Dr Aseni Wickramatillake

Substance

Dose

Duration/chronicity

Individual degree of tolerance

Time since last dose

Person’s expectations as to the substances effect

Contextual variables

Underlying CNS changes that occur following repeated use of a drug such that the person develops tolerance and/or withdrawal

The need to use a greatly increase amount of a substance in order to achieve the desired effect OR

A markedly diminished effect being associated with continued use of the same amount of the substance

The degree to which tolerance develops varied greatly between drugs

Maladaptive behavioral change with physiological & cognitive effect that occurs

when concentration of a substance declines in the body

Alcohol = Ethyl alcohol or ethanol

Is not digested in the human body

Is absorbed directly from the stomach (20%) and intestines (80%) into the blood stream

Thereafter carried to every part of the body

Liver is responsible for eliminating the alcohol by CH3CH2OH (alcohol) H20 + CO2

Drunkenness occurs when drinking is > elimination by liver

Alcohol break down is slow. Approx: one unit per hour (however varies on the individual)

1 unit = half pint of beer / standard glass of wine or spirits

Alcohol is removed from the blood at a rate of approximately 15mg per 100ml per hour

15 mg/100ml /hour

Eg: 1 ½ pints of beer or 3 whiskies

▪ = blood alcohol level of 45-50 mg/100ml

▪ Excretion time= 45/15 =3-4 hours for blood alcohol level to normalize

Absorption rate is dependent on the type of drink (alcohol with fizzy mixes are more rapidly absorbed into the blood)

Body weight (reduced weight leads to greater effects)

Amount of food in the digestive tract (proteins will slow down processing of alcohol)

Individual metabolic differences

Alcohol elimination rate cannot be sped up

Black coffee, steam baths or fresh air will not change the rate of oxidation

Sleeping may actually prolong the rate of elimination due to slow body functions and slow metabolic rate

Eating during drinking will only slow the rate of absorption not the elimination

BAL (blood alcohol level) 0.08 or 1.0 g/dl- legal definition

Depressants slow the activity of the central nervous system (CNS)

Reduce tension and inhibitions

May affect judgment, motor activity, and concentration

Low doses ▪ Mood lability

▪ Impaired judgment

▪ Ataxia

At higher doses

▪ nystagmus

▪ slurred speech

▪ decreased concentration

▪ anterograde memory loss "blackouts".

Levels of impairment and concentration of ethyl alcohol in the blood:

BAC = 0.06: Relaxation and comfort

BAC = 0.09: Intoxication

BAC > 0.55: Death

▪ Most people lose consciousness before they can drink this much

Effects of alcohol:

a. Impaired judgment

b. Impaired ability to reason

c. Degraded muscular co-ordination

d. Lack of inhibition and self control resulting in increased recklessness

e. Degraded vision

f. Balance and sensory illusions

g. Disrupted sleep patterns (alcohol degrades REM sleep and causes early waking)

h. Heightened susceptibly to hypoxia i. Physical damage to the liver, heart, brain and

blood cells j. Disrupts short and long term memory k. Slow reaction time l. Allows the feeling that performance is

improved

High altitude, less oxygen, worsens effects Consumption above the following levels can

cause permanent damage to the body:

Men - 5 units daily 21 units per week Women - 3 units daily 14 units per week

Alcoholic is danger to himself/herself and others Alcoholics must admit to their alcoholism and

willingness to accept treatment is the most important element

Total abstinence is the only realistic goal as they cannot return to controlled drinking

High level of social drinking can be damaging even without alcohol dependence

No profession is exempted from the illness Some people often erroneously use alcohol to

unwind and as an sleep aid

“ when the excessive use of alcohol repeatedly damages a person’s physical, mental, or social life” WHO

Single most important characteristic of the alcoholic’s use of drink is a loss of control with a continuing progression to more and heavier drinking or regular binges lasting days or even weeks.

Alcoholics may not present the classic picture of a derelict existing on cheap wine or methylated spirits

Most are supposedly sober citizens with responsible jobs as doctors, lawyers, managers or even clergy

a. Drinking alone b. Gulping the first drink c. Preoccupation with the next drink d. Becomes defensive and angry when criticized

about the drinking habits e. Protection of the alcohol supply f. Use of alcohol as a tranquilizer g. Loss of memory of events when drunk h. Requirement to increase the intake to feel good i. Morning shakes j. High tolerance to alcohol k. Loss of control of drinking

Early

Anxiety

Irritability

Tremor

Decreased consciousness

Insomnia

As withdrawal continues

Delirium tremens (confusion, alternating level of consciousness, hallucinations, HTN, tachycardia, diaphoresis, vascular collapse) - usually appear within 72 hours after stopping

Seizures- within 48-72 hrs

CIWA (Clinical Institute Withdrawal Assessment for Alcohol)

Assigns numerical values to orientation ▪ Tremor

▪ Sweating

▪ Anxiety

▪ Agitation

▪ Tactile/ auditory/ visual disturbances

Benzodiazepines agonist of GABA and cross tolerant with alcohol reduce risk seizures

Anticonvulsants reduce risk of seizures, may reduce kindling, helpful for protracted withdrawal.

fetal alcohol syndrome (FAS): low birth weight, irregularities in head and face, intellectual deficits

Cognitive - support, education, skills training, psychological, group discussion

Medications

Disulfiram

Naltrexone

Acamprosate

Substances may cause temporary changes in behavior, emotion, or thought

Substance intoxication is a form of poisoning

Dose makes the Poison (Paracelsus)

Factors of substance abuse Sociocultural

Psychological

Biological

Abstinence with positive attitude

Experiment with friends – Peer pressure

Start use

Regular increasing to heavy use

Abuse

Control

A maladaptive pattern of use leading to impairment, in at least one of the following, occurring within a 12-month period:

recurrent substance use resulting in a failure to fulfill 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

A person relies on harmful or hazardous use of psychoactive

substances, including alcohol and illicit drugs excessively and repeatedly, impeding normal psychological and social functioning.

A maladaptive pattern of use, leading to impairment as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

▪ Increased tolerance

▪ Withdrawal

▪ The substance is often taken in larger amounts or over a longer period than was intended

▪ There is a persistent desire or unsuccessful efforts to cut down or control substance use

▪ A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects

▪ Important social, occupational, or recreational activities are given up or reduced because of substance use

▪ 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

Living in stressful socioeconomic conditions

Higher rates of unemployment correlate with higher rates of alcohol use

People of lower socio economic groups have higher rates of substance use in general

Abuse and dependence are more likely to appear in societies where substance use is valued or accepted

Behaviorists: operant conditioning may be significant in continuation of substance abuse. Temporary reduction of tension of the drug lead

to a rewarding effect

Increasing the likelihood to repeatedly seek similar reactions

Genetics may also play a significant role in

substance abuse (common among relatives)

Depressants

Stimulants

Hallucinogens

Cannabis

Polydrug use

Slow the activity of the central nervous system Reduce tension/anxiety and inhibitions

Slowed pulse, breathing and blood pressure

Poor judgment

Impaired motor activity/ coordination

Poor concentration and memory

Widely used depressants:

1. Alcohol

2. Sedative-hypnotic drugs

3. Opioids

Produce feelings of relaxation and drowsiness

low doses - calming or sedative effect

high doses - sleep inducers or hypnotics

Examples

Barbiturates

Benzodiazepines

Can be swallowed or injected

BARBITURATES

Consumed as a pill Low doses - reduce

anxiety, induce muscle relaxation and mild euphoria

Barbiturates are metabolized by the liver

Fatal in overdose (coma, respiratory–cardiac arrest)

BENZODIAZEPINES

Relieve anxiety Most popular sedative-

hypnotics: Xanax and Valium

Rarely fatal when taken alone

Slurred speech Impaired judgment Poor concentration Irritability Hostility Unsteady gait Excessive muscle relaxation of the diaphragm may cause

respiratory arrest

Withdrawal can cause delirium and seizures

1. Natural compounds – moderate dose leads to pain relief and induce sleep

a) Opium b) Heroin c) Morphine d) Codeine

2. Synthetic compounds - methadone

Collectively as “narcotics”

Each drug has a different strength, speed of action, and tolerance level

Can be injected, swallowed, smoked, snorted

• Opioids bind to the receptors in the

brain that ordinarily receive

endorphins a neurotransmitter

which relieve pain and reduce

emotional tension

Effects

pain relief

loss of inhibition

ecstasy

euphoria

drowsiness

nausea

poor coordination

constipation

confusion

sedation

respiratory depression and arrest

unconsciousness, coma, death

narrowing of the pupils

Opioids are often “cut” with noxious chemicals

(impurities)

Dirty needles and other equipment can spread infection

Clonidine(catapres) –suppresses opiate withdrawal symptoms

Can be use legally in medical treatment (pain relief)

Oxycodone (OxyContin, Percodan, & Tylox)

Hydrocodone (Vicodin, Zydone, and Lortab)

Heroin ▪ Rapid dependence, tolerance ▪ Significant withdrawal symptoms

▪ Anxiety and restlessness ▪ Muscle twitching, aches ▪ Fever ▪ Vomiting ▪ Weight loss

▪ Overdose ▪ Paralysis of breathing due to shut down the respiratory center

in the brain ▪ Death

▪ Withdrawal ▪ 6-24hr (Last up to 72 hours)

Types Amphetamine Cocaine Nicotine Caffeine MDMA (3,4-methylenedioxy-N-methylamphetamine) -Ecstasy Methamphetamine Ritalin

Use Injected Smoked Snorted Swallowed

Increase the activity of the central nervous system

Effects Increased heart rate and/or irregular heart beat Raised blood pressure Increased mental alertness Feelings of exhilaration Increased energy Heart failure Nervousness Insomnia Reduced appetite Weight loss

Derived from the leaves of the coca plant (alkaloid substance)

The most powerful natural stimulant

Around 3% of the population will become dependent on cocaine at some point in their lives

Use: freebase form – more expensive Crack a powerful form of freebase – rock crystal heated,

melted down for smoking in a pipe – cheaper than cocaine

Work by increasing dopamine at key receptors in the brain (mesolimbic areas) by preventing the neurons that release it from reabsorbing it

Increase norepinephrine and serotonin

Euphoric rush Pain reliever Increase sexual desire Increase self confidentiality ( can achieve

anything)

It stimulates the central nervous system and decreases appetite

Overdose can cause paranoia, hallucinations, insomnia, heart problems leading to death

Manufactured in the laboratory

Used in medical treatment

Stimulate the CNS by increasing dopamine, norepinephrine, and serotonin

Chronic use can reduce the volume of the hippocampus

Rapid tolerance and dependency

Serious depression and sleepiness on withdrawal Withdrawal within few hours

Increase alertness and motor activity

Reduce fatigue

Increased energy,

Sleeplessness

Decreased appetite

Increase heart rate

High-euphoric feeling

Hyper-activity/vigilance

Talkativeness

Grandiosity

Hallucinations

Anxiety

Repetitive behaviors

Anger

Irritability

Fighting/ hostility

▪marked dysphoria

▪fatigue

▪vivid & unpleasant dreams

▪hyper or insomnia

▪psychomotor act

Caffeine is the world’s most widely used stimulant

Around 80% of the world’s population consume it daily

Forms of Caffeine ▪ Coffee

▪ Tea

▪ Cola

▪ Chocolate

▪ Over the counter medication

More than 2 to 3 cups of brewed coffee can lead to caffeine intoxication

6-8 cups of normal strength a or coffee daily will lead to dependence

As little as 200 mg may reduce performance An average coffee drinker consumes 3.5 cups

a day (360-440mg) To be fatal, 10 g (100 cups) of coffee need to

be consumed (seizures and respiratory failure)

An intake of 25-30 cups a day is sufficient to show signs of altered physiological functions

Hear odd noises

See flashes of light or halos

Exhibit withdrawal symptoms

Extreme nervousness

Increased heart rate

Raised blood pressure

Caffeine is excreted from the urine and is a diuretic

a. Ulcers and other digestive disorders b. Increase risk of cardiac arrest c. Hypertension d. Personality disorders e. Chronic muscle tension f. Insomnia g. Disorientation h. Hyper-activeness (especially in children)

Usually occurs 12-16 hours after the last dose Irritability Sluggishness Headaches Depression Drowsiness Lethargy Occasional nausea and vomiting (in the most

serious case)

Tobacco – Nicotine Stimulates dopamine neurons in mesolimbic area 1 of 6 deaths related to tobacco use Commonly cause Lung cancer Other Effects Emphysema Cancers of larynx, esophagus, pancreas, bladder, cervix,

stomach Sudden infant death syndrome Pregnancy complications Cardiovascular disease

Known as psychedelic drugs Produce powerful changes in sensory perceptions Natural compounds

Mescaline

Psilocybin (extracted from Mushroom) Synthetic compounds

Lysergic acid diethylamide (LSD)

MDMA (ecstasy) Use

Swallow

Smoke

Increased body temperature Heart rate Blood pressure Loss of appetite Sleeplessness Numbness Weakness Tremors Altered states of perception

and feeling (flashbacks) Disrupted time perception

Nausea

Anxiety

Depression

Lability of mood

Paranoid delusions

Colourful Visual Hallucinations

Dilated pupils

Sweating

Blurred vision

Decreased coordination

Tolerance and withdrawal are rare Dangers

▪ experience of a “bad trip” – the experience of enormous unpleasant perceptual, emotional, and behavioral reactions

▪ risk of hallucinogen persisting perception disorder (“flashbacks”) –can occur long after last dose

Produced from varieties of the hemp plant

The major active ingredient in cannabis is tetrahydrocannabinol (THC)

Types Hashish- solidified resin of the tops of cannabis plant , stronger

than marijuana Marijuana - a mixture of buds, crushed leaves, and flowering tops

Use Swallow Smoke

Euphoria Slowed thinking and

reaction time Rapid emotional

changes Impaired memory and

learning Anxiety Panic attacks Confusion Impaired balance and

coordination

Cough and frequent respiratory infections

Damage to lung structure and functions (chronic users)

Increased heart rate and blood pressure

Increase appetite Dry mouth Blood shot eyes

Marijuana users can develop tolerance and withdrawal ( flu type symptoms and irritability)

Most widely used illicit drug Prohibited to be used in medical treatment High potency of the drug can cause

▪ Panic reactions similar hallucinogens

▪ Sensorimotor effects –increased accidents

▪ Poor concentration and impaired memory

SAMHSA, 2006 Substance Abuse and Mental Health Services Administration. (2007). Results from the 2006 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-32, DHHS Publication No. SMA 07-4293). Rockville, MD.

SAMHSA, 2006

Substance Abuse and Mental Health Services Administration. (2007). Results from the 2006 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-32, DHHS Publication No. SMA 07-4293). Rockville, MD.

Behavioral therapy Use of classical conditioning principles in

treatment

▪ limited success long-term when used alone

▪ can be helpful when combined with other approaches

Substance Abuse

Unpleasant Stimulus

Lose Craving

Biological medication

Antagonist drugs: Oppose the action of a neurotransmitter (Chantix for smoking)

Social therapy

Community prevention programmes

Self-help treatment programmes

Culture sensitive programmes

No single treatment for all Treatment should be readily available Treatment should attend to multiple needs of

the individual and not just the abuse Multiple methods of treatment may be

required Adequate duration of treatment for

effectiveness

Abstinence

Detoxification

Hospital Care Outpatient

Inpatient

Anonymous group/ individual therapy

Likely to happen if adequate treatment is not given

2/3 likely to relapse

Death due to suicide, homicide or accident or overdose

Communicable diseases and STDs such as HIV due to shared needles and unprotected sex

Illegal activities to obtain money for the supply of drugs Dealing drugs. theft, prostitution etc.

Exposure to infectious diseases via shared needles e.g. HIV Evidence suggests that free needles reduces

infectious diseases associated with IV drug use