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ALCOHOL, OPIOIDS AND OTHER SUBTANCE-

RELATED DISORDES
2
ND
GROUP
INTRODUCTION
Substances abuse problem causes significant disabilities for a
relatively high percent-age of the population
Substance-induced syndromes can mimic the full range of
psychiatric illnesses! including mood! psychotic! and an"iety disorder
#atient $ho are diagnosed $ith primary substance use disorder
must be evaluated for another psychiatric disorder %dual diagnosis& that
maybe contributing to the substance abuse or dependence
Classification
There are many classes of substances that are associated $ith these
disorder '
(lcohol %ethanol&) $ood alcohol %methanol&
(mphetamine) (mphetamine-li*e substance
Caffeine + Cannabis
Coccaine + ,alusinogen) #sychedelics
Inhalant + Nicotine
Opioids + #hencyclidine %#C#&
Sedatives! ,ypnotics! and (n"iolytics
#rescribed drugs and over the counter %OTC& mediction
(nabolic-(ndrogenic Steroid
Terminology
Dependence
(buse
-isuse + (ddiction
Into"ication + .ithdra$al
Tolerance + Cross-Tolerance
Neuroadaptation + Co-dependence
EVALUATION
To"icology ' Urine or blood test
#hysical /"amination
Diagnosis
abuse is the chronic use and eventually produce dependence on the drug
$ith tolerance and $ithdra$al symptoms
Treatment
The management of abuse or dependence involve abstinence and
long-term treatment
ALCOHOL RELATED DISORDER
The disorder of alcohol associated $ith alcoholism generally can be
divide into three groups %0& disorder related to the direct effect of alcohol on
the brain %1& disorder related to behavior associated $ith alcohol %2& disorder
$ith persisting effects
ALCOHOL DEPENDENCE AND ABUSE
0 Definition
#attern of compulsive alcohol use! defined in DS--I3-TR by the
presence of three or more ma4or areas of impairment related to alcohol
occurring $ithin the same 01 months
1 #harmacology
a #harmaco*inetics
b Neuropharmacology
2 /pidemiology
056 of $omen and 176 of men have met the diagnostic criteria for
alcohol abuse during their lifetimes and 26 to 76 of $omen and 056 of
men have met the diagnostic criteria for the more serious diagnosis of
alcohol dependence
8 /tiology
%0& close family member
%1& the identical t$in of an alcoholic person
%2& adopted-a$ay chidren of alcoholic person
7 Diagnosis! Sign and Symptoms
a (lcohol Dependence
1
Tolerance is the phenomenon in the drin*er The development
of tolerance! especially mar*ed tolerance! usually indicates dependence
-ild tolerance is common but severe tolerance is uncommon
b (lcohol (buse
Chronic use of alcohol that leads to dependence tolerance or
$ithdra$al
9/valuation
the proper evaluation of the alcohol user re:uires some suspicion
on the part of the evaluator
;Treatment
the goal is the prolonged maintenance of total sobriety Initial
treatment re:uires deto"ification and treatment of any $ithdra$al symptoms
<-edical Complication
is a to"ic to numerous organ system
ALCOHOL INTOICATION
(lcohol Into"ication
0Definition
The recent ingestion of sufficient amount of alcohol to produce
acute maladaptive behavioral changes
1Diagnosis! Sign and Symptoms
-ild into"ication may produce a rela"ed! tal*ative! euphoric or
disinhibited person! severe into"ication often leads to more maladaptive
changes
Severe into"ication can lead to $ithdra$n behavior! psychomotor
retardation! blac*outs! and eventually obtundation! coma! and death
2/valuation
( through medical evaluation should be conducted) consider a
possible subdural haematoma! or a concurrent infection (l$ays evaluate
for possible into"ication $ith other substance
8Treatment
a Ussualy only supportive
b -ay give nutrients
c Obsevation for complications may be re:uaired
d (lcoholic idiosyncratic into"ication is a medical
emergency
ALCOHOL!INDUCED PS"CHOTIC DISORDER# $ITH HALLUCINATION
The male to female ratio is 8'0 The condition usually re:uires at least 05
years of alcohol dependence If the patient is agitated! possible treatment
include ben=odia=epine or lo$ doses of high potency antipsychotic
ALCOHOL $ITHDRA$AL
begins $ithin several hours after cessation of or reduction in prolonged
heavy alcohol consumption (t least 1 of follo$ing must be present'
autonomic hyperactivity! hand tremor! insomnia! nausea or vomiting!
transient illusions or hallucination! an"iety! grand mal sei=ures! and
psychomotor agitation
ALCOHOL $ITHDRA$AL DELIRIU%
0Diagnosis! sign and symptoms
a Delirium
b -ar*ed autonomic hyperactivity tachycardia! s$eating fever! an"iety or
insomnia
c (ssociated feature
d Typical feature
1-edical $or*up
a Complete history and physical
b >aboratory test
2Treatment
a ta*e vital sign every 9 hour
b observe the patient constantly
c decrease stimulation
d correct electrolyte imbalance
e if the patient is dehydrated! hydrate
f chlordia=epo"ide! in the geriatric patient! give lora=epam
g thiamine
h ?olic acid
i One multivitamin daily
4 -agnesium sulfat
* (fter the patient is stabili=ed! taper chlordia=epo"ide
l #rovide medication for ade:uate sleep
m Treat malnutrition if present
n This regimen allo$s for a very fle"ible dosage of chlordia=epo"ide
o @enerally antipsychotic should be use cautiously because they can
precipitate sei=ures
ALCOHOL!INDUCED PERSISTIN& A%NESTIC DISORDER
2
Disturbance in short-term memory resulting from prolonged heavy use of
alcohol
0 $ernic'e(s ence)*alo)at*y (n acute syndrome caused by thamin
deficiency Characteri=ed by nystagmus!abducens and con4ugated ga=e
palsies! ata"ia and global confusion Other symptoms may include
confabulation! lethargy!indifference! mild delirium! an"ious insomnia! and
fear of the dar* Treat $ith thiamin until ophtalmoplegia resolves! may also
re:uire magnesium
1+ ,orssa'of(s syn-rome
( chronic condition! ussualy related to alcohol dependence! $herein
alcohol represent a large portion of the caloric inta*e for years Cased by
thiamin deficiency Characteri=ed by retrograde and anterograd amnesia In
addition of thiamine replacement! clonidine and propanolol may be of some
limited use
SUBSTANCES!INDUCED PERSISTIN& DE%ENSIA
This diagnosis should be made $hen other causes of dementia have been
e"cluded and history of chronic heavy alcohol abuse is evident
-anagement is similar to that for dementia of other causes
O#IOID
0Introduction
Opioid include the natural drug opium and its derivatives In
addition to synthetic drug $ith similar action The natural drug derived from
opium include morphin and codein The synthetic opioids include
methadone! o"ycodone!etc heroin is concidered a semisynthetic drug an
has the strongest euphoriant property! thus producing the most craving
OPIOID
1/pidemiology
the opioid drug most associated $ith abuse in heroin! $ith an estimated
955555 heroin user reporterd in US
2Route of administration
Depends on the drug Opium is smo*e ,eroin is typically in4ected or
inhaled nasaly
8 Dosage
Often difficult to determine by history for t$o reason ' %0& the abuser has
no $ay *no$ing the concentration of the heroin ,e or she has bought and
may underestimated the amount ta*en %1& the abuser may over state the
dosage an attempt to get more methadone
7Into"ication
Ob4ective sign and symptom
CNS depression! decreased gastrointestinal motility! respiratory
depression! analgesia! nausea and vomiting! slurred speech! hypotension!
bradycardia! pupillary constriction! sei=ure %in overdose& Tolerant patient still
have pupillary constriction and constipation
b Sub4ective sign and symptoms
/uphoria! decreased attention and memory! dro$siness! and
psychomotor retardation
9Treatment
ICU admission and support of vital functions
Immediately administer 5!< mg nalo"one I3 and $ait 07 minutes
If no response give 0!9 mg I3
If still no response give 2!1 mg I3 and suspect another diagnosis
If successful! continue at 5!8 mgAhour I3
(l$ays consider possible polysubstance overdose
;Tolerance! dependence! and $ithdra$al
Develop rapidly $ith long term opioid use .ithdra$al is seldom a
medical emergency Clinical signs are fluli*e and include drug craving!
an"iety! lacrimation! rhinorrhea! s$eating! insomnia!etc The goal of
deto"ification is to minimi=e $ithdra$al symptoms
<Deto"ification
if ob4ective $ithdra$al signs are present give 05mg methadone! if
$ithdra$al persist after 8-9 hour! give an additional 7-05mg! $hich may
repeated every 1 to 9 hours Total dose in 18 hours e:uals the dose for the
second day %seldomB85mg& @ive t$ice a day or every day decrease dosage
by 7 mgAday for heroin $ithdra$al
COpioid substitutes
-ethadone maintenance program do decrease rates of heroin use
>evomethadyl is a longer acting opioid than methadone
Duprenorphine is a partial E-opioid receptor agonist that is use for both
deto"ification and maintenance treatment
05Therapeutic communities
residential programs that emphasi=e abstinence and group therapy in a
structured environment
00Other interventions
/ducation of ,I3 transmissions! free needle e"change program!
individual and group psychotherapies! self-help groups and outpatient drug-
free programs are also of benefit
FRIS n (D(-
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