Substance Abuse

Psychiatry Substance Abuse Dr Los Baños 3rd/November 13, 2008 Eis, Isay, Jasy, Candy

SUBSTANCE ABUSE A growing BIOPSYCHOSOCIAL problem       

Estimated 190 million addicts around the world About 3-4% of the total world population regularly abuse drugs 140 million marijuana addicts 30 million amphetamine-type stimulants addicts 13 million heroin addicts 8 million cocaine addicts Int’l drug cartel earn $400B/year=8% of the world trade

PHILIPPINES  1.7 million drug users  1.2 million Filipino Youth using drugs (National Youth Commission)  Monthly consumption of 5-10 grams  At 5 gms=8.5 million grams total consumption per month = 17B pesos monthly = 204 B pesos annually SUBSTANCE  When taken into the body can alter consciousness or state of the mind and/or body  It may be o Legal but controlled or taxed o Legal prescribed with restrictions o Illegal o Naturally occurring o Synthetic NEGATIVE PERCEPTIONS Obstacle to Recognition  Drug abuser “deny” substance problem  Strong negative counter transference feelings of physician – prone to neglect, misunderstance, be biased

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Substance abuse as “hopeless” condition “Missed Diagnosis”

THE COMMONLY ABUSED DRUGS/SUBSTANCES:

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Opioids and opiates – opium, morphine, methadone, codeine, meperidine (Demerol)

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Sedatives/Hypnotics – barbiturates, benzodiazepines, chloral hydrate and others

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Hallucinogens – LSD, phencyclidine (PCP), cannabis (marijuana)

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Stimulants – amphetamines, metamphetamine (Shabu) and cocaine

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Alcohol – beer, gin, wine Caffeine – coffee, softdrinks Nicotine – cigarettes, chewing tobacco

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Inhalants and Solvents – (volatile hydrocarbons) – rugby, kerosene, gasoline, thinner

SUBSTANCES OF ABUSE/DEPENDENCE Most substances of abuse have therapeutic indications. “There are no truly dangerous drugs, there are only people who use drugs dangerously.” DSM IV: SUBSTANCE RELATED DISORDERS I. Substance Use Disorders: Abuse and Dependence II. Substance Induced Disorders: Intoxication, Withdrawal, Delirium, Dementia, Amnestic, Psychotic, Mood, Sexual Dysfunction, Anxiety, Sleep Disorders SUBSTANCE ABUSE A. A maladaptive pattern of substance use leading to clinically significant impairment or distress 1) Recurrent substance use resulting in a failure to fulfill major obligations at work, school, or home 2) Recurrent substance use in situations in which it is physically hazardous 3) Recurrent substance-related legal problems 4) Continued substance use despite having persistent or recurrent social or interpersonal problems caused by the effect of the substance B. The symptoms have never met the criteria for substance dependence SUBSTANCE DEPENDENCE A. A maladaptive pattern of substance use, leading to clinically significant distress or impairment 1. Tolerance a. A need for markedly increased amounts of the substance to achieve intoxication or desired effect b. Markedly diminished effect with continued use of the substance 2. Withdrawal a. Characteristic withdrawal syndrome b. The same substance is taken to relieve or avoid withdrawal 3. The substance is often taken in larger amounts or over a longer period than was intended 4. There is a persistent desire or unsuccessful efforts to cut down or control substance use 5. A great deal of time is spent in activities necessary, to obtain or use the substance, or recover from its effects

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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

Specify if: With physiological dependence Without physiological dependence SUBSTANCE RELATED DISORDERS: I. Substance Use Disorders: Abuse and Dependence “A person may be a substance dependent but not necessarily a substance abuser and vice versa.” Patterns of Drug Use:

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Experimenters - used drugs once or a few times and have stopped- “for curiosity” Recreational Use Casual users o Take drugs for “fun” o Thrill and excitement o Peer influence – need for acceptance Iatrogenic substance abuse/dependence

Profile of a Filipino Drug User (CY 1998) Age: 26 years old Sex: Male (12:1) Civil Status: Single (55.78%) Birth order: eldest Family size: 3-4 siblings Educational High School (22.77%) Attainment: IQ: Average Occupation: Workers employees 42.51% Unemployed 21.75% Self-employed 12.58% Students 12.16% OSY 3.68% Economic Status: middle income Place of Residence: Urban esp. NCR 58.31% Region IV 22.315 Region III 5.37% Region VII 4.57% Region X 2.55% Nature of Drug Mono-drug use Taking: Drugs of Use: Shabu, Mairjuana Duration of Drug More than 2 years Taking: Etiology and Pathophysiology • biological • psychological • social Biological Genetic Studies • S.A. 3-4x higher in monozygotic twins • Alleles with variations in dopamine receptor more common in S.A.

Risk Factor Studies • sons of alcoholic hyporesponsive to alcohol and sedative drugs Neurobiological Substrates: • Dopamine – novelty seeking (frequent) exploratory behavior and intensely pleasurable responses • Serotonin – modulate harm avoidance (tendency to respond intensely to aversive stimuli and their conditional signals) • Norepinephrine – modulate reward dependence (resistence to extinction of previously rewarded behavior) Psychological • depression • sensation seeking • instant gratification • relief form distress-escape, rebellion, attentiongetting, alienation • personality problems Social • peer culture • family influences • unemployment/urbanization Diagnosis • appropriate history • laboratory tests • manifestations of intoxication, tolerance, withrdrawal o Polydrug use – dilemma • observation for several hours or days Substance Intoxication A. development of substance specific syndrome due to a recent ingestion of substance B. significant maladaptive behavior or psychological changes due to CNS effects C. symptoms are not due to a medical condition nor another mental disorder Substance Withdrawal A. Development of substance specific syndrome due to a cessation/reduction of prolonged or heavy use of substance B. Substance-specific syndrome causes clinically significant distress or impairment in important areas of functioning C. Symptoms are not due to general medical condition nor another mental disorder PHASES OF ADDICTION 1. Initial phase (Pre-alcoholic phase) • use of alcohol/drugs is socially motivated • taking the drugs becomes a means of dealing with stress 2. Prodromal Phase • warns or signals disease onset • to take drugs is already a “need” • the addicted individual begins hiding and camouflaging the drugs use to avoid facing the consequences

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to look “okay” to the outside world requires effort Crucial Phase • key symptoms of loss of control • can control whether to take or not but cannot control the amount • rationalization

Phases of Addiction • Attempts to make external changes to control his/her drug use: o Periods of abstinence o Change in type of drug o Change in intake pattern o Geographical escape (moves) o Changes in job, etc • Begins to recognize that there is something wrong/guilty • Losses continue to rise in all life areas: persona, social, family, friends, legal • Life is now drug-centered

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Isolation  Nutrition problems

4. Chronic Phase • Drug use starting earlier in the day and becoming intoxicated almost daily • Tremors alleviated by drug intake to become functional • Health problems become obvious • Drug tolerance • Moral deterioration • Impairment in memory, problem-solving , abilities, and psychomotor skills • Amotivation • Can no longer rationalize • Defeat Harmful Effects of Drugs and Drug Abuse 1. Physical Effects • Malnutrition • Illneses o PTB, bronchitis, hepatitis, cirrhosis, gastric ulcer, heart diseases, AIDS, blood poisoning, coma, stroke • Skin infections • Overdosage • Severe irritation of nasal passages 2. Psychological Effects • Amotivational Syndrome • Tolerance • Psychosis • Paranoia • Difficulty in remembering • Diminished ability to cope with problems 3. Social Effects • Disruption and disharmony within families • Deviant behavior • Deterioration in interpersonal interaction • Socially non-functional

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Tendency to commit crimes and bizarre sexual acts • Threat to security and integrity of nations through corruption, terrorism, intimidation, etc. Economic Effects: • Taxpayers’ money spent on T & R, law enforcement efforts, etc • Decreased productivity and more job related accidents • Increased cost of doing business due to absenteeism, sloppy workmanship, defective products, etc • Decreased crop production/food shortage due to marijuana cultivation Spiritual Moral Effects • Spiritual bankruptcy • Lowering of moral standards • Improper and unconventional behavior • Prostitution Effects on the Family: • Feelings of frustration, pain, and disappointment • Intense feeling of humiliation and guilt by family members • Low self-esteem among family members • Spirit of togetherness/unity is lost • Occurrence of domestic violence • Loss of money and valuables

GOALS • Clearing the mind and body of drugs • Allowing the person to begin to see what he is doing to himself MANAGEMENT Preventive (Primary) 1. Drug Supply Production a. Locate and stop at source b. Obstruct traffic c. Apprehend and penalize pushers 2. Drug demand reduction: drug education programs a. School-based programs Therapeutic (Secondary-short term) 1. Identification of drug/s used 2. Identification and management of drug effects, such as withdrawal, intoxication or overdose, and organic mental disorders a. Withdrawal – symptoms can begin from 848 hours after lost dose ingested, except for cannabis, hallucinogens, inhalants, and PCP B. Therapeutic (Secondary- short term) 1. Identification of drug used 2. Identification and management of drug effects such as withdrawal, intoxication, or overdose, and organic mental disorders a. Withdrawal- symptoms can begin fro, 8-8 hours after last dose ingested except for cannabis, hallucinogens, inhalants, and PCP.

This 1. 2. 3.

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can be managed by: Cold turkey or total abstinence Gradual discontinuation or tapering off Drug substitution, like methadone for heroin, or Phenobarbital for short acting barbiturates like Seconal (?) 4. Pharmacotherapy, such as benzodiazepines for alcohol, propranolol for benzodiazepines Intoxication or overdose- symptoms are due to acute effects of drug ingested

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treatment, such as Naloxone for opioids, benzodiazepines for cocaine, haloperidol for shabu and solvents 2.Physical support, such as hydration, thermal monitoring of cardiovascular status, particularly for comatose or unconscious patients 3.Identification and treatment of concomitant medical and physical problems 4.Identification and management of comorbid psychiatric diagnosis Detoxification- acidification of the urine Rehabilitation and aftercare (tertiary or long term)

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The best approach is one that utilizes a THERAPEUTIC COMMUNITY model. There are two distinguishing features: the practice of group confession of personal failure and total openness and honesty between group members. A key element is Self- help. Main Features Drug abstinence Hierarchical work structure Encounter groups Educational and social activities

AFTER- CARE This is done in out patient basis and the ex-addict comes back for regular check-ups to monitor if he remains drug-free, to offer continued psychological support, and to determine his social adjustments. Treatment Approaches • Psychoanalytic Ego-Analytic approach – Can be resulted when an individual becomes consciously aware of unconsciously stored conflicts and frustrations which have their root in maladjustments. – Catharsisdevelops insight and understanding by the unconscious roots of their problems. • Behavioral approach – Views abuse (drug) within a sociallearning model

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Cognitive therapy Group therapy

SUMMARY • Substance abuse increase the risk of any mental disorder • SA is an unfavorable prognostic indicator for medical psychiatric illness • Substance abusers are difficult medical / surgical patient Parting Words “If the major root causes of a person’s character were identified as the parents, family, home and social environment, culture, education, religion, economy and political environment, mass media and even leadership and role models, then there must be something wrong with all of those worldwide and nationwide. There is a need for us to build ourselves as a people. There is a need to change structure and change people. Sen. Leticia Shahani (A Moral Recovery Program, Building a people- Building a Nation)