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Chapter 10Substance Abuse

Tolerance: increasing dose day by day to have the needed effect of substance.

Withdrawal symptoms: If addict stops taking substance (usually within few hrs.) temporarily, very painful withdrawal sx will appear (psycho-somatic).

-Nicotine withdrawal sx is mostly psychological sx as anxiety & irritability.

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1) Cannabis الحشيش -Marijuana (البانجو) is one type of it .

-Happy sx of taking Cannabis start after few min. if taken by smoking, & after 1/2 hr. if taken by mouth.

-Its effect (if taken by mouth) continues 5-12 hrs.

-If big amount taken by mouth, respiratory center may stop & death will result during sleeping.

-Wrongly cannabis is known as sex stimulus (longer sexual activity) which is not proved scientifically.

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Sx of cannabis Abuse: -Feeling of well-being. -Talkative with feeling of euphoria when talking.-Light head.-Hyperactivity. -Difficulty in orientation (esp. time).-If abuser moves up few steps in stair, will imagine that he is over biggest pyramid.-By increasing dose, hallucination will result.

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Long-term using effect:-Respiratory diseases especially Bronchitis. -Cancer of lung. -Cardio-vascular diseases.N.B: Appetite to sweets will increase -Has negative effect on behavior & ethical manner as laughing in sad situation.

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2) Opiates (األفيون)-Morphine, Heroin, Codeine, Pethedin, Crack.-Used in medical field as pain killer, cough relief. -If taken for few months, withdrawal sx will appear. -Each time amount should increase.-Withdrawal sx will appear after 3 hrs. of taking previous dose & reach its peak in 1-2 days.-Usually it is white.-Used by IV, smoking or sniffing .-Heroin leads to much happiness for abuser. -Abuser health: chronic constipation , poor r/s .

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Withdrawal sx:1-Increase urge to get substance, anxiety. 2- Condition like flue (Rhinitis), much sweating, lacrimation.3-Pain in joints & muscles. 4-Vomiting, diarrhea, abdominal pain, appetite. 5-Difficulty in breathing.

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Cocaine:-Made from the leaves of Coca plant (S. America). -Stimulant drug .-White powder used by sniffing, or IV.-Addict may experience grandiosity which can lead addict to take risks, particularly when driving. -Feeling of anxiety will accompany cocaine use.-Effect of cocaine is very short. -Addict of cocaine may become criminal.-Withdrawal sx of cocaine less severity than opiates.

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Complication of cocaine addiction: -Sleep disturbance.-Decrease appetite, decrease wt. -Skin itching. -Depression. -Criminal behavior.-Impotence.

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Crack: -Crack is the street name for crystallized freebase cocaine. -It is most commonly smoked; which takes less than 20 seconds for feelings of euphoria & pleasure to start.-The happy feelings fade just few minutes later & resulting low can be dramatically dismal.

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Rx of addiction (dependence):Criteria (factors) help in Rx:1-Short period b/w starting of taking substance & Rx.2-Availability of intention of pt. to be treated. 3-Age of pt. 4-Level of education.4-Type of substance.5-Acceptance of pt. to follow up Rx at home.

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Stages of Rx:1-Detoxification: l-2wks (weaning) should be in specialized hospital.2-Rehabilitation: Trial to solve problem with cooperation of family, Reinforcement of positive behavior. 3-Follow up: Very important stage , could be more important than Rx itself.-If pt. is relapsed condition worse.

*In some countries they use methadone with small doses. It is not Rx of addiction, but it is substitution by another type with less withdrawal sx.

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Alcoholism -Alcohol is CNS depressant Effect on the brain: Poor judgmentClumsy motor actionsSlurred speech Depressed motor area of brainEmotional labilityConfusionStuporComaDeath (respiratory paralysis)

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With chronic use: -Alcoholic dementia -Social relation inhibition-Marital problems-Occupational problems-Violence-Legal problems increased accidents. Medical problems: Liver cirrhosis, fatty infiltration, gastritis, gastric ulcers, vitamin deficiency (especially thiamin), peripheral neuropathy.

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Epidemiology: -In many countries, alcohol is widely used & abused. -Some people take alcohol occasionally for social reasons or to relieve tension.-Prevalent in early 20-35 years age group.-Onset is in early 20s.-Sx of alcoholism start to appear in 30’s. -Alcoholism can coexist with other psychiatric disorders like: Depression, bipolar, anxiety, & personality disorders.

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Etiology:-Alcoholism is not single disorder, it can have many causes.-Some alcoholics start to drink in an attempt to treat psychiatric problems: anxiety, depression, mania, etc. or physical disorder: pain.-Some people develop alcoholism & become dependent. -The short-term sedative effect of drinking alcohol is replaced by long term dysphoric mood & withdrawal sx which push alcoholic to drink more.

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1. Biological Theory:-Some studies found genetic factor behind alcoholism.

-In one study it was found that 25% of fathers of alcoholic pts. were alcoholic.

-Concordance of alcoholism in monozygotic twins is twice as dizygotic twins.

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2. Psychoanalytic theory : -Individuals who abuse alcohol (or other substances) have undeveloped egos r/s, failure in completing tasks of separation-individuation.

-Person retains highly dependent mature, with characteristics of poor impulse control, low frustration tolerance & low self-esteem.

-Superego is weak, resulting in absence of guilt feelings for their behavior.

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3. Learning theory:Release of anxiety becomes reinforcement for further drinking as it results in temporary reduction of fear & conflict.

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Clinical Picture :Alcoholic intoxication -Maladaptive behavior: sexual & aggressive behavior, labile impaired judgment, impaired social or occupation functions.

-Somatic sx: slurred speech, in-coordination, unsteady gait, nystagmus, flushed face.

-Hematomas & contusions due to falls, hypothermia in cold weather.

-Other sx like liver cirrhosis, peripheral neuropathy & cerebral ataxia.

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Alcohol withdrawal: -Syndrome observed after cessation or reduction of alcohol intake after prolonged period of use.Sx: -Nausea & vomiting.-Malaise, headache, insomnia. -Autonomic hyperactivity. - Anxiety, irritability or depression. - Seizures, especially if past hx of epilepsy.- Hallucinations or illusions.

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1) Delirium Tremens:-Occur in 5% of hospitalized alcoholics within 1 week after cessation or reduction of alcohol intake.-Withdrawal sx progress to state of delirium.Essential features: -Delirium: Clouding of consciousness, disorientation, visual or tactile hallucination.-Autonomic hyperactivity: Tachycardia, sweating, HTN.-Fluctuating level of psychomotor activity: Pt. is sometimes hyperexcitable & sometimes lethargic.Rx: -Benzodiazepines 25 to 50 mg, chlordiazepoxide (librium) 2-4 hrs., adequate nutrition & hydration.

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2) Alcoholic hallucinosis:-In some pts. visual or auditory hallucinations occur within 48 hrs. after cessation of alcohol with no sx of delirium & continue after recovering from withdrawal sx. -Course is short, hallucinations disappear within several weeks or few months.

Rx:-Like delirium, Benodiazepines, nutrition & adequate hydration.-If case is prolonged, anti-psychotics may be used.

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3) Alcohol Amnestic Disorder Encephalopathy:A) Wernick’s Encephalopathy: -Acute reversible neurological syndrome that results from prolonged heavy drinking of alcohol.

-Etiology is due to Thiamin deficiency malnutrition that accompanies as predisposing factor.

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Essential factors are -Ataxia.-Opthalmoplegia: (cranial nerve paralysis).-Nystagmus.-Confusion.-Spontaneous recovery within few days or weeks. -It can progress to Alcohol Amnestic Disorder.

RX:-High doses of parenteral Thiamin & response is rapid.-If Rx delayed, irreversible damage occurs & respond to Rx.

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B)Alcohol Amnestic Disorder (Korsakoff’s Syndrome):-Chronic irreversible disorder resulting from heavy alcohol intake.-Irreversible impairment of memory occurs.

Etiology: is also due to Thiamin deficiency.-Course is short & recovery occurs in only 20% of cases.

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4) Alcoholic Dementia: -Dementia that persists for longer than 3 weeks after cessation of alcohol intake.-Usually occurs in heavy drinkers above 35 y/o who have been drinking for long period.

Essential features:-Impairment of intellectual abilities. -Memory impairment. -Social & occupational impairment. -Condition is chronic & irreversible.-Rx is supportive.

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Rx of Alcohol Dependence:I. Psychotherapy: -To explore the desire of alcoholic to be intoxicated (drinking is treated as a psychological defense).-Anxiety producing factors are discussed .-There should be supportive & active periods of depression are treated by psychotherapy & anti-depressants.

Behavioral Therapy:-Teaching alcoholic other ways to relieve anxiety like relaxation training & assertiveness skills.-Positive reinforcement is used to reinforce abstinence.

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II. Medications:Disulfuram: (Antabuse): used to produce undesirable side effects if alcohol is taken. -Given in dose of 25 only after last drink.-If pt. drinks alcohol while on disulfuram, he experiences nausea, palpitation, dizziness, hypotension, numbness in extremities.-These effect are toxic reactions due to accumulation of acetaldehyde in blood.

Psychotropic medication: Anti-depressants or anxiolotics to treat depression, anxiety or irritability that may occur during abstinence.

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III. Support Groups:-Some alcoholics who have been treated form support groups to help other alcoholics.-These are voluntary organizations that may help pt. during his Rx.Ex: Alcoholics Anonymous (AA).