Substance Use Disorder

Addiction (DSM 5)

By

Soheir H. ElGhonemy

Assist. Professor of Psychiatry- Ain Shams University- Egypt

Member of International Society of Addiction Medicine

Member of European and American Psychiatric Associations

Trainer Approved by NCFLD

Dopamine Pathways

Functions

•reward (motivation)

•pleasure,euphoria

•motor function

(fine tuning)

•compulsion

•perserveration

•decision making

Serotonin Pathways

Functions

•mood

•memory

processing

•sleep

•cognition

nucleus

accumbens

hippocampus

striatum

frontal

cortex

substantia

nigra/VTA

raphe

Medial Forebrain Bundle

Ventral tegmental area (VTA)

(Lateral) hypothalamus (LH)

Nucleus accumbens (NAc)

Frontal cortex (FC) - key portions

Prefrontal cortex (pfc)

Orbitofrontal cortex (ofc)

Drugs Associated wth

Neurotransmitters

Why do people have “drugs of choice”?

Dopamine - amphets, cocaine, alcohol

Serotonin - LSD, alcohol

Endorphins - opioids, alcohol

GABA - benzos, alcohol

Glutamate -alcohol

Acetylcholine - nicotine, alcohol

A Brain Chemistry Disease!

Addicting drugs seem to “match” thetransmitter system that is not normal

A chronic, relapsing, medical disease

There are mild, moderate, and severe forms

Detox is traditionally the first step in thetotal treatment process

Methadone and nicotine maintenance isevidence that some people require achemical to overcome the non-normaltransmitter system

Figure 5

The combination of neuroadaptations in the braincircuitry for the three stages of the addiction cyclethat promote drug-seeking behavior in theaddicted state.

Activation of the ventral striatum/dorsalstriatum/extended amygdala driven by cuesthrough the hippocampus and basolateralamygdala and stress through the insula.

The frontal cortex system is compromised,producing deficits in executive function andcontributing to the incentive salience of drugscompared to natural reinforcers.

Dopamine systems are compromised, and brainstress systems such as CRF are activated toreset further the salience of drugs and drug-related stimuli in the context of an aversivedysphoric state

Common Underlying NeurobiologicalFactors Can Be

Neurochemical (imbalance of

neurotransmitters)

Structural/anatomical (same

regions and pathways)

Genetic (inherited factors that

compromise function)

Drug Disorder

Cocaine and Methamphetamine Schizophrenia, paranoia,

anhedonia, compulsive

behavior

Stimulants Anxiety, panic attacks, mania

and sleep disorders

LSD, Ecstasy & psychedelics Delusions and hallucinations

Alcohol, sedatives, sleepaids

& narcotics

Depression and mood

disturbances

PCP & Ketamine Antisocial behavuor

DRUG USE(Self-Medication)

STRESS

CRF

Anxiety

CRF

Anxiety

What Role Does Stress Play

In Initiating Drug Use?

Consequence: There is no “cure”…

To be successful, treatment is a Lifetime

Process

Science is helping to improve our

strategies and successes

History Taking

The history is the chronological story of the

patient’s life from birth to present

Personal data:

Name, age, sex, marital status, religion,

address, occupation, education.

n.b.; source of referral could be mentioned

here if the patient won’t cooperate

Personal History:

Birth and developmental milestones, family

atmosphere, school performance and general

conduct in school, educational achievement,

occupational history, sexual and marital history.

Attempt to correlate social problems with

evolving drug problems. Enquire about impact

of drug use on lifestyle.

Family History:

Brief vignette of father, mother and other

siblings should include age, occupation

and relation with the client. History of

psychiatric problems or problems

resulting from alcohol, drugs or nicotine.

Drug History:

This section should attempt to give a clear picture of

initiation of drug use accounting for each specific

drug. The evolution of drug use with the

development of personal and social problems as a

consequences of drug use.

Type, quantity, and route of use of each individual

drug. Alcohol consumption should be checked as a

routine part of drug history taking.

Drug use in the past 24 hr.:

Detailed and sensitive questioning around this will not

only provide data about drug use and drug

dependence but should give a clear picture of the

client’s lifestyle and daily stresses and strains.

Drug use in the past month:

Should try to draw a picture of drug use over the past

4 weeks.

History of abstinence:

Number of trials , how , duration of each and reason

for relapse.

Legal History:

Charges, convictions, imprisonments and

violent incidents.

Sexual and Marital History:

Sexual behavior and marital relation and if

extramarital relationships. Relation of sexual

or marital problems to drug use.

Occupational History:

Relationships of jobs and relations to drug

use. Current employment status.

Present life situation:

Family and social support. Non drug use

friends, leisure activities and

occupational prospects, financial status

and accommodations.

Mental state examination:

On admission:

Describe relevant features. Positive and

negative findings regarding both physical

and mental condition of the client. Focus

on physical signs of drug withdrawal, liver

diseases signs and any neurological

dysfunctions. Sites of injections and any

infections.

Mental state should include level of

consciousness, alertness and orientation and as

well as level of cooperativeness. Ability to give

history will provide data about their intelligence,

cognitive state and level of insight into their

condition.

General state of dress and grooming as well as

evidence of agitation, calmness or detachment

from problem should be checked.

Pattern of sleep, appetite, energy level,

mood state and suicidal ideations giving

data about special and general

psychological state.

Any delusions or hallucinations should

be considered and relation to client

intoxication or withdrawal states

Follow up setting is meant for better

elaboration of the client’s condition and

allow building rapport for setting

management plan.

A thorough history is the substrate for a

considered opinion about the client. What is

the best for the client. History is cornerstone

in the substance abuse field.

Patient with treatment program:

Substance is being used.

Recent regular use.

Psychiatric status.

Medical condition.

Social network.

Legal aspects.

Goals of treatment:

A.Help the individual to be drug

free( detoxification).

B.Help to maintain drug free state (

relapse prevention)

C.Long term Rehabilitation.

Classification of substance:

I. CNS depressants: Alcohol

Opiates

Sedative hypnotics

II.CNS stimulants: Amphetamines

Cocaine

III.CNS hallucinogens: Cannabis

LSD

Anticholinergics

Stimulation : Depression :a. Anxiety .

b. Insomnia.

c. Twitches.

d. Convulsions.

e. Hyperthermia.

f. Tachycardia.

g. Irritability.

h. Excitement.

i. Tremors.

j. Hypertension.

k. Tachypnea

a. Apathy.

b. Retardation.

c. Inattentive.

d. Stupor.

e. Hypotension.

f. Bradypnea.

g. Ataxia.

h. Lethargy.

i. Drowsiness.

j. Confusion.

k. Hypothermia

l. Bradycardia &Coma.

Drugs of abuse that can be tested in urine:

Alcohol: 7-12 hrs.

Amphetamine : 48 hrs.

Barbiturate ; short: 24 hrs. , long acting: 3 wks.

Benzodiazepine: 3 days.

Cannabinoides : 3 days ---4 wks “ depending on the use; chronic use leads to lengthening of period”

Cocaine : 6- 8 hrs.

Codeine : 48 hrs.

Heroin : 36—72 hrs.

Methadone : 3 days.

Morphine : 48 – 72 hrs

The Neuropharmacology of Drugs of

Abuse

Psychoactive drugs alter normal neurochemical

processes . This can occur at any level of activity

including :

a. mimicking the action of a neurotransmitter .

b. altering the activity of a receptor .

c. acting on the activation of second messengers

d. directly affecting intracellular processes that control

normal neuron functioning.

Routes of administration:

It affects how quickly a drug reaches the

brain ,also ,chemical structure of a drug

plays an important role in the ability of a drug

to cross from the circulatory system into the

brain.

Four routes:

oral.nasal.Intravenous.inhalation.

alcoholMild and moderate intoxication:

1.Impaired attention , poor motor coordination.

2.Dystharthria- ataxia , nystagmus, slurredspeech.

3.Prolonged reaction time, flushed faceorthostatic hypotension.

4.Hematemesis and stupor.

Pathological intoxication:

1.Excited , psychotic state following min.consumption in susceptible individuals.

Intoxication associated with belligerence.

Uncomplicated Withdrawal:

Coarse tremors of hands, tongue, eyelids andat least one of the following:

Nausea or vomiting.

Malaise or weakness.

Autonomic hyperactivity.

Anxiety, Depressed mood or irritability.

Transient hallucination or illusions.

Headache , insomnia.

Withdrawal complication:

Seizures.

Hallucination.

Delirium.

Management:

I. Avoid aspiration by placing patient’s face down or on one

side. Hospitalization is usually necessary.

II. Parenteral sedatives or physical restrains.

III. Low dose sedative ; Lorazepam 1-2 mg, physical

restrains or further sedation by Haloperidol IM 5 mg.

IV. Parenteral dose of Thiamine 100 mg.

V. Benzodiazepine tapering.

VI. Thiamine 50 mg PO.

VII. Multivitamin PO.

VIII.Folate 1 mg PO.

Over a week for uncomplicated withdrawal.

Opiate:Patients rarely seek treatment for intoxication.

Overdose :

I. Respiratory and CNS depression.

II. Depression.

III.Gastric hypomotility with ileus.

IV. Non-cardiogenic pulmonary edema.

Withdrawal:

I. Lacrimation, rhinorrhea.

II. Diaphoresis, yawing, sneezing.

III. Malaise, irritability, nausea and vomiting.

IV. Diarrhea, myalgia, arthralgia, bone ache.

Management of Opiate overdose:

I. Respiratory depression : air way support

II. Cardiopulmonary suppression: NaloxoneHydrochloride 0.4 mg or 0.01 mg\ kg IV,repeated dose of Naloxone infusion0.4 mg\ hr. for 12 hrs. subsequent to theinitial boluses.

III. Pulmonary edema : Intubation and pressureventilation ;ICU admission.

IV. Gastric lavage or induced emesis followedby activated Charcoal for orally ingestedoverdose.