Substance related

Disorders
 Psychoactive Substance
Psychoactive (psychotropic) substance is
any substance which after absorption
has influence on mental processes both
cognitive and affective.
 Substance abuse
➢Substance abuse can be defined as using
a drug in a way that is inconsistent with
medical or social norms and despite
negative consequences.
 Detoxification
➢ Detoxification is the process of safely
withdrawing from a substance.

Intoxication
 Intoxication is use of a substance that results
in maladaptive behavior.
 Withdrawal syndrome
➢Withdrawal syndrome refers to the
negative psychological and physical
reactions that occur when use of a
substance ceases or dramatically
decreases.
 Blackout
➢ Itis an episode during which the person
continues to function but has no conscious
awareness of his or her behavior at the time
nor any later memory of the behavior.
 Tolerance
➢ Tolerance is defined as the need for
increasingly larger or more frequent doses of
a substance in order to obtain the desired
effects originally produced by a lower dose.
 Dependence
➢ Dependence A compulsive or chronic
requirement. The need is so strong as to
generate distress (either physical or
psychological) if left unfulfilled.
 Substance Classes
➢ Alcohol ➢ Opioids
➢ Caffeine ➢ Sedatives,
➢ Cannabis hypnotics, and
➢ Hallucinogen anxiolytics
s ➢ Stimulants
● PCP ➢ Tobacco
● others
➢ Other
➢ Inhalants
 Etiology
➢ Biological factor
➢ Social factors
➢ Psychological factor
➢ Psychiatric disorders
➢ Environmental factors
 Biological Factors

1.Genetics
➢ Children of alcoholics are three times
more likely than other children to become
alcoholics
➢ Biological offspring of alcoholic parents
have a significantly greater incidence
of alcoholism than offspring of nonalcoholic
parents.
➢Monozygotic twins have a higher rate
for concordance of alcoholism than
dizygotic
 Biochemical factors
➢ Norepinephrine and dopamine have been
implicated in opioid, cocaine and ethanol
dependence.
➢ Abnormalities in alcohol dehydrogenase in
alcohol dependence
 Psychological factors
➢ Loneliness
➢ Unmet needs
➢ Low self esteem
➢ Desire to escape from reality
➢ Sense of adventure
➢ Pleasure seeking
➢ Sense of inferiority
➢ Poor impulse control
 Social factors
➢ Religious reasons
➢ Peer pressure
➢ Urbanization
➢ Extended period of education
➢ Unemployment
➢ Overcrowding
➢ Poor social support
➢ Effect of tv and other mass media
➢Occupation: barmen, executives,
salesmen, actors, entertainers, army
personnel, medical personnel.
 Psychiatric disorders
➢Depression
➢Anxiety disorder
➢Schizophrenia
➢Personality disorder
 Social and Environmental
Factors
➢laws,
➢cost, and availability
 Substance-Related Disorders
➢2Groups:
● Substance Use Disorders

• Abuse or dependence
● Substance-Induced Disorders

● Intoxication, withdrawal, delirium, dementia,

amnesia, psychosis, mood disorder, anxiety

disorder, sexual dysfunction, and sleep
disorders
 Comorbidity
➢ Up to 50% of addicts have comorbid
psychiatric disorder
● Antisocial PD

● Depression

● Suicide
 Options for where to treat
➢ Hospitalization-
Due to drug OD, risk of severe withdrawal,
medical comorbidities, requires restricted access
to drugs, psychiatric illness with suicidal ideation

➢ Residential treatment unit

No intensive medical/psychiatric monitoring
needs
Require a restricted environment
Partial hospitalization
➢ OutpatientProgram -No risk of med/psych morbidity
and highly motivated patient
 Treatment
➢ Behavioral Interventions
Motivation to change
Group Therapy
Individual Therapy
Self-Help Recovery Groups (AA)
Therapeutic Communities Aversion
Therapies
Family Involvement/Therapy
Relapse Prevention
 Treatment
➢ Pharmacologic Intervention
➢ Treat Co-Occurring Psychiatric Disorders
● 50% will have another psychiatric disorder

➢ Treat Associated Medical Conditions

➢ cardiovascular, cancer, endocrine,

hepatic, hematologic, infectious,

neurologic, nutritional, GI, pulmonary,
renal, musculoskeletal
 Alcohol

Alcoholism refers to the use of alcoholic

beverages to the point of causing damage
to the individual, society or both.
 PHYSIOLOGIC EFFECTS OF
LONG-TERM ALCOHOL USE
➢ Cardiac myopathy
➢ Pancreatitis
➢ Esophagitis and Gastritis
➢ Hepatitis
➢ Cirrhosis
➢ Leukopenia
➢ Thrombocytopenia
➢ Protein malnutrition
➢ Vitamin deficiency
➢ Sexual dysfunction
➢ Fetal alcohol syndrome(low birth weight
and inteligency)
➢ Social problems
➢ Financial problem
➢ Occupational problem
➢ Criminality
➢ Marital dishormony
➢ Wernicke-Korsakoff Syndrome
 Acute Intoxication
▪
Blood Alcohol Level - ➢ Can be fatal (loss of
0.08g/dl airway protective reflexes,
▪ Progress from mood pulmonary aspiration,
lability, impaired profound CNS depression)
judgment, and poor
coordination to
increasing level of
neurologic impairment
(severe dysarthria,
amnesia, ataxia)
 Alcohol Withdrawal syndrome
➢ Early
●
anxiety, irritability, tremor, insomnia, nausea, tachycardia,
HTN, hyperthermia, hyperactive reflexes
➢ Seizures
● generally seen 24-48 hours
● most often Grand mal
➢ Withdrawal Delirium Tremens
● generally between 48-72 hours
● altered mental status, hallucinations, marked
autonomic instability
● life-threatening
 Alcohol Withdrawal
➢ Benzodiazepines
● GABA agonist - cross-tolerant with alcohol
● reduce risk of SZ; provide comfort/sedation
➢ Anticonvulsants
● reduce risk of SZ
● Carbamazepine or Valproic acid
➢ Thiamine supplementation
● Risk thiamine deficiency (Wernicke/Korsakoff)
 Alcohol induced amnestic
disorder
➢Thiamine deficiency is most frequent
cause of amnestic disorder.
➢Wernicke’s encephalopathy:
❑Cerebral ataxia
❑6th cranial nerve palsy
❑Periperal neropathy
➢Korsakoff’s psychosis
❑ Gross memory disturbance
❑ Disorientation
❑ Confusion
❑ Confabulation: the unconscious filling of
memory gaps by imagined or untrue
experience due to memory loss
❑ Poor attention span
❑ Impaired insight
 Alcohol induced psychiatric
disorder
➢ Alcohol induced dementia
➢ Alcohol induced mood disorder
➢ Alcohol induced anxiety disorder
➢ Suicidal behaviour
➢ Pathological jealousy
➢ Alcoholic seizures
➢ Alcoholic hallucinosis: auditory
 Alcohol treatment

➢ Outpatient CD treatment:
● support, education, skills training,

psychiatric and psychological treatment, AA

➢ Medications:
● Disulfiram

● Naltrexone

● Acamprosate
 Medications-alcohol deterrent
therapy
➢ Disulfiram (antabuse) 250mg-500mg po daily
● Inhibits aldehyde dehydrogenase and dopamine
beta hydroxylase
● Aversive reaction when alcohol ingested-
vasodilatation, flushing, hypotenstion/ HTN, coma /
death
● Psychiatric side effects - psychosis,
depression, confusion, anxiety
● Dermatologic rashes and itching
● Watch out for forms of alcohol - sauces, mouth
wash, cough meds, alcohol based hand sanitizers,
etc
 Medications
➢ Naltrexone
● Opioid antagonist thought to block mu
receptors reducing intoxication euphoria and
●
cravings
Hepatotoxicity at high dose

➢ Acamprosate(Campral)
● Unknown MOA but thought to stabilize neuron
excitation and inhibition - may interact with GABA
and Glutamate receptor - cleared renally (check
kidney function)
Benzodiazepine (BZD)
 Benzodiazepine (BZD)

➢ Intoxication
● Similar to alcohol but less
cognitive/motor impairment
● Variable rate of absorption (lipophilia)

and onset of action and duration in

CNS
● The more lipophilic and shorter the duration

of action, the more "addicting" .

 Benzodiazepine
➢ Withdrawal
● Anxiety, irritability, insomnia, fatigue, HA,
tremor, sweating, poor concentration
● Common detox mistake is tapering too fast;
symptoms worse at end of taper
● Convert short elimination BZD to longer
elimination half life drug and then slowly taper
● Outpatient taper- decrease dose every 1-2

weeks and not more than 5 mg Diazepam

dose equivalent
 Benzodiazapines
➢ Alprazolam
➢ Oxazepam
➢ Temazepam
➢ Clonazepam
➢ Lorazepam
➢ Chlordiazepoxide
➢ Diazepam
 Opiods
➢ The commonly abused opioids(narcotics)
are heroin (brown sugar).
➢ Synthetic preparation like pethidine,
fortwin.
 OPIOIDS
Bind to the Opioid receptor in the CNS to modulate pain

➢ Intoxication
➢ Pinpoint pupils,
sedation, constipation, bradycardia,
hypotension and decreased respiratory rate

➢ Withdrawal
➢ Not life threatening unless severe medical illness but
extremely uncomfortable.
➢ dilated pupils lacrimation, goosebumps, diarrhea,
myalgias, arthralgias, dysphoria or agitation

➢ Neuroadaptation: increased DA and decreased NE

Treatment – Opiate Use Disorder

● Rx- symptomatically with antiemetic,

antacid, antidiarrheal, muscle relaxant
(methocarbamol), NSAIDS, clonidine and
maybe BZD

● support, education, skills building, psyatric

and psychological treatment.
 Medications
Naltrexone - binds and blocks opioid
receptors, and reduces and suppresses opioid
cravings.

Buprenorphine  - is an substitute opioid used to

treat opioid use disorder, acute pain and chronic
pain

Methadone - is a synthetic Opioid agonist used

for opioid maintenance therapy in opioid
dependence and for chronic pain management
Treatment - Opiate Use Disorder

➢ Naltrexone
● Opioid blocker, mu antagonist
● 50mg po daily
➢ Methadone
● Mu agonist
●
Start at 20-40mg
●
Average dose 80-100mg daily
➢ Buprenorphine
● Partial mu agonist

Mu - opioid receptor
 Stimulants

➢ Stimulants (Amphetamines, Cocaine,

Others)
➢ Stimulants are drugs that stimulate or excite
the central nervous system.
 STIMULANTS

➢ Intoxication (acute)
● Psychological
signs
●
euphoria, hyperactivity, restlessness, interpersonal
sensitivity, anxiety, tension, anger, impaired judgment

●
Physical signs

●
tachycardia, papillary dilation, HTN, diaphoresis,
chills, weight loss, chest pain, cardiac arrhythmias,
confusion, seizures, coma
 STIMULANTS

➢ Chronic intoxication
●
affective blunting, fatigue, sadness, social
withdrawal, hypotension, bradycardia,
muscle weakness
➢ Withdrawal
● Not severe but have exhaustion with sleep

● Treat with rest and support

 Cocaine
➢ Route: nasal, IV or smoked
➢ Has vasoconstrictive effects that may
outlast use and increase risk for CVA and
MI
➢ Neuroadaptation: cocaine mainly
prevents reuptake of DA
 Treatment - Stimulant Use
Disorder (cocaine)
➢ Treatment including support, education,
Psychotherapy
➢ Pharmacotherapy
● Amyl nitrite is an antidote

● Antidepressants
 Amphetamines
➢ Similar intoxication syndrome to cocaine but
usually longer
➢ Route - oral, IV, nasally, smoked
➢ No vasoconstrictive effect
➢ Neuroadaptation
inhibit reuptake of DA, NE, SE - greatest effect on DA
➢ Chronic use results in neurotoxicity
possibly from glutamate and axonal
degeneration
➢ Can see permanent amphetamine
psychosis with continued use
➢ Treatment similar as for cocaine but no known
substances to reduce cravings
 Treatment – Stimulant Use
Disorder (amphetamine)
➢ Treatment: including support, education
➢ No specific medications have been found
helpful in treatment
 Tobacco

➢ Most important preventable cause of death/disease

➢ 45% of smokers die of tobacco induced disorder
➢ Second hand smoke causes death / morbidity
➢ Psychiatric pts at risk for Nicotine dependence- 75%-90
% of Schizophrenia pts smoke
 Tobacco
➢ No intoxication diagnosis
● initial use associated with dizziness,

nausea
➢ Neuroadaptation
nicotine acetylcholine receptors on DA
neurons in ventral tegmental area release DA
➢ Tolerance
● rapid

➢ Withdrawal
● irritability, anxiety, decreased
concentration, insomnia, increased
appetite
 Treatment – Tobacco Use
Disorder
➢ Cognitive Behavioral Therapy
➢ Agonist substitution therapy
● nicotine gum , transdermal patch, nasal spray
➢ Medication
● Bupropion 150mg
➢ Aversive Therapy
● Cytisine (Tabex)
Inhalants or volatile solvents
Commonly used solvents are:

Petrol
Aerosols
Thinners
Industrial solvents
 Intoxication
➢Euphoria
➢Excitement
➢Slurringof speech
➢Impaired judgement
 Withdrawal symptoms

➢ Anxiety
➢ Depression

Complications

➢ Liver,kidney and brain damage

➢ Peripheral neuropathy
 Treatment

➢Reassurance
➢Diazepam for intoxication
 Barbiturates
Commonly abused are:
➢ Secobarbital
➢ Pentobarbital
➢ Amobarbital
 Intoxication

➢ Incoordination
➢ Slurred speech
➢ Attention and memory impairment
➢ Irritability

Complications
➢ IV routeuse can cause localized cellulites,
embolism, abscesses
 Withdrawal syndrome

➢Delirium
➢Seizures
➢Restlessness
 Treatment

➢ Symptomatic treatment
➢ Induction of vomiting
➢ Use activated charcoal to reduce a absorption
in case of intoxication
 Hallucinogens
➢ Naturally occurring
Peyote cactus; magic mushroom- oral
➢ Synthetic agents

LSD (lysergic acid diethylamide) – oral

Psilocybin
Tryptamines
Phenethylamines
 Intoxication
➢ illusions, sensitivity of touch, taste/ smell
altered, tearfulness, euphoria, panic,
impairment judgment
 Cannabis

➢ Delta-9 –tetra-hydrocannabinol (THC ) is the psychoactive

ingredient in cannabis - C21H30O2
➢ The content of THC range from 2% to 5 % in “Marijuana”
Hashish can contain up to 15% THC
 THC acts on the cardiovascular and CNS Cannabis
receptors - in brain
 We make our own endogenous cannabis in the form of
anandamide , a derivative from arachidone acide

P.S. Anandamide regulates memory, appetite, mood,

learning and motor coordination
 Cannabis Related Disorders

Most commonly used illicit(illegal,unlawful) drug in US

Prevalence – 3% adolescence and 1.5% in adults
More common in males than females
Cannabis use disorders have increased over past decade
Few clear medical conditions associated with use
60% of adolescents also have Conduct Disorder or
ADHD
Can lead to substance-induced psychotic or anxiety
disorder, sleep disorder or delirium
Cannabis is not lethal even at very high doses
 Here are some common terms
for Marijuana
Pot. Weed. Grass. 420. Ganga. Dope. Herb.
Joint. Blunt. Reefer. Mary Jane. Buds. Stinkweed.
Nuggets. Chronic. Hay. Rope. Gangster.
Skunk. Boom. Block. Boo. Broccoli.
Burrito. Burnie. Charge.

Modes of administration:
• Smoking (Cigarette or pipe)
• Inhaling the smoke through a water-cooled apparatus
called a “bong” which softens irritation and aids in
deeper inhalation.
 CANNABIS

Intoxication-
Appetite and thirst increase
Colors/ sounds/ tastes are clearer
Increased confidence and euphoria
Relaxation
Increased libido
Transient depression, anxiety, paranoia
Tachycardia, dry mouth,
Slowed reaction time/ motor speed Impaired
cognition
Psychosis
 CANNABIS
➢ Neuroadaptation
Neuromodulator effect; decrease uptake of
GABA and DA

➢ Withdrawal
Insomnia, irritability, anxiety, poor appetite,
depression, physical discomfort
 CANNABIS
➢ Treatment
Detox and rehab
Behavioral model
No pharmacological treatment but may treat
other psychiatric symptoms
 Synthetic cannabinoids
• Class of molecules that bind to the same receptors to
which cannabinoids (THC and CBD)
• They are designer drugs, commonly sprayed onto
plant matter and are usually smoked
• They have been marketed as herbal incense, or
"herbal smoking blends",and sold under common
names like K2, Spice, and Synthetic Marijuana
• Synthetic cannabinoids are designed in an attempt to
avoid legal restrictions on cannabis
 Negative Effects
• Palpitations
• Paranoia (delusions and hallucinations)
• Intense anxiety 
• Nausea
• Vomiting
• Confusion
• Seizures

There have also been reports of a strong compulsion

to re-dose, withdrawal symptoms and persistent
cravings
 Interesting Facts
• Synthetic marijuana compounds began to be
manufactured and sold in the early 2000s
• From 2008 to 2014, 142 synthetic cannabinoids were
reported to the European Monitoring Centre for Drugs
and Drug Addiction (EMCDDA)
• United States Food and Drug Administration warned
of significant health risks from synthetic cannabinoid
products that contain the rat poison brodifacoum,
which is added because it is thought to extend the
duration of the drugs' effects. Severe illnesses and
death have resulted from this contamination
 PHENACYCLIDINE (PCP)
"Angel Dust"
➢ Dissociative anesthetic
Intoxication:
➢ severe dissociative reactions – paranoid delusions,
hallucinations, can become very agitated/ violent
with decreased awareness of pain.
➢ Cerebellar symptoms - ataxia
➢ With severe over dose - mute, catatonic, muscle rigidity,
HTN, hyperthermia, coma and death
 PCP
➢ Treatment

● antipsychotic drugs or BZD if required Low

●
stimulation environment

➢ Neuroadaptation
● opiate receptor effects

➢ No tolerance or withdrawal
 Caffeine Related Disorders
More than 85% of children and adult consume caffeine
regularly
Most widely used drug in the world
Symptoms include withdrawal and tolerance
No caffeine use disorder
Significant growth in energy drinks with young
individuals
Taking oral contraceptives decreases elimination of
caffeine (increased risk of intoxication)
 Caffeine Intoxication
In excess of 250mg and cause distress and
impairment
 Restlessness
 Nervousness
 Excitement
 Insomnia
 Flushed face
 Diuresis
 GI disturbance
 Muscle twitching
 Rambling flow of thought and speech
 Tachycardia or cardiac arrhythmia
 Periods of inexhaustibility
 Psychomotor agitation
 Caffeine Withdrawal

 Following cessation or reduction in use within 24

hours by 3 or more of following symptoms appear:
 Headache
 Marked fatigue or drowsiness
 Dysphoric mood, depressed mood or irritability
 Difficulty concentrating
 Flu-like symptoms (nausea, vomiting, muscle pain)
 Gambling Disorder
o Previously known as “Pathological gambling”
and was in category of Impulse Control Disorder
o Problematic gambling leading to significant
impairment or distress
o Leading 4 or more of the following symptoms
over a 12 month period
Gambling Disorder Diagnostic Criteria
o Needs to gamble with increasing amount money for
desired excitement
o Is irritable when attempting to cut down or stop
gambling
o Repeated unsuccessful efforts to control, cut back or
stop gambling
o Often preoccupied with gambling
o Gambles when feeling distressed
o After losing money gambling, often returns another
day to get even
Lies to conceal the extent of involvement with
gambling
Jeopardized or lost a significant relationship,
job, or career opportunity due to gambling
Relies on others to provide money to relieve
financial situations caused by gambling

Severity Rating
Mild: 4-5 criteria
Moderate: 6-7 criteria
Severe: 8-9 criteria
 Gambling Disorder
o About 0.2% - 0.3% of general population
o 3x more likely in males
o About 17% commit suicide
o Often associated with SUDs and impulse
control disorders (males) and mood/anxiety
disorders (female)