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PAC Workshop
PAC Workshop
PAC Workshop
Topic 1:
Biomedical
Understanding of
Addiction
Dr. Luke Woon Sy-Cherng
Clinical Specialist (Psychiatry)
Outline
Basic brain anatomy and functions – reward pathway
Pathophysiology of addiction
Major types of substances
Aetiological (Causal) factors
Epidemiology – Worldwide & Malaysia
General understanding of major mental disorders
Emotions, memory and arousal
Reward Pathway of the Brain
Neurotransmission Synapse
(Stahl, 2010)
Neurotransmitters
Serotonin (5-HT)
Dopamine (DA) Monoamines
Norepinephrine (NE)
Acetylcholine (Ach)
Glutamate
GABA (γ-aminobutyric acid)
Targets of Psychotropic Agents
Transporters
Receptors
Enzymes
Blockade of reuptake
transporter
↑ availability of
neurotransmitter at
the synaptic cleft
(Stahl, 2010)
Inhibition of enzyme Reduced breakdown of NT More NT available
(Stahl, 2010)
Action of Psychotropic Agents at
Receptors
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
(Stahl, 2010)
(Koob & Volkow, 2016)
(Stahl, 2010)
Addiction
Impulsivity Compulsivity
Substances listed in DSM-5
Diagnostic & Statistical Manual, 5th Edition is a set of
diagnostic criteria published by the American Psychiatric
Association that has been widely used internationally
Substances included in DSM-5 are:
oAlcohol o Opioids
oCaffeine o Sedatives/Hypnotics/Anxiolytics
oCannabis o Stimulants
oHallucinogens o Tobacco
oInhalants o Others/Unknown Substances
(Stahl, 2010)
Actions of Substances in the Brain
Substance Receptor Action Corresponding Neurotransmitter
(AADK, 2017)
(AADK, 2017)
(AADK, 2017)
(AADK, 2017)
Schizophrenia
POSITIVE SYMPTOMS NEGATIVE SYMPTOMS
Delusions Affective blunting
Hallucinations Avolition
Disorganized speech & Alogia
disorganized behaviours
Asociality
Anhedonia
A) Nigrostriatal
pathway
B) Mesolimbic pathway
C) Mesocortical
pathway
D) Tuberoinfundibular
pathway
(Stahl, 2010)
Mesolimbic pathway
Too much dopamine
Positive symptoms
(Stahl, 2010)
(Stahl, 2010)
EPS = extrapyramidal
symptoms
- Acute dystonias
- Parkinsonism
- Akathisia
- Tardive dyskinesia
(Stahl, 2010)
Hyperprolactinemia:
-Galactorrhoea
(breast secretions)
-Amenorrhoea
(irregular menses)
(Stahl, 2010)
Anticholinergic Effect
(Stahl, 2010)
Typical Antipsychotics
Generic name Brand name
Haloperidol Haldol
Sulpiride Dogmatil
Trifluoperazine Stelazine
Thioridazine Mellaril
Perphenazine Trilafon
Chlorpromazine Thorazine
Fluphenazine decanoate* Modecate
Flupenthixol decanoate* Fluanxol
Zuclopenthixol decanoate* Clopixol
*IM depot injection
Atypical Antipsychotics
Dopamine antagonism (D2 antagonist) at:
Mesolimbic pathway – improve positive symptoms
Metabolic syndrome:
Central obesity
Hypertension
High triglyceride level
Low HDL level
High blood sugar level
Atypical Antipsychotics
Generic name Brand name
Clozapine Clozaril
Olanzapine Zydis
Quetiapine Seroquel
Asenapine Saphris
Risperidone Risperdal
Paliperidone Invega
Aripiprazole Abilify
Clozapine
2nd line treatment
Indicated for treatment-resistant schizophrenia
Multimodal antidepressant
- Vortioxetine (Brintellix)
SSRIs
Generic name Brand name
Fluoxetine Prozac
Sertraline Zoloft
Paroxetine Paxil
Fluvoxamine Luvox
Escitalopram Lexapro
Citalopram Celexa
Common side effects:
Nausea, vomiting, abdominal pain, diarrhoea
Headache, anxiety, insomnia
Sexual dysfunction
Discontinuation symptoms
SNRIs
Generic name Brand name
Venlafaxine Effexor
Desvenlafaxine Pristiq
Duloxetine Cymbalta
Common side effects:
Nausea, dry mouth, constipation
Headache, dizziness, insomnia
Discontinuation symptoms
(Stahl, 2010)
Mood Stabilizers
(Stahl, 2010)
Classes of Mood Stabilizers
Lithium
Anticonvulsants
Atypical antipsychotics
Lithium
Treatment of moderate to severe mania
Prophylaxis of bipolar disorder
Reduces risk of suicide
(Stahl, 2010)
Valproate
Sodium valproate: Also known as valproic acid (Brand name:
Epilim)
Treatment of bipolar mania & depression
Prophylaxis of bipolar disorder
(Stahl, 2010)
(Stahl, 2010)
Benzodiazepines
Generic name Brand name
Alprazolam Xanax
Midazolam Dormicum
Lorazepam Ativan
Clonazepam Rivotril
Diazepam Valium
Side effects:
Headache, confusion, blurred vision
Risk of falls and fractures
Respiratory depression
*Dependence
Serotonergic Agents
- Almost all SSRIs and some other antidepressants
(Stahl, 2010)
Prison & Addiction Conference 2018
Topic 2:
Substance Use &
Related Disorders -
Focusing on Stimulants
Dr. Luke Woon Sy-Cherng
Clinical Specialist (Psychiatry)
Outline
Spectrum of substance-related disorders
Substance use & mental disorders
General principles of treatment
Stimulant use and related disorders
Emerging synthetic drugs (New psychoactive substances)
Spectrum of Substance-related Disorders
Substance use disorder
Substance intoxication
Substance withdrawal
Substance-induced disorders, e.g.
Psychotic disorder
Bipolar disorder
Depressive disorder
Anxiety disorder
Substance Use Disorder
DSM-5 does not separate the diagnoses of substance abuse
and dependence as in DSM-IV.
Rather, criteria are provided for substance use disorder,
accompanied by criteria for intoxication, withdrawal and
substance-induced disorders
The threshold for substance use disorder diagnosis is set at 2
or more criteria
Severity: 2–3 criteria indicate a mild disorder; 4–5 criteria, a
moderate disorder; and 6 or more, a severe disorder.
Early remission: at least 3 but less than 12 months
Sustained remission: at least 12 months
Diagnostic Criteria: Stimulant Use
Disorder
A. A pattern of amphetamine-type substance, cocaine, or other stimulant
use leading to clinically significant impairment or distress, as manifested by
at least two of the following, occurring within a 12-month period:
1. The stimulant is often taken in larger amounts or over a longer period
than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control
stimulant use.
3. A great deal of time is spent in activities necessary to obtain the
stimulant, use the stimulant, or recover from its effects.
4. Craving, or a strong desire or urge to use the stimulant.
5. Recurrent stimulant use resulting in a failure to fulfill major role
obligations at work, school, or home.
6. Continued stimulant use despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of the
stimulant.
Diagnostic Criteria: Stimulant Use
Disorder
7. Important social, occupational, or recreational activities are given up or
reduced because of stimulant use.
8. Recurrent stimulant use in situations in which it is physically hazardous.
9. Stimulant use is continued despite knowledge of having a persistent or
recurrent physical or psychological problem that is likely to have been
caused or exacerbated by the stimulant.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of the stimulant to achieve
intoxication or desired effect.
b. A markedly diminished effect with continued use of the same amount of
the stimulant.
11. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for the stimulant
b. The stimulant (or a closely related substance) is taken to relieve or avoid
withdrawal symptoms.
(APA, 2013)
Diagnostic Criteria: Stimulant
Intoxication
A. Recent use of an amphetamine-type substance, cocaine, or other
stimulant.
B. Clinically significant problematic behavioral or psychological changes (e.g.,
euphoria or affective blunting: changes in sociability: hypervigilance:
interpersonal sensitivity: anxiety, tension, or anger; stereotyped behaviors:
impaired judgment) that developed during, or shortly after, use of a
stimulant.
C. Two (or more) of the following signs or symptoms, developing during, or
shortly after, stimulant use:
1. Tachycardia or bradycardia.
2. Pupillary dilation.
3. Elevated or lowered blood pressure.
4. Perspiration or chills.
5. Nausea or vomiting.
Diagnostic Criteria: Stimulant
Intoxication
6. Evidence of weight loss.
7. Psychomotor agitation or retardation.
8. Muscular weakness, respiratory depression, chest pain, or cardiac
arrhythmias.
9. Confusion, seizures, dyskinesias, dystonias, or coma.
D. The signs or symptoms are not attributable to another medical condition
and are not better explained by another mental disorder, including
intoxication with another substance.
(APA, 2013)
Diagnostic Criteria: Stimulant
Withdrawal
A. Cessation of (or reduction in) prolonged amphetamine-type substance,
cocaine, or other stimulant use.
B. Dysphoric mood and two (or more) of the following physiological changes,
developing within a few hours to several days after Criterion A:
1. Fatigue.
2. Vivid, unpleasant dreams.
3. Insomnia or hypersomnia.
4. Increased appetite.
5. Psychomotor retardation or agitation.
C. The signs or symptoms in Criterion B cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
D. The signs or symptoms are not attributable to another medical condition
and are not better explained by another mental disorder, including
intoxication or withdrawal from another substance.
(APA, 2013)
Substance Use & Mental
Disorders
Addiction is a chronic relapsing and remitting disorder that
severely impacts the course, treatment and prognosis of mental
illness.
Conversely, mental illness also impacts the course and
treatment of the substance use disorder (SUD).
Historically, patients with co-occurring disorder (COD) would
receive treatment for one disorder after another, or in different
settings.
(SAMHSA, 2014)
Scope of COD in the Community
(SAMHSA, 2014)
Complications of Comorbid
Disorders
•Dual diagnosis has much higher rate of adverse outcome than
single diagnosis (Drake, 2007):
Higher rate of relapse and hospitalization
Victimization
Violence
Incarceration
Homelessness
Serious blood-borne infection (HIV, Hepatitis C)
Completed suicide
(Drake, 2007)
Complications of Comorbid
Disorders
Subjects with co-occurring depressive disorder and AUD
report more previous depressive episodes and suicide
attempts.
More than a third of panic disorder patients have a lifetime
history of SUD.
Patients with PTSD have 2 to 4 times greater than non-PTSD
patients risk for SUD.
SUD worsens the course and treatment outcome in bipolar
disorder and is associated with violence against self and
others.
(SAMHSA, 2005)
Integrated Treatment
Mental health and substance abuse treatment are
evaluated and addressed by:
Same team
Same location
Same time
(SAMHSA, 2005)
Stage-wise Treatment
Intervention tailored to the person’s stage of treatment or
recovery, based on concept of stages of change.
It consist of 4 stages:
1. Engagement interventions
2. Motivational intervention
3. Active treatment
4. Relapse prevention
(SAMHSA, 2005)
Stage-wise Treatment
Engagement
interventions – to
address with difficulty in
engagement into the
system
Motivational
intervention – address
Relapse prevention
unmotivated person for
changes
Active treatment
– help patient to acquire skills
and supports, promote
adherence, self, vocational,
medications
(SAMHSA, 2005)
Stage-wise Treatment
Pre-contemplation — Engagement
Contemplation and Preparation —
Assertive outreach, practical help Persuasion
(housing, entitlements, other), and an
Education, goal setting, and building
introduction to individual, family,
awareness of problem through
group, and self-help treatment
motivational counseling
formats
(SAMHSA, 2005)
Evidence-based Psychosocial
Treatments
Motivational Enhancement Therapy (MET)
Brief, patient-centred directive therapy focusing on
interventions designed to enhance motivation for change and
facilitate transition from one stage of change to the next
(Prochaska et al, 1992).
5 identifiable stages: pre-contemplation, contemplation,
preparation, action, and maintenance.
Clinician facilitates greater awareness by exploring substance
use patterns around times of stress or illness exacerbation.
Exploring pros and cons of behaviour change via a decisional
balance analysis.
(Yuodelis-Flores et al., 2012)
The Trans-theoretical Model
Polysubstance abuse
For those dependent on opioids and stimulant, the provision
of effective substitution therapy for treatment of the opioid
dependence with methadone/buprenorphine can lead to a
reduction in stimulant use.