Substance Related Disorders

Ronald Chrisbianto Gani
405090223
Faculty of Medicine
Tarumanagara University
EMERGENCY MEDICINE BLOCK
SUBSTANCE RELATED
DISORDERS
SUBSTANCE-RELATED DISORDERS
(INTRODUCTION)
TERMINOLOGY
Dependence : The repeated use of a drug or
chemical substance, with or without physical
dependence
Abuse : use of any drug, usually by self-
administration, in a manner that deviates
from approved social or medical patterns
Misuse : similiar to abuse but usually applies
to drugs prescribed by physicians that are not
used properly
Kaplan and Sadocks Pocket Handbook of Clinical Psychiatry 5th Ed
TERMINOLOGY
Addiction : the repeated and increased use of
a substance, the deprivation of which give rise
to a symptoms of distress and irresistible urge
to use the agent again and which leads also to
physical and mental deterioration
Intoxication : A reversible syndrome caused by
specific substance that affects one or more
mental function (memory, judgement, mood,
orientation, social function, etc)
TERMINOLOGY
Withdrawal : a substance-specific syndrome
that occurs after stopping or reducing the
amount of drug or substance that has been
used regularly over a prolonged period of time
Tolerance : Phenomenon in which after
repeated administration, a given dose of drug
given produces decreased effect or
increasingly larger dose must be administered
to obtain the effect observed with the original
dose
TERMINOLOGY
Cross-Tolerance : the ability of one drug to be
substituted for another, each usually
producing the same physiologic and
psychological effect. Also known as cross-
dependence
Kaplan and Sadocks Synopsis of Psychiatry 10th Ed
EPIDEMIOLOGY
EPIDEMIOLOGY
WHO SCHEMATIC MODEL
CLASSES OF SUBSTANCES
Alcohol
Amphetamine
Caffeine
Cannabis
Cocaine
Hallucinogen
Inhalant
Nicotine

Opioid
Phencyclidine
Sedative, hypnotic,
anxiolytics
Prescribed drugs and
OTC medications
Anabolic-Androgenic
steroids
OPIOID-RELATED DISORDERS
O
P
I
O
I
D
S
ETIOLOGY
Psychosocial factors
Higher in low sosioeconomic class
Children from single parents / divorced parents
Biological & Genetic Factor
Some drugs dependence genetically transmitted
abnormal functioning in dopaminergic or
noradrenergic neurotransmitter system
Psychodynamic theory
Serious ego pathology
EPIDEMIOLOGY
Estimated user in US : 1 million
Lifetime rate : 2%
Age : 30-40 yo
M : F = 3 : 1
Abuse of opioids found in lower
sosioeconomic
Dependence most seen in patient with opioid
medical treatment
OPIOID-RELATED DISORDERS (1)
Route of administrations
Opium : smoked
Heroin : smoked, Injected IV or SC
Some others : oral
Intoxication
Objective S&S : CNS depression, GIT motility ,
respiratory depression, analgesia, nausea &
vomiting, slurred speech, hypotension,
bradycardia, pupilary contraction, seizure (OD)

Subjective S&S : Euphoria (total body orgasm),
anxious dysphoria, tranquility, decreased
attention and memory, drowsiness, psychomotor
retardation
Overdose medical emergency
Often results from combine with other CNS
depressor (alcohol, sedative-hypnotic, etc)
Signs : pinpoint pupil, respiratory and CNS
depression
Treatment for opioid overdose
ICU admission + support vital function (IV fluid)
Administer 0,8mg Naloxone IV, wait 15 mins
If no response, give 1,6mg Naloxone, wait 15 mins
If no response, give 3,2mg Naloxone, suspect
other diagnosis
If success, continue Naloxone at 0,4mg/hour IV
Always consider polysubstance overdose

SLIDE 7
SLIDE 9
DSM IV-TR CRITERIA FOR OPIOID
INTOXICATION
WITHDRAWAL
INTOXICATION DELIRIUM
DSM IV-TR CRITERIA FOR OPIOID-
INDUCED PSYCHOTIC DISORDERS
INDUCED MOOD DISORDERS (1)
INDUCED MOOD DISORDERS (2)
INDUCED SLEEP DISORDERS (1)
INDUCED SLEEP DISORDERS (2)
INDUCED SEXUAL DISFUNCTION (1)
INDUCED SEXUAL DISFUNCTION (2)
OPIOID-RELATED DISORDER NOT
OTHERWISE SPECIFIED
The opioid-related disorder not otherwise
specified category is for disorders associated
with the use of opioids that are not
classifiable as opioid dependence, opioid
abuse, opioid intoxication, opioid withdrawal,
opioid intoxication delirium, opioid-induced
psychotic disorder, opioid-induced mood
disorder, opioid-induced sexual dysfunction,
or opioid-induced sleep disorder.
CLINICAL FEATURES
Adverse effects
Transmission of Hepatitis
and HIV
Idiosyncratic reaction
Overdose may cause
death
MPTP-induced
Parkinsonism
Skin popper
TREATMENT
Medically Supervised Withdrawal
andDetoxification
Opioid agents for treating Opioid withdrawal
Methadone : supress withdrawal syndrome, dose
20-120mg/day, once-daily
Other : levomethadyl (no longer used) &
Buprenorphine
Opioid antagonist : Naloxone, Naltrexone
TREATMENT
Psychotherapy
Therapeutic communities
Education and Needle Exchange
Narcortic Anonymous
HYPNOTICS, SEDATIVES,
ANXIOLYTICS RELATED DISORDERS
HYPNOTICS, SEDATIVES, ANXIOLYTICS
Benzodiazepin
Diazepam (Valium)
Flunitrazepam (Rohypnol)
Barbiturat
Secobarbital (Seconal)
Barbiturat-like substances
Methaqualone (Quaalude)
Meprobamate (Miltown)
BENZODIAZEPINE DISCONTINUATION
SYNDROME
EPIDEMIOLOGY
6% use this drugs before 40 yo
Peak age 26-35 yo
Female : Male = 3 : 1
White : Black = 2 : 1
Barbiturat abuse in patient >40 yo

INTOXICATION AND WITHDRAWAL
DRUG CHALLENGE TEST
MANAGEMENT
AMPHETAMINE-RELATED
DISORDERS
AMPHETAMINES
Preparations : Dextroamphetamine
(dexedrine), metamphetamine (desoxyn),
methylphenidate (Ritalin) less addictive
Epidemiology : 7% population used
amphetamines without medical judgement,
mostly at age 18-25
DSM IV-TR Criteria for amphetamine
dependence and abuse (Slide 7 and 9)

DSM IV-TR CRITERIA FOR
AMPHETAMINE INTOXICATION
AMPHETAMINE WITHDRAWAL
TREATMENT
Antipsychotic and antianxiolytic used in short-
term basis (first few days)
Comorbid : depression antidepressant
Bupropion produce feelings of well being
Multiple therapeutic methods
Individual
Familial
Group psysiotherapy
CANNABIS-RELATED DISORDERS
CANNABIS / MARIJUANA
Main euphoriant : 9-THC
Usually smoked, but sometimes eaten
Epidemiology : 5% lifetime rate of cannabis
abuse, highest at age 18-21 yo
Smoked euphoria in minutes, peak in
30mins, last for 2-4h, motor and cognitive
effects for 5-12h. Can cause dose-dependent
hypothermia and mild sedation
CANNABIS INTOXICATION
COCAINE RELATED DISORDERS
COCAINE-RELATED DISORDERS
Epidemiology
Lifetime abuse 2%
Age 18-25 yo
Male : Female = 2 : 1
Cocaine Intoxication & withdrawal (next slide)
Treatment : symptomatic
Agitation benzodiazepin or antipsychotic
Somatic system beta blockers
COCAINE INTOXICATION
COCAINE WITHDRAWAL
BRAIN INVOLVEMENT
C
O
C
A
I
N
E
National Institute on Drug Abuse
HEROIN
Heroin enters the brain, converted to
morphine, binds to opioid receptors (located
in brain, body,brainstem) affects perception
of pain, and alter breathing, BP, HR, arousal,
etc
Regular heroin use tolerance decreased
physiological and psychological effect of drug
more heroin needed to reach the same
intensity of effect
MARIJUANA / CANNABIS
Enters brain stimulate
dopamine release
euphoria
Impairs brain ability to form
new memory and shift
focus.
Binding to receptor in
cerebelum and basal ganglia
impairs coordination and
balance
Large dose acute
psychosis (hallucinations
and delusions), the cause
remains unknown
MDMA (ECSTASY)
Binds to serotonin transporter prolonged
serotonin signal
Enters serotonergic neurons release more
serotonin
Lesser effect in dopamine
After drugs use : confusion, depression, sleep
problems, drug craving, and severe anxiety
Chronic : impairs cognitive ability
METAMPHETAMINE
Increases the release and block the reuptake
of dopamine euphoria
Chronic abuse reduced motor skills and
impaired verbal learning, severe structural
and functional changes in areas of the brain
associated with emotion and memory
cognitive and emotional problems
LSD
Disrupting interaction of nerve cells and
neurotransmitter serotonin impairs control
of behavioral, perceptual, and regulatory
systems, including mood, hunger, body
temperature, sexual behavior, muscle control,
and sensory perception
Impairs glutamate receptors impairs
perception of pain, responses to the
environment, and learning and memory.
ALCOHOL
No single molecular targets
Effects on membranes of neurons
Short term : increasing fluidity of the membranes
Long term : membranes become rigi
Harrisons Principle of Internal Medicine 18th Ed
SEDATIVES, HYPNOTICS, ANXIOLYTICS
Binds to GABA
A
receptors increase affinity
to GABA increase the flow of chloride ions
thorugh the channel into the neuron
GABA stimulation results less chloride influ
than was caused by GABA stimulation before
benzodiazepine administrations tolerance
and dependence
REFERENCES
Sadock BJ, Sadock VA. Kaplan and Sadocks
Synopsis of Psychiatry 10th Edition.
Philadelphia : Lippincot Williams & Wilkins :
2007.
Sadock BJ, Sadock VA. Kaplan and Sadocks
Pocket Handbook of Clinical Psychiatry 5th
Edition. Philadelphia : Lippincot Williams &
Wilkins : 2010.

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