Substance-Related and Addictive Disorders

Table Of Contents
  1. Changes from DSM-IV to DSM-V
  2. Substance use disorder
  3. Overview
  4. Substance Use Disorder
  5. Substance dependence
  6. Alcohol
  7. Nicotine/Tobacco
  8. Inhalants
  9. Stimulants
  10. Benzodiazepines/Barbiturates
  11. Hallucinogens
  12. Date-Rape Drugs
  13. Opiates (Heroin)
  14. Cannabis
  15. Anabolic steroids

“At first drugs will take away your pain. Then it will take your joy, your freedom, your family your home, your job, your self respect. Eventually it will take away everything and you will be left with nothing BUT the pain you were trying to escape”

Changes from DSM-IV to DSM-V

Substance use disorder

  • Abuse/dependence criteria scrapped to make way for Substance Use Disorder (11 criteria)

Cannabis withdrawal syndrome

  • A. Cessation of cannabis use that has been heavy and prolonged (usually daily or almost daily over a period of at least a few months)
  • B. Three (or more) of the following signs and symptoms developing within approximately 1 week after cessation:
    • Irritability, anger, or aggression
    • Nervousness or anxiety
    • Sleep difficulty (will have strange dreams, and nightmares)
    • Decreased appetite or weight loss
    • Restlessness
    • Depressed mood
    • At least one of the following physical symptoms causing significant discomfort: abdominal pain, shakiness/tremors, sweating, fever, chills, or headache
  • C. Causing significant distress or impairments ( negative consequences in employment, school, arrest etc.)
  • D. Not attributable to another medical condition, other substances, etc.

Caffeine-withdrawal syndrome

Much easier to get caffeine withdrawal nowadays as many products (drinks) have caffeine in them

  • A. Prolonged daily use of caffeine
  • B. Abrupt cessation of or reduction in caffeine use, followed within 24 hours by three (or more) of the following signs or symptoms:
    • Headache
    • Marked fatigue or drowsiness
    • Dysphoric mood, depressed mood, or irritability
    • Difficulty concentrating
    • Flu-like symptoms (nausea, vomiting, or muscle pain/stiffness)
  • C. Cause significant distress or impairment
  • D. Not attributable to another medical condition, other substance, etc.

Gambling disorder

Hence these disorders are called substance-related and addictive disorders

Overview

  • How to tell if a patient is on a substance
    1. The patient tells you
    2. Urine tox screen returns positive
    3. The patient’s friends/family tell you
    4. There a signs of drug use in the physical exam
  • What should you know about the patient?
    • Drugs used: can get a good idea based on the Sx the patient displays
    • How MUCH, how OFTEN and how LONG the patient has been using the drug: relies on the patient’s history or what the companion tells you
    • Route of administration: injection, drinking on an empty stomach, smoking, inhaling snout
    • Duration of Sx: most prefer short-acting ones
    • Age of onset: mostly in early 20s and 20s, AUD mostly in 40s, earlier associated with conduct disorders, schooling problems, personality, other mental illnesses
    • Basic info on the Hx and physical as usual
  • Why is substance use disorder important
    • Alcohol/drug use disorder is common
    • A drug is often missed or undetected (mild effects, users do not know that they meet criteria)
    • Substance use disorder impacts overall health
    • Behavior changes caused by substances are reversible
    • Heavy socioeconomic burden (from the individual, family, community and country at large)
  • Why do clinicians fail to identify substance use disorders in patients
    • May make assumptions about a patient
    • Stigma about drug “abuse/addiction”
    • Afraid to uncover a problem
    • Forgot to ask (time allocation and huge queues)
    • Think you don’t have time

Definitions

Substance use disorder is a cluster of cognitive behavioral and psychological symptoms, indicating that the individual continues using the substance despite significant substance-related problems

  • Drug
    • A substance when taken into a living body alters ≥ 1 function
  • Substance
    • A mixture/compound of chemicals which when taken into the body through a defined mode may affect the functioning of ≥ 1 of the body functions (may create a desired or undesired change)
    • Psychoactive substance: chemicals that produce emotional, cognitive or behavioural changes to users with adverse medical consequences and are unsanctioned
  • Substance use
    • Usage of a drug that induces psychological, and/or behavioural change
    • sounds bad, but not necessarily bad
    • Sanctioned use: approved by society
    • Unsanctioned use: not approved by society
    • Harmful use: using a substance that causes tissue damage or mental illness
  • Substance abuse
    • Substance use that results in maladaptive change in a patient’s life, OR poses a risk to the patient’s/other’s life or well-being
  • Substance intoxication
    • The reversible set of symptoms the patient experiences d/t use of a particular substance
    • The effect of the drug
      • Behavioural and psychological changes
      • ≥ 2 physiological changes
  • Substance tolerance
    • The level of adaptation a patient has to a specific drug, usually requiring the patient to use more of a substance to attain the same desired effect
    • The body gets used to the drug
    • Cross tolerance
  • Substance withdrawal
    • The physiologic, psychological and/or behavioural changes that result from heavy/prolonged use of a substance
    • Symptoms when not having the drug
  • Substance dependence
    • A maladaptive change in behaviour resulting from substance tolerance and substance withdrawal. The patient perceives a need for the substance to avoid unpleasurable feelings
    • Everything in your life revolves around that drug
  • Monopolization (under substance dependence)
    • All you think about is that drug. All your money goes into that drug
  • Loss of control (under substance dependence)
    • Can’t stop yourself from using, at a certain level
  • Social deterioration (under substance dependence)
    • Losing friends.
    • Getting into the wrong crowds (violence, rape) etc.

Specific drugs

  • Alcohol
    • Depressant
  • Nicotine/tobacco
    • Has anxiolytic and stimulant effects
    • Cigarettes
    • Cigars e-cigarettes
    • Kuber
    • Shisha
  • Inhalants
    • Contains benzenene derivatives (Hydrocarbons)
    • Glue
    • Halothane (used as anaesthesia)
    • Pain thinners
    • Solvents
    • Gasoline
  • Stimulants
    • Cocaine
    • Amphetamines (Methamphetamine, dextroamphetamine)
    • Khat/Miraa
    • Mogoka
    • Ephedrine and Pseudoephedrine (prescription meds)
  • Cannabis
    • 9THC in 3 forms: Marijuana, hashish, oil cannabis (most potent, available as vapour that can be inhaled)
  • Sedatives
    • Benzodiazepines
    • Barbiturates
  • Hallucinogens
    • Lysergic Acid Diethylamide (LSD/Ecstasy)
    • Phencyclidine (PCP)
    • Mescaline (Grown commercially, extracted from poppy)
    • Psilocybin (Grown commercially, extracted from shrooms)
  • Date rape drugs
    • Flunitrazepam
    • GHB
  • Opiates
    • Heroin/opium (commonly abused)
    • Codeine
    • Pethidine/Meperidine
    • Fentanyl
    • Morphine
  • Caffeine
    • Does not qualify for the 11 criteria
    • Still a psychoactive (affects emotional, cognitive and behavioural and can cause intoxication and withdrawal)
    • Painkillers
  • Anxiolytics/Sedatives/Hypnotics
    • Benzodiazepines
    • Barbiturates
    • Ketamine (propofol, mandrax – methaqualone)
  • Anabolic steroids
  • Corticosteroids
  • NSAIDS
    • Tramadol
  • Antiparkinsonia meds
    • Benzhexol (Artane)
  • Antihistamines
    • Piriton
  • Nitrous oxide
  • Laxaties/purgatives/diuretics
    • Abused by athletes and models

Substance Use Disorder

Substance use disorder is a chronic brain/physical illness (clear micro/macro changes in the brain), that manifests as compulsive behaviour (repetitive behaviours that are gratifying to the patient**)** and has **social components (**noticed by third parties). THEY ARE MENTAL DISORDERS and are classified in the DSM-V. It is preventable and treatable. DA is the key neurotransmitter involved in substance use disorder, acting via the reward circuit

  • Central circuits involved with addiction
    • Inhibitory pathway: the prefrontal cortex (PFC – abstract thinking, thought analysis, and regulates behaviour mediating conflicting thought and right/wrong decisions); anterior cingulate gyrus (ACG – ”brain gear shifter – makes one flexible and perceives options of life)
    • Motivation/Drive: Orbitofrontal cortex (OFC – cognitive processing of decision making, signalling expected rewards/punishments); subcallosal cortex ( SCC – rich in serotonin transporters, “Gate” that is “left open” leading to depression as 5-HT is depleted)
    • Reward circuit: Ventral Tegmental Area (VTA – DA cell bodies linked with mesocortical and mesolimbic, involved in cognition, motivation and addiction); Nucleus accumbens (NAc – roles in reward, pleasure, laughter, addiction, aggression, fear); Ventral pallidum (VP – part of limbic system associated with reward and incentive motivation)
    • Memory/Learning: 5- 7 (social impairment). Amygdala (involved in memory processing and emotional reactions); Hippocampus (part of the limbic system involved in emotions, rewards, and short/long-term consolidation of information)

Causes of Substance Use Disorder

  • Biological
    • Genetics: parents, relatives, twins, identical/fraternal twins
    • Neurotransmitters: DA, GABA, 5-HT, ACh, Opioid like endorphins
    • Personality: Antisocial, Borderline, Narcissistic (Cluster B)
  • Psychological
    • Stress: major cause; imbalance between demands of life and ability to cope with them
    • Experimentation/curiosity/exploration
    • Social learning theory: Role modelling by parents celebs
    • Parenting style: authoritarian/dictatorial breeds rebellion versus laissez-faire/carefree without direction
    • Lack of love
    • Instability/inconsistency: change of environment, marital conflict
    • Illness or death of a significant other
    • Traumatic situations: divorce, dumped, jilted, disappointments, frustrations
    • Cultural shock
  • Social
    • Search for peer approval or acceptance
    • Culture (muratina, mnazi, busaa, ‘naming of children’)
    • Lax law enforcement (police, courts)
    • Advertisements and marketing which glamorize drugs
    • Easy availability and accessibility
    • Extreme poverty and lack of family support
    • Role of “Traditional African Woman”
  • Spiritual
    • Connect with a higher power
    • To fill a void inside
    • Hunger for divinity
    • Cults/elders
    • Rastafarians (+ cannabis)

Complications of Substance Use Disorder

  • Biological
  • Psychological
  • Social

Treatment of Substance Use disorders

  • Biological
    • Inpatient
    • Outpatient
    • Residential
  • Psychological
    • Family therapy
    • Group therapy
    • Cognitive Behavioral Therapy
  • Social
    • Self-help groups (AA, NA, CR, Overcomers)
    • Vocational (rehabilitation, habilitation)

Criteria for Substance Use Disorder

11 criteria grouped into 4 categories. 0-1 no diagnosis. 2-3 mild SUD. 4-5 moderate SUD. >6 severe SUD.

1 – 4 (impaired control)

  1. Drug taken in large amounts or over a longer period than was intended
  2. Persistent desire or unsuccessful effort to cut down or control substance use
  3. A great deal of time is spent in activities necessary to obtain the drug, use the drug, or recover from its effects
  4. Craving (intense desire or urge for the drug at any time or in an environment where the drug was previously used/obtained – strong for heroin)

5- 6 (social impairment)

  1. Recurrent drug use resulting in a failure to fulfil major role obligations at work, school, college or home
  2. Recurrent drug use despite having persistent or recurrent social/interpersonal problems caused or exacerbated by effects of the drug (arguments, fights with spouse)

7-9 (risky use of substance)

  1. Vital social, occupation, or recreational activities are given up or reduced because of the substance (may withdraw from family activities/hobbies)
  2. Recurrent drug use in situations where it is physically hazardous (driving, machine operation, swimming, walking in dangerous areas)
  3. Drug use continued despite knowledge of having a persistent or recurrent physical/psychological problem that is likely to have been caused or worsened by the drug.

10-11 (Pharmacological criteria)

  1. Tolerance (need more of/ decreased effects of same quantity with continued use)
  2. Withdrawal (Sx or by same/related drug taken to relieve or avoid withdrawal Sx)

Stages of Change Model (Transtheoretical model)

  • Precontemplation
    • The patient is not considering change and is often resistant to discussign the sstage
    • May be in denial or feel discouraged from past relapses
  • Contemplation
    • The patient onsiders change but remains ambivalent (fifty fifty).
    • Focus is more on the cons of stopping than the pros
  • Preparation
    • The patient intends to take action in the near future
    • Makes clear strategies for change
  • Action
    • The patient implements specific observable changes
  • Maintenance
    • The patient maintains the desired behaviour and works to prevent relapse
    • Nicotine – brief (weeks to months)
    • Alcohol – moderately long
    • Heroin – long (≥ 6 months to years)
  • Relapse
    • Can occur at any stage
    • Can be due to stressors.
    • Part of Tx
    • AUD has a relapse rate of 40-60%
    • HTN and asthma have a relapse rate of 50-70%
    • Prevent by: psychotherapy, medications, social, follow-up clinics, rehabilitation/habilitation

Substance dependence

Substance dependence is a disorder on its own characterized by severe negative interference in the patient’s life with inability or lack of willingness to quit. Shows monopolization, loss of control of use, social deterioration (prominent), and symptoms of tolerance and withdrawal. Expect the patient to deny dependence. Treatment involves primary prevention and secondary prevention

  • Risk of substance dependence
    • Family Hx: eg. children of alcoholics are at risk
    • Comorbid psychiatric illnesses: eg. depression
    • Social interactions: if ur friend do heroin, you might
  • Primary prevention
    • Prevents substance dependence from happening in the first place
      • DARE program in schools
      • Ad council public service advertisments
  • Secondary prevention
    • Treats existing substance dependence (psychologic + withdrawal symptoms)
      • Alcoholics anonymous: 12 step process. Works really well. Outpatient treatment for alcoholics.
      • Rehab programs specific to the drug
      • Detoxification
      • Naltrexone: opioid antogonst, prevent’s heroin’s lasabl ffcts. Use in pt not nwithdrwal but at risk of relapse.
      • Disulfiram: “antabuse”, aldehyde dehydrogenase inhibitor. Causes severe vomiting if alcohol is consumed (Negative reinfcmnt). Explain it to the patient + its effect before prescribing.
      • Methadone: Gradation therapy. Outpatient. Opiod agonist that gradually weans a patient off heroin. Reduces withdrawal symptoms

Alcohol

Most significant, most commonly used, and most commonly abused drug. Measured w/BAC. It is a depressant (contrary to popular belief as it can ultimately cause respiratory depression). The WHO recommends no more than 14 units of alcohol per week.

  • Sx Low levels
    • Euphoria
    • Talkativity
  • Sx High-levels
    • Clumsiness
    • Emotional lability
    • Sedation
    • Nausea and vomiting
    • Confusion
    • Coma
    • Death

Alcoholism

Alcoholism is a chronic disease characterized by a fundamental disturbance of the nervous system manifested on a behavioural level by a state of physical dependence. AUD is common in occupations with flexible work schedules and those that facilitate access to alcohol

  • Forms/Definitions (WHO, 1952)
    • Inability to stop drinking before drunkenness is achieved
    • Inability to abstain from drinking because of the appearance of withdrawal
  • Predisposing factors
    • Excessive alcohol use in first-degree relatives (30-60% concordance in monozygotic twins – confirmed by adoption studies done in Scandinavian countries)
  • Blackouts
    • Amnesia (anterograde) during an episode of intoxication
  • Treatment of intoxication
    • ABCs
    • Add thamine (Vit B1; Pabrinex 1 and 2) to IV fluids;
    • Benzodiazepine (Chlordiazepoxide): on a scheduled basis to prevent DTs
    • Do not use antipsychotics (esp Chlorpormazine): may induce more fits
  • Treatment of dependence
    • AA (Group Psychotherapy)
    • Acamprosate: reduces cravings
    • Naltrexone: antagonises endogenous endorphins
    • Disulfiram: blocks metabolism of alcohol causing acetaldehyde accumulation (Flushing, palpitations, vomiting)
  • Why is chlorpromazine (and antipsychotics in general) avoided in patients presenting with alcohol intoxication
    • May worsen respiratory depression
    • May induce more fits

Michigan Alcoholism Screening Test (MAST)

13-item test, self-administered. Sensitivity 30-78%

CAGE Questionaire

Specific to alcohol. Answering 2 or more of these as “yes” means the patient is dependent on alcohol. Sensitivity 60-100%

  1. Do you ever feel like you should Cut down on your drinking?
  2. Do you feel Anger when people confront you about your drinking?
  3. Do you ever feel Guilty about your drinking?
  4. Have you used alcohol as an Eye-opener after waking up?

AUDIT test

10-question audit. Sensitivity 38-40%.

TWEAK test

Tolerance, Worried, Eye-opener, amnesia, cut down. Sensitivity 79%

Alcohol Withdrawal

Occurs within 6-12 hours after the last drink (this is what drives people to continue drinking; may not be a severe illness). It can lead to Delirium Tremens (DTs) which has a mortality rate of 5%. Should be managed acutely to prevent Wernicke-Korsakoff (permanent brain damage and amnesia)

  • Pathophysiology
    • Marked excitatory action mediated by Glutamatergic system
  • Withdrawal Sx
    • Tremor
    • Anxiety
    • Seizure/Hallucinations (Delerium trements)
  • Delirium Tremens Sx
    • Disorientation in time and place (as a result of reduced level of consciousness)
    • Tremors (Marked)
    • Visual, tactile and auditory hallucinations/illusions (Sx tend to be worse in the evening and better in the morning; “Creepy Crawlies” = Formication)
    • Sweating
    • Tachycardia
    • Hypertension
    • Dilated pupils
    • Ataxia
    • Anxious (Very, Very, Anxious
    • Seizures (Rum fits, less common)
  • Complications
    • Post-withdrawal Wernicke’s encephalopathy
    • Korsakoff syndrome (an anamnestic state)
  • Treatment of delirium tremens
    • Admit
    1. Sedate the patient (Diazepam – no limit, as much as needed, Lorazepam)
    2. Dextrose bolus with Vitamin B1 complex (Pabrinex 1 and 2 – continued for 3 months)
    3. Supportive care

Wernicke’s encephalopathy

Caused by thiamine deficiency which causes **gliosis and haemorrhages in structures around the 3rd ventricle and aqueduct (**mamillary bodies, hypothalamus, mediodorsal thalamic nuclei, colliculi, mibdrain tegmentum). If not managed aggressively 80% of patients progress to the amnestic stage (Korsakoff’s syndrome)

  • Papez circuit
    • Important in memory and forgetting
    • Emotional control
  • Sx
    • Global confusion (w/ extreme anxiety)
    • Memory deficit
    • Ocular signs (Nystagmus, weakness of external rectus, conjugate gaze paralysis)

Korsakoff’s Syndrome

May appear without antecedent Wernicke’s encephalopathy. Permanent damage to structures in the limbic system. Lesions are in the dorsomedial thalamus (on histology). Anterograde and retrograde memory loss

  • Sx
    • Clear sensorium (MMSE)
    • Intact intellectual abiliies (hence develops confabulation since they are aware they have memory deficits)
  • Confabulation
    • Ability to fill gaps in memory because intellectal level of patient is conserved
Strutures affectedSx
Wernicke’s (Acute)Cerebellum, Brainstem, Mamillary bodies, Thalamus, HypothalamusConfusion, Ophthalmoplegia, Ataxia, Loss of appetite, Autonomic dysfunction, Peripheral neuropathy
Korsakoff’s (Chronic)Papez circuit, CerebellumAmnesia, Confabulation, Behavioral

Alcoholic Dementia

Associated with white and grey matter loss

Cerebellar degeneration

Very common. As a result of the loss of Purkinje cells in cerebellar cortex

  • Sx
    • Dysarthia
    • Limb ataxia

Alcoholic Hallucinosis

Rare but very characteristic if present. Can be permanent if it is not treated and persists for months.

  • Sx
    • Auditory hallucinations
    • Clear sensorium
    • Distressed (unpleasant)
  • Treatment
    • Antipsychotics

Alcohol-induced depressive symptoms

Occurs in 80% of alcohol dependence. 1.3 male and 1/2 female dependent people experience it. 15% of alcoholics die by suicide

Alcohol-induce anxiety disorder

Occurs in 70% of heavy drinkers

Medical Effects of Alcohol

  • CNS
    • Alcoholic Cerebellar Degeneration
    • Marchiafava Bignami Disease (Demyelination/necrosis of the corpus callosum and related subcortical white matter in chronic ill-fed alcoholics. Dx via CT-scan/MRI**)**
    • Central Pontine Myelinolysis
    • Trauma to the brain
  • GIT
    • Erosive gastritis
    • Peptic ulcer
    • Pancreatitis
    • Liver disease (Alcoholic steatosis, Alcoholic hepatitis, Alcoholic cirrhosis)
  • CVS
    • Hypertension
    • Cardiomyopathy
    • Arrhythmia
    • Congestive Heart Failure
    • CVA
  • GUT
    • Testicular atrophy
    • Infertility
    • QMiscarriage
  • Haemato-oncology
    • Macrocytic anemia
    • Ca-mouth, oropharynx
    • Ca-oesophagus
  • Fetal Alcohol Spectrum Disorder
    • Facial Dysmorphisms (Microcephaly, thin upper lip, Down-slanting eyes, Hypertelorism, epicanthal folds, receding chin)
    • Systemic (VSD, Heart-lung fistulas, Skeletal anomalies, Renal-aplastic or dysplastic, Growth retardation)
    • Intellectual disability

Alcohol-induced Psychotic disorder (including Othello’s Syndrome)

Common in alcoholics. Othello’s syndrome is delusions of infidelity (of jealousy) of a significant other. Very difficult to treat and if attempts do not work divorce is advised. Can lead to homicide.

Nicotine/Tobacco

Not an acute problem. Either pt comes in willingly to quit OR tobacco is a significant risk factor for medical condition e.g CAD. Treatment is by quitting and managing withdrawal Sx

  • Pack years
    • 0 pack years: Non-smoker
    • 1 – 20 pack years: Light smoker
    • 1 – 40 pack years: Moderate smoker
    • 40 pack years: Heavy smoker
  • Nicotine withdrawal Sx
    • Dysphoria
    • Irritability
    • Anxiety
    • Increased appetite
  • Long-term effects
    • COPD
    • Lung cancer
    • Leukoplakia (esp. with chewing tobacco)
  • Managing withdrawal Sx (Nicotine replacement therapy)
    • OTC gums, patches
    • Varenicline (Chantix; side effect = psychosis, suicidality, homicidal)
    • Bupropion (Zyban, SSRI, works very well for patients with refractory addiction, inhibits DA and NE reuptake to reduce craving)
    • Behavioural counselling

Inhalants

Big problem among teens as they are easily accessible (do not need to buy solvents, glues, thinners, or household cleaning products. Generally CNS depressants. Will usually smell the odour on the patient. Do not have withdrawal Sx. Tolerance is very mild.

  • Sx of intoxication
    • Slurred speech
    • Decreased motor coordination
    • Wheezing
    • Belligerence
    • Psychosis
  • Treatment
    • Supportive
    • Antipsychotics in case of agitation

Stimulants

Cocaine/Amphetamines

Block the uptake of serotonin, norepinephrine, and dopamine (reward pathway)

  • Short-term Sx
    • Euphoria
    • Mydriasis
    • Increased motor activity
    • Restlessness
    • reduced appetite
    • Increased body temperature (can lead to deadly hyperthermia, monitor body temp of pt if suspicious or if urine tox comes back positive)
  • Long-term sx
    • Itching
    • Paranoid delusions
    • Prolonged tachycardia
    • Poor dentition
  • Chronic Sx
    • Nasal septum perforation (from chonically inhaling cocaine)
  • Withdrawal Sx
    • Depressed mood (as opposed to euphoria)
    • Increased appetite (as opposed to decreased appetite)
    • Anxiety
    • Tremors
    • Intense psychomotor retardation
  • Treatment of intoxication
    • Supportive care
    • Benzodiazepines (midazolam, alprazolam) PRN: for
    • Antipsychotics: for paranoid delusions or psychotic disorders developed on the ward
    • Beta-Blocker (Propranolol, pindolol): for tachycardia/palpitations
    • Vitamin C: controversion but standard for cocaine/amphetamines (acidifies urine increasing their excretion)
  • Treatment of withdrawal
    • Long-term SSRIs

Catha Edulis (Khat/Miraa)

Amphetamine/like a drug with psychoactive + sympathomimetic effects. The main chemical component is cathinone, tannins, and norephedrine. Can be chewed or consumed as a juice, and is commonly taken with other drugs e.g. alcohol.

  • Intoxication Sx
    • Euphoria
    • Suppressed appetite and hunger
    • Increased alertness
    • Suppresses sleep and fatigue (in work situations)
  • Biological complications
    • Oral complications
    • Dental complications
    • GIT: gastritis, constipation, ischemic colitis
    • CVS: myocardial infarction, severe HTN, Cerebrovascular disease
    • Genitourinary: erectile dysfunction, spermatorrhoea
    • Pregnancy: low birth weight, small head circumference, growth retardation
  • Psychiatric complications of stimulant use
    • Stimulant intoxication (more with amphetamines, less with Khat)
      • Problematic change in behavior/psychological (euphoria, affect blunting, changes in sociability, hypervigilance, interpersonal sensitivity, anxiety, tension, anger impaired judgement, impaired social or occupational functioning)
      • ≥ 2 physiological changes (tachycardia, bradycardiia, mydriasis, HTN, HypoTN, perspiration, chils, N/V, evidence of weight loss, psychomotor agitation or retardation, muscular weakness respiratory depression, CP, arrhythmia, conusion, seizures, dystonia, or coma)
      • Grandiosity (”story za jaba”), talkativeness, alertness, gregariousness, rambing speech, headache, ideas of reference, tinnitus,
      • Psychosis (of the paranoid type) hallucinations may occur (auditory, visual, tactile).
      • Tx: haldol/droperidol in severe agitation
  • Stimulant withdrawal
    • Occurs after cessatiion of use or reduction after prolonged use. Peaks in 2-4 days and resolves after 1week
    • Dysphoric mood + ≥ 2 of the following physiological changes: fatigue, unpleasant dreams, insomnia or hypersomnia, increased appetite, psychmotor agitation, retardation, bradycardia (prominent feature), headache, profuse sweating, muscle cramps, stomach cramps
  • Stimulant-induced psychotic disorder
    • Similar to “paranoid” schizophrenia.
    • Paranoia is a main hallmark
    • Visual hallucination, appropriate affect, hyperactivity hyperesexuality, confusion and incoherence, delusions (of the paranoid spectrum – persecutory, reference)
    • Resolves quickly with medication

Benzodiazepines/Barbiturates

Sedative hypnotics. Generally prescription meds. Commonly seen in suicide attempts (prescribed to pts with anxiety disorders). Dependence on anxiolytics is a myth. Patients usually develop temporary craving + withdrawal but this only lasts a couple of days.

  • Acute intoxication Sx
    • Behavioural disinhibition
    • Somnolence
    • Severe sedation
    • Respiratory depression
  • Withdrawal Sx (has the highest mortality rate)
    • Anxiety
    • Insomnia
    • Hyperactivity
    • Seizure
    • Decreased appetite
    • Tremors
    • Perceptual disturbances and psychosis
  • Treatment of acute intoxication
    • Supportive care
    • Monitor pulse ox, BP
    • Intubation if respiratory depression occurs
    • Flumazenil (antidote, not used commonly in the ED)
  • Treatment of withdrawal
    • Long-acting benzodiazepines (clonazepam, chlordiazepoxide – more commonly prescribed to alcoholics going through withdrawal)

Hallucinogens

Lysergic acid diethylamide (LSD)

Mescaline

Psilocybin: active ingredient in hallucinogenic mushrooms

PCP: unique sx: agitation, aggression, hyperacusis, seizures, coma. Patients on PCP are mean (mean hallucinators).

Work in various mechanisms. Have no addiction profile and withdrawal syndromes. Tolerance is very low.

  • Acute intoxication SX
    • Hallucination
    • Psychotic thought process (ideas of reference, decreased judgment)
    • Clumsiness
    • Mydriasis
    • PCP will additionaly have agitation, aggression, hyperacusis, seizures and coma
  • Treatment
    • Supportive care
    • “Talking down” and reassurance (esp. if frigthened)
    • Antipsychotics PRN
    • Seizure prophylaxis (Benzodiazepines) if suspected PCP use, especially if agitated

Date-Rape Drugs

A vast majority of date-rape patients are women.

Flunitrazepam (Rohypnol – Benzodiazepine)

Gamma Hydroxy-butyrate (GHB – -depressants, same effects as EtOH)

  • What to do for a patient who has been potentially raped
    • Cervical exam: for forensics and STDs
    • Store clothes if within first 24 hours
    • Psychological and community counseling services (social work)
    • Notify law enforcement

Opiates (Heroin)

Binds opiate receptors. Administered IV (will show needle marks forming a track on PE) or Inhaled (increasingly smoked w/cannabis nowadays). Most patients with acute intoxication will present w/coma/death (different formulations with different concentration)

  • A vast majority of date rape patients are women.
    • Clonidine (in-patient)
    • Refer to Methadone clinic on d/c

Cannabis

Commonly used (esp. among pts who use other drugs. There is a myth about it being a gateway drug – Dispelled). Illegal in Kenya. Intoxication is usually an incidental finding on a urine tox screen. Long-term effects are controversial.

  • Sx of acute intoxication
    • Conjunctival injection – Red eyes
    • Increased appetite (”Munchies”)
    • Aloofness
    • Disturbances in time perception
    • Occasional disturbances in sensory perception (rare)
  • Why get a CBC in cannabis use
    • CB2 is found in immune cells (look for leukopenia?.immunosuppression)

Anabolic steroids

Commonly used by teens and young adult males. Long-term use can lead to hypercholesterolemia and CVS problems. Non-addictive and No withdrawal.

Trenbolone acetate, Nandrolone, Oxandrolone, Oxymetholone, Stanzolone

  • Intoxication Sx
    • Aggression (Mostly the only psychiatric Sx)
    • Muscular hypertrophy
    • Breast enlargment
    • Acne
    • Hirsutism (rare)
    • Testicular shrinkage (Rare)
  • Treatment
    • Supportive care
    • Counselling
    • Psychotherapy
    • Antipsychotics (if very aggressive)