SUBSTANCE ABUSE
RELATED PROBLEMS
NUR SAKINAH HAMZAH 1120472
NUR ATHIRAH ISMAIL
1120475
Terminologies :
ABUSE/ HARMFUL USE/ MISUSE
Maladaptive patterns of substance use that impair
health in a broad sense
DEPENDENCE
Certain physiological and psychological phenomena that are
induced by the repeated taking of a substance including:
a strong desire to take the substance
progressive neglect of alternative sources of satisfaction
the development of tolerance
a physical withdrawal state
Terminologies :
TOLERANCE
State in which, after repeated administration, a drug produces a decreased
effect, or increasing doses are required to produce the same effect
WITHDRAWAL
Group of symptoms and signs that occur when a drug is reduced in amount
or withdrawn, which last for a limited time
INTOXICATION
Transient syndrome due to recent substance ingestion that produces
clinically significant psychological and physical impairment
ALCOHOL RELATED
DISORDERS
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An Outline of Alcohol-Related
Disorder :
Alcohol intoxication
Alcohol withdrawal
Delirium Tremens
Alcohol abuse
Alcohol related psychiatric disorder
Wernickes encephalopathy
Korsakov syndrome
Alcohol dementia
Personality deterioration
Mood and anxiety disorder
Suicidal behavior
Pathological jealousy
Alcoholic hallucinosis
Sleep disorder
Alcohol
Alcohol
Activate :
Gamma-aminobutyric acid (GABA)
(inhibitory)
Dopamine
Serotonin
Inhibit :
Glutamate receptor activity
(excitatory)
Voltage-gated calcium channel
Thus, alcohol is a potent CNS
depressant.
Epidemiology
Rate of alcohol misuse and dependence are consistently
higher in men than women
Heaviest drinkers are men in late teens or early
twenties and lower in over 45 years
Followers of certain religion are less likely than general
population.
About 200,000 death each year related to alcohol abuse
About 50% of all automotive fatalities involve drunken
drivers.
Have people
G
E
Eye-opener)
Alcohol intoxication
Also called as simple drunkenness, is the recent ingestion of
sufficient amount of alcohol to produce acute maladaptive
behavioral changes.
B.
C.
One (or more) of the following signs and symptoms developing during, or shortly
after, alcohol use :
1. slurred speech
2. incoordination
3. unsteady gait
4. nystagmus
5. impaired in attention and memory
6. stupor or coma
D. The sign or symptom are not attributed to another medical condition, and are not
better explained by another mental disorder, including intoxification with another
substance.
Alcohol Intoxication
EFFECT
20-50 mg/dL
50-100 mg/dL
100-150 mg/dL
150-250 mg/dL
memory, nausea/vomiting
Coma in the novice drinker
300 mg/dL
400 mg/dL
A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.
B. Two (or more) of the following, developing within several hours to a few days after the
cessation of (or reduction in) alcohol use described in Criterion A :
Wernickes encephalopathy
Acute syndrome caused by thiamine deficiency
secondary to chronic alcohol dependent causing
damage in hypothalamus and thalamus.
Characterised by :
Ataxia
Ocular abnormalities (gaze palsies, nystagmus)
Delirium
Peripheral neuropathy
Treatment
100 300mg of thiamine per day until opthalmoplegia
resolve.
Magnesium (a cofactor for thiamine metabolism)
Korsakoffs syndrome
Untreated Wernickes encephalopathy
Chronic amnestic syndrome.
Often coexist with alcohol-related dementia.
Characterised by :
Alcoholic dementia
Chronic alcohol misuse cause
cognitive impairment : memory,
apraxia, agnosia and executive
function (Sullivan et al.,2010)
Excessive alcohol consumption
Enlarged lateral ventricle
Focal deficit with loss of grey matter
in both cortical and subcortical area.
Demyelination
Atrophy of frontal lobe
Repeated occurrence of
Wernickes encephalopathy
Personality
deterioration
Concerned need
to obtain alcohol
deteriorate
interpersonal and
social function
Suicidal behavior
Alcohol dependent
show risk of suicide of
7% (Inskip et. al,1998 ;
Wilcox, 2004)
Male, older, has long
history of drinking,
depression and previous
attempt
Pathological
jealousy
Excessive drinker
develop an
overvalued idea or
delusion that their
partner is being
unfaithful.
Associated psychiatric
disorder
Alcoholic hallucinosis
Sleep disorder
Intoxication
cause increase
non-rapid eye
movement
(NREM) and
reduce rapid
eye movement
(REM)
Increase
wakefulnes
s, restless
sleep and
vivid
dreams or
nightmare
Brief intervention
Motivational interviewing
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www.health.gov.au/internet/alcohol/publishing.nsf/Content/864FDC6AD475CB2CCA257693007CDE3A/$File/treatqui.pdf
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Increase
motivation to
change
High intensity
psychological
treatment
Support &
advice
Alcoholic
anonymous
Withdraw
alcohol/controll
ed drinking
Medication
Disulfiram,
Acamprosate
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Brief intervention
Simple education and advice
Aim- promote safer drinking
not usually sufficient in individuals who have developed dependence or
experiencing more severe alcohol related harms (for whom more intensive
treatment is recommended).
Delivered in one to four sessions, each lasting from 5-10 minutes to 1 hour.
May be opportunistic, offered to individuals identified through screening who have
not sought treatment.
FLAGS
Feedback
Listen
Advice
Goals
Strategies
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Motivational interviewing
Express empathy
Avoid arguing
Detect and roll with resistance
Point out discrepancies in patients hx
Raise awareness about contrast between substance
users aims and behaviour
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Carbamazepine
Alternative to benzodiazepine
No added benefit of combining carbamazepine and benzodiazepine
Chlomethiazole
o Not recommended dt toxicity when combined with alcohol & danger in overdose
o Use in most severe withdrawal states
Antipsychotic drugs
Lower seizure threshold
Less effective than benzodiazepine to reduce delirium
Reduce agitation
Pt with delusion not respond to benzodiazepine
Vitamin supplement
Thiamine to prevent Wernicke-Korsakof Syndrome
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Psychological treatment
Community reinforcement approach
Social behavior & network therapy
Behavioural self control training
Coping& social skills training
Cognitive behavioral relationship therapy
Cue exposure
Relapse prevention
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Pharmacological treatment
Disulfiram (Antabuse)
To achieve abstinence but concerned of relapse, or have had previous relapses
Block oxidation of alcohol >> acetaldehyde accumulate >> unpleasant reaction to
alcohol >> deter from drinking alcohol
What is the unpleasant reaction?
Facial flushing
Throbbing headache
Hypotension
Palpitation
Tachycardia
Nausea
Vomitting
Adverse effect
Diaorrhea
Nausea
Vomitting
Abdominal pain
Skin rashes
Fluctuations in libido
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Nausea
Vomitting
Headache
Dizziness
Weight loss
Topiramate
Anticonvulsant drug
Improve drinking outcome at dose 100 mg/day
Adverse effects:
Paraesthesia
Anorexia
Headache
Abd. Pain
Sleep disturbance
Cognitive impairment
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Antidepressant medication
Persistent symptoms of major depression after detoxification
TCA not recommended dt potential serious interactions :
cardiotoxicity, death following overdose.
SSRI
Improve drinking outcome in type 1 alcohol dependence
Later age of onset
Anxious trait
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Prognosis of treatment
Better prognosis
Good insight
Social stability (fixed abode,
family support, ability to keep a
job)
Ability to control impulsiveness,
to defer gratification, & to form
satisfactory emotional
relationship
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SUBSTANCE USE
DISORDERS
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OPIOIDS
Opiates VS opiods.
Opiates are natural
analgesics derived from
opium in poppy plant.
Opiods are synthetic
analgesic.
Currently, the term opiods
is used for both natural
and synthetic analgesics.
Natural morphine,
heroine
INTRODUCTION
Misused for euphoriant and anxiolytic effects.
Methods of administration
Intravenous
Subcutaneous (skin popping)
Sniffing (snorting)
Heated on metal foil and inhaled (chasing the dragon)
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Epidemiology
In 2012, the prevalence of illicit opioids use in England is 0.3%.
(Psychiatric Morbidity Survey)
HEROINE
a powdery or crumbly substance
ranging all the way from off-white to dark
brown.
White is the purest form of heroin.
Black tar heroin is nearly black and is
sticky instead of powdery.
Other names:
Fit, Fun, Ubat, Panas, Stuff, Tepung, Cik putih,
Penang pink.
MORPHINE
in pill or liquid form.
Other names: M, White Powder, Monkey,
Morpho, Pok Teh
High potential for addiction and abuse. If
dose is reduced after long-term use,
withdrawal may occur.
Legally used in hospitals.
Clinically cause slow breathing, lowered
heart rate, dopiness, constipation,
euphoria and itchiness.
Overdose symptoms include cold,
clammy skin, low blood pressure, slow
pulse rate and even coma and death.
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OVERDOSE symptoms
Bluish nails or lips, depressed breathing, weak pulse, small pupils, delirium, extreme
drowsiness, coma
ADVERSE EFFECT
BABIES of opioid abuser likely to be premature and have low birth weight.
Withdrawal symptoms after birth irritability, restlessness, tremor and a high pitched
cry.
Other factors include poor nutrition & heavy smoking
Later effect overactive and poor resistance
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MANAGEMENT
Identify opioid users, they present to doctors in 3 situations:
1) Supplies running out. They may request directly or by feigning a painful disorder
2) Drug overdose. Most present with respiratory depression.
3) Acute complication of intravenous drug usage such as local infection, necrosis at
infection site or infection of a distant organ, heart or liver.
Detoxification
) Duration of 4 weeks in residential setting and 12 weeks in community setting.
) When the dose is LOW, opioids can be withdrawn more quickly while giving
sympathetic treatments for withdrawal effects.
) When previous daily dose is HIGH, it is necessary to prescribe an opioid, reducing the
dose gradually.
) Other option: Rapid opioid detoxification- usage of opioid antagonist (naltrexone) +
sedation, but requires a high level of nursing support due to severe withdrawal
symptomatology + need to monitor airway in sedated patient.
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MANAGEMENT
Drug used for treating withdrawal symptoms:
In pregnant users
in first trimester, avoid detoxification and aim for mother to engage in a
multidisciplinary care programme for
stabilization on a suitable dose of methadone
Avoidance of illegal drug use
High level of antenatal care
Methadone Maintenance
therapy
4) No chronic illness
5) Intra-venous drug user
6) High self-motivation to stop
HOW
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CANNABIS
Derived from the plant
Cannabis sativa
Marijuana Grass, Ganja
Epidemiology
The most commonly used
illicit drug
Most frequent use - Czech
Republic (45%)
Lowest use - Armenia (3 %)
Third highest rate - UK (29
Clinical effects
Cannabis intoxication
Exaggerate the pre-existing mood
(exhilaration or depression)
Increased enjoyment of aesthetic
experiences
Distortion of the perception of
time and space.
Reddening of the eyes, dry
mouth, tachycardia, irritation of
the respiratory tract, and
coughing.
Can lead dangerous driving
Mechanical action
Pharmacological effects
mediated through
interaction with a specific
cannabinoid receptor in the
central nervous system.
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Adverse effects
Medical illness
Social
Poor psychosocial outcomes
mood disorder
poor educational performance
job instability,
uptake of more harmful illegal
drugs.
Psychological effects
Anxiety.
Dependence
Tolerance
Withdrawal syndrome
( irritability, nausea,
insomnia, and
anorexia)
Psychosis
Depersonalization
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Treatment
Cannabis dependence
Behavioural and psychological interventions to maintain
an abstinent state
Motivational enhancement therapy (MET)
Cognitive Behavioural Therapy (CBT)
* both are some thing
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CNS
STIMULANT
Amphetamine
Methamphetamine (syabu,
sejuk, batu)
Cocaine
Ectasy
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AMPHETAMINE
used as a street drug,
known as speed, whizz, ice,
Other name: kuda, yaba.
Epidemiology:
Currently used rather less
than
cocaine in the UK,
although
they were used more
previously.
Clinical effects
Adverse effects
Over-talkativeness, overactivity,
insomnia, dryness of the lips,
mouth, and nose, and anorexia.
The pupils dilate, the pulse rate
increases, and the blood pressure
rises.
Large doses
Withdrawal syndrome
placental
mild cases - low mood
and abruption
decreased energy.
heavy users- depression,anxiety,
tremulousness, lethargy, fatigue,
and nightmares. Craving for the
drug may be intense, and suicidal
ideation may be prominent.
*Notes : - This drugs are quickly
eliminated
- urine sample should be taken
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Amphetamine-induced psychosis
Repetitive stereotyped behaviour
(e.g. repeated tidying).
Paranoid psychosis
persecutory delusions, auditory and visual hallucinations, and
sometimes hostile and dangerously aggressive behaviour
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Treatment
Acute overdoses
Sedation
Management of hyperpyrexia and cardiac arrhythmias.
Toxic symptoms
resolve quickly when the drug is stopped.
Antipsychotic drug - control florid symptoms.
Dependence
Abstinence is the usual goal
Social and psychological interventions (CBT, contingency management)
Withdrawal syndrome
Benzodiazepines
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COCAINE
INTRODUCTION
Strong illicit stimulant used as
recreational drug.
Made from leaves of coca
plant
EPIDEMIOLOGY
Lifetime use of cocaine in
households in England is 6.3%
0.4% of them meets the
dependence criteria.
COCAINE
CLINICAL EFFECTS
Psychological
Excitement
Increased energy
Euphoria
Grandiose thinking
Impaired judgement
Sexual disinhibition
Physical
Tachycardia
Increased blood pressure
ADVERSE EFFECTS
CVS - Cardiac arrhythmia, MI, Myocarditis, Cardiomyopathy
Cerebrovascular - Cerebral infarction, SAH, TIA
Infective abscess, septicaemia, hepatitis
Obstetric reduced fetal growth, miscarriage, premature labour, placenta abruption
Others - Seizures & respiratory arrest
Higher doses > visual and auditory hallucinations > paranoid ideation > aggressive behaviour
Prolonged use of high dosage > paranoid psychosis with violent behaviour + formication
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WITHDRAWAL SYNDROMES
Dysphoria
Anhedonia
Anxiety
Irritability
Fatigue
Hypersomnolence
TREATMENT
Acute intoxication require
sedation with benzodiazepines
Management of hypertension
and seizures
Psychosocial approach
Cognitive-behavioural therapy
Contingency management
12 step approaches
programme
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HALLUCINOGE
NS
Diverse group of drugs that
alter perception (awareness of
surrounding objects and
conditions), thoughts, and
feelings
Hallucinogen/ Psychotomimetic
Cause hallucinations, or sensations and images that seem real
though they are not
Do not cause physical dependence or withdrawal. Some develop
tolerance
Synthetic
Lysergic acid diethylamide
(LSD),
Methyldimethoxyamphetamin
e
Ketamine
Phencyclidine (PCP)
Dextromethorphan (DXM)
Natural
sp. Of mushrooms contain of
psilocybin (magic mushroom)
Peyote (spineless cactus)
Ayahuasca (plant tea)
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Phencyclidine (PCP)
Angel Dust, Hog, Love Boat, and Peace Pill
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Ketamine
K, Special K, or Cat Valium.
Low dose- mood elevation
High dose- paranoia, hallucinations,
thought disorder, and confusion, sensory and perceptual
distortions and out-of-body experiences
Intoxification- sympathetic overactivity, with chest pain,
tachycardia, and palpitations. Difficulty in breathing, ataxia,
mutism, and temporary paralysis.
Rx- symptomatic and supportive.
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CNS
DEPRESSANTS
-Anxiolytic & Hypotic Agents
-CLUB DRUGS : Erimin-5,
Rohypnol Dan Valium
BENZODIAZEPINES
Widely used for therapeutic purposes
Develop dependence high dose + prolonged usage
(>6 months)
Withdrawal symptoms
anxiety symptoms anxiety, irritability, sweating, tremor,
sleep disturbance
altered perception depersonalization, derealisation,
hypersensitivity to stimuli, abnormal body sensation and
abnormal sensation of movement
other features (rare) depression, suicidal behaviour,
psychosis, seizures, delirium tremens
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BARBITURATES
Formerly used in general anaesthesia
Depression of CNS & respiratory system
CNS: cause sedation, reduce excitement, impaired concentration,
mental & physical sluggishness, higher dose ( anaesthesia, coma &
death)
Respi: suppress the baroreceptor & chemoreceptor response to CO2
Develop dependence
Withdrawal symptoms
Tremors, nausea vomiting, delirium, seizures, cardiovascular
collapse
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INHALANTS
- Solvent / Volatile Substance
- Terms inhalation
- Huffing - Inhaling substances soaked
into a rag
- Sniffing/Snorting - Inhaling fumes
directly from a container
- Bagging - Inhaling fumes from a
substance placed inside of a bag
Types of inhalants
Liquids
Paint thinner
Paint Remover
Dry-Cleaning Fluids
Degreasers
Gasoline
Glues
Correction Fluids,
Felt-Tip Markers
Aerosols
Spray Paints
Deodorant
Hair Sprays
Vegetable Oil Sprays
Fabric Protector
Spray
Gases
Chloroform
Nitrous Oxide
Whipped Cream
Cans
Butane Lighters
Propane Tanks
Refrigerants
Nitrites
Leather Cleaner
Room Deodorizer
Food Preservatives
Sexual Enhancers
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Effects of Inhalant
Euphoria
Blurry
Vision
Slurred
speech
Hallucinati
ons
Drowsines
s
Disorientation
Coma,
Death
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Other adverse
effects of
inhalant
- Sudden sniffing death
syndrome
- Asphyxiation
- dependence can develop if
use is regular
- withdrawal symptoms
(sleep disturbance,
irritability, nausea,
tachycardia, rarely
hallucination)
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Signs of Abuse
HELP acronym
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Treatment
Treatment
approaches
for inhalant
abusers must
be tailored to
meet their
unique
needs.
A good
treatment
program for
anyone with
an inhalant
abuse
problem
includes:
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Thanks!
Any questions?
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