Substance Use Disorders

Shaikha Alharmoodi
Outline

Alcohol
Cocaine
Amphetamine
Opioids
Benzodiazepines
Marijuana
LSD
PCP
Ecstasy
Substance Use Disorder

• DSM-V: Two or more of the symptoms during a 12-month period: -

• Tolerance
• Withdrawal
• Taken in larger amounts or over a long time
• Unsuccessful efforts to cut down or control use
• Lots of time spent to obtain, use, or recover from
• Craving or a strong desire or urge to use
• Failure to fulfill obligations at work, school, home
• Continued use despite social or interpersonal problems
• Social/occupational activities given up or reduced
• Use despite knowledge of having a problem
Alcohol

• Alcohol = ethyl alcohol = ethanol

• Found in alcoholic beverages
Alcohol intoxication
• Commonly abused substance
Alcohol use disorder
• Metabolized by liver
Alcohol withdrawal
• Activates GABA receptors
Alcohol intoxication

• CNS depression
• Slurred speech
• Incoordination
Most
MostUSUSstates:
states:legal
legal
• Unsteady gait limit
limit 80mg/dL, 0.08g/dL
80mg/dL, 0.08 g/dL
or 8%
or 8%
• Stupor
• Coma
Alcohol Use Disorder

Recurrent drinking causing impaired social functioning and many medical complications: -
Gastritis, hepatitis, cirrhosis, pancreatitis, dilated cardiomyopathy, and refractory
hypertension

• Wernicke Encephalopathy: -
Visual disturbances/nystagmus , gait ataxia, confusion, and often reversible with thiamine.

• Korsakoff Amnesia: -
Recent memory affected more than remote, can’t form new memories, confabulation, lack
of interest or concern (apathy), lack of insight and usually permanent.
Alcohol Use Disorder Management

Disulfiram
Naltrexone
• Inhibits aldehyde dehydrogenase
• Long acting opioid antagonist
• Acetaldehyde accumulates
• Endogenous opioids reinforce alcohol effects
• Triggers catecholamine release
• Given orally to prevent relapse
• Sweating, flushing, palpitations, nausea, vomiting

Acamprosate
Modulates NMDA receptors
SE: - diarrhea
 Alcohol withdrawal

Onset since last

Manifestations Symptoms/signs
drink (hr)

Anxiety, insomnia, tremors, diaphoresis, palpitations,

Mild withdrawal 6-24
gastrointestinal upset, intact orientation

Seizures Single or multiple generalized tonic-clonic 12-48

Alcoholic
Visual, auditory, or tactile; intact orientation; stable vital signs 12-48
hallucinosis

Confusion, agitation, fever, tachycardia, hypertension,

Delirium tremens 48-96
diaphoresis, hallucinations
Alcohol Withdrawal Treatment

• Benzodiazepines
• Functional liver: diazepam or chlordiazepoxide (long-acting)
• Cirrhosis or alcoholic hepatitis: lorazepam (short acting)
• Improve agitation and prevent progression
Cocaine

• Two key physiologic effects

• #1: Local anesthetic (Na channel blocker)
• #2: Inhibits monoamine reuptake
• Monoamines: dopamine, serotonin, NE
• Sympathetic activation
Cocaine intoxication
•Euphoria, anxiety, less need to sleep and
Treatment:
Treatment:benzodiazepines
benzodiazepines
increased energy Avoid beta-blockers:-
Avoid beta-blockers:-
•Agitation/psychosis (tactile hallucinations) •• Increased
Increasedalpha
alphaeffects
effects
•• Worsening of
Worsening of
•Chest pain
hypertension
hypertension and andchest
chest
•Seizures pain
pain
•Tachycardia/hypertension
•Fever (increased muscle activity due to
dopamine)
•Mydriasis
•Angina and myocardial infarction, due to
vasoconstriction and high BP (high demand and
low supply)
Cocaine Withdrawal

• Occurs with stopping after chronic, heavy use

• Usually not life-threatening
• Depression and anhedonia (crash)
• Anxiety
• increased appetite
• Increased sleep

TX:- supportive, antipsychotics if the patient experienced severe psychosis

Amphetamines

• Stimulants
• Indirect sympathomimetics and Increase synaptic dopamine/NE levels

Amphetamine Intoxication: -
• Similar to cocaine
• Euphoria/fever
• Sympathetic stimulation
• Tachycardia, hypertension
• Pupillary dilation, sores, and decaying teeth
• Rhabdomyolysis/seizures/ischemia
• Treatment: benzodiazepines
• Withdrawal syndrome similar to cocaine
Opioids

• Activate opioid receptors: mu, kappa and delta

• Prototype: morphine
• Also hydromorphone, meperidine, fentanyl, codeine
• Drug of abuse: heroin (diamorphine)
• Pain relief (analgesia)
• Euphoria
• Sedation
Opioids intoxication: -

• Most common cause of drug overdose death

• Euphoria to depressed mental status
• Decreased respiratory rate
• Decreased bowel sounds
• Miotic (constricted) pupils
Treatment:
Treatment:--
• Seizures ••Naloxone
Naloxone
••Short-acting
Short-actingopioid
opioidantagonist
antagonist
• Constipation ••May
May cause withdrawalififdose
cause withdrawal dosetoo
too
high (“overshoot”)
high (“overshoot”)
• Skin warmth and flushing
Opioid Withdrawal

• Occurs in opioid-dependent individuals

• Usually starts 6-12 hours after last dose
• Reversal of CNS, eye, skin, GI effects
• Restlessness
• Yawning
• Rhinorrhea and lacrimation
• Piloerection
• Nausea, vomiting, abdominal cramps
• Diarrhea
Opioid withdrawal medical therapy

Clonidine
Clonidine
•• Central
Central alpha
alpha agonist
agonist
•• Blunts
Blunts sympathetic
sympathetic activation
activation
•• Sedating
Sedating
Opioid
Opioid agonists
agonists
•• Buprenorphine
Buprenorphine
•• Methadone
Methadone
Opioid Use Disorder: -

• Buprenorphine
• Partial agonist (agonist and antagonist effects)
• Long duration of action
• Sublingual tablet
• May cause withdrawal
• Combined with naloxone
• Prevents abuse
• Naloxone not absorbed sublingually
• Crushed pill →IV injection →no effect
Methadone Naltrexone

• Long-acting oral opiate • Long-acting opioid antagonist

• Reduces cravings • Blocks effects of opioids if taken

• Maintenance • Administered to detoxified patients

• Strictly regulated/controlled to prevent relapse

• Some data show prevention of
relapse
• Also used in alcohol use disorder
Benzodiazepines
oxazepam, lorazepam, diazepam

• Many medical uses (seizures, anxiety, alcohol

withdrawal)
• Increase GABA activity
• Rarely cause respiratory depression (safer drugs)
• Classic overdose presentation:
• CNS depression with normal vitals Flumazenil
Flumazenil
••Antagonist
Antagonistof ofbenzodiazepine
benzodiazepinereceptor
receptor
• Altered mental status ••Use to treat overdose
Use to treat overdose
••Overdose
Overdosehashaslow
lowmortality
mortalityrate
rate
• Slurred speech
••Flumazenil may cause withdrawal
Flumazenil may cause withdrawal
• Ataxia seizures
seizures
Benzodiazepine Withdrawal

• Occurs with abrupt cessation after chronic use

• Similar to alcohol withdrawal
• Tremors
• Anxiety
• Depressed mood (“dysphoria”)
• Hypersensitivity to sensations (noise, touch)
• Psychosis
• Seizures
• Can be life-threatening
• Treatment: benzodiazepines
Marijuana

• Derives from cannabis (plant)

• Psychiatric activity from tetrahydrocannabinol (THC) • Euphoria
• Also called dronabinol • Anxiety
• Stimulates cannabinoid receptors in CNS • Impaired coordination
• Conjunctival injection
• Dry mouth
• Increased appetite
• Tachycardia and blood pressure fluctuations
• Rarely causes hallucinations or psychosis
• Usually not life-threatening

Treatment: Supportive and symptomatic.

Marijuana

• Withdrawal symptoms may include

irritability, anxiety, restlessness,
aggression, strange dreams,
depression, headaches, sweating,
chills, insomnia, and low appetite.

Treatment: Supportive and symptomatic.

Ecstasy/ (MDMA) Ecstasy Withdrawal
• Euphoria
• “Crash” after using MDMA
• Alertness
• Depression and anxiety
• Increased sociability
• Fatigue and lethargy
• Increased sexual desire
• Difficulty concentrating
• Bruxism(grinding teeth)
• Loss of appetite
• Hyponatremia
• Jaw soreness (fromgrinding teethwhile high)
LSD: Lysergic acid diethylamide
• Causes LSD “trip”
• Feeling of expanded consciousness
• Can sense things beyond usual reality
• Synesthesia (a blending of the senses)
• “Hearing" colors or "seeing" sounds
• Depersonalization
• Feeling disconnected or detached from body
• “Bad trip” (paranoia, anxiety)
• May causes “flashbacks”
PCP
• Inhibits reuptake of dopamine, NE, 5HT
• Increases sympathetic activity
• Stimulant
• Altered mental status
• Psychosis (with hallucinations)
• “Psychomotor agitation”
• Classically agitated, violent behavior
• Tachycardia, hypertension
• Nystagmus (repetitive involuntary eye movements)
• Rarely coma and seizures with overdose
PCP
• Psychosis plus loss of pain/sensation
• Patients may dissociate
• Walk into traffic
• Jump from buildings
• Treatment:
• Benzodiazepines
• Haloperidol (rapid-acting anti-psychotic)
Thank you
 References : -
Retrieved August 4, 2022, from
https://www.uworld.com/courseapp/usmle/v7/testinterface/launchtest/8849069/264529165/2/1

Stead, L., Stead, M., Kaufman, M., Toy, E., & Klamen, D. (2004). Psychiatry clerkship: First aid
clinical clerkship. McGraw Hill Higher Education.

Retrieved August 4, 2022, from https://www.boardsbeyond.com/