Presentation on theme: "Substance Use Disorders"— Presentation transcript:
1Substance Use Disorders Dr Hani ZakriST3 in PsychiatryDrug Addiction: A Complex IllnessDrug addiction is a complex illness. The path to drug addiction begins with the act of taking drugs. Over time, a person’s ability to choose not to take drugs is compromised. This in large part is a result of the effects of prolonged drug use on brain functioning, and thus on behavior. Addiction, therefore, is characterized by compulsive, drug craving, seeking, and use that persists even in the face of negative consequences.1
3“.”“Here's to alcohol: the cause of, and solution to, all of life's problems.”
4Substance use disorders Summary ClassificationAetiologyNeurobiologyAlcohol withdrawalDelirium TremensWernicke Korsakoff SyndromeOpiate DependenceManagement of opiate withdrawalTreatment approaches for substance use problemsThese are some of the aspects I will be touching upon today during the course of the next one hour.
5A SIMPLE CLASSIFICATION Stimulants; wake you up, speed you up and give you energy e.g. amphetamine, cocaine and EcstasyDepressants; make you calm and drowsy e.g. opioids, benzodiazepines,volatile substances and cannabisHallucinogens; change your perception, by distorting what you see and hear e.g. LSD and magic mushroomsA very simple classification of drugs can be based on their effect. So that would be as stimulants, depressants and hallucinogens
6Spectrum of substance use Recreational UseAcute IntoxicationHarmful UseDependence syndromeSustance use can exist anywhere along this broad spectrum, from recreational use which can include your average trip to the pub to a full fledged dependence syndrome
7Acute intoxicationTransient condition following use of alcohol or drugs, closely related to dose and following which recovery is usually complete.I’m sure a lot of you have been in this position before, so I don’t really need to elaborate further on this. The key here is that recovery is usuallly complete.
8Harmful Substance Use A pattern of substance use that causes damage to physical health, mental healthor social circumstances.Ingestion of excessive amounts“Idiosyncratic” Reactions e.g. XTCAccidental Overdose e.g. heroinMethod of Administration e.g. IV usePolice involvement, Work affected etc.In addition to these examples whats also important is to remember that harm need not be restricted only to physical health. Mental health problems secondary to drug and alcohol use such as drug induce psychosis shall also come under this.
9Wake up Question?Mr Smith used to drink at various places , having various drinks. Now he drinks just only at home sticking to vodka?SalienceNarrow repertoireLoss of controlRelief drinkingTolerance
10Dependence Syndrome: 3 or more of the following in the past year….. Compulsion and CravingsPhysiological withdrawal state on cessation, relief useToleranceDifficulty controlling onset, termination, levels of useSalience/Primacy – neglect of alternative pleasuresPersistent use despite overt harm(reinstatement, narrowing of repertoire)The next step in the progression of the disorder after harmful use. The 5 C’s as well as other features such as reinstatement after a period of abstinence and narrowing of repertoire.
11Wake up Question?Which one of the following is not criterion for dependence according to DSM-IV?ToleranceWithdrawalCompulsion to drinkLoss of social activitiesContinued intake
13“Biopsychosocial”I’m sure this is a term u have all heard before, few other disorders capture the essence of this better than susbtance use disorders
14Theories & Genes Social learning model: maladaptive behaviour Disease model : loss of control, reduce self blame4 alcohol dehydrogenase : mild protection12 aldehyde dehydrogenase : 12% oriental ; significant protection.40% had family Hx4 fold increase risk of alcoholism
15Disposition to drug/alcohol use IndividualSocialFactors influencing an individuals substance useEarly influencesGenetic predisposition- explains 60% risk in alcoholism, 4x↑in 1st degree rels, MZ/DZ concordance = 2/1Key learning experiencesAdopted children x ↑4 riskPersonality factors- socially phobic, anxious, impulsive, risk taking v cautiousEarly influencesPeer group influencesFamily, parental substance useCultural factorsImmediate factorsDemographic factors, OccupationSocial pressures, Peers, Religious beliefsAvailability, Price, AdvertisingImmediate factorsMood statesWithdrawal statesDisposition to drug/alcohol useApproachAvoidanceQuite a crowded slide. It attempts to look at the factors which influence an individuals susceptibility to use substances as well as the factors which influence his behaviour once he begins to use themDrug/alcohol UseAversive consequencesToxic effectsIllnessPsychosocial dysfunctionReinforcing consequencesMood enhancementPsychosocial facilitationRelief of withdrawals, neuroadaptation
16Wake up Question?Chris and ken are class mate. Chris’s dad is alcoholic. How many times is Chris more likely to have problems with alcohol?2-3 times4-10 times10-20 times50 times100 times
17NEUROBIOLOGYI’ll speak a bit about the neurobiology behind substance use.
18The reward pathway Slide 11: The reward pathway Tell your audience that this is a view of the brain cut down the middle. An important part of the reward pathway is shown and the major structures are highlighted: the ventral tegmental area (VTA), the nucleus accumbens and the prefrontal cortex. The VTA is connected to both the nucleus accumbens and the prefrontal cortex via this pathway and it sends information to these structures via its neurons. The neurons of the VTA contain the neurotransmitter dopamine which is released in the nucleus accumbens and in the prefrontal cortex (point to each of these structures). Reiterate that this pathway is activated by a rewarding stimulus. [Note: the pathway shown here is not the only pathway activated by rewards, other structures are involved too, but only this part of the pathway is shown for simplicity.]18
19Reward Pathway activated by. Natural Rewards…… FoodWaterSexNurturingExercise ……Chemical RewardsDrugs and alcoholCoffeeNicotine…….As addiction develops natural rewards becomes less effectiveNormally the reward pathway is activated by natural rewards which act as positive reinforcers. But drugs of abuse produce far greater effects on the pathway than natural rewards. Therefore over time the brain directs its normal drives away from natural rewards towards the drugs. In severe addiction as occurs with the more powerful drugs such as heroin all natural drives may be subsumed to the need for the drug and addict may ignore his self care, food, work etc
21EpidemiologyAlcohol consumption ↑, costs Scotland > £1 billion/yearM/F ratio 2/1,trend towards ↑drinking in young women while men 20-2427% men,14% women in Scotland drink in excess of the government recommended limits (Scottish Health Survey 2003)33,000 premature deaths /yr in Eng, WalesOne of the biggest public health problems. Costs scottish economy more than one billion each year. Also no matter what field of medicine u specialise in there is no escaping from dealing with alcohol related morbidity.
22Epidemiology 1 in 5 attending GPs 1 in 6 attending A&E 1 IN 16 hospital admissionVulnerable populations... Homeless (1/3), prisoners80% suicides, 80% deaths by fire, 50% homicides40% RTA’ s, 30% fatal RTA’ s, 15% deaths by drowning
23Screening tools CAGE: sensitivity 62% AUDIT (Alcohol use disorder s identification test ): sensitivity 83%MAST (MICHIGAN alcohol screening test)
24CAGE Have you ever felt you should Cut down on your drinking? Have people Annoyed you by criticizing your drinking?Have you ever felt bad or Guilty about your drinking?Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?4 quick questions, can be easily fit into a consultation. Important to ask them before taking an alcohol history.
25Recognition and detection of alcohol problems Amount in unitsPattern of drinkingTime of first drink, Early morning withdrawalsCompulsion, craving, tolerance, salienceCAGE > 2 positive ? Alcohol dependentGGT (80% sensitivity 80% specificity, detects 1/3)MCV(50% sensitivity, 90% specificity, raised in 60%)CAGE+MCV+GGT detects 75%First step is obviously to recognise and identify the problem, be it in general practice or in the OPD or in the hospital wards. Take a good history.
26Sensible Drinking Low risk: Men < 21 units/week Women < 14 units/weekHarmful Drinking: Men >50 units/weekWomen >35 units/week2 alcohol free days per weekNo more than 8 units in one sittingRCPsych, RCGP, RCP
27Units Unit = vol of alcohol (mls) x ABV (%) 1000 1 unit = 8 g alcohol= 1 std measurespirits, ½ pint beerABV= alcohol by volume
28Wake up Question?The amount of alcohol in two pints (568mls) of beer at 4% ABV is:7 U10 U2 U5 U4.5 U
29Biopsychosocial effects of alcohol Physical - Dyspepsia, HBP, Gout, Psoriasis, Falls, Trauma, Withdrawal syndrome, Cirrhosis, Cardiomyopathy, Neuropathy, Seizures, DeathMental - Depression, Anxiety, ARBD, Psychosis (Hallucinosis), BlackoutsSocial - Marital diffs, absenteeism, debt, drink driving, legal problems, drifting, unemployment, Homelessness, Isolation, deprivation.So what does alcohol do to u? well a whole bunch of not so nice things
30Neuropharmacological Effects Mechanism not well understoodCNS DepressantEnhances inhibitory neurotransmission at GABA- A receptorsReduces Excitatory transmission at NMDA Glutamate Receptors
31Alcohol withdrawal Often missed clinically! Suspect if anxious, restless, irritable, alcohol on breath, excessive capillarisation on facial skin/conjunctivae,↑GGT, MCV, AST/ALT ratio >2Majority - 85% require no detox… advice, support will suffice as mild, self limiting< 5% develop Delirium Tremens (DT’s)A few will need inpatient detoxification( DT’S, Epilepsy, no social support)Most detoxs’ done as day patient
32Wake up Question?The mortality rate for person treated for alcohol withdrawal :1%20%30%40%50%
33Alcohol Withdrawal> 10 units/day will likely experience some withdrawalSpectrum of severityUsually within 24 hours after last drinkLasts 5-7 days*Tremor*Nausea*Sweating* Headache, ↑HR, ↑ BP *Dysphoria - depression, anxiety, sleep disturbance, sensitivity to sound, hallucinations, seizures
34Wake up Question?What is the typical time period in which withdrawal Sx appear?2 weeks2-3 days2 months5 days
35Management Diagnose it! Quiet, well lit room with familiar staff Exclude other co existing pathologyRe hydrationBenzodiazepines… Chlordiazepoxide on reducing scaleRegular reviewParenteral B vitamins ..to prevent Wernicke’s – must be given IV or IM
36Wake up Question?Which is the treatment of choice for seizures (SE) in alcohol withdrawal?DiazepamPhenytoinCarbamazepineLorazepamChlordiazepoxide
37Complications Uncontrolled withdrawal Delirium Tremens Withdrawal seizuresWernicke's encephalopathyElderly maybe sensitive to benzodiazepines, cautious monitoring.Patients with liver disease may be sensitive to benzodiazepines, cautious monitoring.
38Wake up Question?Failure to Dx and Tx with thiamine for Wernicke's encephalopathy has mortality rate of :5%10%20%30%50%
39Delirium Tremens Severe withdrawal state – medical emergency Reduced or stopped drinking hrsPrecipitated by trauma, infection, head InjuryTremor, sweating, dehydration, fever, ↑HR, ↑temp, HBP, agitation, delirium - fluctuating consciousness, orientation, hallucinations - *visual, fear, paranoia, seizures,, circ.collapse5-10% mortality treated, 35-40% UntreatedBest treatment is prevention!Hallucinations: complex and appear very realistic. Pt. described a 5 piece band made up of leprechauns who came out from behind the ecg monitor at night and played for him.
40Management Early diagnosis Quiet, well lit room with familiar staff Exclude other co existing pathologyRe hydrationRegular reviewBenzodiazepines - may need high dosesParenteral B vitamins – Wernicke’sHaloperidol if hallucinating
41Wake up Question?Malnourished Patient was due surgery. Developed DTs, no signs of Wernicke's encephalopathy. What is your best strategy for thiamine replacement in this patient ?Oral thiamine 30 mg TDSOral thiamine 50 mg TDSIV thiamine 250mg TDSIM thiamine 50mg TDSNot required
43Wernicke – Korsakoff syndrome Organic brain syndrome induced by deficiency of Vitamin B1 - ThiamineWernicke’s encephalopathy - Acute Confusional State, Ataxia, Nystagmus, Tremor OphthalmoplegiaKorsakoff’s syndrome- long term sequelae. STM impairment, confabulation
44Wake up Question?If untreated what percentage Wernicke’s encephalopathy develop Korsakoff’s syndrome?5%10%20%30%75%
45Thiamine Co enzyme in glucose, lipid metabolism Involved in the production of A A’s, glucose derived neurotransmitters, MyelinNeurotoxicity occurs when citric acid cycle is impaired and lactate accumulatesDeficiency due toReduced intake - alcohol for food, GI upsetMalabsorption - malnutrition, effect of alcoholReduced storage - liver damageImpaired utilisation - liver damageGlucose load on admission to hospital(glucose drip! , meal)
46Wernicke – Korsakoff syndrome Fallacies –1.Rare condition -NO ! actually common and often missed, less than 10% diagnosed before post mortem2.Classic triad necessary for diagnosis -NO ! - classic triad only present in 10% of cases, presentation is non-specific, most common feature is confusionClassical triad of ataxia, opthalmoplegia and confusion
47Wernicke’s encephalopathy Potentially life-threateningPotentially treatableClinical diagnosis “non specific presentation”10% classic triad, 23% ataxia, 29% ophth.82% confusion - non specific - assoc with W/D, DT’s, ↓ BP, ↓ tempCan evolve as series of minor sub clinical encephalopathies(Acute/insidious onset - similar pathology)
48Wake up Question? The symptom that responds earlier to thiamine is : AtaxiaConfusionOpthalmoplegiaAmnesiaApathy
49Korsakoff’s syndrome Classically - STM memory impairment Confabulation (not universal)Rel.intact intellectual functioningNot always preceded by Wernicke’smemory of remote events may also be disturbed, memory often improvesOverlap with alcohol dementiaPersonality change, ↓ spontaneity etc.Charecterized by deficiets in anterograde and retrograde memory, apathy and relative preservation of other intellectual abilities.
50Prognosis of Korsakoff’s Psychosis Worse if sudden onset and “pure”Better with more global cog. Impairment – rewiring?Better in non alcoholic cases of WKSImproves with abstinence from alcoholVictor % Long Term Care28% slight recovery25% sig. recovery21% complete recovery
51Treatment Prophylaxis - all inpt detox 1 pair iv/im 3-5 days Treatment pairs iv/im TDS 3 daysIf response 1 pair 5 daysno response stop 3 daysAtaxia, polyneuritis, confusion, ↓ memory - continue to treat as long as clinically improvingDilute, infuse over 30 mins, CPR facilities
52Wake up Question?The following are diagnostic features of alcohol dependence except:compulsion to take alcoholescalation of amount usedwithdrawal syndromevisual hallucinations.
53Wake up Question? The following drugs are correctly described: disulfiram inhibits the breakdown of alcoholacamprosate is a potent anticonvulsantnaltrexone blocks the effects of endogenous opioidschlormethiazole is the treatment of choice for medically assisted detoxification.
54Wake up Question?The following is NOT cause of raised mean cell volume:iron deficiency anaemiaAlcoholpernicious anaemiapregnancyheavy smoking.
55Wake up Question?All of the following tests usually remain elevated for four weeks or more after an episode of alcohol misuse except?aspartate amino transferasewhite cell countserum ethanolgamma glutamyl transferase.
57Epidemiology 1/20 Scottish adults have used drugs in the past month. 1% adults in Glasgow opiate dependent70% IVDU in Glasgow Hep C positiveMajor public health problem. Not just in terms of the direct effects of drug use but also as a result of the knock on effects. So things like hep c and hiv from ivda and increase in crime to fund drug habits
58Opiate Intoxication ↓Pupils, ↓consciousness, ↓RR, ↓HR, Coma→ Death Medical emergencyNaloxone iv – but Beware - short acting (45min)!!!Why?.. Purity of street heroin variable, “greedy”,Loss of Tolerance after detox,“Accidental OD’s” esp. if poly drug use“Re instatement deaths”
59Biopsychosocial effects of Opiates Physical - Constipation, loss of appetite, lethargy, accidental OD, Withdrawal syndrome, HIV, Hep C , Weight Loss, DVT’s, abscesses, infectionsMental - mood swings, depressionSocial - Family and marital problems, absenteeism, Debts, Lifestyle change- drug seeking, Imprisonment, Homelessness, Isolated, Violence, Prostitution,
60Wake up Question?Tolerance does NOT develop to which of the following :SedationInsomniaConstipationMiosis
61Opiate Withdrawal – “flu” Spectrum of severityWithin 12 hours, peak 72 hoursPupillary dilatation, Piloerection, Rhinorrhoea, Lacrimation, Sneezing, Nausea, Vomiting, Diarrhoea, Muscle, stomach cramps, Anxiety, Dysphoria, Cravings, ↑HR, HBPResolved within a week but some mild symptoms persist longer - sleep, mood
62Wake up Question?Which of the following is NOT found in opiate withdrawal ?Abdominal painDry eyesVomitingSweatingDilated pupils
63Wake up Question? The half life of Methadone in regular user is : 4-6 hours : opioid naive10-20 hours24-36 hours72-90 hours1 hour
64Management…… Opiate withdrawal is not an emergency!!! Take time to consider options, be safeDon’t be pressurised into prescribingOptions are detox. or substitution, will need worked up for bothDepends on the patient’s wishes and overall situation at the timeNo point de-toxing if they wish to continue using, or if they are socially unstable (reinstatement death!)Counsel carefully.Incorporate harm reduction advice
65Management - DetoxLofexidine detox– alpha 2 agonist , usually as a day patient, rarely as in patient - relieves physical withdrawal symptomsSupportive care and adjuvant treatment with Buscopan, Paracetamol, Imodium, diazepamNaltrexone “Blocker” after detox, reduces cravingsCounsellingPsychosocial HelpWarn Re: loss of tolerance and risk of Reinstatement death!!!!!
66Wake up Question?What is the equivalent dose of methadone for 0.5 g of street Heroin?30-40 ml of 1mg/ml mixture
67Management - Substitution Confirm opiate dependence by urine and observation of withdrawalTitrate substitute carefullyWork towards stability and then detoxMethadoneMust be daily supervised dispensing1/3 leakage to street!Buprenorphine – sublingual, again superviseddispensing as risk of leakage: drug of choice in low BP
69Matching patients to treatment No single treatment is appropriate for allEffective treatment addresses multidisciplinary needs not just drug and alcohol useTreatment must address medical, psychological, social, family, legal, and vocational problems.No one size fits all
70Principles of Treatment What stage are they at ?How can I best help this person at this stage?Would they like help? Are they Motivated?“Psycho education”Are they aware of the facts and options?“Harm Minimisation”Will they consider reducing intake? Safer use?“Abstinence”Do they wish to stop completely?“Pharmacotherapy ”Will they consider medication?“Psychological treatments”
71What stage are they at? Enter: Harmful use Exit: Abstinence, moderationRelapsePre- contemplationMaintenanceActionContemplation“Cycle of Change” Prochaska and DiClementi (1984 )
72Harm minimisation: Cutting down B vitamins to protect brain (alcohol) Smoking instead of injectingUsing Needle exchangeHep B vaccinationSafe Sex advice (Hep B,C,HIV)Substitution therapy - Methadone↓alcohol if Hep C positive and opiate dependentRisks of cocaine, Alcohol – “coca ethylene”
73Abstinence: Really ready to give it up? Is this the right time? Good social support?Need a Detox?Need Rehabilitation?Will medication help?- cravings, relapse prevention
74Detoxification Not always necessary Not always desired Must be planned, never rush into itTiming is crucialAlcohol detox usually as day patient, but some need in patient( fits, DTs, Head injury, isolated)Opiate detox usually as day patient