Drug dependence and substance

related psychiatric disorders

 Criteria for Dependence
• 1.A diagnosis of dependence should be made if 3 or more of
the following have been experienced or exhibited at any time
in the same 12 months period:
• 2.Tolerance defined by either need for markedly increased
amounts of substance to achieve intoxication or desired
effect, or markedly diminished effect with continued use of
the same amount of the substance
• 3.Withdrawal, as evidenced by either of the following: the
characteristic withdrawal syndrome for the substance,
• Or
•
• The same (or closely related) substance is taken to relieve or avoid
withdrawal symptoms
• 4.The substance is often taken in larger amounts over a longer
period of time than was intended
• 5.Persistent desire or repeated unsuccessful efforts to cut down or
control substance use
• 6.A great deal of time is spent in activities necessary to obtain the
substance, use the substance, or recover from its effects
• 7.Important social, occupational, or recreational activities given up
or reduced because of substance use
• 8.Continued substance use despite knowledge of having had a
persistent or recurrent physical or psychological problem that was
likely to have been caused or exacerbated by the substance
Types of dependence producing drugs
• CNS stimulant
• Amphetamine, cocaine, MDMA (ecstasy)
• CNS depressant
• Opiates-morphine,pethadine, heroin, methadone
• Barbiturate, Benzodiazepine
• Cannabis
• Hallucinogen—LSD,Phencyclindine
• Volatile substances
 Causes of drug misuse/Dependence
• No single cause
• Four factors are important
• Availability of drugs
• A vulnerable personality
• An adverse social environment
• Pharmacological factors
• Personal factors
• Living in a disrupted families
• Poor school record, truancy or delinquency
• Presence of depression or anxiety
• Genetic factors
• Social environment
• Peers pressure
• Social deprivation
• Neurobiology of drug use, misuse
• Drug act as a positive reinforcers because they
cause positive subjective experiences such as
euphoria or reduction in anxiety
• Physiological and non physiological
dependence
• Physiological dependence is characterized by
tolerance and withdrawal syndrome
• Nonphysiological dependence is characterized
by desire for the drug and drug seeking
behaviour
 Adverse effects of drug misuse
• Physical effects
• Intra venous drug use include HIV infection
and Hepatitis B and C
• Vein thrombosis
• Bacteria endocarditis
• Accidental overdose
• Social consequences
• Unemployment
• Accidents petty crimes
 Diagnosis of drug misuse
• History
• Physical examination---needles marks, vein
thrombosis
• Behavioural signs—absence from school,
work, occupational decline, neglect
appearance, isolate themselves from former
friends, adopting new friends in a drug culture
• Minor criminal offences
• Medical presentation
• Asking for control drugs to relief pain
• Drug related complications, cellulitis,
hepatitis, accidents, treatment of acute drug
effects, overdose, withdrawal symptoms
 Taking drug history
• Typical drug- using day or week
• Types and quantities of drug taken
• Symptoms experienced when drugs are
unavailable
• Tolerance and primacy of drug habit
• Risky behaviour
• Developmental history of drug misuse
• Abstinence and relapse triggers
• Medical and social complications
• Psychiatric and forensic history
 Laboratory diagnosis
• Urine testing
• Blood, saliva and hair analysis
 Prevention, Treatment and
rehabilitation
• Prevention
• Restriction of availability
• Education programme
• Identification and treatment of family
problems that may contribute to drug taking
 Treatment
• Drug withdrawal (or detoxification)
• Drug Maintenance
• Harm reduction programmes
• Psychosocial treatments
 Amphetamines
• Previously used in treatment of nasal
congestion,obesity
• Still use in treatment of ADHD and narcolepsy
• Also known as speed
• Ice –pure form

• Route---oral, inhale, smoke, injecting

 Clinical effects
• Increase CNS effects
• Immediate effects on the mood
• Over talkativeness, over activity, insomnia,
dryness of the lips, mouth and nose ,
anorexia,
• Pupil dilate, pulse rate increase,BP raise
• Large doses---cardiac arrhythmia, severe
hypertension, CVA,seizures and coma
• Adverse psychological effects
• Dysphoria,irritability,insomnia, confusion
• Anxiety, panic, depression, antisocial
behaviour and paranoid psychosis
 Amphetamine induced psychosis
• Prolonged use of high dose of amphetamine may
result in repetitive stereotyped behaviour(e.g.
repeated tidying)
• Paranoid psychosis likened to paranoid
schizophrenia may be induced by prolonged high
doses, the features include persecutory delusion,
auditory and visual hallucination and sometimes
hostile and aggressive behaviour
• Usually condition subside within a week but
occasional last longer
 Tolerance and dependence
• Tolerance lead to intake of high doses
• Withdrawal syndrome or crash consist of low
mood and decrease energy to severe
depression, craving can be very severe,
suicidal ideation prominent
 Prevention and Treatment
• Restriction of the drugs and careful
prescribing
• Treatment of acute overdose requires
sedation, and management of hyperpyrexia
and cardiac arrhythmias
• Anti psychotic drugs may be needed to control
psychotic symptoms
 Treatment of Dependence
• Goal---abstinence
• BDZ ---for acute distress
• Anti depressant for depression
• Maintenance for those who can not stay
abstinence with use of oral amphetamine
 MDMA(ecstasy)
• 3,4 methylenedioxy methamphetamine
• Synthetic drug listed under hallucinogenic
drugs in DSM 1V
• It has stimulant as well as hallucinogenic
properties
• It increase the release of dopamine as well as
serotonin
 Clinical effects
• Positive mood states with feeling of euphoria,
sociability and intimacy
• Produce the sensation of newly discovered
insights and heightened perceptions
• Physical effects includes loss of appetite,
tachycardia, bruxism and sweating
 Adverse reactions
• Death due to hyperthermia, cardiac
arrthymia,CVA
• Acute and chronic paranoid psychosis
• Flash back
• Depression, anxiety , depersonalization
 Cannabis
• Derived from plant Cannabis sativa
• Consumed either as the dried vegetative parts
in the form known as Marijuana or grass
• Or as a resin secreted by the flowering shoots
of the female plant
• THC –most active pharmacological substance
 Clinical effects
• Vary with the dose , patient expectation and
the mood and the social setting
• User describing as high, but it seem to
exaggerate the pre existing mood
• Distortion of the perception of time and space
• Redden eyes, dry mouth, tachycardia,
irritation of respiratory tract and coughing
 Adverse effects
• No serious adverse effects in those using
intermittently in small doses
• No positive evidence of teratogenicity
• Potentially carcinogenic
• Most common psychological adverse effects in
acute users is anxiety
• Mild paranoid ideation is not uncommon
• At high doses toxic confusional states and
occasionally psychosis in clear consciousness may
occur
 Cannabis and mental illness
• Studies found that risk of developing
Schizophrenia was higher in individuals who
used cannabis
• Increase risk of developing psychosis
• Chronic user develop a motivational state
 Management
• Psychosocial intervention