substance misuse disorders

7/31/2019 Substance Misuse Disorders

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SUBSTANCE MISUSE DISORDERS

Dr. Ravi Paul

2012/05/12 1Dr. Ravi Paul ([email protected])


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Alcohol-Related Disorders

Alcohol use disordersAlcohol dependenceAlcohol abuse



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Alcohol-Related Disorders

Alcohol-induced disordersAlcohol intoxicationAlcohol withdrawal

Alcohol withdrawal deliriumAlcohol-induced persisting amnestic disorderAlcohol-induced psychotic disorder

Alcohol-induced mood disorder

Alcohol-induced anxiety disorder



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Substance/Alcohol Abuse

A maladaptive pattern of substance use leading toclinically significant impairment or distress, asmanifested by one (or more) of the following, occurringwithin a 12-month period:

1. recurrent substance use resulting in a failure to fulfilmajor role obligations at work, school, or home (e.g.,repeated absences or poor work performance relatedto substance use; substance-related absences,

suspensions, or expulsions from school; neglect ofchildren or household)

2. recurrent substance use in situations in which it isphysically hazardous (e.g., driving an automobile or

operating a machine when impaired by substance use)2012/05/12 4Dr. Ravi Paul ([email protected])


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Substance/Alcohol Abuse

3. recurrent substance-related legal problems (e.g.,arrests for substance-related disorderly conduct)

4. continued substance use despite having

persistent or recurrent social or interpersonalproblems caused or exacerbated by the effects ofthe substance (e.g., arguments with spouse aboutconsequences of intoxication, physical fights)

The symptoms have never met the criteria forSubstance Dependence for this class of substance

2012/05/12Dr. Ravi Paul ([email protected]) 5


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Substance/Alcohol Dependence

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

A. tolerance, as defined by either of the following: a need for markedly increased amounts of the substance to

achieve intoxication or desired effect

markedly diminished effect with continued use of the same

amount of the substanceB. withdrawal, as manifested by either of the following:

the characteristic withdrawal syndrome for the substance

the same (or a closely related) substance is taken to relieve

or avoid withdrawal symptoms 2012/05/12 6Dr. Ravi Paul ([email protected])


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Substance/Alcohol DependenceC. the substance is often taken in larger amounts or over a longer

period than was intended

D. there is a persistent desire or unsuccessful efforts to cut downor control substance use

E. a great deal of time is spent in activities necessary to obtain

the substance , use the substance , or recover from its effects

F. important social, occupational, or recreational activities aregiven up or reduced because of substance use

G. the substance use is continued despite knowledge of having a

persistent or recurrent physical or psychological problem that islikely to have been caused or exacerbated by the substance(e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognitionthat an ulcer was made worse by alcohol consumption)



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Alcohol Intoxication Recent ingestion of alcohol.

Clinically significant maladaptive behavioral orpsychological changes (e.g., inappropriate sexual oraggressive behavior, mood lability, impaired judgment,impaired social or occupational functioning) that developedduring, or shortly after, alcohol ingestion.

One (or more) of the following signs, developing during, orshortly after, alcohol use: slurred speech in coordination unsteady gait

nystagmus impairment in attention or memory stupor or coma

The symptoms are not due to a general medical conditionand are not better accounted for by another mental

disorder. 2012/05/12 8Dr. Ravi Paul ([email protected])


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Alcohol WithdrawalA. Cessation of (or reduction in) alcohol use that has been heavy and

prolonged.B. Two (or more) of the following, developing within several hours to a

few days after Criterion A: autonomic hyperactivity (e.g., sweating or pulse rate greater than 100) increased hand tremor (Classic sign after 6-8 hours) insomnia nausea or vomiting transient visual, tactile, or auditory hallucinations or illusions ( 8 to

12hours) psychomotor agitation

anxiety grand mal seizures (12 to 24 hours)

C. The symptoms in Criterion B cause clinically significant distress orimpairment in social, occupational, or other important areas offunctioning.

D. The symptoms are not due to a general medical condition and arenot better accounted for by another mental disorder.2012/05/12 9Dr. Ravi Paul ([email protected])


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Drug Therapy for Alcohol

Intoxication and Withdrawal

Clinical Problem Drug Route Dosage Comment

Tremulousness

and mild to

moderate

agitation

Chlordiazepoxide Oral 25-100 mg every

4-6 hr

Initial dose can

be repeated

every 2 hr until

patient is calm;subsequent

doses must be

individualized

and titrated

Diazepam Oral 5-20 mg every 4-6

hrHallucinosis Lorazepam Oral 2-10 mg every 4-

6 hr

Extreme agitation Chlordiazepoxide Intravenous 0.5 mg/kg at 12.5mg/min Give until patientis calm;

subsequent

doses must be

individualized

and titrated

Withdrawal

seizures

Diazepam Intravenous 0.15 mg/kg at 2.5

mg/min

Delirium tremens Lorazepam Intravenous 0.1 mg/kg at 2.0

mg/min



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Substance/Alcohol withdrawal

delirium Disturbance of consciousness (i.e., reduced clarity of

awareness of the environment) with reduced ability tofocus, sustain, or shift attention.

A change in cognition (such as memory deficit,

disorientation, language disturbance) or the developmentof a perceptual disturbance that is not better accountedfor by a preexisting, established, or evolving dementia.

The disturbance develops over a short period of time

(usually hours to days) and tends to fluctuate during thecourse of the day.

There is evidence from the history, physical examination,or laboratory findings that the symptoms in Criteria A andB developed during, or shortly after, a withdrawalsyndrome. 2012/05/12 11Dr. Ravi Paul ([email protected])


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Alcohol-Induced Persisting

Amnestic Disorder

Diagnosis and Clinical Features

The essential feature of alcohol-induced

persisting amnestic disorder is a disturbancein short-term memory caused by prolongedheavy use of alcohol. Because the disorderusually occurs in persons who have been

drinking heavily for many years, the disorderis rare in persons younger than age 35.



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Wernicke- Korsakoff's Syndrome

Wernicke's encephalopathy (acute condition)

Korsakoff's syndrome (a chronic condition).

The pathophysiological connection between thetwo syndromes is thiamine deficiency, causedeither by poor nutritional habits or bymalabsorption problems.



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Wernicke's encephalopathy

Wernicke's encephalopathy, also calledalcoholic encephalopathy, is an acuteneurological disorder characterized by:

Confusion

Ataxia (affecting primarily the gait),

Nystagmus

Wernicke's encephalopathy is completelyreversible with treatment

Wernicke's encephalopathy may clearspontaneously in a few days or weeks or may

progress into Korsakoff's syndrome.2012/05/12 14Dr. Ravi Paul ([email protected])


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Management

Early stages, 100 to 300mg parenteralthiamine, (effective in preventing theprogression into Korsakoff's syndrome).

Followed by 100 to 300mg mg orally and iscontinued for 1 to 2 weeks.

In patients with alcohol-related disorders whoare receiving IV administration of glucosesolution, it is good practice to include 100 mgof thiamine in each litre of the glucosesolution.



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Korsakoffs Syndrome

The cardinal features of Korsakoff's syndrome areimpaired recent memory and anterograde amnesiain an alert and responsive patient.

Confabulation.

Treatment:

Thiamine 100 mg PO two to three times daily;

the treatment regimen should continue for 3 to 12months.

Only about 20 percent of patients with Korsakoff'ssyndrome recover.



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Alcohol-Induced Psychotic

DisorderA. Prominent hallucinations or delusions. Note: Do not

include hallucinations if the person has insight that theyare substance induced.

B. There is evidence from the history, physicalexamination, or laboratory findings of either (1) or (2):

1. the symptoms in Criterion A developed during, orwithin a month of, substance intoxication or

withdrawal2. medication use is etiologically related to the

disturbance



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Alcohol-Induced Psychotic

DisorderC. The disturbance is not better accounted for by a psychotic disorderthat is not substance induced. Evidence that the symptoms precedethe onset of the substance use (or medication use); the symptomspersist for a substantial period of time (e.g., about a month) after thecessation of acute withdrawal or severe intoxication, or aresubstantially in excess of what would be expected given the type or

amount of the substance used or the duration of use; or there isother evidence that suggests the existence of an independent nonsubstance-induced psychotic disorder (e.g., a history of recurrentnon substance-related episodes).

D. The disturbance does not occur exclusively during the course of adelirium.

Note: This diagnosis should be made instead of a diagnosis ofsubstance intoxication or substance withdrawal only when thesymptoms are in excess of those usually associated with theintoxication or withdrawal syndrome and when the symptoms aresufficiently severe to warrant independent clinical attention.



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Fetal Alcohol Syndrome

Women who are pregnant or are breast-feedingshould not drink alcohol. When mothers drinkingalcohol expose fetuses to alcohol in utero it inhibits

intrauterine growth and postnatal development. Fetal alcohol syndrome is the leading cause of

mental retardation in the United States

Microcephaly, craniofacial malformations, and limband heart defects are common in affected infants.

Women with alcohol-related disorders have a 35percent risk of having a child with defects.


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