Substance Related Disorders
Dr. Anurag Mishra M.D.
Coordinator- Psychoanalytical Wing
Max Hospitals- Delhi
Substance vs Drug
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Drug- Manufactured chemical
Many substances associated with
abuse patterns :
1. Occur Naturally- opium, cannabis
2. Not meant for human consumption- petrol,
solvents
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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
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1.
2.
3.
4.
5.
6.
7.
Impairment or distress because of 3 or more of the
following at any time in a year:
Tolerance: increased amount of substance to produce
same effect / decreased effect with same amount
Withdrawal: typical withdrawal syndrome/ substance or
related compound used to relieve or avoid withdrawal
Use of substance in greater amounts or for a longer
time than originally intended
Unsuccessful attempts or wishes to cut down
Significant time spent in obtaining, using, recovering
Giving up social, occupy, recreational activities
Continued use despite knowledge of physical/ mental
problems
Substance Dependence
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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
•
1.
2.
3.
4.
Pt. not meeting criteria for Dependence with
any one of following in a year:
Failure to fulfill major role obligations
Recurrent use of substance in hazardous
situations
Recurrent legal problems resulting from
substance use
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.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Intoxication: Reversible substance specific syndrome
Substance withdrawal
Substance induced delirium
Substance withdrawal delirium
Substance induced persisting dementia
Substance induced persisting Amnestic disorder
Substance induced psychotic disorder
Substance induced mood disorder
Substance induced anxiety disorder
Substance induced sexual dysfunction
Substance induced sleep disorder
Alcohol Intoxication
Mild
• Overconfidence
• Mood swings, emotional
outbursts, euphoria
• Nausea, vomiting
• Restlessness
Severe
• 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/ coma
T/t (treatment)
1. Conscious pt.- wait!
• Agitation- BZD, anti psychotic
2. Unconscious pt.- keep warm
• Prevent aspiration
• Increased ICT- mannitol
• Hemodialysis in extremes
Sedative, Hypnotic, Anxiolytic
Intoxication
T/t
• BZD, Barbiturates
Mild
• Euphoria
• Sedation
• Paradoxical excitement
• Nystagmus, dysarthria, impaired
attention & memory
• Postural hypotension
Severe (suicide attempts, overdose)
• Coma
• Respiratory depression
• Low BP
• Low cardiac output
• Low temp.
• Coma
• Death
1.
2.
3.
4.
5.
Protect airway
Oxygen
Ventilation
Prevent further body heat loss
I.v. fluids and BP maintenance
with Dopamine
6. Forced diuresis
7. Hemodialysis
Stimulant Intoxication
• Amphetamines,
methamphetamine, cocaine
Mild
• 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 Hemorrhage
T/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
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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 & Coma
T/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, irritability
T/t: Thiamine, BZD
Alcohol Withdrawal
Motor Seizures (Rum fits)
• Seizure in<48 hrs after
stopping
• T/t: I.v. BZD
Alcohol 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 psychotics
Wernicke-Korsakoff Syndrome
• Wernicke’s Encephalopathy/
Alcoholic encephalopathyataxia, giddiness, eye signs
• Korsakoff’s Syndrome/ Chronic
Amnestic Syndrome: Impaired
memory
• T/t: thiamine
Sedative, Hypnotic, Anxiolytic
Withdrawal
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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 )
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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
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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. Detoxification
2. Insistence on
abstinence
3. Avoidance of other
substance
associated with
dependence or
abuse
4. Involvement of
family
5. Toxicology screens
6. Self help groups
7. Treat complications
8. Psychotherapy
9. Treat co morbidities
10. Treat complications