Drug abuse (dependence) Definitions: Substance abuse and dependence refers to any continued pathological use of a medication, non

on medically indicated drug (called drugs of abuse) They normally are distinguished as follows: Substance abuse is any pattern of substance use that results in repeated adverse social consequences related to drug taking, for example, interpersonal conflicts, failure to meet work, family or school obligations or legal problems Substance dependence, commonly known as addiction, is characterized by physiological and behavioral symptoms related to substance use, these symptoms include the need for increasing amounts of the substance to maintain desired effects, withdrawal if drug-taking ceases, and a great deal of time spent in activities related to substance use.

WHO described dependence as a syndrome includes: 1. A compulsion to use the drug, usually during attempts to stop consumption 2. The wish to cease drug use although intake continues 3. Adaptive changes in the nervous system leads to tolerance and withdrawal symptoms 4. Drug intake to relieve withdrawal symptoms 5. Priority to drug seeking

On this ground, dependence means that the person becomes in continuous need for the drug, stoppage of administration leads to: a) Withdrawal symptoms (physical dependence): It is a serious characteristic illness occurs on withdrawal of the drug due physical dependence which could be stopped by administration of the drug b) Desire to the euphoria: (craving): it is due to psychological dependence on the effect of the drug Tolerance:

 It is a tendency to increase the dose of the drug because the repetition with the same dose has progressively less effect and the dose needs to be increased to obtain the same effect Progressive increase of the dose leads to failure of the proper feeding resulting in physical deterioration then stop working then forced to do anything to get the drug then moral deterioration

Cross tolerance: Ability of one drug to suppress manifestations of physical dependence produced by another (substitution therapy) Causes of substance dependence: They are not well established but three factors are believed to contribute to substance-related disorders: Genetic factors Psychopathology Social learning 1- Genetic factors: In genetic epidemiological studies of alcoholism , the probability of identical twins both exhibiting alcohol dependence was significantly greater than with fraternal twins thus suggesting a genetic component in alcoholism It is unclear whether the genetic factor is related to alcoholism directly or it is linked to other psychiatric disorders that are known to be associated with substance abuse

2- Psychopathology They include antisocial personality disorder, bipolar disorder, depression, anxiety disorder and schizophrenia 3- Social environment: In this model, drug taking is essentially a socially learned behavior. Local social norms determine determine the likelihood that a person is exposed to the substance and whether continued use is reinforced. For example, individuals may by observing family or peer role models learn that substance use is normal. Clinical presentation of drug dependence in general:

a. Due to dependence Withdrawal symptoms Craving

b. Due to tolerance: Physical deterioration Moral deterioration

c. Due to acute toxicity Overdose Synergism or potentiation with other drugs Adultration and foreign substance

d. Due to infective disease Viral hepatitis AIDS

General management of dependence: a. Treating the physical dependence by withdrawal Appropriate withdrawal is preferrd in treatment of all types of drug dependence except morphine and barbiturates b. Treating the psychological dependence by rehabilitation c. Follow-up Dependence producing drugs: a. Stimulants: b. Natural: coffee, tea and cocaine Synthetic: amphetamine and methamphetamine

Depressants: hypnotics, tranquillizers

c. Hallucinogens d. Euphoriants Opium or morphine and heroine dependence Gradual physical deterioration Gradual moral deterioration

Injection marks Miosis, constipation, loss of appetitie and euphoria Severe withdrawal syptomps Gradual withdrawal is needed in treatment, may be relieved by barbiturates and tranquillizers

Barbiturate dependence Physical deterioration Mental deterioration Severe withdrawal sypmtoms Gradual withdrawal is needed in treatment Gradual withdrawal may be relieved by tranquillizers

Alcohol dependence Physical deterioration Mental deterioration Jealous husband syndrome: the person becomes jealous with excessive sexual desire and impotence at the same time Coarse tremors in the lips and hands Pachymeningitis hemorrhagica (chronic subdural hematoma) Appropriate withdrawal is preferred Antabuse (disulfiram): alcohol dehydrogenase inhibitor. If alcohol is taken during administration of antabuse, a disturbance occurs in alcohol metabolism. It stops at acetaldehyde stage, the accumulation of acetaldehyde leads to undesirable effects (tachycardia, palpitation and vomiting). This will make the patient hates alcohol.

Amphetamine dependence Action: Stimulation of cerebral cortex Stimulation of reticular formation Suppression of appetite Physical deterioration

Mental deterioration Personality changes (suicide or homicide) Abrupt withdrawal

Cocaine dependence Physical deterioration Mental deterioration Cocaine bug: the patient feels as if insects are creeping under the skin Moral deterioration Sexual perversion Increase aggressiveness