1. Disorders Due to Psychoactive Substance Use Department of Psychiatry 1 st Faculty of Medicine Charles University, Prague Head: Prof. MUDr. Jiří Raboch, DrSc.

2. Psychoactive Substance Psychoactive (psychotropic) substance is any substance which after absorption has influence on mental processes both cognitive and affective. 1.stimulative 2.suppressive 3.hallucinogenic

3. Mental and Behavioural Disorders Due to Psychoactive Substance Use Disorders due to use of: F10.x alcohol F11.x opioids F12.x cannabinoids F13.x sedatives or hypnotics F14.x cocaine F15.x other stimulants (caffeine) F16.x hallucinogens F17.x tobacco F18.x volatile solvents F19.x multiple drugs and other psychoactive drugs

4. Mental and Behavioural Disorders Due to Psychoactive Substance Use Specific Clinical Conditions: F1x.0 Acute intoxications F1x.1 Harmful use F1x.2 Dependence syndrome F1x.3 Withdrawal state F1x.4 Withdrawal state with delirium F1x.5 Psychotic disorder F1x.6 Amnesic syndrome F1x.7 Residual state, late-onset psychotic disorder F1x.8 Other mental and behavioural disorders F1x.9 Unspecified mental and behavioural disorder

5. F1x.0 Acute Intoxication Df.: A transient condition following the administration of psychoactive substance resulting in disturbances in level of consciousness, cognition, perception, affect or behaviour, or other psychophysiological functions and responses A transient condition following the administration of psychoactive substance resulting in disturbances in level of consciousness, cognition, perception, affect or behaviour, or other psychophysiological functions and responses Closely related to dose levels Closely related to dose levels Uncomplicated Uncomplicated With trauma or other medical complications With trauma or other medical complications With delirium With delirium With coma With coma With convulsions With convulsions Pathological intoxication (applies only to alcohol) Pathological intoxication (applies only to alcohol)

6. F1x.1 Harmful Use The damage may be physical and/or mental. The damage may be physical and/or mental. Socially negative consequences are not evidence (neither acute intoxication or hangover). Socially negative consequences are not evidence (neither acute intoxication or hangover).

7. F1x.2 Dependence Syndrome (Addiction) a)A strong desire or sense of compulsion to take the substance („craving“) b)Difficulties in controlling substance-taking c)Withdrawal sy characteristic for the substance d)Evidence of tolerance e)Progressive neglect of pleasures and interests f)Persisting with substance use despite clear evidence of overtly harmful consequences Physical dependence Physical dependence Psychic (psychological) dependence Psychic (psychological) dependence

8. F1x.2 The Course of Dependence Syndrome F1x.20 currently abstinent (remission) F1x.21 currently abstinent in a protected environment F1x.22 currently abstinent on a maintenance regime F1x.23 currently abstinent - receiving treatment with aversive or blocking drugs (naltrexone, disulfiram) F1x.24 currently active dependence F1x.25 continuous (chronic) use F1x.26 episodic use (dipsomania)

9. F1x.3 Withdrawal State Symptoms occurring on absolute or relative withdrawal of a substance after repeated and prolonged use of the substance Symptoms occurring on absolute or relative withdrawal of a substance after repeated and prolonged use of the substance UncomplicatedUncomplicated With convulsionsWith convulsions

10. F1x.4 Withdrawal State with Delirium Delirium tremens - in severely dependent users with a long history of use of alcohol Delirium tremens - in severely dependent users with a long history of use of alcohol Prodromal symptoms: insomnia, tremor, fears followed by illusions, hallucinations, clouding of consciousness and marked tremor Prodromal symptoms: insomnia, tremor, fears followed by illusions, hallucinations, clouding of consciousness and marked tremor

11. F1x.5 Psychotic Disorder Psychotic phenomena occurring during or immediately after psychoactive substance use Psychotic phenomena occurring during or immediately after psychoactive substance use Schizophrenia-like Schizophrenia-like Predominantly delusional, hallucinatory, depressive, manic (alcoholic hallucinosis, jealousy) Predominantly delusional, hallucinatory, depressive, manic (alcoholic hallucinosis, jealousy) Persistence for more than 48 hours Persistence for more than 48 hours

12. F1x.6 Amnesic Syndrome Impairment of recent memory (learning of new material) Impairment of recent memory (learning of new material) Absence of defect in immediate recall, of impairment of consciousness, and of generalized cognitive impairment Absence of defect in immediate recall, of impairment of consciousness, and of generalized cognitive impairment History of chronic use of psychoactive substance (Korsakov’s psychosis or syndrome) History of chronic use of psychoactive substance (Korsakov’s psychosis or syndrome)

13. F1x.7 Residual and late-onset psychotic disorder Onset related to the use of psychoactive substance, the disorder should persist beyond any period of time during which direct effects of the psychoactive substance might be assumed Onset related to the use of psychoactive substance, the disorder should persist beyond any period of time during which direct effects of the psychoactive substance might be assumed Flashbacks - duration in seconds or minutes, duplication of previous drug-related experiences Flashbacks - duration in seconds or minutes, duplication of previous drug-related experiences Personality disorder Personality disorder Dementia Dementia

14. F10.x Mental Disorders Due to Use of Alcohol Acute intoxication: Acute intoxication: euphoria, flushed face, ataxia, slowed reaction time, impaired motor performance, slurred speech, poor concentration; in higher doses behavioural changes – disinhibition of sexual and aggressive impulses, increased suicidal and homicidal behavioureuphoria, flushed face, ataxia, slowed reaction time, impaired motor performance, slurred speech, poor concentration; in higher doses behavioural changes – disinhibition of sexual and aggressive impulses, increased suicidal and homicidal behaviour Pathological intoxication: Pathological intoxication: sudden change of consciousness with aggressive behaviour and amnesiasudden change of consciousness with aggressive behaviour and amnesia Harmful use: Harmful use: physical complications – hypertension, arteriosclerosis, heart infarction, cardiomyopathy, brain stroke, liver cirrhosis, fatty liver, gastritis, etc.physical complications – hypertension, arteriosclerosis, heart infarction, cardiomyopathy, brain stroke, liver cirrhosis, fatty liver, gastritis, etc. psychic complications - depressionpsychic complications - depression

15. F10.x Mental Disorders Due to Use of Alcohol Dependence syndrome: Dependence syndrome: increased tolerance to alcohol, morning drinking, alcohol bouts, blackouts, deterioration in occupational and marital life, behavioural changes, withdrawal symptomsincreased tolerance to alcohol, morning drinking, alcohol bouts, blackouts, deterioration in occupational and marital life, behavioural changes, withdrawal symptoms Withdrawal state: Withdrawal state: tremor, anxiety, easy getting startled, agitation, insomnia, nausea, sweating, epileptic seizures and delirium tremenstremor, anxiety, easy getting startled, agitation, insomnia, nausea, sweating, epileptic seizures and delirium tremens Delirium tremens: Delirium tremens: usually starts in evening hours – growing tremulousness, severe agitation, anxiety and perceptual distortionusually starts in evening hours – growing tremulousness, severe agitation, anxiety and perceptual distortion a state seriously endangering patient's lifea state seriously endangering patient's life recovery after several days, retrograde amnesiarecovery after several days, retrograde amnesia

16. F10.x Mental Disorders Due to Use of Alcohol Other psychotic disorders: Other psychotic disorders: alcoholic hallucinosisalcoholic hallucinosis pathological jealousypathological jealousy Korsakov's psychosisKorsakov's psychosis Wernicke encephalopathyWernicke encephalopathy alcoholic dementiaalcoholic dementia Treatment of alcoholism Treatment of alcoholism Withdrawal from alcohol, benzodiazepines, clomethiazolWithdrawal from alcohol, benzodiazepines, clomethiazol Aversion therapyAversion therapy Alcohol-Antabuse (disulfiram) Reaction (AAR)Alcohol-Antabuse (disulfiram) Reaction (AAR) PsychotherapyPsychotherapy

17. F11.x Mental Disorders Due to Use of Opioids Morphine, heroin (diacetylmorphine), codeine, pethidine, methadone Morphine, heroin (diacetylmorphine), codeine, pethidine, methadone Heroin: Heroin: dependence develops within two weeks of daily usedependence develops within two weeks of daily use overdose may lead to deathoverdose may lead to death withdrawal symptoms are extremely unpleasantwithdrawal symptoms are extremely unpleasant needle-sharing represents a serious risk of transmission of HIV and hepatitis B + C virusesneedle-sharing represents a serious risk of transmission of HIV and hepatitis B + C viruses treatment of the withdrawal state – buprenorphine, benzodiazepines, spasmolytics; in serious cases of dependence heroin is replaced by methadonetreatment of the withdrawal state – buprenorphine, benzodiazepines, spasmolytics; in serious cases of dependence heroin is replaced by methadone

18. F12.x Mental Disorders Due to Use of Cannabinoids Marijuana (marihuana) is a colloquial term for dried leaves and flowers of cannabis plant (Cannabis sativa L.) Marijuana (marihuana) is a colloquial term for dried leaves and flowers of cannabis plant (Cannabis sativa L.) Δ 9 -tetrahydrocannabinol (Δ 9 -THC) is responsible for the psychoactive properties of the cannabis plant Δ 9 -tetrahydrocannabinol (Δ 9 -THC) is responsible for the psychoactive properties of the cannabis plant Complex physiological functions of the cannabinoid system: motor coordination, memory procession, control of appetite, pain modulation and neuroprotection Complex physiological functions of the cannabinoid system: motor coordination, memory procession, control of appetite, pain modulation and neuroprotection Summary of adverse effects: Summary of adverse effects: acute: anxiety, panic, impaired attention, memory, reaction time and psychomotor performance and coordination, increased risk of road accident, and increased risk of psychotic symptoms among vulnerable personsacute: anxiety, panic, impaired attention, memory, reaction time and psychomotor performance and coordination, increased risk of road accident, and increased risk of psychotic symptoms among vulnerable persons chronic: chronic bronchitidis, a cannabis dependence syndrome, subtle impairments of attention, short-term memory and ability to organize and integrate complex informationchronic: chronic bronchitidis, a cannabis dependence syndrome, subtle impairments of attention, short-term memory and ability to organize and integrate complex information

19. F12.x Mental Disorders Due to Use of Cannabinoids Effect of cannabinoids on central nervous system: Euphoria, enhancement of sensory perception, tachycardia, antinociception, difficulties in concentration, impairment of memory Euphoria, enhancement of sensory perception, tachycardia, antinociception, difficulties in concentration, impairment of memory Cannabis use may exacerbate symptoms of schizophrenia and may precipitate disorders in persons who are vulnerable to developing psychosis; heavy cannabis use may increase depressive symptoms among some users Cannabis use may exacerbate symptoms of schizophrenia and may precipitate disorders in persons who are vulnerable to developing psychosis; heavy cannabis use may increase depressive symptoms among some users Tolerance develops; the relatively long half-life and complex metabolism of cannabis may result in a low intense withdrawal syndrome Tolerance develops; the relatively long half-life and complex metabolism of cannabis may result in a low intense withdrawal syndrome Marijuana use tends to impair executive function in the brain, e.g. higher risk for all types of injuries is associated with cannabis use Marijuana use tends to impair executive function in the brain, e.g. higher risk for all types of injuries is associated with cannabis use Cannabis abuse and dependence were highly associated with increasing risks of other substance dependence Cannabis abuse and dependence were highly associated with increasing risks of other substance dependence

20. F13.x Mental Disorders Due to Use of Sedatives and Hypnotics benzodiazepines – potentiate the action of GABA benzodiazepines – potentiate the action of GABA risk of dependence risk of dependence short-acting benzodiazepines: alprazolam, flunitrazepam, oxazepam, lorazepam, temazepam short-acting benzodiazepines: alprazolam, flunitrazepam, oxazepam, lorazepam, temazepam long-lasting benzodiazepines: diazepam, clorazepate, chlordiazepoxide, etc. long-lasting benzodiazepines: diazepam, clorazepate, chlordiazepoxide, etc. withdrawal state can be accomplished with epileptic seizures withdrawal state can be accomplished with epileptic seizures interaction with alcohol may induce qualitative changes of consciousness interaction with alcohol may induce qualitative changes of consciousness

21. F14.x,15.x Mental Disorders Due to Use of Stimulants Cocaine, amphetamine, metamphetamine (pervitine), phenmetrazine, methyphenidate, MDMA (ecstasy, methylenedioxymetamphetamine) Cocaine, amphetamine, metamphetamine (pervitine), phenmetrazine, methyphenidate, MDMA (ecstasy, methylenedioxymetamphetamine) Positive mood, activity, planning, diminished need of sleep Positive mood, activity, planning, diminished need of sleep Tachycardia, arrhythmia, hypertension, hyperthermia, intracerebral haemorrhage Tachycardia, arrhythmia, hypertension, hyperthermia, intracerebral haemorrhage Withdrawal symptoms: severe craving, depression, decreased energy, fatigue, sleep disturbance Withdrawal symptoms: severe craving, depression, decreased energy, fatigue, sleep disturbance Prolonged use can trigger paranoid psychoses, impulsivity, aggressivity, irritability, suspiciousness and anxiety states Prolonged use can trigger paranoid psychoses, impulsivity, aggressivity, irritability, suspiciousness and anxiety states

22. F16.x Mental Disorders Due to Use of Hallucinogens Lysergid acid diethylamide (LSD), psilocybin, mescaline, phencyclidine Lysergid acid diethylamide (LSD), psilocybin, mescaline, phencyclidine Acute intoxication: distorted perception (optic hallucinations and illusions); unpredictable and dangerous behaviour Acute intoxication: distorted perception (optic hallucinations and illusions); unpredictable and dangerous behaviour Withdrawal syndrome has not been described Withdrawal syndrome has not been described

23. F18.x Mental Disorders Due to Use of Volatile Solvents Toluene, acetone, adhesives, petrol, cleaning fluids, etc. Toluene, acetone, adhesives, petrol, cleaning fluids, etc. Acute intoxication: euphoria, disorientation, incoordination, slurred speech; optic hallucinations Acute intoxication: euphoria, disorientation, incoordination, slurred speech; optic hallucinations The way of use is very dangerous The way of use is very dangerous

24. Drug Addiction Treatment HEALTH SERVICE: acute states (detox program, tox. psychosis) acute states (detox program, tox. psychosis) weaning treatment weaning treatment after-treatment care after-treatment care substitution (maintainance) treatment substitution (maintainance) treatment OUT OF HEALTH SERVICE: contact centers contact centers daily static centers daily static centers therapeutic communities therapeutic communities after-treatment centers after-treatment centers protected workshops and habitations protected workshops and habitations mutual help groups – Alcoholics Anonymous, Narcotics Anonymous mutual help groups – Alcoholics Anonymous, Narcotics Anonymous

25. Links Czech National Focal Point for Drugs and Drug Addiction: Czech National Focal Point for Drugs and Drug Addiction: www.drogy-info.cz European Monitoring Centre for Drugs and Drug Addiction: European Monitoring Centre for Drugs and Drug Addiction: http://www.emcdda.eu.int/