SUBSTANCE ABUSE
BY
DR. RABIE A. HAWARI
Consultant Psychiatrist
Clinical Assistant Professor
-:W.H.O.1969
- A drug is any substance that , when taken , into the living organism,
may modify one or more of its functions,
- Drug Abuse is the persistent or sporadic excessive use of a drug
inconsistent with, or unrelated to, acceptable medical practice,
- Drug Dependence is a state – psychic and sometimes also
physical – resulting from interaction between a living organism and
a drug, characterized by behavioral and other responses that
always include a compulsion to take the drug on a continuous or
periodic basis in order to experience its psychic effect, and
sometimes to avoid the discomfort of its absence. Tolerance may or
may not be present, a person may be dependent on more than one
drug.
-: Dependence
= Psychological :- overwhelming repetitive need to seek
whatever ease, pleasure or stimulus is provided by a
drug, is common to all drugs of dependent,
= Physical :- relates to the pharmacology of a drug, in the
course of repeated administration of certain drug the
body's metabolic processes adapt themselves to these
drugs, if such a drug is suddenly withdrawn, the
metabolic balance is upset and this lead to withdrawal
symptoms.
= Tolerance :- diminishing response to repeated dose of a
drug.
-: Dependence continue
Withdrawal or Abstinence Symptoms :- symptoms =
occur after a sudden stoppage of a drug which are due
to hyperactivity of those functions preciously depressed
,by the drug
e.g. 1- convulsions and/or delirium tremens following a
.rapid withdrawal of barbiturates or alcohol
vomiting, diarrhea, lacrimation, sweating, -2
sneezing, and restlessness following abrupt cessation of
.large morphine intake
-: Elements of dependence
1- Withdrawal Symptoms :- e.g. fits
2- Withdrawal relief :- need to get a relief from WDS.
3- Tolerance :- diminished response to repeated dose.
4- Subjective change :- sense of compulsiveness.
5- Narrowing repertoire :- taking more.
6- Salience :- important thing.
7- Reinstatement :- back to drinking level fast.
-: Classes of drugs
1. Stimulants :- coffee , amphetamine , cocaine ,
2. General Depressants :- alcohol , barbiturates ,
3. Opiates :- pethidine , morphine , heroin,
4. Hallucinogenic :- muscolain , L.S.D. ( lysergic acid
diethylamide ),
5. Others :- cannabis = sedative & stimulants.
benzodiazepines = sedative & hypnotics.
nicotine = stimulant & depressive.
solvents = (glue, petrol, acetone) C.N.S.
depressants.
-: Routes of Administration
a. Smoked = hash , tobacco , heroin,
b. Sniffed = cocaine,
c. Chewed = tobacco , ghat,
d. Orally = tablets , alcohol ,
e. Injected = i.v. or i.m. – heroin , barbiturates.
-: Epidemiology
= age :- alcohol 40 – 54
drugs 20 – 39.
= sex :- alcohol M : F - 2.5 : 1
drugs M : F - 4 : 1
= social class :- all social classes.
= urban / rural :- increased in urban areas.
= general hospital patients :- 20% male – 4% female
with alcohol problem.
-: Etiology
Multifactorial
a) Genetics :- no conclusive evidence.
For alcohol = parents & siblings 2&1/2 times that of
general population,
= MZ : DZ 71% : 32%,
= adoption 4 x control.
b) Psychological theories :-
* Behavioral :-
1. Modeling,
-: Etiology continue
Psychological theories – behavioral ( continue )
Primary direct reinforcement e.g. stimulus, .2
.sedation reinforce abuse behavior
.Secondary reinforcement e.g. the environment .3
cues are linked with pharmacological effect of drugs
.i.e. advertisement on t.v. and newspapers
-: Analytic *
addicts considered fixed at or regressed to an oral “
.level of sexual development
-: Etiology continue
c) Social & Family factors :-
- peer group pressures,
- demands of culture and subculture,
- associated with parental disharmony & use of drugs &
alcohol,
d) Other factors :-
- personality & attitudes :-
* break rules, truancy ,
* grow before time, sexual promiscuity,
* miserable and anxious.
-: Etiology continue
Other factors continue:-
- supply and easy availability
* prescribed Benzodiazepine,
* legal alcohol & tobacco,
* illegal cocaine & hash.
- occupation risk :-
* those involved in manufacture and sale of alcohol,
* company directors and commercial travelers,
* services,
* journalists , entertainers , doctors , nurses.
Problem of dependence :-
a) Physical :- = over dose death,
= contamination e.g. AIDS,
= tissue damage e.g. ulcerative (stomach,
nasal), perforation , thrombosis , cancer,
= dietary deficiency.
b) Psychological :-= intoxication accidents, poor function,
= WDS. e.g. hallucinations & delusions.
c) Social :- = harm to self and other,
= family problems e.g. divorce, battered wives,
= crimes , prostitution.
-:Alcohol related psychiatric illness
- Blackout : amnesia with high blood level,
- Fits : with heavily alcohol dependent,
- Delirium Tremens : 2-4 days of sudden cessation
delirium, tremor, hallucination, delusion, dehydration, low
bp, seizure, coma, death.,
- Alcohol Hallucination : auditory, 3rd. Person, conscious.
- Agoraphobia, depression, suicide, morbid jealousy, low
sexual drive, impotence,
- Anemia (B12, folate ), Fetal Alcohol Syndrome ( poor
growth, impaired intellect, craniofacial, cardiovascular
defects ),
-:Alcohol related psy. Illnesses continue
- Wernicke – Korsakoff`s Syndromes : - ( degenerative
changes in upper brain stem, thalamus hypothalamus,
mammillary bodies),
* Wernicke’s Encephalopathy = neuropathy, confusion,
nystagmus, staggering gait.
* Korsakoff’s Psychoses = dementia, impaired recent
memory, confabulation, perseveration.,
- Dementia : following prolonged heavy intake and persist
at least 3 wks. After cessation of alcohol ingestion.,
- Brain damage :- studies showed excess cerebral atrophy
among alcoholics.
-: Management & Treatment
# Assessment :-
- full Hx. + family Hx. of abuse,
- drug Hx. = type(s), rout, amount, effect, last use, cast,
- physical examination = general health, needle tracks,
- social (isolation), psychiatric (hallcin., delusion) & criminal
(theft, jail) Hx.,
- urine tests ( except for LSD ,& solvents ),
- evidence of dependent ,
- withdrawal signs & symptoms ,
- legal requirements.
-:Manage.& treatment continue
a) Opiate -: Methadone = cross - tolerance= in decrease
dose regime,
b) Alcoholism:- Detoxification =
- sedation : chlormethiazone, benzodiazepine,
- nutritional ; balanced diet,
- rehydration : correct electrolytes imbalance,
- vitamin : hi – potency parentrovite or thiamine inj.
- anticonvulsant : for fits,
- antabuse : for longer term aims ( Disulfiram )
: Management & treatment continue
c) Amphetamine Psychoses = phenothiazine , usually
psychoses fades after 5 – 7 days.,
d) Barbiturates =
- inpatient care & close observation,
- short acting barbiturates to control WDS. e.g.
pentobarbitone 4 – 6 hourly,
- after stabilization a very gradual redaction , 10%
of total dose each day,
- phenytoin – as anticonvulsant cover .
-: Prognosis & Abstinence
Predictors of good prognosis=
( older , social support , motivated , first treatment,
adequate intelligence , absence of antisocial personality
traits.)
Abstinence =
- mature – out , mid 30’s,
- relationship with non-addict,
- dramatic change in context of addiction,
- intensive support : Alcohol Anonymous (AA) , self-
helped group , good rehabilitation.
