Substance related disorders

SCENARIO IN MALAYSIA
 Half of all illegal drug use in Malaysia involves
heroin.
 Records from 2006 show there were 22,811
drug users who had been officially detected,
and this is a drop from 2005 when there were
34,813 cases detected.
 The majority of drug users seem to live in
Pulau Pinang and Kedah.
 It is believed that at least 1.1% of the
Malaysian population is involved in illegal drug
use.
 SCENARIO IN MALAYSIA

 Majority of drug users are amongst young

people (71.76%) with 20.42% of them aged
between 13 and 24 years old

 74% of HIV cases in Malaysia are among the

injecting drug user community.

 Heroin and morphine (62.92%) are 2

commonest drugs to be abused.
 SCENARIO IN MALAYSIA
 Most Commonly Abused Drugs in
Malaysia
 Heroin is the most widely abused illegal drug in Malaysia.
 Methamphetamine is the second most widely abused drug
in the country.
 There is a growing market for amphetamine type
stimulants.
 Kratom (Ketum) comes from a tree that can be commonly
found in South East Asia. The leaves can produce mild
stimulant or opiate-type effects.
 Cannabis
 Ketamine
 Ecstasy (MDMA)
 Problems Related to Drug
Addiction in Malaysia
 Drug addiction in Malaysia causes huge
difficulties for the individual and their family.
The main problems associated with such
behavior include:
 The individual does not have to be using these
substances for very long before they become
addicted to them. Once the individual has developed
a physical and psychological dependence these drugs
take over and destroy their life.
 Most drug users do not have the financial resources
to cover their drug habit. This means that they will
often turn to crime in order to be able to afford these
substances.
 Problems Related to Drug
Addiction in Malaysia
*

 Drug abuse has a devastating impact on

the individual’s mental and physical
health. Unless these people are able to
stop the substance abuse it will kill
them.
 Some individuals will become violent
when they are intoxicated from these
substances. They may also engage in
other inappropriate ways.
 Problems Related to Drug
Addiction in Malaysia

 The drug user will be unable to live up to their

potential while they are addicted to these
substances. It can mean that their life is
wasted.

 It is common for drug users to overdose on

these substances. The fact that these
substances are provided illegally means that
their strength cannot be controlled.
 Problems Related to Drug
Addiction in Malaysia
 A significant number of drug users will end
up in prison. They may develop a revolving
door pattern where they are in and out of
prison on a regular basis.
 Young people who become addicted to these
substances will be limiting their future
possibilities in life. It is not possible to
perform well in school or college while
abusing drugs.
 Drug users will find it hard to maintain
steady employment and most become
unemployable.
Treatment of Drug Addiction in
Malaysia
*
 Up until the late 1990s the main
means for tackling drug addiction was
enforced rehabilitation in detention
centers.
 This approach has not been
successful and now other means of
dealing with the problem are being
considered. Some of the options open
to those who wish to escape addiction
include:
 Treatment of Drug Addiction in
Malaysia
 Rumah Ikhtiar aims to reintegrate the addict
back into society. During their stay the
individual is taught living skills and they also
receive other types of training so that they can
have a second chance in life.

 Narcotics Anonymous offers a 12 Step solution to help

the individual overcome their drug addiction. The aim is
to not only to help the individual overcome their
addiction but also to give them a program so they can
find true happiness in life.
Treatment of Drug Addiction in
Malaysia
 Some Malaysians are going abroad in
order to find the best possible help
for their addiction problems.
 DARA Rehab is based in Thailand and
is the first and largest English-
speaking substance abuse treatment
facility in Asia.
 Psychoactive Substance

Psychoactive (psychotropic) substance

is any substance which after
absorption has influence on mental
processes both cognitive and
affective.
1. stimulative
2. suppressive
3. hallucinogenic
 PSYCHOACTIVE SUBSTANCES
 Alcohol  Hallucinogens
 Opioids  Sedatives and hypnotics
 Cannabinoids  Inhalants
 Cocaine
 Amphetamine and other
stimulants
 Nicotine
 WHAT IS DEPENDENCE?
 Craving – incessant desire to procure and use the substance

 Difficulty in controlling intake

 Withdrawal state

 Tolerance

 Progressive neglect of alternative interests

 Persistent use despite evidence of harmful consequences

 HARMFUL USE
 Pattern of use that is physically hazardous

 Substance related legal implications

 Failure to fulfill role obligations

 Criteria for dependence should not be met

 INTOXICATION

 Administration of the drug resulting in disturbances of

consciousness, cognition and perception, affect or behavior

 Level of the drug is generally high

 WITHDRAWL

 Emergence of symptoms, relatively specific to the drug,

following a total or partial withdrawal of the drug usually after
high dose usage.

 In general, there is a relief from the withdrawal symptoms

following the administration of the drug
 Warning Signs Of A Substance Use
Disorder
 An Abrupt Change In Attitude
 Mood Swings
 A Decline In Performance
 Increased Sensitivity
 Secrecy
 Physical Changes
 Money Problems
 Changes in Appearance
 Defiance of Restrictions
 Changes in Relationships
 ETIOLOGY
BIOLOGICAL PSYCHOLOGICAL SOCIAL
Genetic eg documented in Curiosity Peer pressure
Cloninger’s classification
Low self esteem Modeling
Reward pathway
Poor impulse control Easy availability
Associated
physical/psychiatric
disorder Childhood trauma Family discord

Pharmacological Escape from reality Permissiveness

properties
Learning and conditioning Religion
Dopamine and multiple
neurotransmitters
REWARD PATHWAY
PFC: planning complex
cognitive behavior,
personality expression,
decision making, and
moderating social
behavior.
Septum: relay station
linked with the main
hippocampus &
hypothalamus; part of
limbic system
Nucleus accumbens:
work with VTA involve
in the mechanism of
pleasure
Amygdala: fight & flight reaction
Locus coerulous: alarm centre in the brain packed by Noredrinaline
Hypothalamus: memory
MFB: integration of reward & pleasure / hedonic pathway
Routes of Administration of Drugs
ALCOHOL
 CNS depressant
 10% absorbed from stomach and 90% metabolized in the liver.

 Effects depend on the Blood Alcohol Concentration

 80mg/dl – legal limit for driving
 Permissible units: 7-14 units /wk & 14-21 units/wk respectively
for females & males
 Questionnaires and screening instruments
CAGE
A U D I T ( Alcohol Use Disorders Identification
test)
CLASSIFICATION OF ALCOHOLISM
 Jellinek: alpha, beta, gamma, delta, epsilon
 Gamma type is called as malignant alcoholism

 Cloninger
 Type1 - onset>25 years ,strong environmental influence, loss
of control, guilt

 Type II - <25 years ,strong family history, males, novelty

seeking, aggressive behavior
 Signs of Alcohol Abuse
 Problems remembering things recently said or done
 Getting drunk on a regular basis
 Lying about how much alcohol one is drinking
 Thinking that alcohol is necessary to have fun
 Having frequent hangovers
 Feeling run-down, depressed, or even suicidal
 Having "blackouts"--forgetting what you did while
drinking
 Having problems at school or getting in trouble with
the law
 LAB MARKERS FOR DEPENDENCE

 Gamma glutamyl transferase >40 iu/l – determines recent

consumption
 Mean corpuscular volume >92 fl
 Liver function tests alkaline phophatase, AST, ALT,
 Carbohydrate deficient transferrin – sensitive and specific
indicator but expensive
 COMPLICATIONS
PSYCHIATRIC
 Acute intoxication
 Withdrawal syndrome
Delirium tremens
Withdrawal seizures
 Alcoholic hallucinosis
 Alcoholic dementia, alcohol
induced mood/psychotic
disorder, sexual dysfunction
PHYSICAL
 Wernicke’s encephalopathy
 Korsakoff’s psychosis
 Marchiafava bignami disease
 Central pontine myelinolysis,
Cerebellar degeneration
 Peripheral neuropathy
 Fetal alcohol syndrome
 DELIRIUM TREMENS
 It is the symptom of complicated withdrawl
 Develops in 2-3 days of abstinence
 Clouding of consciousness
 Disorientation
 Visual hallucinations
 Autonomic disturbances
 Psychomotor agitation (sun downing pattern)
 Insomnia (reversal of sleep wake cycle)
 Dehydration
 RUM FITS
 It is also called as alcohol withdrawl seizures

 Stereotyped generalised tonic clonic

 12-48 hours after the last drink

 More than one seizure is common after 3-6 hrs of the first
seizure
 head injuries, CNS infections and neoplasms, hypoglycemia,
hyponatremia, and hypomagnesemia need to be considered
 Treatment of withdrawl is sufficient. No anticonvulsants
needed.
 Alcoholic hallucinosis
 Presence of hallucinations in clear consciousness usually
auditory within 8-12 hours of cessation

 Content is usually derogatory

 Recovery within one month following abstinence

 Wernicke’s encephalopathy

 Acute organic brain syndrome

 Ataxia
 Ocular signs-lateral rectus palsy, gaze palsy, nystagmus,
anisocoria, sluggish reaction to light
 Disorientation, confusion
 Recent memory disturbances
 Treatment –Thiamine (100mg thrice daily orally for 2-3
weeks)
 Korsakoff’s psychosis
 Chronic amnestic syndrome that often follows Wernicke’s
encephalopathy

 Recent memory disturbances (both anterograde and

retrograde amnesia)

 Confabulation is the most prominent feature

 Neuropathological lesions are in bilateral dorsomedial nuclei

of thalamus and mammilary bodies

 Only 20% recover.

 Marchiafava- Bignami disease
 Rare

 Disorientation, epilepsy, ataxia

 Dysarthria, hallucinations, Spastic limb paralysis

 Deterioration of personality

 Widespread demyelination of corpus callosum, optic tracts

and cerebellar peduncles
 Treatment of withdrawal
 Detoxification
Chlordiazepoxide (80-200mg)/day
Diazepam (40-80mg/) / day
Higher dose to start with and taper off –stop by 7-10th day
 Vitamins
Thiamin 100mg od for seven days followed by oral
administration of B1 for 6 months
 Treatment of withdrawal
 Correct hydration

 Need for hospitalisation

 Impending delirium

 Psychiatric co morbidity (antisocial personality,

major depression, anxiety and suicide)

 Physical illness

 Respite to relatives
PRINCIPLES OF MANAGEMENT
 Promote complete abstinence

 Stabilize acute medical/withdrawl symptoms

 Increase motivation for recovery

 Enhance relapse prevention skills

 Sustain abstinence through participation in self-help groups

 Life style modification

TREATMENT OF DEPENDENCE -
PSYCHOLOGICAL
 Motivational interviewing

 Self monitoring and Drink refusal techniques

 Aversion therapy

 Covert sensitization

 Alternative coping skills/Relapse prevention strategies

 Life style modification

 Alcoholic Anonymous GROUP

 PHARMACOLOGICAL Rx
 Deterrent agents eg Disulfiram
Aldeheyde dehydrogenase inhibitor
Disulfiram ethanol reaction
Flushing tachycardia, hypotension, headache,
sweating ,vomiting, nausea due to aldehyde
accumulation can be life threatening

 Dose 250mg/day
 Warning card is essential,Informed consent too
 OTHER AGENTS
 Acamprosate(Calcium acetyl homotaurine) NMDA receptor
antagonist and GABA agonist
333mg 2tab three times a day

 Naltrexone 50mg/day
(Opioid receptor antagonist)

 Others – Topiramate, Carbamazepine, Fluoxetine,

Ondansetron
 OPIOIDS
 Natural alkaloid of opium Receptors
Morphine, Codeine  µ
 Synthetic compound
Heroin, Methadone
 Kappa
 IV drug abuse very common
with opioids and risk of HIV  Lambda
high among intravenous
abusers  Epsilon
 Chasing the dragon – pattern Addiction producing opioids act
of use of opium on µ receptors
 OPIOID DEPENDENCE
 INTOXICATION  WITHDRAWL (starts within 12-
 Apathy 24hrs and subsides within 7-10
days)
 Bradycardia
 Lacrymation/Rhinorrhoea
 Hypotension  Yawning
 Pupil dilatation/Photophobia
 Subnormal body temperature  Autonomic hyperactivity
 Insomnia
 Pinpoint pupils (mydriasis at a  Muscle cramps/Pilo-erection
later stage)  Depressed mood and anxiety
 Respiratory depression  Nausea, G I cramps with diarrhea
 TREATMENT
 Diagnostic confirmation
Naloxone challenge test 0.2 to 0.8 mg i.v – it precipitates
withdrawl symptoms in patients who are dependent on opioids.

Urinary opioids testing

 Treatment of overdose
I V Inj of naloxone 2mg repeated every 1-2 hrs
 TREATMENT
 DETOXIFICATION  MAINTANENCE Rx
 Substitution drugs
 Methadone initiated at 20-25mg/day
 Methadone maintenance
 Buprenorphine (partial mu agonist) 2-
24mg/day  Buprenorphine

 Clonidine-alpha2 agonist (0.3-1.2mg /

day) slowly tapered off  Opioid antagonist
Naltrexone 50mg/day
 LAAM (Levo-alpha-acetyl methadone)
 Other treatment
 Lofexidine 0.4 to 0.6mgb d
Psychotherapy (CBT), Narcotic
anonymous, Therapeutic communities
 CANNABIS
 Other names: grass, hasish, marihuana, ganja
Pot,weed,mary jane
 Hash is the most potent form (resinous
exudate from the leaves). It is smoked as
joints.

 Derived from cannabis sativa plant

 The most active component is Δ-9 tetrahydrocannabinol

 DEPENDENCE
 INTOXICATION  COMPLICATIONS
 Acute intoxication causes
 Conjunctival injection conjunctival injection, and
acute panic reaction
 Increased appetite
 Dry mouth
 Amotivational syndrome
 Tachycardia
 Cannabis psychosis (run
amok/hemp insanity)

 Physical dependence is  Memory impairment and

mild worsening of schizophrenic
symptoms
 MANAGEMENT
 Psychoeducation

 Group therapy

 Individual psychotherapy

 Naltrexone tried in some cases

 No drugs available for relapse prevention

 NICOTINE
Effect of nicotine

 Tachycardia, peripheral vasoconstriction

 Increases blood pressure

 carcinogenic

 Increased mortality due to respiratory and

cardiovascular diseases

 CNS stimulant
 Tobacco Components
Nicotine
 A dangerous, colorless, oily compound.
 Highly addictive stimulant both physically and psychologically.
 Nicotine spreads to the nervous system within 8 seconds
Gases,Vapors,Chemicals and Compounds
 Carbon monoxide and dioxide, nitrogen dioxide, acetone,
 cadmium, pyridine, benzene, phenol, acrolin, vinyl chloride,
 hydrogen cyanide and sulfide, formaldehyde, and ammonia.
 Tar which Contains numerous cancer-causing particles (carcinogens) that
remain in the lungs.
Health Effects Of Smoking On The Body
 NICOTINE & PSYCHIATRY
 Used as self medication. Acts on nicotinic subtype of
acetylcholine receptors.

 Releases dopamine, brain’s reward neurotransmitter

 Relieves extra pyramidal symptoms/reduces negative

symptoms

 Alleviates side effects like drowsiness

 Can lower blood levels of certain drugs upto 50% eg

clozapine, TCAs, olanzapine etc
 TREATMENT
WITHDRAWL  TREATMENT
 12-14 hours after smoking Nicotine replacement therapy
 Depression  Gums 2mg and 4mg not to exceed
20/day
 Anxiety
 lozenges 2mg,4mg
 Restlessness
 inhalers, patches
 Irritablity
 insomnia
Antidepressants
 difficulty in concentration
 bupropion( Contra indicated in seizure)
 increased appetite
 Nortryptiline
 constipation  Varenicline (partial agonist at nicotinic
receptor)
COCAINE
 Derived from erythroxylum coca

 Common street name is crack

 Administration- orally, intranasally, by smoking, parenterally

 A central stimulant which inhibits the reuptake of dopamine,

nor epinephrine and serotonin
 DEPENDENCE
 WITHDRAWL  COMPLICATIONS
 Depressed mood  Acute intoxication
 Fatigue Sweating, tachcardia, puillary
 Generalized malaise dilatation, hypertension
 Vivid and unpleasant dreams  Features of hypomania are
 Agitation and restless seen
behavior followed by slowing  Produces a mild physical but
of activity strong psychological
 Increased appetite dependence
 Craving  Ekbom syndrome (cocaine
bugs)
 TREATMENT
Rx OF OVERDOSE
 Oxygenation
 Muscle relaxants
 Iv thiopentone and diazepam
 Iv propranalol 1mg every min
 Haloperidol
 Control of seizures
Rx OF CHRONIC USE
 To reduce craving for cocaine
amantadine 100 mg b d
bromocriptine 2.5 mg b d
bupropion has also been used with
variable outcome
Other interventions
Supportive psychotherapy
 AMPHETAMINES
 D-amphetamine, MDMA (Ecstasy), Methamphetamine (crystal meth -
injectable form)

 MOA - Dopamine overactivity and MDMA inhibits reuptake of

serotonin into the neuron.

 Amphetamine induced psychosis mimics schizophrenia

 Depression occurs during withdrawl.

 Treatment involves supportive care, acidification with

ammonium chloride and low dose antipsychotics
 HALLUCINOGENS
 Lysergic acid diethylamide (LSD), Psilocybin, Mescaline, Phencyclidine (angel
dust), Ketamine

 LSD (acid) – acts as serotonin agonist

 Synesthesias are commonly reported. (hearing colors/seeing sounds)

 Time distortion, Hallucination, Acute panic reaction (BAD TRIP),

sympathomimetic effects are other features.

 FLASH BACKS (Hallucinogen persisting perception disorder) occurs after

chronic LSD use.

 Phencyclidine induces psychosis almost similar to schizophrenia.

 Treatment – Supportive and symptomatic care, Benzodiazepines

 CAFFEINE
 Caffeine, xanthine derivative is a CNS stimulant

 For intoxication, consumption should be more than 250mg

(>2-3 brewed coffee)

 Caffeine withdrawl starts 6-12 hrs of stopping

(caffeinism marked by anxiety symptoms)

 Symptomatic treatment benefits.

 INHALANT ABUSE
 Volatile solvent, aerosols, gases. Generally they act as CNS
depressants

 Modes of abuse – sniffing, bagging, huffing, inhaling

 Symptoms include
 Inattention, in-coordination, irritability, depression and
sudden death

 Treatment relatively difficult

 CLUB DRUGS
 Ecstasy (MDMA) – party drug (cause mood changes and
sympathomimetic effects)

 Rohypnol (flunitrazepam along with ketamine used as date

rape drug)

 Gamma Hydroxy butyrate (liquid ecstacy)

 Ketamine,

 Acid (LSD).
 Methamphetamine
Thank you