Substance Use DisordersSubstance Use Disorders

Dr Hani Zakri

ST3 in Psychiatry

““.”.”

““Here's to alcohol: the cause of, and solution to, all of life's problems.Here's to alcohol: the cause of, and solution to, all of life's problems.””

Classification Classification Aetiology Aetiology NeurobiologyNeurobiologyAlcohol withdrawalAlcohol withdrawalDelirium TremensDelirium TremensWernicke Korsakoff Syndrome Wernicke Korsakoff Syndrome Opiate DependenceOpiate DependenceManagement of opiate withdrawalManagement of opiate withdrawalTreatment approaches for substance use Treatment approaches for substance use

problems problems

Substance use disordersSubstance use disorders

Summary Summary

A SIMPLE CLASSIFICATION

Stimulants; wake you up, speed you up and give you energy e.g. amphetamine, cocaine and Ecstasy

Depressants; make you calm and drowsy e.g. opioids, benzodiazepines,volatile substances and cannabis

Hallucinogens; change your perception, by distorting what you see and hear e.g. LSD and magic mushrooms

Recreational UseRecreational Use

Acute IntoxicationAcute Intoxication Harmful Use Harmful Use Dependence Dependence

syndromesyndrome

Spectrum of substance useSpectrum of substance use

Acute intoxication

Transient condition following use of alcohol or drugs, closely related to dose and following which recovery is usually complete.

Harmful Substance Use

A pattern of substance use that causes damage to physical health, mental health or social circumstances.

Ingestion of excessive amounts “Idiosyncratic” Reactions e.g. XTC Accidental Overdose e.g. heroin Method of Administration e.g. IV use Police involvement, Work affected etc.

Wake up Question?

Mr Smith used to drink at various places , having various drinks. Now he drinks just only at home sticking to vodka?

A.SalienceB.Narrow repertoire C.Loss of controlD.Relief drinking E.Tolerance

Dependence Syndrome:

3 or more of the following in the past year…..

Compulsion and Cravings Physiological withdrawal state on cessation, relief

use Tolerance Difficulty controlling onset, termination, levels of

use Salience/Primacy – neglect of alternative

pleasures Persistent use despite overt harm (reinstatement, narrowing of repertoire)

Wake up Question?

Which one of the following is not criterion for dependence according to DSM-IV?

A.ToleranceB.WithdrawalC.Compulsion to drinkD.Loss of social activities E.Continued intake

AETIOLOGY

““Biopsychosocial”Biopsychosocial”

Theories & Genes

Social learning model: maladaptive behaviour

Disease model : loss of control, reduce self blame

4 alcohol dehydrogenase : mild protection

12 aldehyde dehydrogenase : 12% oriental ; significant protection.

40% had family Hx 4 fold increase risk of alcoholism

Early influencesGenetic predisposition- explains 60% risk in alcoholism, 4x↑in 1st degree rels, MZ/DZ concordance = 2/1

Key learning experiences

Adopted children x ↑4 risk

Personality factors- socially phobic, anxious, impulsive, risk taking v cautious

Immediate factors Mood states

Withdrawal states

Reinforcing consequencesMood enhancement

Psychosocial facilitation

Relief of withdrawals, neuroadaptation

Early influencesPeer group influences

Family, parental substance use

Cultural factors

Immediate factorsDemographic factors, Occupation Social pressures, Peers, Religious beliefs

Availability, Price, Advertising

Aversive consequencesToxic effects

Illness

Psychosocial dysfunction

Disposition to drug/alcohol

use

Individual Social

Approach Avoidance

Drug/alcohol Use

Factors influencing an

individuals substance use

Wake up Question?

Chris and ken are class mate. Chris’s dad is alcoholic. How many times is Chris more likely to have problems with alcohol?

A.2-3 timesB.4-10 times C.10-20 timesD.50 timesE.100 times

NEUROBIOLOGY

The reward pathway

Reward Pathway activated by. Natural Rewards…… Food Water Sex Nurturing Exercise …… Chemical Rewards Drugs and alcohol Coffee Nicotine…….

As addiction develops natural rewards becomes less effective

ALCOHOL

Epidemiology

Alcohol consumption Alcohol consumption ↑, ↑, costs Scotland > £1 costs Scotland > £1 billion/yearbillion/year

M/F ratio 2/1,trend towards M/F ratio 2/1,trend towards ↑↑drinking in young drinking in young women 16-19 while men 20-24women 16-19 while men 20-24

27% men,14% women in Scotland drink in 27% men,14% women in Scotland drink in excess of the government recommended limits excess of the government recommended limits (Scottish Health Survey 2003)(Scottish Health Survey 2003)

33,000 premature deaths /yr in Eng, Wales33,000 premature deaths /yr in Eng, Wales

Epidemiology

1 in 5 attending GPs1 in 5 attending GPs

1 in 6 attending A&E1 in 6 attending A&E

1 IN 16 hospital admission1 IN 16 hospital admission

Vulnerable populations... Homeless (1/3), prisonersVulnerable populations... Homeless (1/3), prisoners80% suicides, 80% deaths by fire, 50% homicides80% suicides, 80% deaths by fire, 50% homicides40% RTA’ s, 30% fatal RTA’ s, 15% deaths by drowning40% RTA’ s, 30% fatal RTA’ s, 15% deaths by drowning

Screening tools

CAGE: sensitivity 62% AUDIT (Alcohol use disorder s

identification test ): sensitivity 83% MAST (MICHIGAN alcohol screening

test)

CAGE

Have you ever felt you should Cut down on your drinking?

Have people Annoyed you by criticizing your drinking?

Have you ever felt bad or Guilty about your drinking?

Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?

Recognition and detection of alcohol problems

Amount in units Pattern of drinking

Time of first drink, Early morning withdrawals Compulsion, craving, tolerance, salience

CAGE > 2 positive ? Alcohol dependent GGT (80% sensitivity 80% specificity, detects 1/3) MCV(50% sensitivity, 90% specificity, raised in

60%) CAGE+MCV+GGT detects 75%

Low risk: Men < 21 units/week

Women < 14 units/week

Harmful Drinking: Men >50 units/week

Women >35 units/week

2 alcohol free days per week

No more than 8 units in one sitting

RCPsych, RCGP, RCP

Sensible Drinking

Units

Unit = vol of alcohol (mls) x ABV (%) 1000

1 unit = 8 g alcohol= 1 std measure spirits, ½ pint beer

Wake up Question?

The amount of alcohol in two pints (568mls) of beer at 4% ABV is:

7 U 10 U 2 U 5 U 4.5 U

Biopsychosocial effects of alcohol PhysicalPhysical - - Dyspepsia,

HBP, Gout, Psoriasis, Falls, Trauma, Withdrawal syndrome, Cirrhosis, Cardiomyopathy, Neuropathy, Seizures, Death

MentalMental - - Depression, Anxiety, ARBD, Psychosis (Hallucinosis), Blackouts

Social -Social - Marital diffs, absenteeism, debt, drink driving, legal problems, drifting, unemployment, Homelessness, Isolation, deprivation.

Neuropharmacological EffectsMechanism not well understoodCNS Depressant Enhances inhibitory neurotransmission

at GABA-A receptorsReduces Excitatory transmission at

NMDA Glutamate Receptors

Alcohol withdrawal

Often missed clinically! Suspect if anxious, restless, irritable,

alcohol on breath, excessive capillarisation on facial skin/conjunctivae,↑GGT, MCV, AST/ALT ratio >2

Majority - 85% require no detox… advice, support will suffice as mild, self limiting

< 5% develop Delirium Tremens (DT’s) A few will need inpatient detoxification ( DT’S, Epilepsy, no social support) Most detoxs’ done as day patient

Wake up Question?

The mortality rate for person treated for alcohol withdrawal :

A.1%B.20%C.30%D.40%E.50%

Alcohol Withdrawal

> 10 units/day will likely experience some withdrawal

Spectrum of severityUsually within 24 hours after last drinkLasts 5-7 days*Tremor*Nausea*Sweating* Headache,

↑HR, ↑ BP *Dysphoria - depression, anxiety, sleep disturbance, sensitivity to sound, hallucinations, seizures

Wake up Question?

What is the typical time period in which withdrawal Sx appear?

A.2 weeksB.2-3 daysC.2 monthsD.5 days

Management

Diagnose it! Quiet, well lit room with familiar staff Exclude other co existing pathology Re hydration Benzodiazepines… Chlordiazepoxide on

reducing scale Regular review Parenteral B vitamins ..to prevent

Wernicke’s – must be given IV or IM

Wake up Question?

Which is the treatment of choice for seizures (SE) in alcohol withdrawal?

Diazepam Phenytoin Carbamazepine Lorazepam Chlordiazepoxide

Complications

Uncontrolled withdrawalDelirium TremensWithdrawal seizuresWernicke's encephalopathyElderly maybe sensitive to

benzodiazepines, cautious monitoring.Patients with liver disease may be

sensitive to benzodiazepines, cautious monitoring.

Wake up Question?

Failure to Dx and Tx with thiamine for Wernicke's encephalopathy has mortality rate of :

A.5%B.10%C.20%D.30%E.50%

Delirium Tremens

Severe withdrawal state – medical emergency

Reduced or stopped drinking.. 48-72hrs Precipitated by trauma, infection, head Injury Tremor, sweating, dehydration, fever, ↑HR,

↑temp, HBP, agitation, delirium - fluctuating consciousness, orientation, hallucinations - *visual, fear, paranoia, seizures,, circ.collapse

5-10% mortality treated, 35-40% Untreated Best treatment is prevention!

Management

Early diagnosis Quiet, well lit room with familiar staffExclude other co existing pathology Re hydrationRegular reviewBenzodiazepines - may need high dosesParenteral B vitamins – Wernicke’sHaloperidol if hallucinating

Wake up Question?

Malnourished Patient was due surgery. Developed DTs, no signs of Wernicke's encephalopathy. What is your best strategy for thiamine replacement in this patient ?

Oral thiamine 30 mg TDS Oral thiamine 50 mg TDS IV thiamine 250mg TDS IM thiamine 50mg TDS Not required

Wernicke – Korsakoff syndrome

Wernicke – Korsakoff syndrome Organic brain syndrome induced by

deficiency of Vitamin B1 - Thiamine

Wernicke’s encephalopathy - Acute Confusional State, Ataxia, Nystagmus, Tremor Ophthalmoplegia

Korsakoff’s syndrome- long term sequelae. STM impairment, confabulation

Wake up Question?

If untreated what percentage Wernicke’s encephalopathy develop Korsakoff’s syndrome?

A.5%B.10%C.20%D.30%E.75%

Thiamine

Co enzyme in glucose, lipid metabolism Involved in the production of A A’s, glucose derived

neurotransmitters, Myelin Neurotoxicity occurs when citric acid cycle is impaired and

lactate accumulates

Deficiency due to

Reduced intake - alcohol for food, GI upsetMalabsorption - malnutrition, effect of alcoholReduced storage - liver damageImpaired utilisation - liver damageGlucose load on admission to hospital (glucose drip! , meal)

Wernicke – Korsakoff syndrome Fallacies – 1.Rare condition - NO ! actually common and often

missed, less than 10% diagnosed before post mortem

2.Classic triad necessary for diagnosis - NO ! - classic triad only present in 10%

of cases, presentation is non-specific, most common feature is confusion

Wernicke’s encephalopathy Potentially life-threatening Potentially treatable Clinical diagnosis “non specific

presentation” 10% classic triad, 23% ataxia, 29% ophth. 82% confusion - non specific - assoc with

W/D, DT’s, ↓ BP, ↓ temp Can evolve as series of minor sub clinical

encephalopathies (Acute/insidious onset - similar pathology)

Wake up Question?

The symptom that responds earlier to thiamine is :

Ataxia Confusion Opthalmoplegia Amnesia Apathy

Korsakoff’s syndrome

Classically - STM memory impairment Confabulation (not universal) Rel.intact intellectual

functioningNot always preceded by Wernicke’smemory of remote events may also be

disturbed, memory often improvesOverlap with alcohol dementia Personality change, ↓ spontaneity etc.

Prognosis of Korsakoff’s Psychosis Worse if sudden onset and “pure” Better with more global cog. Impairment – rewiring?

Better in non alcoholic cases of WKS Improves with abstinence from alcohol Victor 26% Long Term Care 28% slight recovery 25% sig. recovery 21% complete recovery

Treatment

Prophylaxis - all inpt detox 1 pair iv/im 3-5 daysTreatment 2 pairs iv/im TDS 3 days If response 1 pair 5 days no response stop 3 days Ataxia, polyneuritis, confusion, ↓ memory

- continue to treat as long as clinically improving

Dilute, infuse over 30 mins, CPR facilities

Wake up Question?

The following are diagnostic features of alcohol dependence except:

A. compulsion to take alcoholB. escalation of amount usedC.withdrawal syndromeD. visual hallucinations.

Wake up Question?

The following drugs are correctly described:

A. disulfiram inhibits the breakdown of alcohol

B. acamprosate is a potent anticonvulsantC. naltrexone blocks the effects of

endogenous opioidsD. chlormethiazole is the treatment of

choice for medically assisted detoxification.

Wake up Question?

The following is NOT cause of raised mean cell volume:

A. iron deficiency anaemiaB. AlcoholC. pernicious anaemiaD. pregnancyE.heavy smoking.

Wake up Question?

All of the following tests usually remain elevated for four weeks or more after an episode of alcohol misuse except?

A. aspartate amino transferaseB.white cell countC. serum ethanolD. gamma glutamyl transferase.

DRUGS

Epidemiology

1/20 Scottish adults have used drugs in the past month.

1% adults in Glasgow opiate dependent

70% IVDU in Glasgow Hep C positive

Opiate Intoxication

↓Pupils, ↓consciousness, ↓RR, ↓HR, Coma→ Death

Medical emergency Naloxone iv – but Beware - short acting

(45min)!!! Why?.. Purity of street heroin variable,

“greedy”, Loss of Tolerance after detox, “Accidental OD’s” esp. if poly drug use “Re instatement deaths”

Biopsychosocial effects of Opiates PhysicalPhysical - - Constipation, loss of appetite,

lethargy, accidental OD, Withdrawal syndrome, HIV, Hep C , Weight Loss, DVT’s, abscesses, infections

MentalMental - - mood swings, depression

Social -Social - Family and marital problems, absenteeism, Debts, Lifestyle change- drug seeking, Imprisonment, Homelessness, Isolated, Violence, Prostitution,

Wake up Question?

Tolerance does NOT develop to which of the following :

Sedation Insomnia Constipation Miosis

Opiate Withdrawal – “flu”

Spectrum of severityWithin 12 hours, peak 72 hoursPupillary dilatation, Piloerection,

Rhinorrhoea, Lacrimation, Sneezing, Nausea, Vomiting, Diarrhoea, Muscle, stomach cramps, Anxiety, Dysphoria, Cravings, ↑HR, HBP

Resolved within a week but some mild symptoms persist longer - sleep, mood

Wake up Question?

Which of the following is NOT found in opiate withdrawal ?

Abdominal pain Dry eyes Vomiting Sweating Dilated pupils

Wake up Question?

The half life of Methadone in regular user is :

4-6 hours : opioid naive 10-20 hours 24-36 hours 72-90 hours 1 hour

Management…… Opiate withdrawal is not an emergency!!! Take time to consider options, be safe Don’t be pressurised into prescribing Options are detox. or substitution, will

need worked up for both Depends on the patient’s wishes and

overall situation at the time No point de-toxing if they wish to continue

using, or if they are socially unstable (reinstatement death!)

Counsel carefully. Incorporate harm reduction advice

Management - Detox

Lofexidine detox– alpha 2 agonist , usually as a day patient, rarely as in patient - relieves physical withdrawal symptoms

Supportive care and adjuvant treatment with Buscopan, Paracetamol, Imodium, diazepam

Naltrexone “Blocker” after detox, reduces cravings

Counselling Psychosocial Help Warn Re: loss of tolerance and risk of

Reinstatement death!!!!!

Wake up Question?

What is the equivalent dose of methadone for 0.5 g of street Heroin?

30-40 ml of 1mg/ml mixture

Management - Substitution

Confirm opiate dependence by urine and observation of withdrawal

Titrate substitute carefully Work towards stability and then detox Methadone Must be daily supervised dispensing 1/3 leakage to street! Buprenorphine – sublingual, again supervised dispensing as risk of leakage: drug of choice in

low BP

MANAGEMENT PRINCIPLES

Matching patients to treatment

No single treatment is appropriate for all

Effective treatment addresses multidisciplinary needs not just drug and alcohol use

Treatment must address medical, psychological, social, family, legal, and vocational problems.

Principles of Treatment

What stage are they at ? How can I best help this person at this

stage? Would they like help? Are they

Motivated?“Psycho education” Are they aware of the facts and options? “Harm Minimisation” Will they consider reducing intake? Safer

use?“Abstinence” Do they wish to stop completely? “Pharmacotherapy ” Will they consider medication?“Psychological treatments”

Maintenance

Pre- contemplation

Action Contemplation

Relapse

Enter: Harmful use

Exit: Abstinence, moderation

“Cycle of Change” Prochaska and DiClementi (1984 )

What stage are they at?

Harm minimisation:

Cutting down B vitamins to protect brain (alcohol) Smoking instead of injecting Using Needle exchange Hep B vaccination Safe Sex advice (Hep B,C,HIV) Substitution therapy - Methadone ↓alcohol if Hep C positive and opiate

dependent Risks of cocaine, Alcohol – “coca ethylene”

Abstinence:

Really ready to give it up? Is this the right time?Good social support?Need a Detox?Need Rehabilitation?Will medication help?- cravings, relapse

prevention

Detoxification

Not always necessary Not always desiredMust be planned, never rush into itTiming is crucialAlcohol detox usually as day patient,

but some need in patient( fits, DTs, Head injury, isolated)

Opiate detox usually as day patient

Psychotherapy

Counselling Motivational enhancement therapy Relapse prevention therapy CBT Social skills training Group therapy Family therapy Twelve step programmes - AA, NA Residential rehabilitation

THANK YOUTHANK YOU