Substance Related Disorders

Dr. Anurag Mishra M.D.

Coordinator- Psychoanalytical Wing

Max Hospitals- Delhi

Substance vs Drug

• Drug- Manufactured chemical• Many substances associated with

abuse patterns :1. Occur Naturally- opium, cannabis2. Not meant for human consumption- petrol,

solvents

• Illegal - cocaine• Legal but obtained by illegal means or for

non prescribed purposes- morphine

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

Substance Use Disorders

• Substance Dependence

• Substance Abuse

• “Codependence”

Substance Dependence

• Impairment or distress because of 3 or more of the following at any time in a year:

1. Tolerance: increased amount of substance to produce same effect / decreased effect with same amount

2. Withdrawal: typical withdrawal syndrome/ substance or related compound used to relieve or avoid withdrawal

3. Use of substance in greater amounts or for a longer time than originally intended

4. Unsuccessful attempts or wishes to cut down5. Significant time spent in obtaining, using, recovering6. Giving up social, occupy, recreational activities7. Continued use despite knowledge of physical/ mental

problems

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

Substance Abuse

• Pt. not meeting criteria for Dependence with any one of following in a year:

1. Failure to fulfill major role obligations

2. Recurrent use of substance in hazardous situations

3. Recurrent legal problems resulting from substance use

4. Continued use of substance despite social or interpersonal problems caused by substance

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

Substance Induced Disorders

1. Intoxication: Reversible substance specific syndrome2. Substance withdrawal3. Substance induced delirium4. Substance withdrawal delirium5. Substance induced persisting dementia6. Substance induced persisting Amnestic disorder 7. Substance induced psychotic disorder8. Substance induced mood disorder9. Substance induced anxiety disorder10. Substance induced sexual dysfunction11. Substance induced sleep disorder

Alcohol Intoxication

Mild• Overconfidence• Mood swings, emotional

outbursts, euphoria• Nausea, vomiting • RestlessnessSevere• 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/ comaT/t (treatment)1. Conscious pt.- wait!• Agitation- BZD, anti psychotic2. Unconscious pt.- keep warm• Prevent aspiration• Increased ICT- mannitol• Hemodialysis in extremes

Sedative, Hypnotic, Anxiolytic Intoxication

• BZD, BarbituratesMild• Euphoria• Sedation• Paradoxical excitement• Nystagmus, dysarthria, impaired

attention & memory• Postural hypotensionSevere (suicide attempts, overdose)• Coma• Respiratory depression• Low BP• Low cardiac output• Low temp.• Coma• Death

T/t1. Protect airway2. Oxygen3. Ventilation4. Prevent further body heat loss5. I.v. fluids and BP maintenance

with Dopamine6. Forced diuresis7. Hemodialysis

Stimulant Intoxication• Amphetamines,

methamphetamine, cocaineMild• 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 HemorrhageT/t: hypertension & hyperthermia• Psychosis- antipsychotics

Hallucinogen Intoxication

• 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

Cannabis Intoxication

• 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

Opioid Intoxication

• Opium• Morphine• Heroin• Crack• Brown sugar• Codeine• Pethidine• Fortwin (pentazocin)

Opioid Intoxication

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 & ComaT/t• Supportive care• Naloxone- narcotic antagonist,

reverses coma & apnea but also produces severe withdrawal

Inhalant Intoxication

• 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

Anticholinergic Drug Intoxication

• 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

Alcohol Withdrawal

“The Shakes”• Tachycardia• Tremors• Sweating• Nausea• Hypotension• Weakness• Anxiety, irritabilityT/t: Thiamine, BZD

Alcohol Withdrawal

Motor Seizures (Rum fits)• Seizure in<48 hrs after

stopping• T/t: I.v. BZDAlcohol 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 psychoticsWernicke-Korsakoff Syndrome• Wernicke’s Encephalopathy/

Alcoholic encephalopathy- ataxia, giddiness, eye signs

• Korsakoff’s Syndrome/ Chronic Amnestic Syndrome: Impaired memory

• T/t: thiamine

Sedative, Hypnotic, Anxiolytic Withdrawal

• Anxiety, agitation• Low BP• Weakness & tremors• Fever• Sweating• Delirium• Seizures• Cardiovascular

collapse

• T/t• Withdrawal can be life

threatening• Hospitalization• BZD substitution• Other drugs

Stimulant Withdrawal ( Crash )

• Increased sleep• Nightmares• Fatigue• Lassitude• Increased appetite• Depression ( cocaine

blues)• Suicide attempts• Intense drug craving

• Hospitalization if suicidal

• Antidepressants

Hallucinogen Withdrawal

• 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

Opioid Withdrawal

• 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

Anti Cholinergic Withdrawal

• Influenza like syndrome

• Depression• Seizures• Mania

• T/t :Atropine• Reintroduction and

gradual discontinuation of drug

Nicotine Withdrawal

• Malaise• Irritability• Anxiety • Craving for tobacco• T/t: Nicotine patches• Nicotine gum• SSRI

Treatment

• Five Stages

1. Pre contemplation

2. Contemplation

3. Preparation

4. Action

5. Maintenance

Treatment approach tailored to pt.’s stage of readiness

• Pharmacological agents:

• Alcohol: disulfiram, naltrexone, acamprosate, gabapin

• Opioid: Naltrexone• Nicotine: Nicotine

gum, patches

Treatment

1. Detoxification2. Insistence on

abstinence3. Avoidance of other

substance associated with dependence or abuse

4. Involvement of family

5. Toxicology screens6. Self help groups7. Treat complications8. Psychotherapy9. Treat co morbidities10.Treat complications