Psychiatry

Lecture 18: Substance Use Disorders (part 2)

Clinical Features of Substance Abuse

The C.F. include effects of use of the substance and the effects of withdrawal after
abstinence from the substance.

Category Effects of use Effects of withdrawal

Sedatives Mood elevation Mood depression
Alcohol Decreased anxiety Increased anxiety
Benzodiazepines • Sedation • Insomnia
Barbiturates • Behavioral disinhibition • Delirium (including psychotic
• Respiratory depression symptoms)
(particularly the barbiturates) • Seizures
• Cardiovascular collapse
opioids Mood elevation Mood depression
Heroin Decreased anxiety Increased anxiety
Opioids used medically • Sedation • Autonomic stability
(e.g., methadone, • Analgesia • "Flu -like" symptoms (e.g.
codeine, morphine) • Respiratory depression muscle aches, sweating)
• Constipation • Piloerection
• Pupil constriction • Yawning
• Stomach cramps and diarrhea
• Pupil dilation
Stimulants Mood elevation Mood depression
Amphetamines • Insomnia • Lethargy
Cocaine • Deceased appetite • Increased appetite
Caffeine and nicotine • Increased cardiovascular, • Decreased cardiovascular,
(minor stimulants) neurological, and Gl activity neurological
• Psychotic symptoms and gastrointestinal activity
• Pupil dilation • Fatigue
• Hallucinations (often tactile) • Headache
Hallucinogens Mood elevation Few if any
Marijuana • Altered perception (e.g.,
Hashish hallucinations, illusions)
LSD • Cardiovascular symptoms
PCP • Hyperthermia and sweating
Psilocybin • Tremor
Mescaline • Nystagmus (PCP)

TREATMENT
Treatment of withdrawal symptoms includes immediate (emergency) treatment or
detoxification ("detox") and extended treatment aimed at preventing relapse ("maintenance")

Category Immediate treatment/detoxification

Sedatives Hospitalization
Alcohol • Flumazenil (benzodiazepine receptor antagonist)
 Benzodiazepines • Substitution of long-acting barbiturate (e.g., phenobarbital) or
Barbiturates benzodiazepine (e.g., chlordiazepoxide [Librium]) in decreasing doses
• Intravenous diazepam (Valium), lorazepam (Ativan), or phenobarbital
if seizures occur
• Specifically for alcohol: thiamine, and restoration of nutritionaI state

opioids • Hospitalization and naloxone (Narcan) for overdose

Heroin • Clonidine to stabilize the autonomic nervous system during
Opioids used medically withdrawal
(e.g., methadone, • Substitution of long-acting opioid (e.g., methadone) in decreasing
codeine, morphine) doses to decrease withdrawal symptoms
• Benzodiazepines to decrease agitation
Stimulants Benzodiazepines to decrease agitation
Amphetamines • Anti psychotics to treat psychotic symptoms
Cocaine • Medical and psychological support

Minor stimulants Eliminate or taper from the diet

Caffeine • Analgesics to control headache due to withdrawal
Nicotine
Hallucinogens Calming or "talking down" the patient
Marijuana • Benzodiazepines to decrease agitation
Hashish • Antipsychotics to treat psychotic symptoms
LSD
PCP
Psilocybin
Mescaline

Case Examples ‫لالطالع‬

Case 1- alcohol withdrawal

THE PATIENT
A very thin, 63-year-old woman is brought to the hospital after a fall outside of a neighborhood bar
Radiologic studies indicate that the patient has a fractured hip, and surgery is performed
immediately.
Two days later, the patient begins to show an intense hand tremor and tachycardia as well as
increased temperature, blood pressure, and respiration. She tells the doctor that she has been
"shaky" ever since her admission and that the shakiness is getting worse. The patient states that
although she feels very frightened,
she is comforted by the fact that the nurse who is treating her is an old friend (she has never met
the nurse before).
She also reports that she has started to see ants crawling on the walls and can feel them crawling
on her arms. The doctor notes that the patient's speech seems to be drifting from one subject to
another.
COMMENT
The most likely cause of the patient's symptoms, which include tremor, tachycardia, illusions
(believing the nurse is an old friend), and tactile hallucinations (e.g., formication, the feeling of
insects crawling on the skin), is alcohol withdrawal delirium.This patient is most likely a heavy
drinker who is experiencing withdrawal because of hospitalization. DTs during alcohol withdrawal
are more common in physically ill or undernourished patients such as this one.
MANAGEMENT
Ideally, this patient's heavy prior alcohol use would have been identified on the first day of
hospitalization. If at that time she had received a benzodiazepine such as chlordiazepoxide
(Librium) every 2 to 4 hours, the severe symptoms of withdrawal may have been attenuated.

Because the severe symptoms have already appeared, higher doses of chlordiazepoxide (e.g., 25
to 50 mg every 2 to 4 hours) or lorazepam given intravenously are now needed. Thiamine,
supportive treatment for the patient's anxiety, and therapy to restore her fluid and nutritional status
are also indicated.

Case 2 – use of hallucinogenic agent

THE PATIENT
At 9:00a.m. on a Sunday morning, a 15-year-old boy is brought to the emergency room by his
father. The father states that he found his son on the roof of their house bragging that he could fly.
The boy is a good student and has friends, and there is no history of bizarre behavior.
When questioned, the patient tells the doctor that he is floating in space and that the lights in the
emergency room are huge, glaring suns in the sky. He says that his vision and sense of smell are
more acute than they have ever been. He reports that he has not used any drugs but that the
previous evening he went to a party where he ate a piece of "dream cake" given to him by a friend.

COMMENT
This patient most likely has taken a hallucinogenic agent. Because LSD is active when ingested, it is
likely that LSD was in the cake that the patient ate at the party. Although the cake was eaten the
previous evening, the effects of LSD can last 12 hours.

MANAGEMENT
There is no specific treatment for hallucinogen use. However, this patient must be protected from
harming himself when having delusional beliefs such as his ability to fly. Reassurance and support
in the form of "talking down" the patient and use of benzodiazepines to control his anxiety are
useful.
With no preexisting psychiatric condition, there should be no long-term sequelae of this experience
for the teenager. However, he may experience disturbing "flashbacks" in which he relives this
experience when not using LSD, sometimes even months later.

Case 3 – use of cocaine

THE PATIENT
A 19-year-old man is brought to the emergency department by a friend. The patient is speaking
rapidly in an excited fashion and says he is "on top of the world" because he is communicating
mentally with the President. Physical examination reveals dilated pupils, erythema of the mucous
membranes of the nose, and tachycardia. When examined by a physician 1 hour later, the patient
seems depressed and shows little response to her presence.
COMMENT
The fact that this patient has gone from euphoric and psychotic (the hallucination about the
President) to depressed and unresponsive in only 1 hour, combined with the findings of dilated
pupils and erythema (redness) of the nose (from snorting the drug), indicate that this patient has
used cocaine.

THE END