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1 ABDULLAH AL-SUBAIE, MBBS, FRCP (C) PROFESSOR OF e.

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Presentation on theme: "1 ABDULLAH AL-SUBAIE, MBBS, FRCP (C) PROFESSOR OF e."— Presentation transcript:

1 1 ABDULLAH AL-SUBAIE, MBBS, FRCP (C) PROFESSOR OF e

2 2 HIV/AIDS Unipolar depressive disorders Road traffic accidents Tuberculosis Alcohol use disorders Self inflicted injuries Iron-deficiency anemia Schizophrenia Bipolar affective disorder Violence

3 3 % with SubstanceOdds Axis / Disorders Abuse or DependenceRatio Bipolar I617.9 Bipolar II484.7 Schizophrenia474.6 Panic Disorder362.9 OCD Dysthymia312.4 Unipolar Depression271.9 Phobia231.6

4  Anxiolytics and hypnotics  Opioids  Stimulants  Hallucinogens  Cannabis  Organic solvents 4

5 5 Prevalence Issues

6 6  Substance Abuse $660 billion  Alcohol $224 billion  Illicit Drugs $181 billion  Smoking $193 billion  Cancer $265 billion  MVC $99 billion  Diabetes $174 billion  Cardiovascular Diseases $291 billion

7 Global Drug Abuse  The global annual prevalence rate of all illicit drugs ranges from 3.3% to 4.1% of total world population  The most widespread illicit consumption is of cannabis products  About one third of the world’s population age 15 and over are tobacco smokers  Abuse spread relatively slowly in the 1980’s, but increased in a number of countries in the 1990’s 7

8  About one third of the world’s population age 15 and over are tobacco smokers  Abuse spread relatively slowly in the 1980’s, but increased in a number of countries in the 1990’s  In the Americas, the second most widely abused drug is cocaine  Opiate use, while less prevalent, causes by far the greatest medical problems 8 Global Drug Abuse

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18 18 A. The development of a reversible substance- specific syndrome due to recent use of a substance. Different substances may produce similar or identical syndromes. B. Clinically significant maladaptive behavioral or psychological changes that are due to the effect of the substance on the central nervous system (eg, belligerence, mood lability, cognitive impairment, impaired judgment, impaired social or occupational functioning) and develop during or shortly after use of the substance. C. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

19 A. The development of a substance-specific syndrome due to the cessation of (or reduction in) substance use that has been heavy and prolonged. B. The substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder. 19

20 A maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by one (or more) of the following, occurring within a 12-month period: 1. Recurrent substance use resulting in a failure to fulfil major role obligations at work, school, or home (such as repeated absences or poor work performance related to substance use; substance- related absences, suspensions, or expulsions from school; or neglect of children or household). 2. Recurrent substance use in situations in which it is physically hazardous (such as driving an automobile or operating a machine when impaired by substance use) 20

21 3. Recurrent substance-related legal problems (such as arrests for substance related disorderly conduct) 4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (for example, arguments with spouse about consequences of intoxication and physical fights). 21

22 A. Maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12- month period: 1. Tolerance 2. Withdrawal 3. The substance is often taken in larger amounts or over a longer period than was intended 4. There is a persistent desire or unsuccessful efforts to cut down or control substance use 22

23 Defined by either of the following: a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect b) markedly diminished effect with continued use of the same amount of the substance 23

24 As manifested by either of the following: a) the characteristic withdrawal syndrome for the substance (refer to criteria of withdrawal of the specific substance) b) the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms. 24

25 5. A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain- smoking), or recover from its effects 6. Important social, occupational, or recreational activities are given up or reduced because of substance use 7. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., continued drinking despite recognition that an ulcer was made worse by alcohol consumption) 25

26 with physiological dependence: evidence of tolerance or withdrawal (i.e. either item 1 or 2 is present) without physiological dependence: no evidence of tolerance or withdrawal (i.e. neither item 1 nor 2 is present) 26

27  Every dependent is an abuser !  Every abuser is a dependent ! 27

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29  When medical or psychiatric problems may be related to alcohol or drugs.  When certain drugs are requested for unsatisfactory reasons.  When needle tracks and thrombotic veins are found.  Finding scars of previous abscesses. 29

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31  When urine tests positive (except LSD and solvents).  When Gamma–Glutmyle–transferase (GGT) and MCV are elevated.  In cases of self neglect, and school or occupational decline.  In history of former friends loss and joining the “drug culture.”  In history of thefts and prostitution. 31

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33 33 Seeking Stimulation Or Avoiding Pain

34 34 Reasons Why College Students Use Drugs

35 35  Many college students have false perception of how much their peers use marijuana.  In a recent survey, students estimated that 58% of their peers had used marijuana at least once in the past one month, and that 22.4% of them used it daily.  I fact, only 11.4% used marijuana in the pst month and only 1% had used daily Did You Know?

36 Prescribed Benzodiazepines Legal alcohol & nicotine Illegal cocaine, hash 36   

37 Personal characteristics:  Difficulty accepting authority, truancy and poor schooling in teenagers.  Personality disorder, disorganized life & unstable relationships.  Sexual promiscuity. 37

38  Disorganized families.  Unhappy childhood.  History of mental illness or personality disorder in family. 38

39 Social Pressures:  especially in teenagers & school children.  unemployment. Primary effect of the substance Secondary effect of the substance (milieu). 39

40 1. Review history with the patient regarding :  Type of drug (s) and amount  I.V. usage and its dangers  Evidence of dependence  Complications of drugs (physical, psychological and social).  Personal and social resources and problems 40

41 2 Manage withdrawal symptoms 3 Treat urgent medical / psychiatric complications 4 Set attainable goals:  Abstaining from drug  Parting from drug culture  Dealing with personal and financial problems  Establishing new interests 41

42 5. Set longer-term goals:  Individual or group counseling  Help for family  Rehabilitation 6. Self-help groups 42

43 43 Prevention Of availability Improve awarenessIncrease restrictions Of advertising Through media Through schools

44  General medical complications e.g. AIDS, endocarditis  Local effects of I.V. injections e.g. thrombosis.  Impaired functioning, failure of social relations, accidents, family problems and neglect.  Debts due to expensive illicit drugs  Prostitution and crime.  Death. 44

45 45 Abuse & dependence

46  Cut down  Annoyed  Guilty  Eye opener 46 C A E G

47  In England, 6% of men & 1% of women admitted to consumption of >50 units/week.  Lifetime prevalence rate was 0.45% among Chinese in Shanghai & 23% among Native Mexican-Americans  Dependence is usually established in mid- forties for men and a few years later for women.  Dependence is generally more common in disadvantaged areas.  Occupation: Executives, service men, journalists, Salesmen and movie industry unit = 1 cl.

48 Blackouts amnesia to events that occur during the period of intoxication Idiosyncratic intoxication markedly changed behavior (usually aggressive) occurring within minutes of drinking a small amount of alcohol Other effects euphoria/dysphoria, irritability sedation, memory & judgment impairment disinhibition, aggression, violence, accident proneness 48

49 Wernicke’s encephalopathy Cause: Thiamin deficiency leading to bilateral degeneration of the posterior hypothalamus, hippo- campus and mamillary bodies. Features: Delirium, Ataxia and Ophthalmoplegia. 49

50 Korsakov’s syndrome (alcohol amnestic syndrome) Features :  Prominent disturbance of recent memory in the absence of generalized intellectual impairment  Immediate recall is good but recent memory is impaired  Confabulation and disorientation to time may occur. New learning is impaired.  Occurs after prolonged use  On CT scan: Ventricles may be enlarged and sulci may be widened. CT changes may partially resolve on abstinence 50

51  Depression/ Suicide  Anxiety  Personality changes  Pathological jealousy  Sexual dysfunction  Hallucinations  Social damage  Crimes  Road traffic accidents  Occupational problems  Family conflicts and losses 51

52 1. Assess: Extent of drinking Evidence of dependence Alcohol related disability 2. Arrange for and treat withdrawal symptoms: Sedation Thiamin and Vitamin B supplements Rehydration 52

53 3. Treat urgent psychiatric or medical problems: 4. Long term treatment of:  Medical and psychiatric disability  Interpersonal problems  Social problems ( work, law, finance, interests) 3. Arrange for rehabilitation:  Individual and / or group counseling  Self help group e.g. alcohol anonymous  Help for family  Disulfiram (antabuse)- inhibits acetaldehyde dehydroginase… 53

54  Generally poor:  At 6/12: 25% remain abstinent  At 18/12: 10% remain abstinent 54

55  Good prognostic factors include:  Good insight  Strong motivation  Supportive family  Stable job  Ability to form good relationship  Control of impulsivity and ability to defer gratification 55

56 Outcome depends more on the patient than on the treatment

57 Hash or Marijuana 57

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59  Derived from the plant Cannabis sativa  Effect varies according to dose, user’s expectation and social setting  Exaggerates the preexisting mood (euphoria or dysphoria)  Physical dependence and withdrawal symptoms do not occur  Acute intoxication may lead to psychosis while chronic use may lead to “amotivational syndrome 59

60 INHALENTS 60

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62  Most common among teenagers.  Intoxication leads to drunkenness, delirium, uncoordinated gait, nausea, vomiting, and coma.  Visual hallucinations are common.  More psychological than physical dependence.  It has a neurotoxic effect leading to peripheral neuropathy and cerebellar dysfunction.  Over dosage may be fatal and chronic use may lead to psychosis.  Very cheap and easily obtained. 62 Due to: hepatorenal, brain & bone marrow toxicity, bronchial asthma & cardiorespiratory arrest, coma, asphyxiation with plastic bags, trauma …

63 AMPHETAMINES AND COCAINE 63

64 64 الأبيض, أبو قوسين, قضوم, حمص, حلاوة, لجج, لجة, أبو ملف ، داتسون, طباشير, كبتي

65  Lead to elevation of mood, over-activity, insomnia, over-talkativeness, and anorexia.  Cardiac arrhythmia and malignant hypertension may result from high doses.  Death  Prolonged use may result in paranoid psychosis resembling schizophrenia  Physical dependence is not severe  Withdrawal may lead to severe depression and suicide  Treatment includes abstinence, antidepressants and neuroleptics 65

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67 LSD, DISMETHYL TRYPTAMINE AND ANTICHOLINERGIC 67

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69  Lead to distortion or intensification of perceptions or frank hallucinations.  Time moves slowly  Profound meaning of ordinary events.  Body image distortions and depersonalization may occur.  Experience may be pleasant, distressing, or frightening leading to dangerous unpredictable behavior.  Physical effects include hypertension  Flashbacks may occur  More psychological than physical dependence  Treatment is diazepam or phenothiazines (avoid in case of anticholinergic over-dose) 69

70 HEROIN, MORPHINE, CODEINE AND PETHEDIN 70

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72  Lead to immediate effects of euphoria, analgesia, reduced appetite, respiratory depression, drowsiness, gastrointestinal spasms, fits…  Tolerance develops rapidly  Withdrawal symptoms: craving, agitation, insomnia, pains and arthralgia, abdominal cramps, runny nose and eyes, sweating, diarrhea, piloerection, dilated pupils, tachycardia and disturbed temperature control.  Withdrawal starts within 6 hours, peaks in 24–48 hours and it is not life threatening  Short-term treatment includes: relief of withdrawal symptoms.  Long-term treatment includes: methadone replacement and rehabilitation  Treatment outcome remains poor in the best hands.  Death results in about: 10%-20% in 7 years. 72

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