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  1. 1. SUBSTANCE RELATED DISORDERS Owondo Thomas Bwindi Community Hospital
  2. 2. INTRODUCTION • Since the beginning of human history and before, people have found ways to alter their bodies and their consciousness by taking substances such as herbs, alcohol, and drugs. • Some people are able to keep using drugs on an occasional basis. Many other people are not so lucky. For these unlucky others, their use of drugs begins (gradually in some cases, abruptly in others) to increase, and the amount of attention they spend thinking about getting high, purchasing drugs, preparing drugs and taking drugs increases until it becomes the center of their lives. © 2017 Thomas Owondo. All rights reserved. 2
  3. 3. INTRODUCTION • As their consumption of drugs rises, users may become physically dependent on their drug to the extent that if they do not take it on a particular day, they get sick. • As dependence increases, tolerance to the drugs increases as well - meaning that it takes more and more of the drug to get the same 'high' or 'buzz' effect. © 2017 Thomas Owondo. All rights reserved. 3
  4. 4. INTRODUCTION • Substance-related disorders are diagnosed when use of any substance, whether recreational or prescribed, becomes excessive and leads to significant impairment or distress. • Substance-related disorders are generally divided into two groups: ➢ Substances-induced disorders and ➢ Substance-use disorders. © 2017 Thomas Owondo. All rights reserved. 4
  5. 5. INTRODUCTION ➢Substances-induced disorders include; ▪ Intoxication, ▪ Withdrawal, ▪ Other mental disorders that can be caused by substances, such as psychotic disorders and sleep disorders. ➢ Substance-use disorders include; ▪ Dependence and abuse. © 2017 Thomas Owondo. All rights reserved. 5
  6. 6. CATEGORIES OF SUBSTANCES • There are three main types of psychoactive drugs that people take to change how they feel or behave. • They include ➢ Depressants, ➢ Stimulants, ➢ Hallucinogens. In addition to these, ➢ Other drugs of abuse – Include inhalants, anabolic steroids, medications. © 2017 Thomas Owondo. All rights reserved. 6
  7. 7. Depressant drugs • Depressant drugs slow down or depress the functions of the central nervous system. • This doesn’t mean they make you depressed; rather the quantity, concentration, environment and mood of the user all contribute to the effects. • In small quantities they can cause a person to feel more relaxed and less inhibited. • In larger quantities they may cause unconsciousness, vomiting, and in some cases, death. • Depressants affect concentration and coordination. • They slow down a person’s ability to respond to unexpected situations. © 2017 Thomas Owondo. All rights reserved. 7
  8. 8. Depressant drugs • Alcohol, opiates and opioids (including heroin, opium, morphine, codeine, methadone, pethidine and palfium); • Cannabis (marijuana, hashish); • Tranquillisers and hypnotics (including Rohypnol, Valium, Serepax, Mogodon, Eupynos, Ativan, Ketamine). • Some solvents and inhalants (petrol, glue, paint thinners, lighter fluid). © 2017 Thomas Owondo. All rights reserved. 8
  9. 9. Stimulant drugs • They speed up or stimulate the central nervous system and can make the user feel more awake, alert, or confident. • Stimulants increase heart rate, body temperature and blood pressure. Depending on the dose, other physical effects include loss of appetite, dilated pupils, talkativeness, agitation and inability to sleep. • Higher doses can ‘over stimulate’ the user and cause anxiety, panic, seizures, headaches, stomach cramps, aggression and paranoia. • Prolonged use of stimulants can also cause these effects. • Strong stimulants can ‘mask’ the effects of depressants such as alcohol, and this can increase the potential for aggression, or pose problems for driving. © 2017 Thomas Owondo. All rights reserved. 9
  10. 10. Stimulant drugs • Mild stimulants include: tea, coffee, cola drinks, tobacco/nicotine and ephedrine (used in cough medicines). • Stronger stimulants include: amphetamines, cocaine, ecstasy (also classified as an hallucinogen), slimming tablets (Duromine, Tenuate, Dospan and Ponderax). © 2017 Thomas Owondo. All rights reserved. 10
  11. 11. Hallucinogenic drugs • They distort perceptions of reality. Users may see or hear things that do not actually exist, or that are exaggerated in relation to normal sensory experience (Alter sensory perception). • The effects of hallucinogens are not easy to predict – they often depend on the mood of the user and the context of use. • The main physical effects are dilation of the pupils, loss of appetite, increased activity, talking or laughing, jaw clenching, sweating, stomach cramps and nausea. © 2017 Thomas Owondo. All rights reserved. 11
  12. 12. Hallucinogenic drugs • Hallucinogenic drugs include: LSD (lysergic acid diethylamide), magic mushrooms (psilocybin), mescalin (peyote cactus), ecstasy (MDMA – methylene dioxymethylamphetamine), cannabis (in higher concentrations, as well as being a depressant). © 2017 Thomas Owondo. All rights reserved. 12
  13. 13. Anabolic steroids • Anabolic steroids are one type of performance-enhancing drug or medication. They mimic testosterone in the body to enhance performance by making muscle cells larger and by allowing the body to recover more quickly from the stress of exercise. • Some people use anabolic steroids to enhance performance in sport and for body-building. • Side effects or consequences of anabolic steroid use include: dependence and tolerance, depression (in withdrawal), organ disease or cancer, increased blood pressure, auto-immune suppression, decreased libido, breast tissue changes in men and women, growth of facial hair and deepening of the voice in women. © 2017 Thomas Owondo. All rights reserved. 13
  14. 14. Anabolic steroids • Testosterone (Axiron, Androgel, Fortesta, Testopel, Striant, Delatestryl, Testim, Androderm) • Androstenedione • Stanozolol (Winstrol) • Nandrolone (Deca-Durabolin) • Methandrosteolone (Dianabol) © 2017 Thomas Owondo. All rights reserved. 14
  15. 15. WHY PEOPLE USE SUBSTANCE © 2017 Thomas Owondo. All rights reserved. 15
  16. 16. EFFECTS OF SUBSTANCE USE • Different patterns of drug use result in different types of problems. © 2017 Thomas Owondo. All rights reserved. 16
  17. 17. Psychoactive drug that depresses the nervous system.
  18. 18. ALCOHOL • Alcohol is commonly used to celebrate, relax, or socialize with others, and drinking in moderation is typically seen as a reasonable behavior. • Individuals have different genetic make ups and early experiences, they may respond differently to alcohol and other drugs and have a different risk for drug abuse and dependence. • Moderate alcohol consumption does not generally cause any psychological or physical harm. However, if who enjoy social drinking increase their consumption or regularly consume more than is recommended, Alcohol Use disorder may eventually develop. © 2017 Thomas Owondo. All rights reserved. 18
  19. 19. Categorization of alcohol use disorders • Like other substances, alcohol use can be categorized as follows; ➢ Alcohol Use Disorders; ⚫ Alcohol Dependence ⚫ Alcohol Abuse ➢ Alcohol-Induced Disorders; ⚫ Alcohol Intoxication ⚫ Alcohol Withdrawal ⚫ Alcohol -Induced Psychiatric Syndromes (E.g; Psychosis, Mania etc) © 2017 Thomas Owondo. All rights reserved. 19
  20. 20. ALCOHOL USE DISORDER (AUD) • Alcoholism, now known as alcohol use disorder, is a condition in which a person has a desire or physical need to consume alcohol, even though it has a negative impact on their life. • A person with this condition does not know when or how to stop drinking. They spend a lot of time thinking about alcohol, and they cannot control how much they consume, even if it is causing serious problems at home, work, and financially. • Alcohol use disorder is defined by a cluster of behavioral and physical symptoms, which can include withdrawal, tolerance, and craving. © 2017 Thomas Owondo. All rights reserved. 20
  21. 21. SUB CLASS OF AUD 1. Alcohol Dependence; A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by 3+ of the following, at any time in a 12-month period: ➢ Tolerance ⚫ A need for markedly increased amounts of substance to achieve intoxication or desired effect ⚫ Markedly diminished effect with continued use of the same amount of substance ➢ Withdrawal ⚫ Characteristic withdrawal syndrome for substance ⚫ The same or a closely related substance taken to relieve or avoid withdrawal symptoms ➢ Substance taken in larger amounts or over longer period than intended. 21
  22. 22. Alcohol Dependence ➢ Craving for alcohol is indicated by a strong desire to drink that makes it difficult to think of anything else and that often results in the onset of drinking. ➢ Persistent desire or unsuccessful efforts to cut down or control substance use. ➢ A great deal of time is spent in activities necessary to obtain or use the substance or recover from its effects. ➢ Important social, occupational, or recreational activities are given up or reduced because of substance use. ➢ Substance use is continued despite having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. Specifiers: •With Physiological Dependence – evidence of tolerance or withdrawal. •Without Physiological Dependence – no evidence of tolerance or withdrawal
  23. 23. SUB CLASS OF AUD 2. Alcohol Abuse; • Maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by 1 or more of the following, occurring in a 12- month period: ➢ Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home ➢ Recurrent alcohol use in situations in which it is physically hazardous (e.g. driving while impaired) ➢ Recurrent alcohol use -related legal problems (e.g. disorderly conduct) ➢ Recurrent alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the alcohol (e.g. arguments with significant other about substance use, physical fights)
  24. 24. ALCOHOL USE DISORDE (AUD) • Alcoholism, or alcohol dependence, used to be considered the most severe form of alcohol abuse. The DSM-V integrates alcohol abuse and alcohol dependence, into a single disorder called alcohol use disorder (AUD) with mild, moderate, and severe sub- classifications. • Mild: The presence of two to three symptoms • Moderate: The presence of four to five symptoms • Severe: The presence of six or more symptoms. © 2017 Thomas Owondo. All rights reserved. 24
  25. 25. Differential Diagnosis of Substance Dependence & Abuse • Continuum of Substance Use: Recreational Use → Problematic Use → Substance Abuse → Substance Dependence • Substance Dependence: adverse consequences & tolerance, withdrawal, compulsive use. • Substance Abuse: adverse consequences, but absence of tolerance, withdrawal, or compulsive use. • Consider factors such as age, sex, culture, and health. • Once person has met criteria for Substance Dependence for a substance, they can never be given diagnosis of Substance Abuse for that substance.
  26. 26. ALCOHOL INDUCED DISORDERS • Some of the disorders are: ➢Alcohol intoxication ➢Alcohol withdrawal, ➢Alcohol-induced persisting dementia, ➢Alcohol-induced persisting amnestic disorder, ➢Alcohol-induced psychotic disorder, ➢Alcohol-induced mood disorder ➢ Alcohol-induced etc……. © 2017 Thomas Owondo. All rights reserved. 26
  27. 27. ALCOHOL INTOXICATION • Alcohol intoxication is a harmful physical condition caused when you drink more alcohol than your body can handle. It is also called ethanol poisoning, or being drunk. • Alcohol intoxication results as the amount of alcohol in your bloodstream increases. The higher the blood alcohol concentration is, the more impaired you become. • The development of a reversible substance-specific syndrome, due to recent ingestion of, or exposure to, a substance. • Clinically significant maladaptive behavioral or psychological changes develop during or shortly after use of the substance due to the effect of the substance on the central nervous system. • Intoxication is not diagnosed when someone simply ingests a substance that has the desired effect and no undesired side effects. 27
  28. 28. Signs and symptoms of Alcohol Intoxication Physical • Breath that smells like alcohol • Blackouts or seizures • Enlarged pupils • Eye movements that are faster than normal for you • Fast heartbeats and slow breaths • Loss of balance, or no ability to walk straight or stand still • Nausea and vomiting • Slurred or loud speech Behavioral • Quick mood changes: You feel happy and quickly become angry, or you easily become sad. You may act out violently. • Risky sexual behavior: You have sex that is not protected, or you have sex with many people. • Work or school trouble: You have many absences or do not finish your work. © 2017 Thomas Owondo. All rights reserved. 28
  29. 29. ALCOHOL WITHDRAWAL • If you drink alcohol heavily for weeks, months, or years, you may have both mental and physical problems when you stop or seriously cut back on how much you drink. This is called alcohol withdrawal. Symptoms can range from mild to serious. • Alcohol withdrawal syndrome is the clinical syndrome that occurs when people who are physically dependent upon alcohol stop drinking or reduce their alcohol consumption. • The substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. © 2017 Thomas Owondo. All rights reserved. 29
  30. 30. Clinical Information • Current substance use • History of substance use • History of substance use emergencies & treatment • Cognitive impairment, e.g. confusion, disorientation, impaired attention, rambling thoughts, drowsiness • Physiological signs, e.g. tachycardia, hypertension, hypotension, dilation or constriction of pupils • Neurological signs, e.g. slurred speech, lack of coordination, ataxia, dystonia, tremor, seizure, etc. • Psychomotor agitation or retardation • Changes in personality, mood, anxiety • Urine drug screening, blood alcohol level • Changes in social or family life • Current and past legal problems
  31. 31. Alcohol withdrawal syndrome • During the first several days after you quit drinking, you may experience withdrawal symptoms. Over time, your body becomes dependent on your drinking frequency and patterns. However, when you abruptly stop drinking, your body requires time to figure out what chemicals it’s missing. This phase is what produces the painful side effects. • Alcohol withdrawal syndrome can occur when you quit drinking and may trigger life-threatening health complications. © 2017 Thomas Owondo. All rights reserved. 31
  32. 32. Alcohol withdrawal syndrome • Alcohol withdrawal syndrome (AWS) is the name for the symptoms that occur when a heavy drinker suddenly stops or significantly reduces their alcohol intake. • Alcohol withdrawal syndrome is divided into 4 categories: ➢Minor withdrawal ➢Major withdrawal ➢Withdrawal seizures ➢Delirium tremens (DTs) © 2017 Thomas Owondo. All rights reserved. 32
  33. 33. Alcohol withdrawal syndrome • Minor withdrawal (withdrawal tremulousness); ➢Occurs within 6-24 hours following the patient’s last drink and is characterized by tremor, anxiety, nausea, vomiting, and insomnia. • Major withdrawal (alcoholic hallucinosis); ➢Major withdrawal (hallucinations) occurs 10-72 hours after the last drink. The signs and symptoms include visual and auditory hallucinations, whole body tremor, vomiting, diaphoresis, and hypertension. © 2017 Thomas Owondo. All rights reserved. 33
  34. 34. Withdrawal seizures (rum fits); ➢ Occur within 6-48 hours of alcohol cessation; they are major motor seizures that take place during withdrawal in patients who normally have no seizures and have normal electroencephalograms (EEGs). ➢ These seizures are typically generalized and brief. In the absence of treatment, multiple seizures occur in 60% of patients, but the duration between the first and last seizure is usually less than 6 hours. ➢ Only 3% of patients go on to develop status epilepticus. © 2017 Thomas Owondo. All rights reserved. 34
  35. 35. Withdrawal seizures (rum fits) conti • An alcohol withdrawal seizure is frequently the first sign of alcohol withdrawal, and no other signs of withdrawal may be present after the seizure abates. About 30-40% of patients with alcohol withdrawal seizures progress to DTs. • Alcohol withdrawal seizures usually occur only once or recur only once or twice, and they generally resolve spontaneously. If a patient has seizures that are not typical of alcohol withdrawal seizures (such as partial or focal seizures, prolonged seizures, or seizures with a prolonged postictal state) or has signs of significant head trauma, then the underlying cause of the seizure should be investigated. © 2017 Thomas Owondo. All rights reserved. 35
  36. 36. DELIRIUM TREMENS • DTs is the most severe manifestation of alcohol withdrawal. • It occurs 3-10 days following the last drink. • Clinical manifestations include; Agitation, Global confusion, Disorientation, Hallucinations (Tactile and visual), fever, hypertension, diaphoresis, and autonomic hyperactivity (tachycardia and hypertension). Profound global confusion is the hallmark of delirium tremens. © 2017 Thomas Owondo. All rights reserved. 36
  37. 37. DELIRIUM TREMENS • The "symptoms are characteristically worse at night". • Other common symptoms include intense perceptual disturbance such as visions of insects, snakes, or rats. These may be hallucinations or illusions related to the environment, e.g., patterns on the wallpaper or in the peripheral vision that the patient falsely perceives as a resemblance to the morphology of an insect, and are also associated with tactile hallucinations such as sensations of something crawling on the subject—a phenomenon known as formication. © 2017 Thomas Owondo. All rights reserved. 37
  38. 38. Management of DTs • It is a psychiatric/medical emergency with a high mortality rate, making early recognition and treatment essential.. • Admission is a priority. • Treatment in a quiet intensive care unit with sufficient light is often recommended. • Benzodiazepines are the medication of choice. • The vitamin thiamine is recommended. • The antipsychotic haloperidol may also be used. © 2017 Thomas Owondo. All rights reserved. 38
  39. 39. GENERAL MANAGEMENT OF AUD • SEARCH FOR IT © 2017 Thomas Owondo. All rights reserved. 39
  40. 40. © 2018 Thomas Owondo. All rights reserved. ANY QUESTIONS