Substance Use Disorder Addiction (DSM V) By Soheir H. ElGhonemy Assist. Professor of Psychiatry- Ain Shams University
May 12, 2015
Substance Use DisorderAddiction (DSM V)
By
Soheir H. ElGhonemy Assist. Professor of Psychiatry- Ain Shams University
Drug Abuse and Addiction are Among
the Most Serious Public Health
Problems Facing Our Society and
frequently coexist with other Mental
and Physical Disorders
Dopamine Pathways
Functions•reward (motivation)•pleasure,euphoria•motor function (fine tuning)•compulsion•perserveration•decision making
Serotonin Pathways
Functions•mood•memory processing•sleep•cognition
nucleusaccumbens
hippocampus
striatum
frontalcortex
substantianigra/VTA
raphe
Medial Forebrain Bundle
Ventral tegmental area (VTA) (Lateral) hypothalamus (LH) Nucleus accumbens (NAc) Frontal cortex (FC) - key portions
Prefrontal cortex (pfc) Orbitofrontal cortex (ofc)
Drugs Associated wth Neurotransmitters
Why do people have “drugs of choice”?
Dopamine - amphets, cocaine, alcohol Serotonin - LSD, alcohol Endorphins - opioids, alcohol GABA - benzos, alcohol Glutamate -alcohol Acetylcholine - nicotine, alcohol
A Brain Chemistry Disease!
Addicting drugs seem to “match” the transmitter system that is not normal
A chronic, relapsing, medical disease There are mild, moderate, and severe forms Detox is traditionally the first step in the total
treatment process Methadone and nicotine maintenance is
evidence that some people require a chemical to overcome the non-normal transmitter system
Figure 5
The combination of neuroadaptations in the brain circuitry for the three stages of the addiction cycle that promote drug-seeking behavior in the addicted state.
Activation of the ventral striatum/dorsal striatum/extended amygdala driven by cues through the hippocampus and basolateral amygdala and stress through the insula.
The frontal cortex system is compromised, producing deficits in executive function and contributing to the incentive salience of drugs compared to natural reinforcers.
Dopamine systems are compromised, and brain stress systems such as CRF are activated to reset further the salience of drugs and drug-related stimuli in the context of an aversive dysphoric state
Common Underlying NeurobiologicalFactors Can Be
Neurochemical (imbalance of
neurotransmitters)
Structural/anatomical (same
regions and pathways)
Genetic (inherited factors
that compromise function)
Drug Disorder
Cocaine and Methamphetamine Schizophrenia, paranoia, anhedonia, compulsivebehavior
Stimulants Anxiety, panic attacks, mania and sleep disorders
LSD, Ecstasy & psychedelics Delusions and hallucinations
Alcohol, sedatives, sleepaids & narcotics
Depression and mood disturbances
PCP & Ketamine Antisocial behavuor
DRUG USE(Self-Medication)
DRUG USE(Self-Medication)
STRESSSTRESS
CRFCRF
AnxietyAnxiety
CRFCRF
AnxietyAnxiety
What Role Does Stress Play In Initiating Drug Use?
What Role Does Stress Play In Initiating Drug Use?
Consequence: There is no “cure”…
To be successful, treatment is a
Lifetime Process
Science is helping to improve our
strategies and successes
History Taking
The history is the chronological story of the patient’s life from birth to present
Personal data:
Name, age, sex, marital status, religion,
address, occupation, education.
n.b.; source of referral could be
mentioned here if the patient won’t
cooperate
Personal History:
Birth and developmental milestones, family
atmosphere, school performance and
general conduct in school, educational
achievement, occupational history, sexual
and marital history.
Attempt to correlate social problems with
evolving drug problems. Enquire about
impact of drug use on lifestyle.
Family History:
Brief vignette of father, mother and
other siblings should include age,
occupation and relation with the
client. History of psychiatric
problems or problems resulting
from alcohol, drugs or nicotine.
Drug History:
This section should attempt to give a clear
picture of initiation of drug use accounting for
each specific drug. The evolution of drug use
with the development of personal and social
problems as a consequences of drug use.
Type, quantity, and route of use of each
individual drug. Alcohol consumption should
be checked as a routine part of drug history
taking.
Drug use in the past 24 hr.:
Detailed and sensitive questioning around this will
not only provide data about drug use and drug
dependence but should give a clear picture of the
client’s lifestyle and daily stresses and strains.Drug use in the past month:
Should try to draw a picture of drug use over the
past 4 weeks.History of abstinence:
Number of trials , how , duration of each and
reason for relapse.
Legal History:
Charges, convictions, imprisonments and
violent incidents.Sexual and Marital History:
Sexual behavior and marital relation and
if extramarital relationships. Relation of
sexual or marital problems to drug use.Occupational History:
Relationships of jobs and relations to
drug use. Current employment status.
Present life situation:
Family and social support. Non drug
use friends, leisure activities and
occupational prospects, financial
status and accommodations.
Mental state examination:On admission:
Describe relevant features. Positive and
negative findings regarding both physical
and mental condition of the client. Focus
on physical signs of drug withdrawal,
liver diseases signs and any neurological
dysfunctions. Sites of injections and any
infections.
Mental state should include level of
consciousness, alertness and orientation and
as well as level of cooperativeness. Ability to
give history will provide data about their
intelligence, cognitive state and level of
insight into their condition.
General state of dress and grooming as well
as evidence of agitation, calmness or
detachment from problem should be checked.
Pattern of sleep, appetite, energy
level, mood state and suicidal
ideations giving data about special
and general psychological state.
Any delusions or hallucinations
should be considered and relation to
client intoxication or withdrawal states
Follow up setting is meant for better
elaboration of the client’s condition and
allow building rapport for setting
management plan.
A thorough history is the substrate for a
considered opinion about the client. What is
the best for the client. History is cornerstone
in the substance abuse field.
Patient with treatment program:
Substance is being used.
Recent regular use.
Psychiatric status.
Medical condition.
Social network.
Legal aspects.
Goals of treatment:
A.Help the individual to be drug free( detoxification).
B.Help to maintain drug free state ( relapse prevention)
C.Long term Rehabilitation.
Classification of substance:
I. CNS depressants: Alcohol Opiates Sedative hypnotics
II.CNS stimulants: Amphetamines Cocaine
III.CNS hallucinogens: Cannabis LSD Anticholinergics
Stimulation : Depression :a. Anxiety .
b. Insomnia.
c. Twitches.
d. Convulsions.
e. Hyperthermia.
f. Tachycardia.
g. Irritability.
h. Excitement.
i. Tremors.
j. Hypertension.
k. Tachypnea
a.Apathy.
b.Retardation.
c. Inattentive.
d.Stupor.
e.Hypotension.
f. Bradypnea.
g.Ataxia.
h.Lethargy.
i. Drowsiness.
j. Confusion.
k. Hypothermia
l. Bradycardia
&Coma.
Drugs of abuse that can be tested in urine:
Alcohol: 7-12 hrs.Amphetamine : 48 hrs.Barbiturate ; short: 24 hrs. , long acting: 3 wks.
Benzodiazepine: 3 days.Cannabinoides : 3 days ---4 wks “ depending on the use; chronic use leads to lengthening of period”
Cocaine : 6- 8 hrs.Codeine : 48 hrs.Heroin : 36—72 hrs.Methadone : 3 days.Morphine : 48 – 72 hrs
The Neuropharmacology of Drugs of Abuse
Psychoactive drugs alter normal neurochemical
processes . This can occur at any level of activity
including :
a. mimicking the action of a neurotransmitter .
b. altering the activity of a receptor .
c. acting on the activation of second
messengers
d. directly affecting intracellular processes that
control normal neuron functioning.
Routes of administration:
It affects how quickly a drug reaches the
brain ,also ,chemical structure of a drug
plays an important role in the ability of a
drug to cross from the circulatory system
into the brain. Four routes:
oral.nasal.Intravenous.inhalation.
alcoholMild and moderate intoxication:
1.Impaired attention , poor motor coordination.
2.Dystharthria- ataxia , nystagmus, slurred speech.
3.Prolonged reaction time, flushed face orthostatic hypotension.
4.Hematemesis and stupor.Pathological intoxication:5.Excited , psychotic state following min.
consumption in susceptible individuals.Intoxication associated with belligerence.
Uncomplicated Withdrawal: Coarse tremors of hands, tongue, eyelids
and at least one of the following: Nausea or vomiting. Malaise or weakness. Autonomic hyperactivity. Anxiety, Depressed mood or irritability. Transient hallucination or illusions. Headache , insomnia.Withdrawal complication:Seizures.Hallucination.Delirium.
Management:
I. Avoid aspiration by placing patient’s face down or on one side. Hospitalization is usually necessary.
II. Parenteral sedatives or physical restrains.III. Low dose sedative ; Lorazepam 1-2 mg, physical
restrains or further sedation by Haloperidol IM 5 mg.
IV. Parenteral dose of Thiamine 100 mg.V. Benzodiazepine tapering.VI. Thiamine 50 mg PO.VII. Multivitamin PO.VIII.Folate 1 mg PO.
Over a week for uncomplicated withdrawal.
Opiate: Patients rarely seek treatment for intoxication.
Overdose :
I. Respiratory and CNS depression.II. Depression.III.Gastric hypomotility with ileus.IV. Non-cardiogenic pulmonary edema.
Withdrawal:
V. Lacrimation, rhinorrhea.VI. Diaphoresis, yawing, sneezing.VII. Malaise, irritability, nausea and vomiting.VIII.Diarrhea, myalgia, arthralgia, bone ache.
Management of Opiate overdose: I. Respiratory depression : air way support II. Cardiopulmonary suppression: Naloxone
Hydrochloride 0.4 mg or 0.01 mg\ kg IV, repeated dose of Naloxone infusion 0.4 mg\ hr. for 12 hrs. subsequent to the initial boluses.
III. Pulmonary edema : Intubation and pressure ventilation ;ICU admission.
IV. Gastric lavage or induced emesis followed by activated Charcoal for orally ingested overdose.
26 year old heroin addict. He has all the symptoms of
withdrawal. He has a runny nose, stomach cramps,
dilated pupils, muscle spasms, chills despite the warm
weather, elevated heart rate and blood pressure, and is
running a slight temperature. Aside from withdrawal
symptoms, this man is in fairly good physical shape. He
has no other adverse medical problem and no
psychological problems. At first he is polite and even
charming to the staff. He’s hoping you can just give him
some “meds” to tide him over until he can see his
regular doctor. However, he becomes angry and
threatening to you and the staff when you tell him you
may not be able to comply with his wishes.
He complains about the poor service he’s been
given because he’s an addict. He wants a bed
and “meds” and if you don’t provide one for
him you are forcing him to go out and steal and
possibly hurt someone, or, he will probably just
kill himself “because he can’t go on any more in
his present misery.” He also tells you that he is
truly ready to give up his addiction and turn his
life around if he’s just given a chance, some
medication, and a bed for tonight.
The 26 year old is a heroin addict in
withdrawal. His signs and symptoms all
indicate opiate withdrawal. He has a runny
nose, stomach cramps, dilated pupils, muscle
spasms, chills, despite the warm weather,
elevated heart rate and blood pressure, and
is running a slight temperature. He may or
may not have other drug issues. A urine
analysis may provide some answers to this
question.
The second patient is an older man in his late sixties
and is a bit disheveled in appearance. He is
accompanied by his lady. The lady tells you that she
found him earlier this evening trying to enter his
apartment door. He was sweaty, his eyes where
dilated, and his hands were trembling so badly that
he could not get the key in the door. He kept calling
her by another name and saying he was trying to get
into his office to do some work. She says he retired
years ago. His blood/alcohol level is low and his
speech is not slurred.
He can correctly identify himself but, also appears
confused. He is unable to tell you the month or season. His
nose and cheeks are red with tiny spider veins and his
stomach distended and when he extends his hands out in
front of him they are very tremulous. His demeanor is
polite and apologetic to you and the staff. He tells you he
has never had a problem with alcohol. He then admits to
an occasional drink
every now and then. He did have a few drinks earlier
today but can’t say exactly when. However, he is willing to
come into the hospital for a brief stay if really thought it
was necessary.
late 50’s and has all the signs and symptoms of a late stage
alcoholic starting to go into alcohol withdrawal. He was
sweaty, his eyes were dilated and his hands were trembling
so badly that he could not get the key in the door. He kept
calling his lady by another name . His blood/alcohol level is
low and his speech is slurred, but appears confused. His
nose and cheeks are red with tiny spider veins, he has a
distended abdomen and when he extends his hands out in
front of him they are very tremulous. He probably does not
have other drugs in his system like benzodiazepines. They
would act as a stabilizer in his condition and these drugs are
often given to treat Alcohol withdrawal.
Delirium tremors or “DT’s”. The symptoms are
as follows: they begin with anxiety attacks,
increasing confusion, poor sleep, marked
sweating, and fleeting hallucinations or
nocturnal illusions which arouse fear. Some
patients may suffer grand mal seizures, several
in short succession. There is a trembling of the
hands at rest, sometimes extending to the
head and trunk. Walls are falling, floors are
moving, and rooms will be rotating.
Injuries often occur because patients are
unable to maintain their balance at this stage.
These falls can cause severe head and neck
injuries. Animal hallucinations are frequent and
often incite terror. It is also typical that in these
delirious, confused, states the person will
return to a habitual activity usually work
related.
In this case he is imagining himself back at
work and trying to get into his office.