substance related disorders

Ronald Chrisbianto Gani405090223

Faculty of MedicineTarumanagara University

EMERGENCY MEDICINE BLOCK

SUBSTANCE RELATED DISORDERS

SUBSTANCE-RELATED DISORDERS(INTRODUCTION)

TERMINOLOGY

• Dependence : The repeated use of a drug or chemical substance, with or without physical dependence

• Abuse : use of any drug, usually by self-administration, in a manner that deviates from approved social or medical patterns

• Misuse : similiar to abuse but usually applies to drugs prescribed by physicians that are not used properly

Kaplan and Sadock’s Pocket Handbook of Clinical Psychiatry 5th Ed

TERMINOLOGY

• Addiction : the repeated and increased use of a substance, the deprivation of which give rise to a symptoms of distress and irresistible urge to use the agent again and which leads also to physical and mental deterioration

• Intoxication : A reversible syndrome caused by specific substance that affects one or more mental function (memory, judgement, mood, orientation, social function, etc)


TERMINOLOGY• Withdrawal : a substance-specific syndrome

that occurs after stopping or reducing the amount of drug or substance that has been used regularly over a prolonged period of time

• Tolerance : Phenomenon in which after repeated administration, a given dose of drug given produces decreased effect or increasingly larger dose must be administered to obtain the effect observed with the original dose


TERMINOLOGY

• Cross-Tolerance : the ability of one drug to be substituted for another, each usually producing the same physiologic and psychological effect. Also known as cross-dependence


Kaplan and Sadock’s Synopsis of Psychiatry 10th Ed

EPIDEMIOLOGY


WHO SCHEMATIC MODEL


CLASSES OF SUBSTANCES

• Alcohol• Amphetamine• Caffeine• Cannabis• Cocaine• Hallucinogen• Inhalant• Nicotine

• Opioid• Phencyclidine• Sedative, hypnotic,

anxiolytics• Prescribed drugs and

OTC medications• Anabolic-Androgenic

steroids


OPIOID-RELATED DISORDERS

OPIOIDS


ETIOLOGY

• Psychosocial factors– Higher in low sosioeconomic class– Children from single parents / divorced parents ↑

• Biological & Genetic Factor– Some drugs dependence genetically transmitted– abnormal functioning in dopaminergic or

noradrenergic neurotransmitter system• Psychodynamic theory– Serious ego pathology


EPIDEMIOLOGY

• Estimated user in US : 1 million• Lifetime rate : 2%• Age : 30-40 yo• M : F = 3 : 1• Abuse of opioids found in lower

sosioeconomic• Dependence most seen in patient with opioid

medical treatment


OPIOID-RELATED DISORDERS (1)

• Route of administrations– Opium : smoked– Heroin : smoked, Injected IV or SC– Some others : oral

• Intoxication– Objective S&S : CNS depression, GIT motility ↓,

respiratory depression, analgesia, nausea & vomiting, slurred speech, hypotension, bradycardia, pupilary contraction, seizure (OD)



– Subjective S&S : Euphoria (total body orgasm), anxious dysphoria, tranquility, decreased attention and memory, drowsiness, psychomotor retardation

• Overdose medical emergency– Often results from combine with other CNS

depressor (alcohol, sedative-hypnotic, etc)– Signs : pinpoint pupil, respiratory and CNS

depression



• Treatment for opioid overdose– ICU admission + support vital function (IV fluid)– Administer 0,8mg Naloxone IV, wait 15 mins– If no response, give 1,6mg Naloxone, wait 15 mins– If no response, give 3,2mg Naloxone, suspect

other diagnosis– If success, continue Naloxone at 0,4mg/hour IV– Always consider polysubstance overdose


SLIDE 9


DSM IV-TR CRITERIA FOR OPIOID INTOXICATION


DSM IV-TR CRITERIA FOR OPIOID WITHDRAWAL


DSM IV-TR CRITERIA FOR OPIOID INTOXICATION DELIRIUM


DSM IV-TR CRITERIA FOR OPIOID-INDUCED PSYCHOTIC DISORDERS


DSM IV-TR CRITERIA FOR OPIOID-INDUCED MOOD DISORDERS (1)


DSM IV-TR CRITERIA FOR OPIOID-INDUCED MOOD DISORDERS (2)


DSM IV-TR CRITERIA FOR OPIOID-INDUCED SLEEP DISORDERS (1)


DSM IV-TR CRITERIA FOR OPIOID-INDUCED SLEEP DISORDERS (2)


DSM IV-TR CRITERIA FOR OPIOID-INDUCED SEXUAL DISFUNCTION (1)


DSM IV-TR CRITERIA FOR OPIOID-INDUCED SEXUAL DISFUNCTION (2)


OPIOID-RELATED DISORDER NOT OTHERWISE SPECIFIED

• The opioid-related disorder not otherwise specified category is for disorders associated with the use of opioids that are not classifiable as opioid dependence, opioid abuse, opioid intoxication, opioid withdrawal, opioid intoxication delirium, opioid-induced psychotic disorder, opioid-induced mood disorder, opioid-induced sexual dysfunction, or opioid-induced sleep disorder.


CLINICAL FEATURES

• Adverse effects– Transmission of Hepatitis

and HIV– Idiosyncratic reaction

• Overdose may cause death

• MPTP-induced Parkinsonism

Skin popper


TREATMENT

Medically Supervised Withdrawal andDetoxification

• Opioid agents for treating Opioid withdrawal– Methadone : supress withdrawal syndrome, dose

20-120mg/day, once-daily– Other : levomethadyl (no longer used) &

Buprenorphine• Opioid antagonist : Naloxone, Naltrexone


TREATMENT

• Psychotherapy• Therapeutic communities• Education and Needle Exchange• Narcortic Anonymous


HYPNOTICS, SEDATIVES, ANXIOLYTICS RELATED DISORDERS

HYPNOTICS, SEDATIVES, ANXIOLYTICS

• Benzodiazepin– Diazepam (Valium)– Flunitrazepam (Rohypnol)

• Barbiturat– Secobarbital (Seconal)

• Barbiturat-like substances– Methaqualone (Quaalude)– Meprobamate (Miltown)


BENZODIAZEPINE DISCONTINUATION SYNDROME


EPIDEMIOLOGY

• 6% use this drugs before 40 yo• Peak age 26-35 yo• Female : Male = 3 : 1• White : Black = 2 : 1• Barbiturat abuse in patient >40 yo


INTOXICATION AND WITHDRAWAL


DRUG CHALLENGE TEST


MANAGEMENT


AMPHETAMINE-RELATED DISORDERS

AMPHETAMINES

• Preparations : Dextroamphetamine (dexedrine), metamphetamine (desoxyn), methylphenidate (Ritalin) less addictive

• Epidemiology : 7% population used amphetamines without medical judgement, mostly at age 18-25

• DSM IV-TR Criteria for amphetamine dependence and abuse (Slide 7 and 9)


DSM IV-TR CRITERIA FOR AMPHETAMINE INTOXICATION


DSM IV-TR CRITERIA FOR AMPHETAMINE WITHDRAWAL


TREATMENT

• Antipsychotic and antianxiolytic used in short-term basis (first few days)

• Comorbid : depression antidepressant• Bupropion produce feelings of well being• Multiple therapeutic methods– Individual– Familial– Group psysiotherapy


CANNABIS-RELATED DISORDERS

CANNABIS / MARIJUANA

• Main euphoriant : Δ9-THC• Usually smoked, but sometimes eaten• Epidemiology : 5% lifetime rate of cannabis

abuse, highest at age 18-21 yo• Smoked euphoria in minutes, peak in

30mins, last for 2-4h, motor and cognitive effects for 5-12h. Can cause dose-dependent hypothermia and mild sedation


DSM IV-TR CRITERIA FOR CANNABIS INTOXICATION


COCAINE RELATED DISORDERS

COCAINE-RELATED DISORDERS

• Epidemiology– Lifetime abuse 2%– Age 18-25 yo– Male : Female = 2 : 1

• Cocaine Intoxication & withdrawal (next slide)• Treatment : symptomatic – Agitation benzodiazepin or antipsychotic– Somatic system beta blockers


DSM IV-TR CRITERIA FORCOCAINE INTOXICATION


DSM IV-TR CRITERIA FOR COCAINE WITHDRAWAL


BRAIN INVOLVEMENT

COCAINE

National Institute on Drug Abuse

HEROIN

• Heroin enters the brain, converted to morphine, binds to opioid receptors (located in brain, body,brainstem) affects perception of pain, and alter breathing, BP, HR, arousal, etc

• Regular heroin use tolerance decreased physiological and psychological effect of drug more heroin needed to reach the same intensity of effect


MARIJUANA / CANNABIS• Enters brain stimulate

dopamine release euphoria• Impairs brain ability to form

new memory and shift focus. • Binding to receptor in

cerebelum and basal ganglia impairs coordination and balance

• Large dose acute psychosis (hallucinations and delusions), the cause remains unknown


MDMA (ECSTASY)

• Binds to serotonin transporter prolonged serotonin signal

• Enters serotonergic neurons release more serotonin

• Lesser effect in dopamine• After drugs use : confusion, depression, sleep

problems, drug craving, and severe anxiety• Chronic : impairs cognitive ability


METAMPHETAMINE

• Increases the release and block the reuptake of dopamine euphoria

• Chronic abuse reduced motor skills and impaired verbal learning, severe structural and functional changes in areas of the brain associated with emotion and memory cognitive and emotional problems


LSD

• Disrupting interaction of nerve cells and neurotransmitter serotonin impairs control of behavioral, perceptual, and regulatory systems, including mood, hunger, body temperature, sexual behavior, muscle control, and sensory perception

• Impairs glutamate receptors impairs perception of pain, responses to the environment, and learning and memory.


ALCOHOL

• No single molecular targets• Effects on membranes of neurons– Short term : increasing fluidity of the membranes– Long term : membranes become rigi

Kaplan and Sadock’s Synopsis of Psychiatry 10th EdHarrison’s Principle of Internal Medicine 18th Ed

SEDATIVES, HYPNOTICS, ANXIOLYTICS

• Binds to GABAA receptors increase affinity to GABA increase the flow of chloride ions thorugh the channel into the neuron

• GABA stimulation results less chloride influ than was caused by GABA stimulation before benzodiazepine administrations tolerance and dependence


REFERENCES

• Sadock BJ, Sadock VA. Kaplan and Sadock’s Synopsis of Psychiatry 10th Edition. Philadelphia : Lippincot Williams & Wilkins : 2007.

• Sadock BJ, Sadock VA. Kaplan and Sadock’s Pocket Handbook of Clinical Psychiatry 5th Edition. Philadelphia : Lippincot Williams & Wilkins : 2010.

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