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Substance Use Disorders Substance Use Disorders Dr Hani Zakri ST3 in Psychiatry.

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Presentation on theme: "Substance Use Disorders Substance Use Disorders Dr Hani Zakri ST3 in Psychiatry."— Presentation transcript:

1 Substance Use Disorders Substance Use Disorders Dr Hani Zakri ST3 in Psychiatry


3 . Here's to alcohol: the cause of, and solution to, all of life's problems. Here's to alcohol: the cause of, and solution to, all of life's problems.

4 Classification Classification Aetiology Aetiology Neurobiology Neurobiology Alcohol withdrawal Alcohol withdrawal Delirium Tremens Delirium Tremens Wernicke Korsakoff Syndrome Wernicke Korsakoff Syndrome Opiate Dependence Opiate Dependence Management of opiate withdrawal Management of opiate withdrawal Treatment approaches for substance use problems Treatment approaches for substance use problems Substance use disorders Summary

5 A SIMPLE CLASSIFICATION Stimulants; wake you up, speed you up and give you energy e.g. amphetamine, cocaine and Ecstasy Depressants; make you calm and drowsy e.g. opioids, benzodiazepines,volatile substances and cannabis Hallucinogens; change your perception, by distorting what you see and hear e.g. LSD and magic mushrooms

6 Recreational Use Recreational Use Acute Intoxication Acute Intoxication Harmful Use Dependence syndrome Dependence syndrome Spectrum of substance use

7 Acute intoxication Transient condition following use of alcohol or drugs, closely related to dose and following which recovery is usually complete.

8 Harmful Substance Use A pattern of substance use that causes damage to physical health, mental health or social circumstances. Ingestion of excessive amounts Idiosyncratic Reactions e.g. XTC Accidental Overdose e.g. heroin Method of Administration e.g. IV use Police involvement, Work affected etc.

9 Wake up Question? Mr Smith used to drink at various places, having various drinks. Now he drinks just only at home sticking to vodka? A. Salience B. Narrow repertoire C. Loss of control D. Relief drinking E. Tolerance

10 Dependence Syndrome: 3 or more of the following in the past year….. Compulsion and Cravings Physiological withdrawal state on cessation, relief use Tolerance Difficulty controlling onset, termination, levels of use Salience/Primacy – neglect of alternative pleasures Persistent use despite overt harm (reinstatement, narrowing of repertoire)

11 Wake up Question? Which one of the following is not criterion for dependence according to DSM-IV? A. Tolerance B. Withdrawal C. Compulsion to drink D. Loss of social activities E. Continued intake


13 Biopsychosocial Biopsychosocial

14 Theories & Genes Social learning model: maladaptive behaviour Disease model : loss of control, reduce self blame 4 alcohol dehydrogenase : mild protection 12 aldehyde dehydrogenase : 12% oriental ; significant protection. 40% had family Hx 4 fold increase risk of alcoholism

15 Early influences Genetic predisposition- explains 60% risk in alcoholism, 4xin 1 st degree rels, MZ/DZ concordance = 2/1 Key learning experiences Adopted children x 4 risk Personality factors- socially phobic, anxious, impulsive, risk taking v cautious Immediate factors Mood states Withdrawal states Reinforcing consequences Mood enhancement Psychosocial facilitation Relief of withdrawals, neuroadaptation Early influences Peer group influences Family, parental substance use Cultural factors Immediate factors Demographic factors, Occupation Social pressures, Peers, Religious beliefs Availability, Price, Advertising Aversive consequences Toxic effects Illness Psychosocial dysfunction Disposition to drug/alcohol use IndividualSocial Approach Avoidance Drug/alcohol Use Factors influencing an individuals substance use

16 Wake up Question? Chris and ken are class mate. Chriss dad is alcoholic. How many times is Chris more likely to have problems with alcohol? A. 2-3 times B times C times D. 50 times E. 100 times


18 The reward pathway

19 Reward Pathway activated by. Natural Rewards…… Food Water Sex Nurturing Exercise …… Chemical Rewards Drugs and alcohol Coffee Nicotine……. As addiction develops natural rewards becomes less effective


21 Epidemiology Alcohol consumption, costs Scotland > £1 billion/year Alcohol consumption, costs Scotland > £1 billion/year M/F ratio 2/1,trend towards drinking in young women while men M/F ratio 2/1,trend towards drinking in young women while men % men,14% women in Scotland drink in excess of the government recommended limits (Scottish Health Survey 2003) 27% men,14% women in Scotland drink in excess of the government recommended limits (Scottish Health Survey 2003) 33,000 premature deaths /yr in Eng, Wales 33,000 premature deaths /yr in Eng, Wales

22 Epidemiology 1 in 5 attending GPs 1 in 5 attending GPs 1 in 6 attending A&E 1 in 6 attending A&E 1 IN 16 hospital admission 1 IN 16 hospital admission Vulnerable populations... Homeless (1/3), prisoners Vulnerable populations... Homeless (1/3), prisoners 80% suicides, 80% deaths by fire, 50% homicides 80% suicides, 80% deaths by fire, 50% homicides 40% RTA s, 30% fatal RTA s, 15% deaths by drowning 40% RTA s, 30% fatal RTA s, 15% deaths by drowning

23 Screening tools CAGE: sensitivity 62% AUDIT (Alcohol use disorder s identification test ): sensitivity 83% MAST (MICHIGAN alcohol screening test)

24 CAGE 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)?

25 Recognition and detection of alcohol problems Amount in units Pattern of drinking Time of first drink, Early morning withdrawals Compulsion, craving, tolerance, salience CAGE > 2 positive ? Alcohol dependent GGT (80% sensitivity 80% specificity, detects 1/3) MCV(50% sensitivity, 90% specificity, raised in 60%) CAGE+MCV+GGT detects 75%

26 Low risk: Men < 21 units/week Women < 14 units/week Harmful Drinking: Men >50 units/week Women >35 units/week 2 alcohol free days per week No more than 8 units in one sitting RCPsych, RCGP, RCP Sensible Drinking

27 Units Unit = vol of alcohol (mls) x ABV (%) unit = 8 g alcohol= 1 std measure spirits, ½ pint beer

28 Wake up Question? The amount of alcohol in two pints (568mls) of beer at 4% ABV is: 7 U 10 U 2 U 5 U 4.5 U

29 Biopsychosocial effects of alcohol Physical - Physical - Dyspepsia, HBP, Gout, Psoriasis, Falls, Trauma, Withdrawal syndrome, Cirrhosis, Cardiomyopathy, Neuropathy, Seizures, Death Mental - Mental - Depression, Anxiety, ARBD, Psychosis (Hallucinosis), Blackouts Social - Social - Marital diffs, absenteeism, debt, drink driving, legal problems, drifting, unemployment, Homelessness, Isolation, deprivation.

30 Neuropharmacological Effects Mechanism not well understood CNS Depressant Enhances inhibitory neurotransmission at GABA- A receptors Reduces Excitatory transmission at NMDA Glutamate Receptors

31 Alcohol withdrawal Often missed clinically! Suspect if anxious, restless, irritable, alcohol on breath, excessive capillarisation on facial skin/conjunctivae, GGT, MCV, AST/ALT ratio >2 Majority - 85% require no detox… advice, support will suffice as mild, self limiting < 5% develop Delirium Tremens (DTs) A few will need inpatient detoxification ( DTS, Epilepsy, no social support) Most detoxs done as day patient

32 Wake up Question? The mortality rate for person treated for alcohol withdrawal : A. 1% B. 20% C. 30% D. 40% E. 50%

33 Alcohol Withdrawal > 10 units/day will likely experience some withdrawal Spectrum of severity Usually within 24 hours after last drink Lasts 5-7 days *Tremor*Nausea*Sweating* Headache, HR, BP *Dysphoria - depression, anxiety, sleep disturbance, sensitivity to sound, hallucinations, seizures

34 Wake up Question? What is the typical time period in which withdrawal Sx appear? A. 2 weeks B. 2-3 days C. 2 months D. 5 days

35 Management Diagnose it! Quiet, well lit room with familiar staff Exclude other co existing pathology Re hydration Benzodiazepines… Chlordiazepoxide on reducing scale Regular review Parenteral B prevent Wernickes – must be given IV or IM

36 Wake up Question? Which is the treatment of choice for seizures (SE) in alcohol withdrawal? Diazepam Phenytoin Carbamazepine Lorazepam Chlordiazepoxide

37 Complications Uncontrolled withdrawal Delirium Tremens Withdrawal seizures Wernicke's encephalopathy Elderly maybe sensitive to benzodiazepines, cautious monitoring. Patients with liver disease may be sensitive to benzodiazepines, cautious monitoring.

38 Wake up Question? Failure to Dx and Tx with thiamine for Wernicke's encephalopathy has mortality rate of : A. 5% B. 10% C. 20% D. 30% E. 50%

39 Delirium Tremens Severe withdrawal state – medical emergency Reduced or stopped drinking hrs Precipitated by trauma, infection, head Injury Tremor, sweating, dehydration, fever, HR, temp, HBP, agitation, delirium - fluctuating consciousness, orientation, hallucinations - *visual, fear, paranoia, seizures,, circ.collapse 5-10% mortality treated, 35-40% Untreated Best treatment is prevention!

40 Management Early diagnosis Quiet, well lit room with familiar staff Exclude other co existing pathology Re hydration Regular review Benzodiazepines - may need high doses Parenteral B vitamins – Wernickes Haloperidol if hallucinating

41 Wake 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 TDS Oral thiamine 50 mg TDS IV thiamine 250mg TDS IM thiamine 50mg TDS Not required

42 Wernicke – Korsakoff syndrome

43 Wernicke – Korsakoff syndrome Organic brain syndrome induced by deficiency of Vitamin B1 - Thiamine Wernickes encephalopathy - Acute Confusional State, Ataxia, Nystagmus, Tremor Ophthalmoplegia Korsakoffs syndrome- long term sequelae. STM impairment, confabulation

44 Wake up Question? If untreated what percentage Wernickes encephalopathy develop Korsakoffs syndrome? A. 5% B. 10% C. 20% D. 30% E. 75%

45 Thiamine Co enzyme in glucose, lipid metabolism Involved in the production of A As, glucose derived neurotransmitters, Myelin Neurotoxicity occurs when citric acid cycle is impaired and lactate accumulates Deficiency due to Reduced intake - alcohol for food, GI upset Malabsorption - malnutrition, effect of alcohol Reduced storage - liver damage Impaired utilisation - liver damage Glucose load on admission to hospital (glucose drip!, meal)

46 Wernicke – Korsakoff syndrome Fallacies – 1.Rare condition - NO ! actually common and often missed, less than 10% diagnosed before post mortem 2.Classic triad necessary for diagnosis - NO ! - classic triad only present in 10% of cases, presentation is non-specific, most common feature is confusion

47 Wernickes encephalopathy Potentially life-threatening Potentially treatable Clinical diagnosis non specific presentation 10% classic triad, 23% ataxia, 29% ophth. 82% confusion - non specific - assoc with W/D, DTs, BP, temp Can evolve as series of minor sub clinical encephalopathies (Acute/insidious onset - similar pathology)

48 Wake up Question? The symptom that responds earlier to thiamine is : Ataxia Confusion Opthalmoplegia Amnesia Apathy

49 Korsakoffs syndrome Classically - STM memory impairment Confabulation (not universal) Rel.intact intellectual functioning Not always preceded by Wernickes memory of remote events may also be disturbed, memory often improves Overlap with alcohol dementia Personality change, spontaneity etc.

50 Prognosis of Korsakoffs Psychosis Worse if sudden onset and pure Better with more global cog. Impairment – rewiring? Better in non alcoholic cases of WKS Improves with abstinence from alcohol Victor 26% Long Term Care 28% slight recovery 25% sig. recovery 21% complete recovery

51 Treatment Prophylaxis - all inpt detox 1 pair iv/im 3-5 days Treatment 2 pairs iv/im TDS 3 days If response 1 pair 5 days no response stop 3 days Ataxia, polyneuritis, confusion, memory - continue to treat as long as clinically improving Dilute, infuse over 30 mins, CPR facilities

52 Wake up Question? The following are diagnostic features of alcohol dependence except: A. compulsion to take alcohol B. escalation of amount used C. withdrawal syndrome D. visual hallucinations.

53 Wake up Question? The following drugs are correctly described: A. disulfiram inhibits the breakdown of alcohol B. acamprosate is a potent anticonvulsant C. naltrexone blocks the effects of endogenous opioids D. chlormethiazole is the treatment of choice for medically assisted detoxification.

54 Wake up Question? The following is NOT cause of raised mean cell volume: A. iron deficiency anaemia B. Alcohol C. pernicious anaemia D. pregnancy E. heavy smoking.

55 Wake up Question? All of the following tests usually remain elevated for four weeks or more after an episode of alcohol misuse except? A. aspartate amino transferase B. white cell count C. serum ethanol D. gamma glutamyl transferase.


57 Epidemiology 1/20 Scottish adults have used drugs in the past month. 1% adults in Glasgow opiate dependent 70% IVDU in Glasgow Hep C positive

58 Opiate Intoxication Pupils, consciousness, RR, HR, Coma Death Medical emergency Naloxone iv – but Beware - short acting (45min)!!! Why?.. Purity of street heroin variable, greedy, Loss of Tolerance after detox, Accidental ODs esp. if poly drug use Re instatement deaths

59 Biopsychosocial effects of Opiates Physical - Physical - Constipation, loss of appetite, lethargy, accidental OD, Withdrawal syndrome, HIV, Hep C, Weight Loss, DVTs, abscesses, infections Mental - Mental - mood swings, depression Social - Social - Family and marital problems, absenteeism, Debts, Lifestyle change- drug seeking, Imprisonment, Homelessness, Isolated, Violence, Prostitution,

60 Wake up Question? Tolerance does NOT develop to which of the following : Sedation Insomnia Constipation Miosis

61 Opiate Withdrawal – flu Spectrum of severity Within 12 hours, peak 72 hours Pupillary dilatation, Piloerection, Rhinorrhoea, Lacrimation, Sneezing, Nausea, Vomiting, Diarrhoea, Muscle, stomach cramps, Anxiety, Dysphoria, Cravings, HR, HBP Resolved within a week but some mild symptoms persist longer - sleep, mood

62 Wake up Question? Which of the following is NOT found in opiate withdrawal ? Abdominal pain Dry eyes Vomiting Sweating Dilated pupils

63 Wake up Question? The half life of Methadone in regular user is : 4-6 hours : opioid naive hours hours hours 1 hour

64 Management…… Opiate withdrawal is not an emergency!!! Take time to consider options, be safe Dont be pressurised into prescribing Options are detox. or substitution, will need worked up for both Depends on the patients wishes and overall situation at the time No point de-toxing if they wish to continue using, or if they are socially unstable (reinstatement death!) Counsel carefully. Incorporate harm reduction advice

65 Management - Detox Lofexidine detox– alpha 2 agonist, usually as a day patient, rarely as in patient - relieves physical withdrawal symptoms Supportive care and adjuvant treatment with Buscopan, Paracetamol, Imodium, diazepam Naltrexone Blocker after detox, reduces cravings Counselling Psychosocial Help Warn Re: loss of tolerance and risk of Reinstatement death!!!!!

66 Wake up Question? What is the equivalent dose of methadone for 0.5 g of street Heroin? ml of 1mg/ml mixture

67 Management - Substitution Confirm opiate dependence by urine and observation of withdrawal Titrate substitute carefully Work towards stability and then detox Methadone Must be daily supervised dispensing 1/3 leakage to street! Buprenorphine – sublingual, again supervised dispensing as risk of leakage: drug of choice in low BP


69 Matching patients to treatment No single treatment is appropriate for all Effective treatment addresses multidisciplinary needs not just drug and alcohol use Treatment must address medical, psychological, social, family, legal, and vocational problems.

70 Principles 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

71 Maintenance Pre- contemplation ActionContemplation Relapse Enter: Harmful use Exit: Abstinence, moderation Cycle of Change Prochaska and DiClementi (1984 ) What stage are they at?

72 Harm minimisation: Cutting down B vitamins to protect brain (alcohol) Smoking instead of injecting Using Needle exchange Hep B vaccination Safe Sex advice (Hep B,C,HIV) Substitution therapy - Methadone alcohol if Hep C positive and opiate dependent Risks of cocaine, Alcohol – coca ethylene

73 Abstinence: 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

74 Detoxification Not always necessary Not always desired Must be planned, never rush into it Timing is crucial Alcohol detox usually as day patient, but some need in patient( fits, DTs, Head injury, isolated) Opiate detox usually as day patient

75 Psychotherapy Counselling Motivational enhancement therapy Relapse prevention therapy CBT Social skills training Group therapy Family therapy Twelve step programmes - AA, NA Residential rehabilitation


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