1. IzBen C. Williams, MD, MPH Instructor

2. SUBSTANCE ABUSE The Abuse of Alcohol and other Psychoactive Substances

3. Overview Definitions: Definitions: Substance use disorders are divided into……. 1. Substance abuse – 2. Substance dependence: 1. Abuse plus withdrawal symptoms, tolerance or a pattern of repetitive use 2. Concept of cross tolerance

4. Overview Definitions: Definitions: Substance abuse is the use of a psychoactive substance (drug) to such an extent that it seriously interferes with health or occupational and social functioning (obligations, interpersonal and legal problems, risks, ) This definition is objective and non-judgmental. The emphasis is on dysfunction rather than on social or cultural norms, or on the enhancement of pleasure or performance

5. Overview Substance abuse is a major public health problem globally Substance abuse is a major public health problem globally Alcoholism is the most common substance use disorder In the USA, deaths associated with alcohol abuse and alcoholism now rank third behind heart disease and cancer Certain basic principles of diagnosis and treatment apply to all psychoactive substance use disorders

6. Overview Definitions: Definitions: Substance dependence is a pathologic pattern of substance use that results in impairment or distress. Characterized by: Withdrawal: physiological and/or psychological symptoms after reduction or cessation of intake of a substance Tolerance: decreased effect with continued use of the same amount of the substance Other characteristics: CAGE features, time spent, physical or mental problems, compromises commitments

7. Overview Definitions: Definitions: Physiologic dependence Refers to the presence of either tolerance or withdrawal

8. Overview Observation: Observation: Although the focus in this lecture is on “recreational” drugs, it should be noted that prescribed psychoactive medications can also be abused Physicians who prescribe such drugs have a responsibility to monitor their effects on a patient and to ensure that dependence or toxicity are not developing

9. Illicit drug use profile The use of Illicit drugs in the USA has been increasing. In 2002, an estimated 8.3% of the population aged 12 or older had used an illicit drug or abused a psychotherapeutic medication (such as a pain reliever, stimulant, or tranquilizer) in the past month. In 2012, that figure stood at 9.2 % of the population. The increase mostly reflects a recent rise in the use of marijuana, the most commonly used illicit drug.

10. Illicit drugs use profile 2012

11. Illicit drug use trends

12. Illicit drug use profile The use of Illicit substances is more common among young adults, ages 18-25 And it is twice as common in males Most abused substances can be administered by a number of routes Routes that provide quick access to the bloodstream, and hence the brain, are often preferred by abusers

13. Specific-substance use Classification A.CNS Stimulants B.Sedatives, Hypnotics and Anxiolytics C.Opioids D.Hallucinogens and Phencyclidine E.Cannabis F.Inhalants

14. Specific-substance use A.CNS Stimulants A.CNS Stimulants They include: Caffeine, Nicotine Amphetamines and related compounds Cocaine Methamphetamine Phenmetrazine

15. Specific-substance use A.CNS Stimulants A.CNS Stimulants Increase the availability of dopamine: Amphetamines cause the release of dopamine Cocaine blocks the reuptake of dopamine Increased availability of dopamine at the synapse is believed to be involved in the euphoric effects of stimulants and opioids

16. Specific-substance use A.CNS Stimulants A.CNS Stimulants Use of Amphetamines Depression in the elderly and in the medically ill who cannot tolerate antidepressants, Augmentation of antidepressants in treatment-resistant depression Narcolepsy ADD in children & Adult (residual) ADD The most common clinically used amphetamine is methylphenidate (Ritalin)

17. Specific-substance use A.CNS Stimulants A.CNS Stimulants Cocaine Clinically used for nosebleed and in local anesthetic of the ENT Nicotine Toxic to all systems and decreases life expectancy more than the use of any other substance

18. Specific-substance use A.CNS Stimulants A.CNS Stimulants Cocaine Intoxication: euphoria, fighting, grandiosity, confused speech impaired judgment, high » crash » withdrawal Withdrawal: dysphoric mood, irritability, anxiety, fatigue, agitation, occurs within 24 hrs after cessation of last use Delirium: within 24 hours Delusional Disorder: usually persecutory, distorted body images and faces » aggression and violence

19. Specific-substance use B.Sedatives, Hypnotics and Anxiolytics B.Sedatives, Hypnotics and Anxiolytics These are CNS depressants; they include: (Alcohol) Barbiturates and related drugs Benzodiazepines (tranquilizers and hypnotics) Chloral compounds (eg chloral hydrate)

20. Specific-substance use B.Sedatives, Hypnotics and Anxiolytics B.Sedatives, Hypnotics and Anxiolytics This group of drugs work primarily by increasing the activity of the inhibitory neurotransmitter GABA Withdrawal effects could be life threatening (include seizures, and CVS compromise) so inpatient care for withdrawal is often necessary and advisable

21. Specific-substance use B.Sedatives, Hypnotics and Anxiolytics B.Sedatives, Hypnotics and Anxiolytics Alcohol associated problems: Acute: relational, suicide, abuse, rape, various indiscretions and infarctions Chronic: Thiamine deficiency, GI, fetal, liver, CNS including DTs, Intoxication Legal intoxication.08%-.15% bac Coma usually above.50% dependent on use history

22. Specific-substance use B.Sedatives, Hypnotics and Anxiolytics B.Sedatives, Hypnotics and Anxiolytics Barbiturates: Uses: sleeping pills, sedatives, tranquilizers, anticonvulsants, anesthetic Clinically: respiratory depression, low safety margin (suicide), risk of death from withdrawal

23. Specific-substance use B.Sedatives, Hypnotics and Anxiolytics B.Sedatives, Hypnotics and Anxiolytics Benzodiazepines: Uses: tranquilizers, sedatives, muscle relaxants, treats alcohol withdrawal, Clinically: by itself high safety margin Benzodiazepine receptor antagonists such as s Flumazeni can reverse benzodiazepine effects in cases of overdose

24. Specific-substance use C. OPIOIDS - These include MorphineAlphaprodine HydromorphoneOxycodone OxymorphoneLevophanol HeroinMeperidine MethadonePropoxyphene CodineHydrocodone

25. Specific-substance use C.Opioids C.Opioids Uses: Analgesia (morphine), drugs of abuse (heroin), Clinically: Abused opioids cross bbb, have a faster onset of action, and are more euphoric than medically used opioids, death from withdrawal rare

26. Specific-substance use C.Opioids C.Opioids Methadone is a synthetic opioid Others are LAMM and Buprenorphine (Temgesic) Uses: treatment of heroin addiction but can itself cause physical dependence and tolerance. ‘legal’ opioids can be substituted for illegal opioids to prevent withdrawal symptoms Advantages over heroin: can be taken orally, have a longer duration of action, and can block both the withdrawal and euphoric actions of heroin (temgesic); they also cause less euphoria and drowsiness

27. Specific-substance use D.Hallucinogens and Phencyclidine D.Hallucinogens and Phencyclidine They include: Lysergic acid diethylamide (LSD) Mescaline Phencyclidine Psilocybin

28. Specific-substance use D.Hallucinogens and Phencyclidine D.Hallucinogens and Phencyclidine These drugs produce altered states of consciousness, mediated by increased availability of serotonin LSD is ingested and PCP is smoked in marijuana (*) or cigarette Both cause altered perception (bad trip) with intoxication PCP causes more episodes of violent behavior, hypothermia and nystagmus, and consumption of more than 20 mg may cause convulsion, coma and death

29. Specific-substance use E.Cannabis -1 E.Cannabis -1 Specific substances include: Marijuana Hashish ∆-tetrahydrocannabinol (THC)

30. Specific-substance use E.Cannabis -2 E.Cannabis -2 Intoxication by marijuana and related substances rarely produces hallucinations More common side effects are Euphoria, anxiety, increased suggestibility, distortion of time and space, increased appetite Red conjunctivae, dry mouth, tachycardia, no change in pupils

31. Specific-substance use E.Cannabis -3 E.Cannabis -3 In low doses, marijuana increases appetite and relaxation and causes conjunctival reddening Chronic users experience lung problems associated with smoking and a decrease in motivation ‘the amotivational syndrome’ characterized by apathy and lack of desire to work Treatment: like most hallucinogens, the psychological effects are eased by reassurance in a quiet setting

32. Specific-substance use F.Inhalants -1 F.Inhalants -1 They include: Gasoline Glue Paint thinner solvents

33. Specific-substance use F.Inhalants -2 F.Inhalants -2 Sniffing of inhalants is increasing among children and adolescents. Brain damage may occur with repeated use, and no antidote or specific treatment exists Intoxication may cause CNS depression, confusion and delirium Chronic use may result in dementia

34. Principles of treatment of Substance-related Disorders Certain approaches are useful for treatment of abuse and dependence of all substances: Certain approaches are useful for treatment of abuse and dependence of all substances: i. Detoxification - the first goal of treatment ii. Insistence on abstinence – few individuals can use addiction substances in moderation after successful treatment but they cannot be identified, hence complete abstinence is advised

35. Principles of treatment of Substance-related Disorders Approaches to treatment for all substances: iii. Avoidance of other substances associated with dependence (beware of tranquilizers) iv. Involvement of family – the family can be important allies in insisting that the patient’s drug abuse problem be dealt with, however substance abuse may also provide the family with a convenient distraction from a less palatable family problem

36. Principles of treatment of Substance-related Disorders Approaches to treatment for all substances: v. Toxicology screens – periodic urine screens are often essential in identifying relapse and non- compliance vi. Self-help groups – Peer support groups provide credibility and encouragement from individuals who have had similar problems and who are adept at dealing with common resistances to treatment. Twelve step programs have been developed for most substances

37. Principles of treatment of Substance-related Disorders Approaches to treatment for all substances: vii. Sanctioned treatment: When an patient is forced to remain in therapy by a le gal sanction, the outcome is better individual is better than when free will is at play viii. Contingency contracting – powerful negative and positive contingencies tied to treatment. Pre-signed letter of patient is mailed by therapist if failures evident. Especially effective in medical licensure

38. Principles of treatment of Substance-related Disorders