and violenceMay remain detectable in urine up to a weekAssociated with 3% substance abuse deaths
PCP
Effects are dose dependent
At low doses acts as a CNS depressant, with nystagmus, blurry vision, incoordination
At moderate doses hypertension, dysarthria, ataxia, muscle rigidity
At high doses agitation, fever, rhabdomyolysis, renal failure
Inhalants
Volatile hydrocarbons inhaled for psychotropic effect
eg gasoline, kerosene, laquers, paint thinner, fingernail polish remover
Typically abused by adolescent males of low SEC groups
Inhalants: Intoxication
Mild euphoria, belligerence, assaultiveness, impaired judgmentAtaxia, confusion, slurred speech, decreased reflexes, nystagmusCan go on to delirium and seizuresLonger term risk of brain injury, liver damage, bone marrow depression, peripheral neuropathies, immunosuppression
Cannabis
5% lifetime useHighest among 18-21 y.o.Highest use among caucasians compared to other ethnic groupsEuphoric effects appear within minutes, peak at 30 mins and last 2-4 hoursMotor and cognitive effects can last 5 to 12 hours
Cannabis
Intoxication: euphoria, anxiety, suspiciousness, time distortion, conjuctival injection, increased appetite, dry mouth, tachycardia
Can cause depersonalization and hallucinations
High doses can cause cannabis psychosis lasting up to 6 weeks
Amphetamines
Release catecholamines, primarily dopamine
Effects are euphoric and anorectic
Usually taken orally, but can be smoked, inhaled and injected
Clinical syndromes similar to cocaine
Amphetamines
7% of population
Highest use in 18 to 25 year old range
Men = women
Examples: dexedrine, speed, methylphenidate, khat, methcathinone crystal meth
Can induce a paranoid psychosis
Intoxication resolves in 24 - 48 hours
MDMA
3,4 methylenedioxyamphetamine
“ecstasy” “E”
Increased self confidence, sensory sensitivity, sense of personal closeness with others
Activating, energizing, some hallucinogenic potential,
Associated with hyperthermia
“poppers”
Amyl nitrate
Used during sex to intensify orgasm through vasodilation
Can produce light headedness, euphoria and giddiness
Should not be used with viagra as combo can cause cardiovascular collapse and death