Substance Abuse and Addiction

Dr. Robin Victor
PGT, Deptt Of Psychiatry
Silchar Medical College & Hospital
1

Dependence- The repeated use of a drug or
chemical substance, with or without physical
dependence.
Abuse- Use of any drug, usually by self
administration, in a manner that deviates
from approved social or medical patterns.
Misuse- Similar to abuse but usually applies
to drugs prescribed ny physicians that are
not used properly.
3

Intoxication- is used for a reversible
nondependent experience with a substance that
produces impairment.
Tolerance- defined by either of the following:
 Need for markedly increased amounts of the substance to
achieve intoxication.
 Desired effect markedly diminished effect with continued
use of the same amount of the substance.
Cross Tolerance- Refers to the ability of one drug
to be substituted for another, each usually
producing the same physiological and
psychological effects.
4

 Addiction- the repeated and increased use of a
substance, the deprivation of which gives rise to
symptoms of distress and the irresistible urge to
use the agent again and which leads to physical
and mental deterioration.
5

The National Institute of Drug Abuse (NIDA) and other
agencies, such as the National Survey of Drug Use and Heath
(NSDUH), conduct periodic surveys of the use of illicit drugs in
the United States.
- As of 2012, an estimated 22.5 million persons over the age of 12
years (about 10 percent of the total US population) were
classified as suffering from a substance-related disorder.
- Of this group, about 15 million were dependent on, or abused,
alcohol.
6

According to the data from the NSDUH survey on the percentage of
respondents who reported using various drugs.
- In 2012, 669,000 persons were dependent on, or abused, heroin;
- 1.7 percent (4.3 million) abused marijuana;
- 0.4 percent (1 million) abused cocaine;
- 2 million were classified as dependent on, or abuse of, pain relievers.
7

National Survey on the Extent, Pattern
and Trends of Drug Abuse in India (2010),
the first of its kind.
It showed that the number of chronic
substance-dependent individuals were as
follows:
10 million (alcohol)
2.3 million (cannabis)
0.5 million (opiates)
8

 The survey not only points to the
problem of India’s population having
twice the global (and Asian) average
prevalence of illicit opiate
consumption, but also shows that the
treatment resources available are not
commensurate with the ‘burden of
work’ (number of dependent drug
users) requiring immediate treatment.
9

1. GENETICS
 According to the National Institute on Drug
Abuse, scientists recognize that genetic
predispositions to drug abuse exist, but they have
yet to pinpoint the specific genes involved. This
may have to do with a brain "feel good" chemical
called dopamine, and a person's gene-controlled
relationship with it.
10

2. FAMILY
 Drug addiction is more common in
some families and likely involves
genetic predisposition.
 If a blood relative, such as a parent or
sibling, with alcohol or drug problems
is present in the family there is risk of
developing a drug addiction.
11

3. GENDER
 Men are more likely to have problems
with drugs than women are.
 However, progression of addictive
disorders is known to be faster in
females.
12

4. PEER PRESSURE.
Peer pressure is a strong factor in starting to
use and abuse drugs, particularly for young
people.
13

5. CO-MORBID MENTAL HEALTH
DISORDER.
Presence of a mental health disorder such as :
 Depression
 Anxiety disorder
 Phobia
 Personality disorder
 Attention-deficit/hyperactivity disorder
(ADHD)
 Post-traumatic stress disorder
Increases the likelihood to become dependent
on drugs
14

6. TAKING A HIGHLY ADDICTIVE
DRUG.
 Some drugs, such as stimulants, cocaine or
painkillers, may result in faster
development of addiction than other drugs.
However, taking drugs considered less
addicting — so-called "light drugs" — can
start a person on a pathway of drug use
and addiction.
15

7. SOCIO-ECONOMIC STATUS
 Research suggests that there is a strong
association between poverty, social
exclusion and problematic drug use.
Those who are unemployed, particularly
long term unemployed, in poor or
insecure housing and are early school
leavers have a higher rate of substance
abuse than those who do not fit into
these categories.
16

 There are four major diagnostic categories in the
Diagnostic and Statistical Manual of Mental Disorders,
fifth edition (DSM-5):
 (1) Substance Use Disorder- the diagnostic term
applied to the specific substance abused (e.g., alcohol
use disorder, opioid use disorder) that results from the
prolonged use of the substance.
 (2) Substance Intoxication- the diagnosis used to
describe a syndrome (e.g., alcohol intoxication or
simple drunkenness) characterized by specific signs
and symptoms resulting from recent ingestion or
exposure to the substance.
17

 (3) Substance Withdrawal- the diagnosis used to
describe a syndrome (e.g., alcohol intoxication or
simple drunkenness) characterized by specific
signs and symptoms resulting from recent
ingestion or exposure to the substance.
 (4) Substance-Induced Mental Disorder.
18

The most frequently encountered substance use disorder explained
are namely:
 1. Alcohol
 2. Cannabis
 3. Opioid
19

 Alcoholism is among the most common psychiatric disorders
observed in the Western world.
 Alcohol-related problems in the United States contribute to 2
million injuries each year, including 22,000 deaths. In India,
• At some time during life, 90 percent of the population in the
United States drinks, with most people beginning their alcohol
intake in the early to middle teens.
20

• After heart disease and cancer, alcohol-related disorders constitute
the third largest health problem in the United States today.
• Beer accounts for about one half of all alcohol consumption, liquor
for about one third, and wine for about one sixth.
• About 30 to 45 percent of all adults in the United States have had
at least one transient episode of an alcohol-related problem, usually
an alcohol-induced amnestic episode (e.g., a blackout), driving a
motor vehicle while intoxicated, or missing school or work because
of excessive drinking.
21

• The psychiatric diagnoses most commonly
associated with the alcohol-related disorders are
- Other substance-related disorders
- Antisocial personality disorder
- Mood disorders
- Anxiety disorders
• Most cases suggest that persons with alcohol-
related disorders have a markedly higher suicide
rate than the general population.
22

ALCOHOL INTOXICATION
Signs of Alcohol Intoxication
1. Slurred speech
2. Dizziness
3. lncoordination
4. Unsteady gait
5. Nystagmus
6. Impairment in attention or memory
7. Stupor or coma
8. Double vision
23

IMPAIRMENT LIKELY TO BE SEEN AT DIFFERENT
BLOOD ALCOHOL CONCENTRATIONS
24
Level Likely Impairment
20-30 mgldL Slowed motor performance and decreased thinking
ability
30-80 mgldL Increases in motor and cognitive problems
80-200 mgldL Increases in incoordination and judgment errors Mood
lability , Deterioration in cognition
200-300 mgldl Nystagmus, marked slurring of speech, and alcoholic
blackouts
>300 mgldl Impaired vital signs and possible death

ALCOHOL WITHDRAWAL
 The cessation or reduction of alcohol use
that was heavy and prolonged as well as
the presence of specific physical or
neuropsychiatric symptoms. The
diagnosis also allows for the
specification ''with perceptual
disturbances.“
The syndrome of withdrawal sometimes
skips the usual progression and, for
example, goes directly to Delerium
tremens.
25

 Tremor of the tongue, eyelids, or outstretched hands
 Sweating
 Nausea, retching, or vomiting
 Tachycardia or hypertension
 Psychomotor agitation
 Headache
 Insomnia
 Malaise or weakness
 Transient visual, tactile, or auditory hallucinations or illusions
 Grand mal convulsions
26

The classic sign of alcohol withdrawal is
tremulousness.(commonly called the "shakes" or the
"jitters") develops 6 to 8 hours after the cessation of
drinking
The psychotic and perceptual symptoms begin in 8 to 12
hours
Seizures in 12 to 24 hours
 Symptoms of delirium tremens (DTs ), called alcohol
delirium in DSM-5 can develop anytime during the first 72
hours, although physicians should watch for the
development of DTs for the first week of withdrawal.
27

TREATMENT OF WITHDRAWAL
The primary medications to control alcohol withdrawal
symptoms are the benzodiazepines given either orally or
parenterally, as they control most of the withdrawal
features.
Clinicians must titrate the dosage of the benzodiazepine,
starting with a high dosage and lowering the dosage as
the patient recovers.
28

Fetal alcohol syndrome, the leading cause of
intellectual disability in the United States, occurs
when mothers who drink alcohol expose fetuses
to alcohol in utero.
Women with alcohol-related disorders have a 35
percent risk of having a child with defects
The alcohol inhibits intrauterine growth and
postnatal development.
29

Microcephaly, craniofacial malformations, and limb
and heart defects are common in affected infants.
Short adult stature and development of a range of
adult maladaptive behaviors have also been
associated with fetal alcohol syndrome.
 Although the precise mechanism of the damage to
the fetus is unknown, the damage seems to result
from exposure in utero to ethanol or to its
metabolites
30

 Nutritional diseases of the nervous system secondary to
alcohol abuse
Wernicke-Korsakoff syndrome
Cerebellar degeneration
Peripheral neuropathy
Optic neuropathy (tobacco-alcohol amblyopia)
Pellagra
31

Alcoholic diseases of uncertain pathogenesis
 Central pontine myelinolysis
 Marchiafava-Bignami disease
 Fetal alcohol syndrome
 Myopathy
 Alcoholic dementia
 Alcoholic cerebral atrophy
32

 Systemic diseases due to alcohol with secondary neurological
complications
 Liver disease
 Gastrointestinal diseases
 Cardiovascular diseases
 Hematological disorders
 Infectious disease, especially meningitis
 Hypothermia and hyperthermia
 Hypotension and hypertension
 Respiratory depression and associated hypoxia
 Toxic encephalopathies, including alcohol and other substances
33

Electrolyte imbalances leading to acute confusional states and, rarely,
local neurological signs and symptoms
Hypoglycemia
Hyperglycemia
Hyponatremia
Hypercalcemia
Hypomagnesemia
Hypophosphatemia
34

Increased incidence of trauma
Epidural hematoma
Subdural hematoma
Intracerebral hematoma
 Spinal cord injury
Posttraumatic seizure disorders
 Compressive neuropathies and brachial plexus injuries (Saturday
night palsies)
Posttraumatic symptomatic hydrocephalus (normal pressure
hydrocephalus)
Muscle crush injuries and compartmental syndromes
35

 Three general steps are involved in treating the alcoholic person
after the disorder has been diagnosed:
 Intervention
 Detoxification
 Rehabilitation.
36

 The goal in the intervention step, which has also been called
confrontation, is to break through feelings of denial and help the
patient recognize the adverse consequences likely to occur if the
disorder is not treated.
 Intervention is a process aimed at maximizing the motivation
for treatment and continued abstinence.
 This step often involves convincing patients that they are
responsible for their own actions while reminding them of how
alcohol has created significant life impairments
37

 Most persons with alcohol dependence have relatively mild
symptoms when they stop drinking.
 If the patient is in relatively good health, is adequately nourished,
and has a good social support system, the depressant withdrawal
syndrome usually resembles a mild case of the flu.
 The essential first step in detoxification is a thorough physical
examination. In the absence of a serious medical disorder or
combined drug abuse, severe alcohol withdrawal is unlikely.
 The second step is to offer rest, adequate nutrition, and multiple
vitamins, especially those containing thiamine
38

 Includes three major components:
1. Continued efforts to increase and maintain high levels of
motivation for abstinence
2. Work to help the patient readjust to a lifestyle free of alcohol
3. Relapse prevention.
39

 Clinicians must recognize the potential
importance of self-help groups such as AA.
 Members of AA have help available 24 hours a
day, associate with a sober peer group, learn
that it is possible to participate in social
functions without drinking, and are given a
model of recovery by observing the
accomplishments of sober members of the
group.
40

 Cannabis preparations are obtained from
the Indian hemp plant Cannabis sativa, a
hardy, aromatic annual herb.
 All parts of Cannabis sativa contain
psychoactive cannabinoids, of which
tetrahydrocannabinol (∂-9-THC) is most
abundant.
 The most potent forms of cannabis come
from the flowering tops of the plants or
from the dried, black-brown, resinous
exudate from the leaves, which is referred
to as hashish or hash
41

 Based on the 2003 National Surveys on Drug Use and Health
(NSDUH), an estimated 90.8 million adults (42.9 percent) aged 18
years or older had used marijuana at least once in their lifetime.
 Among this group, about 2 percent used the drug before age 12,
about 53 percent between 12 and 17 and about 45 percent after
age 18.
 The rate of past year and current marijuana use by males was
almost twice the rate for females overall among those aged 26 and
older. This gap between the sexes narrows with younger users; at
ages 12 to 17, there are no significant differences.
42

 Acute intoxication due to use of cannabinoids
There must be dysfunctional behavior or perceptual abnormalities,
including at least one of the following:
43
• Impaired judgment
• Impaired attention
• Impaired reaction time
• Auditory, visual, or tactile
illusions
• Hallucinations with
preserved orientation
• Depersonalization
• Derealisation
• Interference with personal
functioning
• Euphoria and disinhibition
• Anxiety or agitation
• Suspiciousness or paranoid
ideation
• Temporal slowing (a sense
that time is passing very
slowly, and/or the person is
experiencing a rapid flow of
ideas)

 Traditionally, the amotivational syndrome
has been associated with long-term heavy
use and has been characterized by a
person's unwillingness to persist in a task
be it at school, at work, or in any setting
that requires prolonged attention or
tenacity.
 Persons are described as becoming
apathetic and anergic, usually gaining
weight, and appearing slothful.
44

 Persisting perceptual abnormalities after
cannabis use.
 There are case reports of persons who have
experienced at times significantly sensations
related to cannabis intoxication after the
short-term effects of the substance have
disappeared.
 Continued debate concerns whether
flashbacks are related to cannabis use alone
or to the concomitant use of hallucinogens or
of cannabis tainted with phencyclidine (PCP).
45

 Treatment of cannabis use rests on the same principles as treatment of
other substances of abuse abstinence and support.
 Abstinence can be achieved through direct interventions, such as
hospitalization, or through careful monitoring on an outpatient basis
by the use of urine drug screens, which can detect cannabis for up to 4
weeks after use.
 Support can be achieved through the use of individual, family, and
group psychotherapies.
 Education should be a cornerstone for both abstinence and support
programs.
 A patient who does not understand the intellectual reasons for
addressing a substance-abuse problem has little motivation to stop.
46

 In the developed countries, the opioid drug most
frequently associated with abuse and dependence is
heroine- a drug that is not approved for therapeutic
purposes in the United States.
 These drugs are all prototypical µ-opioid receptor
agonists and all produce similar subjective effects.
 The patterns of use and some aspects of opioid toxicity
are powerfully influenced by the route of
administration and the metabolism of the specific
opioid, as well as by the social conditions that
determine its price and purity and the sanctions
attached to nonmedical use
47

 Opioids have been used for at least
3,500 years, mostly in the form of
crude opium or in alcoholic solutions
of opium.
 Morphine was first isolated in 1806
and codeine in 1832. Over the next
century, pure morphine and codeine
gradually replaced crude opium for
medicinal purposes, although
nonmedical use of opium (as for
smoking) still persists in some parts
of the world.
48

 In 2004, an estimated 118,000 persons had used heroin for the first
time within the past 12 months.
 The average age of first use among recent initiates was 24.4 years in
2004.
 Users of opioids typically started to use substances in their teens and
early 20s; currently, most persons with opioid dependence are in their
30s and 40s.
 The male-to-female ratio of persons with heroin dependence is about 3
to 1.
49

 Early induction into the drug culture is likely in communities in
which substance abuse is rampant and in families in which the
parents are substance abusers.
 A heroin habit can cost a person hundreds of dollars a day; thus, a
person with opioid dependence needs to obtain money through
criminal activities and prostitution. The involvement of persons
with opioid dependence in prostitution accounts for much of the
spread of HIV.
 DSM-5, the lifetime prevalence for heroin use is about 1 percent,
with 0.2 percent having taken the drug during the prior year.
50

 OPIOID INTOXICATION
There must be dysfunctional behavior, as evidenced by at least one
of the following:
 apathy and sedation
 disinhibition
 psychomotor retardation
 impaired attention
 impaired judgment
 interference with personal functioning
51

 At least one of the following signs must be present:
 drowsiness
 slurred speech
 pupillary constriction (except in anoxia from severe overdose,
when pupillary dilatation occurs)
 decreased level of consciousness (e.g., stupor, coma)
52

 Any three of the following signs must be present:
53
• Craving for an opioid
drug
• Rhinorrhoea or
sneezing
• Lacrimation
• Muscle aches or
cramps
• Abdominal cramps
• Nausea or vomiting
• Diarrhea
• Pupillary dilatation
• Piloerection, or
recurrent chills
• Tachycardia or
hypertension
• Yawning

OVERDOSE TREATMENT
 The first task in overdose treatment is to
ensure an adequate airway.
 The patient should be ventilated mechanically
until naloxone, a specific opioid antagonist,
can be given.
 If no response to the initial dosage occurs,
naloxone administration may be repeated
after intervals of a few minutes.
54

 Opioid Agents for Treating Opioid Withdrawal
 Methadone
 Levomethadyl (LAAM)
 Buprenorphine
55

 Therapeutic communities are residences in
which all members have a substance abuse
problem.
 The goals are:
1. To effect a complete change of lifestyle,
including abstinence from substances
2. To develop personal honesty, responsibility,
and useful social skills
3. To eliminate antisocial attitudes and criminal
behavior.
56

 Abstinence is the rule; to be admitted to
such a community, a person must show a
high level of motivation.
 The staff members of most therapeutic
communities are persons with former
substance dependence who often put
prospective candidates through a rigorous
screening process to test their motivation.
57

 Narcotics Anonymous is a self-help
group of abstinent drug addicts modeled
on the 12-step principles of Alcoholics
Anonymous (AA).
 Such groups now exist in most large
cities and can provide useful group
support.
58

 June 26 is celebrated as
International Day against Drug
Abuse and Illicit Trafficking
every year
59

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