Addiction, Opioids, Cannabis, Cocaine, Alcohol, Stimulants.ppt
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This document discusses drug addiction and focuses on opioid and alcohol addiction. It defines drug addiction as a chronic relapsing disorder characterized by compulsive drug use despite negative consequences. The document outlines various substances of abuse including opioids, alcohol, benzodiazepines, and stimulants. It describes the clinical presentations of addiction from experimental use to dependence and withdrawal. Significant details are provided on the neurobiology and pharmacology of opioids and alcohol and how they impact the brain's reward system and lead to tolerance and withdrawal. Health risks of addiction like infectious diseases and physical complications are summarized. The document concludes with discussing harm reduction approaches like methadone maintenance and needle exchange programs.
Addiction, Opioids, Cannabis, Cocaine, Alcohol, Stimulants.ppt
- 1. Drug Addiction Dr. Aziz Mohammad Asstt: Prof: Deptt: Of Psychiatry Khyber Teaching Hospital Peshawar
- 2. DRUG ADDICTION • Chronic relapsing disorder • Compulsive drug seeking & drug taking behaviour, despite serious negative consequences (ICD 10 Criteria) • Induce pleasant states (positive reinforcer) or relieve distress (negative reinforcer) • Continued use induces adaptive changes in the CNS, leading to the development of tolerance, dependence, sensitization, craving & relapse
- 3. Substances of abuse • Opiods; Heroin • Alcohol • Benzodiazepines & Barbiturates • Stimulants: Cocaine & Amphetamines • Cannabinoids • Hallucinogens; LSD, Mescaline • Solvents • Nicotine
- 4. Patterns of Drug Use • Experimental • Recreational • Habitual • Dependant • Other: - Polysubstance use - Dual diagnosis use
- 5. Clinical situations • Harmful use • Dependence syndrome • Withdrawal state +/- delirium; “DT’s” • Drug induced Psychosis • Cognitive impairment syndromes • Acute intoxification • Residual disorders
- 6. ICD-10 Criteria • A strong desire/compulsion to take the substance • Difficulties in controlling substance-taking • A physiological withdrawal state • Evidence of tolerance • Progressive neglect of alternative pleasures • Persisting with substance use despite clear evidence of OVERTLY harmful consequences
- 7. Epidemiology • In Pakistan 6.7 million people estimated to be Opioids Dependent. • Data on Cannabis and Alcohol largely not available. • Cannabis use is far more common than Opioids Dependence.
- 8. Factors influencing drug abuse and dependence • Pharmacological & physiochemical properties of drugs • Personality & Psychiatric disorder - increased risk associated with schizophrenia, BPAD, depression, ADHD. • Genetic factors (that influence metabolism and the effects of drugs)
- 9. Pharmacologic and physiochemical properties • Liposolubility increases the passage through the blood-brain barrier • Water solubility facilitates injection • Volatility favours inhalation in vapour form e.g aerosols / solvents • Heat resistance favours smoking e.g. cannabis • Rapid onset and intensity of effect increase the potential for abuse • A short half-life produces abrupt & intense syndromes of withdrawal
- 10. OPIATES • Strong narcotic analgesics • Derived from the ripe seed capsule of the poppy • Crude opium contains morphine, codeine, other alkaloids • Diamorphine (heroin) made by acetylation • Eaten, sniffed, smoked, injected
- 11. OPIATES • Short term effects – Euphoria, analgesia, sedation & a feeling of tranquillity • Long term effects / Repeated use – Rapid tolerance & physical dependence • Over dose – Lethal respiratory depression
- 12. Opiate Receptors • 3 Major opiate receptors - µ, δ, and к • 3 Endogenous opiate peptides – Encephalins, beta-endorphin, dynoorphin • Agonist action at μ and к receptors causes tolerance and dependence • Opiates activate these receptors which then couple G proteins
- 13. Opiates &The dopamine pathway • Natural rewards and addictive drugs stimulate the release of dopamine from neurones of the presynaptic ventral tegmental area into the nucleus accumbens, causing euphoria & reinforcement of the behaviour • Habituation ( rapid adaptive changes ) occur with natural rewards but not with addictive drugs & each dose stimulates the release of dopamine • Dopamine binds to a G-protein coupled receptor with two subtypes, D1 like, and D2 like.
- 14. Opiates Cont… • Most drugs that produce elevations in mood or euphoria, release dopamine in either the nucleus accumbens or the prefrontal cortex • Opiods release dopamine mainly by an indirect mechanism that decreases the activity of GABA- inhibitory neurones in the ventral tegmental area • Stimulation of κ receptors decreases dopamine levels in the nucleus accumbens and produces aversive responses • Reward & physical dependence are mediated by the activation of μ receptors
- 15. Opiate tolerance • Tolerance leads to increasing doses, or reduction between intervals, or both • Short term administration of opiates activates the μ-opiod Gαi/o- coupled receptor, this leads to a decrease in the number of opiod receptors and to the development of tolerance
- 16. Opiate withdrawal • Withdrawal causes reinstatement of drug use to prevent or decrease physical symptoms and dysphoria • Inhibition of neurones in the locus ceruleus by opiate is a key mechanism in withdrawal • When opiate levels fall the unopposed neurones lead to adrenergic over activity • Activation of к receptors in the ventral tegmental area decreases dopamine in the nucleus acumbens, leading to dysphoria and anhedonia
- 17. Opiate withdrawal • Grade 0 – drug craving, anxiety, drug seeking • Grade 1 – yawning, sweating, runny nose, restless sleep • Grade 2 – dilated pupils, hot and cold flushes, goose flesh (“cold turkey”), aches and pains • Grade 3 – insomnia, restlessness and agitation, abdominal cramps, N+V, diarrhoea, increased pulse , BP and RR
- 18. Hazards • Sterility – abscesses, septicaemia endocarditis • Adulterants – gangrene DVT and pulmonary emboli • Sharing – blood borne diseases HIV, Hepatitis B and C
- 19. Blood borne diseases HIV • Currently IVDU’s account for 37% (1048) • Though the numbers of IVDU’s with HIV increased between 1998-2001, it was followed by a reduction of almost 50% during 2001-2002. This may reflect service expansion or the delay between infection and diagnosis • EMCDDA(2002) record a prevalence rate of 3.3-8.7% of HIV infection among IVDU’s between 1996-2001
- 20. Hepatitis C • HCV prevalence is very high in all countries and settings in Europe, with infection rates of between 40-90% among different IDU subgroups • Prevalence rates 72-73% 1996-2001 (EMCDDA) • No routine data collection in Ireland • 1st study 1995 HCV prevalence 84% - <2 years injecting 70% +ve >2 years injecting 95% +ve
- 21. Methadone • Synthetic opiate • Administered orally • Half-life 24-36 hrs (10-90) ; once daily dosage • Steady state 4-5 days • Dosage 30-60mg • Harm reduction approach • Maintenance / Detoxification
- 22. Methadone Maintenance • Used in the USA since 1960’s • Stabilises lifestyle • Harm reduction benefits 75-90% of patients • Reduces HIV, Hepatitis • Reduces crime • Aim for a dose of 60mg and over
- 23. Harm reduction • As opposed to Abstinence / “curing” • WHO defines Harm reduction as a concept to prevent or reduce negative health consequences associated with certain behaviours • Concerns about transmission of HIV; epidemics in >110 countries; relapsing nature of Addiction • Focuses on minimising health, personal and social harms associated with drug use - the spread of blood-borne diseases, overdoses etc • Ongoing interventions, not short term, as a way to improve health of drug users, their families and society • Marginalised groups
- 24. Interventions include • Information, education, communication • Education about STD’s +safer sex, family planning ; injection techniques • Health care in relation to infectious diseases; screening, immunisation • Substitution with oral drugs • Needle exchange programmes • Linking with other services – e.g. medical, psychiatric, obstetric, dental ; social and forensic • other
- 25. Benefits of methadone • “safe” substitution drug • Effective in engaging and retaining people in treatment • Reduces risk, reduced levels of injection • A factor in improving physical/Mental health and quality of life of patients and their families • Reduces criminal activity and demands on the criminal justice system
- 26. Lofexidine • Alpha-2 adrenergic agonist inhibiting noradrenaline release • Useful in short term users • Detoxify over 2-3 weeks using up to 2mg daily • Daily BP monitoring is essential • Mainly used in in-patient units
- 27. Naltrexone • Narcotic antagonist • Half-life 96 hours • Dose 50mg daily • Used after detoxification • Best when supervised by family • Breaks the cycle of craving
- 28. Alcohol • 1 unit = 10ml / 8g absolute alcohol ( ½ pint lager, glass wine, 25ml spirits) • Hydrophilic, with rapid absorption through the gut • Peak plasma levels reached 30-60 mins post ingestion • Metabolized by hepatic oxidation (ADH)
- 29. Neurobiology of alcohol • Stimulant at low doses, sedative at higher concentrations • Anxiolytic effects mediated by potentiation of inhibitory effects GABA at GABA-A receptors • Disturbs glutamate transmission by inhibiting NMDA receptors,- related to withdrawal seizures, DT’s etc • Unopposed action of GABA and NMDA, increasing neuronal excitability
- 30. Alcohol related physical problems • GIT – oesophagitis, gastritis, reflux, m-w tears, varices, pancreatitis, portal HT, ca’s • Liver – hepatitis, fatty liver, cirrhosis, haemochr, hepatic Ca, hepatic encephalopathy • Cardiovascular – arrythmias, cardiomyopathy, coronary/cerebrovascular disease, hypertension • Metabolic • Endocrine e.g. pseudocushings, hypogonadism, infertility, low libido/impotence • Musculoskeletal e.g. gout, fractures, osteoporosis • Haematological e.g. anaemia, thrombocytopaenia • Respiratory • Dermatological e.g. spider naevi, palmar erythema, eczema, worsening psoriasis
- 31. Alcohol – Neurological problems • Acute intoxication • Mania a potu – pathological drunkenness with minute amounts of alcohol (not in ICD-10) • Methanol poisoning • Amnesic (Korsakoff’s) syndrome & Wernicke’s encephalopathy • Cerebellar degeneration • Ambylyopia- retrobulbar neuritis; may be associated with peripheral neuropathy • Central pontine myelinosis • Dementia, amnesia/blackouts etc • Fetal alcohol syndrome
- 32. Psychological related disorders • Alcoholic Hallucinosis- 10-20% > 6/12 -5-20%...schizoph • Psychiatric comorbidity ECA study -psychiatric dx x3 risk of lifetime alc disor - 13% alcoholics 2nd mood disorder - 22% mood disorder also alcohol disorder • Suicide – approx 25% attempt; male, divorced, personality disorder, older, unemployed, medical issues, hx of DSH • Pathological jealousy- “Othello syndrome” • Anxiety states- panic, OCD, phobias • PTSD - alcohol dampens hyperarousal • Eating disorders – bulemia • Other drug use
- 33. Alcohol withdrawal • Important to recognise – 25% of male medical patients are problem drinkers • Occurs from 6-24 hours after cessation, peaking at day 2-3, highest risk in first 24-48hrs • Range of features – sweating, tremor, nausea, anorexia, vomiting, anxiety, insomnia, restlessness, hallucinations, seizures, nightmare, confusion, hallucinosis
- 34. Delirium tremens • Toxic confusional state with somatic disturbance, occurring in < 5% • Mortality rate of approx 10%( -20%) • Symptoms peak at 3-4 days of withdrawal • Triad of clouding of consciousness, sensory distortion and tremor • Agitation, fear and insomnia, worse at night
- 35. Features of DT’s • Confusion and disorientation. • Clouding of consciousness. • Delusions and hallucinations. • Psychomotor agitation and automatic dysfx. • Perceptual disturbance and fear. • Insomnia and truncal ataxia. • Electrolyte disturbance and dehydration . • Leukocytosis and disordered LFT’s. • EEG shows an increase in fast activity.
- 36. Treatment • Acute withdrawal – Short acting benzodiazepines; chlordiazepoxide, diazepam – minimise the risk of seizures • 40mg clordiazepoxide, 6hourly, (Max 300mg in 24hrs) • Reducing doses over 5-10 days • Consider anticonvulsants (carbamezepine) • Multivitamin preparations- Thiamine / B vitamin - Wernicke-Korsakoff psychosis • Treat infection, dehydration, suicidal ideation etc
- 37. In Patient Treatment • Past History of seizures or epilepsy • Comorbid severe mental illness • Intercurrent acute illness • Previous failed OPD attempts • Elderly patients
- 38. Post-detoxification • Disulfuram (Antabuse) – Inhibitor of aldehyde dehydrogenase. Blocks ethanol metabolism at the acetaldehyde level. ‘Flushing reaction’ • Loading dose 600-800mg per day for 3-4 days • Maintenance 200mg daily • Hypotension and MI with heavy alcohol consumption, potentially fatal • Useful in highly motivated groups and where assisted by family or friends
- 39. Post Detoxification • Naltrexone- Opiate receptor antagonist, thought to negate the euphoria associated with alcohol • DOSE • Acamprosate (Calcium bisacetyl homotaurine)- Synthetic GABA analogue • DOSE • SSRI’s
- 40. Post Detoxification • Psychological interventions; Relapse prevention, MET, cue exposure with response prevention, social skills, relaxation techniques, CBT, Family therapy etc • Alcoholics anonymous – 12 step programme • Residential rehabilitation programmes- minnisota model- social skills, relaxation, structured relapse prevention
- 41. Cognitive & behavioural strategies • By identifying triggers for relapse – neg/pos mood states - poor coping skills - social isolation - craving - family issues And developing global self management strategies in areas of cognitive restructuring, skills training, lifestyle changes
- 42. Brief intervention • Assessmint of intake • Information on harmful drinking, advice Decrease by 50%, as effective as more expensive specialist tx.
- 43. Motivational interviewing • Addressing ambivalence, moving through a cycle of change • 5 tenets - express empathy -help see discrepancies -avoid argument - roll with resistance - support sense of self efficacy
- 44. Prognosis • Poor – alcoholic brain damage, comorbidity, divorced, criminal record, low IQ, poor support and motivation • Valient 2003 – 60 yr follow up -25% dependant -Death rate x 2-3, rare after 70; predictors of positive outcome “the most and least severe alcoholics appeared to enjoy the best longterm chance of remission”
- 45. Cocaine • Substantial increases in drug treatment population • Increasingly reported as 2nd problem drug – 50%IV ( < benzodiazepines ) • Anecdotal reports- across general population • No substitute drug available • Some combined pharmacotherapy's; counselling, CBT, Motivational interviewing • 3% general population report lifetime use; increasing
- 46. Effects and risks of cocaine • Perceived as safe • Increased energy, alertness, talkative, sex drive • Combined with alcohol more toxic than either alone • Severe psychological dependence, cravings • Tolerance develops • unpleasant side effects – dry mouth, sweating, palpitations, anorexia, headaches, abd pain, irritability, paranoia, hallucinations, MI • Fatigue and depression; “crash”; mental problems; nasal / breathing problems • Increased sexual risk behaviour; association with prostitution
- 47. Benzodiazepines