Substance Related Disorders Dr. Y R Bhattarai TMU

What is a drug? A drug is a substance that has an action on biological tissues when administered Some drugs influence mood cognition and behavior ◦ Psychoactive/Psychotropic drugs are like alcohol, cocaine, diazepam etc.

Psychoactive Drugs Substances active on CNS tissues when administered thereby causing changes in mood, cognition, behavior

Psychoactive Substance Psychoactive (psychotropic) substance is any substance which after absorption has influence on mental processes both cognitive and affective.

Drug Action on the Nervous System Most drugs that are abused have a common effect on a particular NT pathway. The basic addiction pathway in the brain is a dopamine pathway followed by serotonin. Activation of this pathway accounts for the positive reinforcement, feeling and makes us want to repeat the action that triggered the feeling. Action on NT systems  Agonist  Antagonist

Drug Action on the Nervous System – Reinforcement

Drug Action on the Nervous System on Repeated Use Tolerance ◦ Decreased response to repeated exposure Dependence ◦ System adapts to presence of drug. Drug necessary for homeostasis Withdrawal ◦ Response to drug leaving the system Addiction ◦ Compulsive engagement in reinforcing behavior

The DSM-IV defines substance abuse as A maladaptive pattern of substance leading to clinically significant impairment or distress as manifestated by one or more of the following: Failure to fulfill major role obligations at home, school, or work. Recurrent substance use in situations in which it is physically hazardous.

Definition.... Recurrent substance related legal problems. Recurrent substance use despite persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.

Classification of the substances that are commonly abused ALCOHOL SEDATIVES, HYPNOTICS & ANXIOLYTICS OPIATES (morphine, heroin) HALLUCINOGENS (LSD, mescaline) STIMULANTS (amphetamine, cocaine) CANNABIS (marijuana, hashish) NICOTINE CAFFEINE INHALANTS (glue, paint, thinner) PHENCYCLIDINE ( PCP, angel dust)

Mental and Behavioral Disorders Due to Psychoactive Substance Use Specific Clinical Conditions:  Acute intoxications  Dependence syndrome  Withdrawal state  Psychotic disorder  Amnesic syndrome  Residual state, late-onset psychotic disorder

Substance Dependence (Addiction) Substance dependence is defined as adaptive pattern of substance use leading to clinically significant impairment, as manifested by three or more of the following occuring at any time in a 12 months period. Tolerance Withdrawal Repeated unintended, excessive use Persistent failed efforts to cut down.

Substance Dependence contd... Excessive time spent trying to obtain the substance Reduction in important social,occupational or recreational activities. Continued use despite awareness that substance is the cause of psychological or physical difficulties. Physical dependence Psychic (psychological) dependence

Withdrawal State Symptoms occurring on absolute or relative withdrawal of a substance after repeated and prolonged use of the substance ◦ Uncomplicated ◦ With convulsions

Influence causing Drug Disorders

Public Health Model Agent – Drug Properties Host – Person Characteristics Environment Access, Norms Media

Epidemiology 37% of people report to having used an illicit substance Abou1/3 rd of psychiatric disorders are abuse disorders. Men outnumber women roughly 2.5times. 15% of people over 28 have a serious substance use problem ◦ 2/3 alcohol ◦ 1/3 other drugs In USA 50% of emergency visits are substance related.

Contd… Male>Female Alcohol use : White=Hispanic>Black Marijuana use: Black>White Alcohol – 59.6% Nicotine – 27.6% Cannabis– 24.9% LSD – 7.6% Hallucinogens % Stimulants – 6.6% Cocaine – 2.7% Heroin – 1.8%

Etiology Psychological: associated with conduct disorder, ADHD, depression Cultural Genetic Neurochemical

Individual-related Risk Factors Early age of onset Presence of early childhood behavioral problems Poor academic performance Risk-taking behaviors Favorable beliefs about substance use Shorter attention spans Increased impulsivity Self medication hypothesis: alcohol for anxiety Innately more tolerant to alcohol

Family-related Risk Factors Favorable beliefs about substance use in parents Parental tolerance of substance use Lack of closeness and attachment between adolescent and parent Lack of discipline/supervision by parent Parental substance use Childhood physical or sexual abuse

Peer-related Risk Factors Peer substance use Favorable peer attitudes to use Greater orientation of adolescents to peers as opposed to parents

Community-related Risk Factors Low SE status High population density High crime rate

Natural History Most adolescents try ‘gateway’ drugs (such as cigarettes or alcohol) which are legal and more accessible such ‘gateway’ drugs then can lead to illicit drug use

PHYSICAL AND PSYCHIATRIC EXAMINATION Denial is very common Try to obtain history from significant family members and friends History should include questions about family function, school and occupational performance, and interactions with friends. Types of substance used, amounts, circumstances of use and drug reactions

Clinical indicators of a substance use problem Psychosocial/behavioral ◦ Change in school performance ◦ Involvement in illegal activities ◦ Sexual acting (ie. Prostitution) ◦ Increased demands for money ◦ Change in peer group/involvement ◦ Driving under the influence

Contd… Medical ◦ Frequent injuries ◦ Suicide attempts ◦ Sudden weight changes ◦ Chronic respiratory symptoms ◦ Gastrointestinal complaints ◦ Insomnia ◦ Infections ◦ Anxiety ◦ Depression ◦ Sexually transmitted diseases

Contd… Historical ◦ Parental use ◦ Estrangement from family ◦ Poor quality relations in the family ◦ Abuse/neglect ◦ Psychiatric disorders ◦ Early age of first use of substances

PREVENTION Preventive programs: teach adolescents how to resist social pressure to use drugs. Detoxification: substance specific Drug rehabilitation: develop new coping skills Self-help groups: alcoholics anonymous Disulfiram Naltrexone methadone

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