Fahad Alosaimi  MBBS, SSC-Psych Psychosomatic medicine Consultant

Assistant professorKing Saud University

السعودية شرق في االدمان نسبة عامي% 300ارتفاع 2006-2005خالل

CNN مكافحة خبير نايس، ماثيو وقال

إن المكتب، في المخدراتاألمفيتامين من األكبر الكميات

في مصادرتها يجريالسعودية، العربية المملكة

لـ حديث في وأضاف،CNN

خالل صادرت الرياض 2008أنمن من 12.8أكثر متري طن

أصل من مليون 15.3األمفيتامينككل المنطقة مستوى على طن

في الطبيب الحقوي، علي أمابن سعود الملك مستشفي

فقال عبدالعزيز،بأن يقولون لديه المرضى إن

على هو لإلدمان األكبر االتجاهاألمفيتامين ثم ومن .الكحول،

What is addiction?In Aug 2011, The American Society of

Addiction Medicine (ASAM) has officially recognized Addiction as mostly:

a)a social problem b) a moral problem c)a criminal problemd)a primary chronic brain probleme)a behavioral disorder occur as the result of

other causes such as emotional or psychiatric problems.

Addiction is not a choice, but choice still plays an important role in getting

help. 

Terminology Abuse: Self-administration of any substance in a

culturally disapproved manner that causes adverse consequences.

Dependence: The physiological state of neuroadaptation produced by repeated administration of a drug, necessitating continued administration to prevent the appearance of the withdrawal state.

Addiction: A nonscientific term that implies dependence.Intoxication:Withdrawal:Tolerance:

Substance Use Disorders (DSM IV-TR)

Substance Abuse:

Repetitive problems in 1 major life areas

Substance Dependence (3 criteria): Tolerance Withdrawal Amount / time Urges, failure to cut down Excessive time obtaining, using &

recovering Activities given up Use despite problems

Common Routes of Substance Abuse

Route substances

Oral alcohol hypnotics - sedatives stimulants hallucinogens

Injections Opioids stimulants

Smoking cannabis PCP

Sniffing cocaine volatile substances

Photo courtesy of the NIDA Web site. From A Slide Teaching Packet: The Brain and the Actions of Cocaine, Opiates, and Marijuana.

Case of Mr.A26 year old male. He came to ER with a runny nose, stomach cramps, dilated

pupils, muscle spasms, chills despite the warm weather, elevated heart rate and blood pressure, and is running a slight temperature.

He has no other adverse medical problem and no psychological problems.

At first he is polite and even charming to you and the staff. He’s hoping you can just give him some “meds” to tide him over until he can see his regular doctor.

However, he becomes angry and threatening to you and the staff when you tell him you may not be able to comply with his wishes.

Case of Mr.BHe is an older man in his late sixties and was a bit disheveled in

appearance.He came to ER accompanied by his neighbour. The neighbour tells you that he found him earlier this evening

trying to enter his apartment door. He was sweaty, his eyes where dilated, and his hands were

trembling so badly that he could not get the key in the door. He kept calling his neighbour by another name and saying he

was trying to get into his office to do some work though he retired years ago.

He can correctly identify himself but, also appears confused & unable to tell you the month or season.

His demeanor is polite and apologetic to you and the staff. He tells you he has never had a problem with ???? but scored

high on the ???? assessment test. He then admits to an occasional ???? every now and then.

QuestionsWhat preliminary Axis I diagnosis would give

each of your patients and why? What, if any, medical danger(s), do you see or

should you consider for either patient? Why?Management?

AssessementCollateral history.Urine screening tests.blood screening tests (alcohol, barbiturates).Pattern of Abuse:What? (type, dose, route, effect: nature and duration).How? (frequency, duration, how long, source, and

situation)Why? (? psychosocial problems).Dependence?

Complications :Psychosocial…..Physical…..

Classes of Substances

Alcoholالخبائث أم

Alcohol Kills More Than AIDS, TB or Violence-WHO report (Feb 2011)Alcohol causes nearly 4% of deaths worldwide,

more than AIDS, tuberculosis or violence.Alcohol is the world's leading risk factor for

death among males aged 15-59,"Alcohol is a causal factor in 60 types of diseases

and injuries.Now we have strong evidence of a causal

relationship between drinking and breast cancer.

20

Epidemiology

dependence is most common in

those aged 40 – 55 years.• In USA :• 13 % men and 4 % women

age 1820-40% hospital admissionsAlcoholics who continue drinking have a

shortened life-span of 15 years why?

Assessment

Risk factors of Alcohol abuseVulnerable personality: impulsive, gregarious, less

conforming, isolated or avoidant persons.Vulnerable occupation: senior businessmen,

journalists, doctors.Psychosocial stresses: social isolation, financial,

occupational or academic difficulties, and marital conflicts.

Emotional problems: anxiety, chronic insomnia depression.

Is your patient ETOH dependent?CAGE questionnaire C = Have you ever felt you must Cut down your

drinking?A = Have people Annoyed you by criticizing your

drinking?G = Have you ever felt Guilty about your drinking?E = Have you ever had a drink first thing in the

morning as an “Eye opener”?

Laboratory Tests

Identify acute and/or heavy drinking (> 5 drinks/day):

Blood Alcohol Levels (BAL).

Gamma-glutamyltransferase (GGTP > 35 IU/L)

Carbohydrate Deficient Transferrin (CDT > 20 IU/L)

Erythrocyte mean corpuscular volume (MCV >91.5 3)

High AST/ALT

*** CDT + GGTP best diagnostic combination.

Alcohol intoxication Ethanol plasma concentrations Vs. CNS effects

Ethanol plasma concentration Ethanol plasma concentration

(per mill)(per mill)

EffectEffect

0.20.2 Feeling of relaxationFeeling of relaxation

0.30.3 Slight euphoriaSlight euphoria

0.50.5 Slight motor incoordinationSlight motor incoordination

11 ataxiaataxia

33 stuporstupor

>>4 4 Coma, death due to the Coma, death due to the respiratory failurerespiratory failure

Alcohol withdrawal 70 % of AD patients & Rate in the elderly. No gender/ethnic differences 85% mild-to-moderate 15% severe and complicated:

Seizures Delirium Tremens

Features : Tremulousness (hands, legs and trunk). Nausea, retching and vomiting. Sweating, tachycardia and fever. Anxiety, insomnia and irritability. Cognitive dysfunctions. Thinking and perceptual disturbances.

Course of AWStagesI (24 – 48 hours):

II (48 – 72 hours):

III (72 – 105 hours):

IV (> 7 days):

SymptomsPeak severity at 36 hours

90% of AW seizuresMost cases self-limited

Stage I symptoms

“Delirium Tremens”

Protracted withdrawal

Delirium TremensFeatures: delirium. gross tremor . autonomic disturbances . dehydration and elecrolyte disturbances.. marked insomnia.

Course : peaks on third or fourth day, lasts for 3 – 5 days, worsens at night, and followed

by a period of prolonged deep sleep,

Complications :

seizures. chest infection, aspiration. violent behaviour. coma. death; mortality rate: 5-15%. Why ? 

Complications of chronic ETOH abuseMedical psychiatric Social

NeurologicalCerebellar degenerationSeizuresPeriphral neuropathyOptic nerve atrophyhead traumaAlimentaryTumours (oesophagus, liver..)gastritis, peptic ulcerPancreatitishepatitis, cirrhosisOthers:cardiomyopathyanaemiaobesityimpotencegynaecomastia

amnesic disorderdeliriumdementiapsychosisdepressionreduced sexual desireinsomniapersonality deteriorationsuicidemorbid jealousy

social isolationjob lossmarital conflictsfamily problemslegal troublessocial stigmaothers

TreatmentTreating Alcohol Intoxicated Patient: Conscious : supportive, antipsychotic if agitated. Unconscious: ABC

Treating Alcohol Withdrawal:Supportive, thiamine & long acting BDZ (Why?) ± anticonvulsants for

seizure. 

Maintaining Abstinence:Medciations: Disulfiram – blockade of aldehydedehydrogenase cummulation of

acetaldehyde - nausea, flushing, tachycardia, hyperventilation, panic… Naloxone – reduces alcohol-induced reward. Acamprosate – anti-craving effects .

Psychological: group Tx, AA, relapse prevention.

Sedatives, Hypnotics, and Anxiolytics

Similar clinical manifestations to alcohol.withdrawal from short-acting substancet (e.g. triazolam) can

begin within 4 - 6 hours .Alcohol and all drugs of this class are brain depressants any

risk? , are cross-tolerant and cross-dependant.withdrawal can be accomplished safely using diazepam,

phenobarbital, and pentobarbital, dose reduced in steps (about 1/4 - 1/10 of daily benzodiazepine dose, every two weeks).

BDZ have a large margin of safety & less addiction potentials.Flumazenil is a BDZ receptor antagonists used in BDZ

overdose.

Inhalants (Volatile Solvents )Examples : Lighter fluids,Spray paints,Cleaning

fluids,Glues,Typewriter correction fluids,Fingernail polish removers.

The active compounds : acetone, benzene or toluene.brain depressants, effects appear within 5 – 10

minutes and may last for several hours.Common among adolescents in lower socioeconomic

groups, usually as occasional experimentation.features of recent abuse : unusual breath or odour,

rashes around the nose and the mouth or the residue on the face, hands or clothing.

InhalantsAcute effects Long term effects

Euphoria excitement disinhibition**High dose:disturbed conciousnessperceptual disturbancesImpulsivenessAssultivenessimpaired judgementSedationslurred speechnystagmus, ataxia, incoordiantionnausea, vomiting. 

Irreversible multi-organ damages (brain, lungs, liver, kidneys, muscles, peripheral nerves and bone marrow).

Psychological dependence.

Death because of: respiratory depression asphyxiation aspiration of vomitus cardiac arrhythmia serious injury

*Course of abuse: short * Treatment : supportive.

STIMULANTSEnhance DA & NE, sympathomimitics peripherally.amphetamine , Khat (Qat), caffeine, cocaine & nicotine

(tobacco).Therapeutic uses : ADHD, narcolepsy,depression &

obesity. Abused by students, long distance drivers..etc.Crack ( smoked, cocaine ) is highly addictive why? Mild w/drawal Sx : low mood and dec. energy.

* In severe cases : depression, anxiety, lethargy, headache , sleep disturbances & craving .

STIMULANTS (Clinical effects)Psychological Physical

Enhanced cognitive functionsElevated moodHyperactivityOver-talkativenessIncreased confidence, self-esteem Insomnia.In high doses / prolonged use:Restlessness, irritabilityParanoid psychosisAggressiveness, hostility

Reduced sense of fatigueReduced appetite (anorexia)Dilated pupilsTremor In high doses / prolonged use:Nausea, vomiting, cardiac arrhythmia. hypertension, CVA, seizures, dizziness, hyperthermia, respiratory distress, cyanosis. rebound rhinitis, nose bleeds & perforated nasal septum(cocaine snorting)

Treatment* Intoxication: supportive ( sedation, antiarrhythmic drugs, Antipsychotics &

urine acidification why?  * Planed Withdrawal : counseling ,sedatives & Antidepressants if needed..

Other stimulantsKhat:

 * The fresh leaves are chewed for their stimulant effect( Cathinone ) .

* Chronic use : infection & loss of appetite.Caffeine

* Intoxication >250 mg. :restlessness * excitement * agitation

insomnia * diuresis * GI upset

tachycardia * muscle twitching * flushed face 

* Withdrawal (after prolonged use and abrupt cessation)

headache * nausea * vomiting * anxiety

dysphoria * fatigue * drowsiness

 

Nicotine CNS stimulants ,agonist at the nicotinic subtype of Ach receptors and

activating DA and NE. & a skeletal muscle relaxant.Why people like smoking? improved attention, learning, reaction time,

and problem - solving ability. Withdrawal features ( peak in 1-2 days, few weeks):

irritability * frustration * poor concentration

insomnia * dysphoric mood * increase appetite.

Smoking causes cancer of the lung, upper respiratory tract, bladder, pancreas, oesophagus and probably kidney and stomach.

Cigarette smoking can induce liver microsomal enzymes and reduce plasma concentrations of antipsychotic agents.

OPIOIDSThis group include: heroin • morphine • codeine • pethidine •

methadone .The medical use of opioids ( e.g. pethidine) is mainly for analgesia . They are abused for their powerful euphoriant effects .Tolerance develops rapidly & diminishes rapidly which is serious

why?Opioid Withdrawal:  flulike Sx , craving.. They are very distressful

but not serious medically. including: lacrimation muscle and joint pain cold and hot flushes nausea, vomiting and diarrhoea piloerection

Opioids ( clinical effects)Psychological Physical

euphoriarelaxationhyperactivitydrowsinessanalgesiareduced sexual desire

small pupilbradycardiareduced appetiteconstipationrespiratory depressionI.V use:

*AIDS * hepatitis

* endocarditis * septicemia

* Acute local infectionsTreatment:*Opioid overdose : supportive +naloxone*Opioid Withdrawal: symptomatic treatment, Counseling, individual or group therapy* Harm reduction strategies: methadone,buprenophine

CANNABIS(clinical effects)Psychological Physical

sense of well beingeuphoriarelaxationenhancement of aesthetic experiences through hightened perceptual awareness impaired memoryimpaired psychomotor performance.dysphoria, depression anxiety, panic attacksamotivation syndrome ? (chronic use)psychosis (risk factor for SCZ)

 

tachycardiareddening of the conjunctivadry mouthrespiratory tract irritationincreased appetite

CANNABISThe active ingredient “9-tetrahydrocannibinol” (THC). With high dose & prolong abuse, tolerance

psychological dependence may occur.Withdrawal from high doses gives rise to a

syndrome of nausea, anorexia, irritability and insomnia.

Chronic use of cannabis can lead to a state of apathy and amotivation (amotivation syndrome) but this may be more a reflection of patient’s personality structure than an effect of cannabis.

 Treatment : Symptomatic , support & counseling.

HALLUCINOGENS (clinical effects)

Psychological Physical

marked perceptual distortion ( changing shapes, colours…)hallucinations ( visual, tactile… )false sense of achievement an strengthdepersonalization, derealizationeuphoria, anxiety, panicparanoid ideationhomicide and suicide tendenciesflashbacks after abstinenceDelirium

PCPeuphoria and peaceful floating sensations.deliriumagitation and aggressive behaviour.

tachycardiahypertension cerebellar signswide pupilshyperemic conjuncitva blurred visionhyperthermiaPiloerection

PCPhypertensive crisisstatus epilepticus malignant hyperthermia

HALLUCINOGENSHallucinogenes can be natural, e.g. Psilocybin

(magic mushroom) or synthetic , e.g. Lysergic acid diethylamide (LSD).

Phencyclidine(PCP) is a dissociative anaesthetic with hallucinogenic effects (a separate category in DSM IV).

Tolerance develops rapidly& reverses quickly in few days.

Abuser can develop a psychological dependence.

Treatment: Supportive & symptomatic. 

QuestionsWhat preliminary Axis I diagnosis would give

each of your patients and why? What, if any, medical danger(s), do you see or

should you consider for either patient? Why?Management?