1. Prof. Fareed A.Minhas
Head,
Institute of Psychiatry
Rawalpindi Medical College
Rawalpindi

2. Substance use disorder (DSM IV)
Disorders due to psychoactive drug use
(ICD 10)
Conditions arising from the abuse of
alcohol, psychoactive drugs and other
chemicals such as volatile solvents

3. DSM IV
ICD 10
Intoxication
Intoxication
Abuse
Harmful use
Dependence
Dependence syndrome
Withdrawal
Withdrawal state
Withdrawal delirium
Withdrawal with delirium
Psychotic disorders
Psychotic disorder
Dementia
Amnestic Disorder
Amnestic syndrome
Mood disorders
Residual and late-
Anxiety disorders
-onset psychotic disorder
Sexual dysfunctions
Other mental and

4. INTOXICATION – transient syndrome due to recent
substance ingestion that produces clinically significant
psychological and physical impairment
ABUSE – maladaptive patterns of substance use that
impair health
DEPENDENCE – certain physiological and
psychological phenomena induced by repeated taking of
a substance (strong desire, neglect to other sources of
satisfaction, development of tolerance and a physical
withdrawal state)

5. TOLERANCE – state in which, after repeated
administration, a drug produces a decreased effect
or increasing doses are required to produce the same
effect
WITHDRAWAL – state is a group of symptoms and
signs occurring when a drug is reduced in amount or
withdrawn, lasting for a limited time
ESCALATION – refers to a phenomenon when a
person taking so called softer drugs moves on to
harder drugs

6. DSM IV
ICD 10
Alcohol
Alcohol
Amphetamines
Caffeine
Other stimulants such
as caffeine
Cannabis
Cannabinoids
Cocaine
Cocaine
Hallucinogens
Hallucinogens
Inhalents
Volatile solvents
Nicotine
Tobacco
Opioids
Opioids
Phencyclidine
Sedatives/Hypnotics
Sedatives/Hypnotics
Multiple drug use

7. Availability of
drugs
A vulnerable
personality
Adverse
Social
circumstances

8. EXTENT OF THE PROBLEM –
- Atleast 300,000 ppl in UK have this problem
- Ppl with drinking problems have a 2 to 3
percent greater chance of dying
- 1 in 5 admissions in acute medical wards in
UK is directly or indirectly related to
alcohol
- Admissions to psychiatric hospitals for this
purpose have increased 25 fold
TERMINOLOGY OF DRINKING HEAVY
BINGE
DRINKERS
PROBLEM
DRINKERS
DRINKERS

9. DETECTION –
History
Absenteeism from work
Unexplained dyspepsia or GI bleeds
Admissions for accidents
Fits, turns or falls
Signs
Plethoric face with/without telangiectases
Blood shot conjuctivae
Smell of stale alcohol
Facial resemblance to Cushing’s Syndrome
Marked tremors and other signs of disease

10. ‘At risk’ factors
Marital discord
Days off work
An affected relative having similar problems
High-risk occupations eg. Salesmen
Associated physical/mental conditions
Markers
Gamma-glutamyl transpeptidase
Mean corpuscular volume (MCV)
Carbohydrate-deficient transferrin
HDL Cholesterol
Blood/Urinary Alcohol

11. Rapid reinstatement
Of syndrome on drinking
After a period of
abstinence
Relief from withdrawal
By further drinking
Withdrawal symptoms
The subjective
Awareness of a
Compulsion to drink
ALCOHOL
DEPENDENCE
SYNDROME
Increased tolerance
To alcohol. Need for
More to achieve
Same results
A narrowing of the
Drinking repertoire
Primacy of drinking
Over other activities

12. SYMPTOMS OF ALCOHOL DEPENDENCE –
Unable to keep a drink limit/Difficulty avoiding getting drunk
Spending considerable time drinking
Missing meals/Memory lapses, blackouts
Restless without drink/Trembling after drinking
Organizing day around drink
Morning retching and vomiting
Sweating at night/Withdrawal fits
Morning drinking/Increased tolerance
Hallucinations/ frank delirium tremens
DIAGNOSTIC CRITERIA OF ALCOHOL WITHDRAWAL

13. Any THREE of the following :
Tremor of outstretched hands, tongue or eyelids
Sweating
Nausea / retching/ vomiting
Tachycardia or hypertension
Anxiety
Psychomotor agitation
Headache
Insomnia
Malaise or weakness
Transient visual, auditory or tactile hallucinations/illusions
Grandmal convulsions

14. TREATMENT –
Raise awareness of the problem
Increase motivation to change
Withdraw alcohol (controlled drinking)
Support and advice
CBT (Social skills, relapse prevention)
Marital therapy
Medication (Diazepam/chlormethiazole/Disulfiram
or Acamprosate)

15.  Psychological dependence
 Glue-sniffing – adolescents. Tolerance develops in
weeks or months
 Intoxication characterized by euphoria,
excitement, floating sensation, dizziness, slurred
speech and ataxia
 Acute intoxication – amnesia + visual hallucinations
 There is risk of tissue damage including that to
bone marrow, brain, liver and kidneys which can prove
fatal

16.  Derived directly from opium poppy: Morphine/Codeine
 Semi-synthetic  Heroine / Diacetylmorphine
Synthetic  Methadone/Meperidine/Dihydrocodeine
 Uses  Pain relief; suppression of cough; treatment of
acute myocardial infarction and also diarrhea
 Effects  Pleasant mood and a euphoric detachment
 Causes of death in narcotics addicts 
Heart disease (including infective endocarditis)
Tuberculosis
Glomerulonephritis
Tetanus/Malaria/Hepatitis B

17.  NARCOTIC ABSTINENCE SYNDROME –
Yawning/Rhinorrhea/Lacrimation
Pupillary dilatation
Sweating/Piloerection/Restlessness
12 – 16
HRS AFTER
DOSE
Muscle twitches/Aches and pains
Abdominal cramps/Vomiting/Diarrhea
Hypertension
Insomnia/Anorexia/Agitation
Profuse sweating/Weight loss
24 – 72 HRS
AFTER
LAST OPIATE
DOSE

18. Abrupt withdrawal is highly dangerous. May
result in a mental disorder, similar to alcohol
withdrawal, may lead to seizure & sometimes to
death.
Withdrawal symptoms may not appear for
several days. Anxiety, restlessness, and
disturbed sleep anorexia, nausea.
May progress to vomiting, hypotension, pyrexia,
tremulousness, major Seizures, disorientation &
hallucinations.

19.  Elevate mood, increase wakefulness, give an
enhanced sense of mental and physical energy
 Pleasurable stimulation & excitement potential
of misuse
 Cocaine, amphetamines, Synthetic
(Phenmetrazine diethylpropon), Khat, Caffeine

20.  Effects similar to these Amphetamines
 Strong Psychological dependence
 Excitation,dilated pupils, tremulousness
 Dizziness and sometimes convulsions
 Confusion, depression, paranoid psychosis and
formication

21.  Chlordiazepoxide (Librium), Diazepam (Valium),
Lorazepam (Ativan) and Nitrazepam (Mogadon)
 Cause:
Sedation, anxiety relief and Muscle relaxation
Withdrawal Symptoms:
Anxiety, restlessness, tachycardia and sensory
disturbances

22. Produce strange, intense, & transcendental
effects,which gives them ‘recreational’ popularity
Peyote, mescaline, ‘Magic mushroom’
LSD:lysergic acid diethyl-amide
Do not give rise to dependence in true sense,
nonetheless use is intensely hazardous

23. Effects vary with dose, persons expectation ,
mood, & social setting
Exaggerates pre-existing mood: exhilaration,
depression or anxiety
Increased enjoyment of aesthetic experience &
distortion of time & space
Reddening of the eyes, dry mouth, irritation of
respiratory treat & coughing

24.  No definite withdrawal Syndrome
 No evidence of Tolerance. No serious side
effects amongst intermittent users
 No evidence of teratogenecity. Not safe in
first trimester
 Psychosis:
disagreement

25. PRE-COMTEMPLATION:
Misuser doesn’t see the problem; others recognize it
CONTEMPLATION:
Individual weighs pros/cons. Considers change is needed
DECISION POINT:
Where the decision is made to act on this issue
ACTION USER:
Choose necessary strategy for change

26. MAINTENANCE GAINS:
Are maintained and consolidated
RELAPSE:
Return to previous pattern of behavior

27. 1.DETOXIFICATION
2.INSISTENCE ON ABSTINENCE
3.INVOLVEMENT OF FAMILY
4.TOXICOLOGY SCREENS (periodic urine
screens are often essential in identifying relapse
and noncompliance)
5.SELF-HELP GROUPS

28. 6. SANCTIONED TREATMENT
(patient forced to remain in therapy by a legal
sanction e.g. drivers/professional license)
7. CONTINGENCY CONTRACTING
(This approach provides a powerful negative
contingency for leaving treatment or relapsing
or a positive contingency for remaining drug
free)