Dear students its a simple presentation of substance abuse or alcoholic withdrawal and treatment. the substance abuse its a common problem of Young generations today, so health prevention and what is the cause of substance abuse in day today life. its only knowledge purpose.

1. Substance use
disorders
MR. VIKRANT KULTHE.

2. Importance
 Drug abuse, misuse, and addiction are
major issues in society because of
enormous personal, social, and economic
costs.
 They also have important psychiatric
components
2

3. Common substances of
misuse/ problem use/ abuse
 Substances which are otherwise socially
acceptable:
Nicotine
Alcohol
Caffeine
Alcohol
Prescribed medications (Pain-Killers,
Benzodiazepines, Cough syrups)
3

4. Common substances of
misuse/ problem use/ abuse
Substances which are otherwise illicit:
Cannabis (charas, bhang and Ganja)
Opium – Morphine, methadone, Heroin
Cocaine, Ecstasy, Amphetamines
(speed)
Hallucinogens – Phencyclidine, LSD
4

5. Common substances of
misuse/ problem use/ abuse
 Substances which have other uses but are
commonly misused:
 Sniffing glue and other volatile substances
like petrol, paint, anaesthetic agents, boot
polish, nail polish, etc.
 Pain killer balms (Tiger balm, vicks inhalers)
 Snake and scorpion bites in some cultures
 Magic mushrooms
5

6. Routes
 Ingested (as powder, tablets, in
drinks or food)
 Inhalation or by smoking
 Topical use (balms and irritant
lotions)
 Intravenous drug use (most
dangerous as also has associated
risk of passing STD and HIV)
6

7. Why do people take drugs?
 The main reason to try to ascertain the reasons
for drug use is that in many cases identification of
the cause can lead to effective interventions
 For Fun, pleasure seeking and due to peer pressure
 To numb unpleasant mood/ pain states/ boredom
 Self medicate for anxiety/ depression/ stress
 To get away from withdrawal symptoms
 Personality (risk taking behaviour)
 Increased risk with family history of substance use or
mood disorders
7

8. How abused substances affect the brain
 Act on the pleasure centre and give
pleasure
 Block the pain centre to reduce pain
 Release extra amounts of neurotransmitters
and cause to have excessive energy/ reduce
depression/ improve mood state
 Act on receptors to reduce anxiety
 Some act on specific areas in brain to cause
effects like hallucinations, delusions,
cognitive problems, etc.
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9. Then why are they bad for us?
• Because very commonly cause physical,
mental, social, legal problems
• Risks are far, far greater than any possible
benefits
• Not known who will get adverse effects and
with how much use (cannot be controlled as
this is not known)
9

10. Then why are they bad for us?
 Contaminants used may have their
own undesirable effects and can be
dangerous
 May lead to severe psychiatric
disorders, like depression, mood
disorders, schizophrenia like state
 Complications due to i/v use (HIV)
10

11. Then why are they bad for us?
 Legal and social complications
 Involvement in criminal activities to fund the
use (may at times take up peddling drugs)
 Poor socio-occupational functioning
 Become marginalised
11

12. Substance-Related Disorders As Classified in DSM-IV.
 Substance use disorders
Substance dependence
Substance abuse
 Substance-induced disorders
Substance-induced intoxication
Substance withdrawal
Substance-induced delirium
12

13. Substance-Related Disorders As Classified in DSM-IV.
 Substance-induced disorders
Substance-induced persisting dementia
Substance-induced persisting amnestic disorder
Substance-induced psychotic disorder
Substance-induced mood disorder
Substance-induced anxiety disorder
Substance-induced sexual dysfunction
Substance-induced sleep disorder
13

14. Terms used
 Problem use/ harmful use/ misuse
 Intoxication
 Craving
 Tolerance
 Withdrawal features
 Abuse
 Dependence
14

15. Problem use/Misuse
 The terms problem use and misuse usually
refer to use of drugs (presciption or other)
for pleasure but with disregard for the
personal (i.e.,Physical and mental), social
and legal dangers.
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16. Substance Intoxication
 The development of a reversible substance-specific
syndrome due to recent ingestion of (or exposure to)
a substance.
 Clinically significant maladaptive behavioural or
psychological changes that are due to the effect of
the substance on the central nervous system.
 The symptoms are not due to a general medical
condition and are not better accounted for by
another mental disorder.
16

17. Craving
 Craving is also a term that is widely used
yet ill defined. Most commonly it is taken
to mean a strong and sometimes
irresistible desire to use a drug
 Craving can also be present as an urge or
desire to use a drug although the sufferer
may be actively denying or resisting its
presence.
17

18. Tolerance
 Same amount of substance does not
produce the desired effect
And therefore this leads to
 Person needing to increase the amount of
substance he uses to produce the desired
effect
18

19. Substance Withdrawal
 The development of syndrome characterised by
physical and psychological symptoms and signs due
to either stopping or reducing the amount of
substance use d (usually after heavy and prolonged
use).
 Causes clinically significant distress or impairment in
social, occupational, or other important areas of
functioning.
19

20. Substance Abuse
A maladaptive pattern of substance use
leading to clinically significant impairment or
distress, as manifested by one (or more) of the
following, occurring within a 12-month period
but does not fulfil the criteria for substance
dependance.
20

21. Substance Abuse
Diagnostic features:
recurrent substance use resulting in failure to
fulfil major role obligations at work, school, or
home
recurrent substance use in situations in which
it is physically hazardous
recurrent substance-related legal problems
continued substance use despite having
persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects
of the substance
21

22. Substance Dependence
A maladaptive pattern of substance use, leading to
clinically significant impairment or distress, as
manifested by three (or more) of the following,
occurring at any time in the same 12-month period
22

23. Substance Dependence
1. Tolerance
2. Withdrawal
3. The substance is often taken in larger amounts or over a longer
period than was intended
4. There is a persistent desire or unsuccessful efforts to cut down
or control substance use
5. A great deal of time is spent in activities necessary to obtain the
substance, use the substance, or recover from its effects
6. Important social, occupational, or recreational activities are
given up or reduced because of substance use
7. The substance 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 substance
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24. Alcohol Dependance
24

25. Alcohol consumption
 Maximum advisable limit is 21 units per week
for males and 14 units per week for females
(difference is due to physical and metabolic
differences)
 One unit of alcohol is amount of alcohol the
body can metabolise and excrete in one hour (it
is approximate 10 ml of absolute alcohol)
25

26. Alcohol by Volume
Alcohol by Volume (abbreviated
as abv or ABV)
It is a standard measure of how much
absolute alcohol is contained in an alcoholic
drink and is expressed as a percentage of
the total volume
Found written on all alcoholic drinks or
beverages
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27. Units of Alcohol
Formula:
The number of units of alcohol in a drink
can be determined by multiplying the
volume of the drink (in millilitres) by its
percentage ABV, and dividing by 1000.
Thus, one 500 ml of beer at 4% ABV
contains: 2 units
 (500*4)/1000= 2
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28. Units of alcohol
 Similarly you can calculate the Units of alcohol for
other drinks
 500 ml of 5% strength beer has 2.5 units
 One litre bottle of 15% strength wine will have 15
units per bottle and therefore 200ml glass of wine
has 3 Units
 One litre of 40% strength Whisky, Rum or Vodka
will 40 Units per bottle and therefore a 60 ml (one
peg measure) will have 2.4 units
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29.  Therefore you can see that it does not take too
much of alcohol to cross the limit for a week
 Often people drink the maximum recommended
limit in one night or over the weekend without
even realizing it
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30. Alcohol Dependence
 Usually start as social drinkers on special occasions
 Slowly start drinking on more days of the week
 Drink seeking behaviour
 Avoiding other activities without alcohol
 Increased tolerance to alcohol
 Craving
 Withdrawal symptoms
 Relief or avoidance of withdrawal symptoms by further drinking
 Reinstatement after abstinence
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31. Sociocultural Risk Factors
 Male role
 Lower education
 Lower income
 Marital breakdown
 Certain occupations
 Idleness
 Cultural ambivalence towards drinking
 Self-fulfilling prophecy
 Socially condoned drunkenness
 Anomie/marginalization
 Social stress
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32. Alcohol Withdrawal syndrome
 Broad range of symptoms and signs, from the
relatively trivial to the life-threatening
 First the symptoms are intermittent and mild, but
as the degree of dependence increases, so do the
frequency and intensity of withdrawal symptoms
 Can occur when blood-alcohol concentrations are
falling (total abstinence not necessary)
 Often leads to drinking first thing in morning to
stop unpleasant symptoms
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33. Alcohol Withdrawal syndrome
Tremor, Nausea, Sweating
Mood disturbance
Hyperacusis, Tinnitus
Muscle cramp
Sleep disturbance
Perceptual distortion, hallucinations Generalized
(grand mal) seizures
Confusion
Delirium tremens
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34. Treatment of Alcohol withdrawal
 In hospital if severe (or past history of seizures,
delirium or poor physical health)
 Replacement with benzodiazepines to reduce
severity (usually long acting like
Chlordiazepoxide). This is tapered off.
 Vitamin injections (Thiamine +++) to prevent
cognitive problems
 Treat symptomatically or underlying causes (for
other physical problems)
34

35. Treatment of Substance Use disorders – General
principles
 Screening high risk groups and early detection
 Investigations and detailed physical and
psychological assessment
 Education of patient and family members
 To do motivational interview to assess readiness for
undergoing treatment and reasons for it
35

36. Treatment of Substance Use disorders – General
principles
 Encourage people who are not yet ready by giving
them evidence of benefits of abstinence and harmful
effects of continuing using the substances
 Do not be critical and give information in a non-
judgemental way
 Detoxification – Gradual reduction or using
replacement substances to reduce withdrawal
features
36

37. Treatment of Substance Use disorders – General
principles
 Treat co – morbid physical and mental
disorders using appropriate treatments
 Assess for risk factors which can lead to
relapse
 CBT (Cognitive – behaviour therapy)
 Family and/or Marital therapy
37

38. Some other treatment modalities
Disulfiram
Can cause severe side-effects when a person who
is on this medication consumes even minute
amount of alcohol
Can be life threatening and cause death
Not a safe method
Acamprosate and Naltrexone
Some evidence to suggest that they can reduce
craving in some people but these treatment are
costly and effective only in 30%
38

39. Other helpful modalities
Alcoholic anonymous
Religious leaders
Supportive work, peers and family
environment
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40. Motivation cycle 40
ContemplationPrecontemplation
Action
MaintenanceAbstinent
and
recovered
Relapse

41. Controlled drinking
Limit number of days of drinking and number of drinks
on any occasion.
Slow the rate of drinking, and/or reduce alcoholic
strength of drinks.
Develop assertiveness skills for refusing drinks.
Design reward system when goals are achieved.
Develop awareness of triggers to over drinking.
Practise other ways of coping with triggers.
Record pattern and amount of drinking, for example in
a diary.
Physician and patient monitor g-glutamyl transferase
blood test results.
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42. Debate
 Total abstinence v/s Controlled drinking
 To completely ban use of alcohol (As in Gujrat and
some muslim countries)
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43. Some measures used to reduce the alcohol
problem
Regulating the availability and conditions of use
Minimum age limits
Taxes and other price increases
Limiting sales outlets, and hours and conditions of
sale
Advertising and promotion restrictions
Education of public using media
Strict laws to monitor drunken behaviour/ driving,
etc.
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44. Opioid
 Dried extract of Papaver Somniferum been used for
centuries
 Highly dependence producing
 Marked increase in use over the years
 India particularly affected as lies between routes of
transport
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45. Opioid derivatives
 Natural
 Morphine
 Codeine
 Synthetic
 Heroin
 Methadone
 Dextropropoxyphene
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46. Opioid derivatives
 Morphine and Heroin most dependence
producing
 Bind to MU receptors to produce effects
 Can cause dependance after a very short
period of exposure
 Tolerance occurs rapidly and sometimes the
dose is increased to 100 times the initial dose
to produce desired effect
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47. Route of administration
 Ingested
 Smoked – commonly known as “chasing
the dragon”. This is commonly seen in
India where heroin is often available in an
impure form called “Smack” or “Brown
sugar”
 Also frequently used intravenously
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48. Acute Intoxication
 Apathy
 Bradycardia
 Hypotension
 Respiratory depression
 Reduced body temp.
 Pin-point pupils
 In case of large overdose – along with the
above will have delayed reflexes, thready
pulse and coma
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49. Withdrawal syndrome
 Starts after 12 – 24 hours and has a peak
within 24 to 72 hours
 Symptoms subside within 7 to 10 days
 Lacrimation, rhinorrhoea, pupillary dilation,
sweating, diarrhoea, yawning, tachycardia,
mild hypertension, insomnia, raised body
temp., muscle cramps, generalised body
ache, severe anxiety, piloerection, nausea,
vomiting and anorexia
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50. Detoxification
 Use of substitute drugs like methadone (not available
in India)
 Clonidine - (Alpha 2 agonist) to reduce withdrawal
symptoms. 0.3 to 1.2 mg per day.
 Naltrexone is an antagonist and can be used to
precipitate a withdrawal and prevent further cravings
 Other drugs – Buprenorphine, Long acting partial
agonist, which can be gradually tapered off
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51. Detoxification
 In India commonly used method is by giving
symptomatic treatment
 For example using Paracteamol for fever,
Antispasmodic for abdominal cramps
 In past “cold turkey” treatment was given, not
advocated at present as can be dangerous and may
cause death
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52. Maintenance therapy
 Methadone maintenance (not available in India)
 Counselling, Group and Behaviour therapy and
CBT
 Narcotics Anonymous
52

53. Cannabis Use disorders
 Also called as Grass, Hashish, Marijuana, Ganja,
Charas and Bhang
 Active chemical is Delta 9 Tetra hydro cannabinol
(THC)
 THC content varies from 1 to 40 % depending upon
the preparation. Lowest in Bhang and highest in
Charas and Hash oil
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54. Effects of Cannabis
 Very mild physical dependence but mild to marked
psychological dependence
 Very mild withdrawal syndrome
 Fine tremors, irritability, restlessness, nervousness,
insomnia, decreased appetite and craving
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55. Acute Intoxication
 Mild impairment of consciousness and
orientation
 Light headedness, Tachycardia, Sense of floating
in air
 Euphoric dream like state
 Photophobia, lacrimation, reddening of
conjunctiva, dry mouth and increased appetite
 Depersonalization, derealization, synesthesia
 Echolalia, echopraxia, visual and auditory
hallucinations
55

56. Treatment
 Mainly consists of supportive and symptomatic
 Sometimes antipsychotics used
 Psychoeducation and psychotherapy main stay of
treatment
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57. Any Questions ?
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58. 58