SUBSTANCE RELATED DISORDERS

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SUBSTANCE RELATED DISORDERS

• Martha J Wunsch MD
• Associate Professor and Chair
• Addiction Medicine
• Edward Via Virginia College of Osteopathic
  Medicine
• Block 9 Class of 2008
• January 9.2006

10/29/04
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What is Addiction/Substance Abuse or Dependence?

• Lack of control of use, escalation of use, and
  compulsive use, even in the face of negative
  health and social consequences. The drug use
  interferes with physical, emotional, and social
  function and destroys societal roles.

Definition from the American Society of
Addiction Medicine
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Substance Related Disorders

• Group of disorders associated with the taking of
  a drug of abuse, the side effects of a medication
  or to toxin exposure.
• Two Categories
• Substance use disorders (abuse, dependence)
• Substance induced disorders (intoxication,
  withdrawal, psychosis, etc.)

DSM IV TR Diagnostic and Statistical Manual of
Mental Disorders, Text Revision. American
Psychiatric Association.
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DSM IV CriteriaSubstance Abuse

• A maladaptive pattern of substance use leading to
  clinically significant impairment or distress, as
  manifested by one or more following occurring
  within a 12 month time period
• Failure to fulfill role obligations (absences or
  poor work, absences or poor performance at
  school, suspension failure to care for children)
• Recurrent use in physically hazardous situations
  (driving, operating machinery)
• Recurrent legal problems (arrests for substance
  related problems, DUI, DIP, possession)
• Continuing to use despite social or interpersonal
  problems. (Recurrent arguments with family
  members about intoxication)

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Case

• 19 year old college student comes to the student
  health service with the complaint that I am
  tired all the time and cant seem to get to
  class
• She had depression in high school after her
  parents were divorced. She wonders if this is the
  problem.
• She notes that her grades are falling
• She was so sleepy, she got a DUI! She hadnt been
  drinking that much when pulled over.
• To top it off, she has to change dorm rooms
  because her room mate studies all the time and
  doesnt like her friends

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Case

• As part of your history you ask her
• Last menstrual period 3 weeks ago, using
  contraception. (Urine pregnancy negative)
• Exercise history Was a runner, stopped in
  college
• Smoking history Denies. Bad for my running
• Alcohol history
• Do you drink alcohol beverages?
• Yes, but only on the weekends
• How many days in the past year have you had 4 or
  more drinks?
• She drinks usually at least 6 shots or 10-12
  beers
• She drinks every Friday, Saturday, and Sunday but
  doesnt drink during the week.

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Substance Abuse

• 19 year old college student who drinks with her
  friends every weekend from Friday until Sunday.
• She always gets drunk--at least 6-9 shots in
  the first two hours
• Has had one DUI and must attend VASAP
• Is failing in school
• Her room mate has asked her to move out because
  she is disruptive to her study hours every weekend

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Substance Abuse

• 19 year old college student who drinks with her
  friends every weekend. She always gets
  drunk--at least 6-9 shots in the first two
  hours
• LEGAL Has had on DUI and must attend VASAP
• JOB Is failing in school because of heavy
  partying
• SOCIAL Her room mate has asked her to move out.
• PSYCHOLOGICAL She may be having a recurrence of
  her depression, although you will need to
  evaluate her further.

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Substance Abuse

• Differs from Dependence.
• Does not include development of tolerance
• Does not include development of withdrawal
  symptoms
• Does not include compulsive use
• DOES include harmful pattern of continued use in
  spite of consequences

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Substance Dependence

• Composed of a cluster of cognitive, behavioral,
  and physiological symptoms.
• Indication of patient continuing to use
  substances despite problems or dysfunction
  related to its use.
• Evidence of physiological dependence is not
  required for diagnosis

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Substance Dependence

• A syndrome characterized by a maladaptive
  pattern of substance use, leading to clinically
  significant impairment of distress, as manifested
  by three or more of the following during a
  12-month period

DSM IV TR Diagnostic and Statistical Manual of
Mental Disorders, Text Revision. American
Psychiatric Association.
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DSM IV CriteriaSubstance Dependence

• Maladaptive pattern of behavior containing 3 or
  more symptoms occurring in a 12 month time
  period
• Tolerance
• Withdrawal
• Use of more than intended
• Attempts to cut down
• Great deal of time spent in attempt to obtain
  substance
• Social or occupational activities given up
• Use of substances despite serious physical or
  psychological consequences

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Tolerance

• The need for markedly increased amounts of the
  substance to achieve intoxication or desired
  effect
• May use a different substance in the same class
  of drug
• Markedly diminished effect with continued use of
  the same amount of the substance
• Patient with change the way the substance is used
  to continue to feel effect
• OralnasalIV use indicates increasing tolerance

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Withdrawal

• The characteristic withdrawal syndrome for the
  substance
• We will learn the signs or symptoms for each drug
  class
• Similar substances have similar withdrawal
  syndromes ( alcohol, benzodiazepines)
• The same or closely related substance is taken to
  relieve or avoid withdrawal symptoms
• Heroin instead of pain pills

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DSM Criteria

• The substance is often taken in larger amounts or
  over a longer period than was intended
• There is a persistent desire or unsuccessful
  efforts to cut down or control substance abuse
• Procuring methadone on the street to treat
  withdrawal from pain pills

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DSM Criteria

• A great deal of time is spent in activities
  necessary to obtain the substance ( such as
  visiting multiple physicians or driving long
  distances), use the substance ( for example chain
  smoking ), or to recover from its effects
• And other obligations are not met
• Important social, recreational, and occupational
  activities are given up or reduced because of
  substance use.

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Lack of control of use

• Ill just have one drink this time
• Ill only party on the weekends
• Ill cut my cigarette use to 1 pack a day
  over the next month
• Inability to stop drinking any time alcohol is
  presentdrinking to intoxication every timeeven
  though she wants to cut down. USE OF MORE THAN
  INTENDED, ATTEMPTS TO CUT DOWN
• A teen may only participate in pharming on the
  weekends, but when Mondays are really rough she
  begins using pills during week. WITHDRAWAL
• Individual begins to need more alcohol to feel
  good or normal. TOLERANCE
• Individual begins to have the flu after a
  weekend of injecting heroin and uses pain pills
  during the week since heroin is not easily
  available. WITHDRAWAL

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A great deal of time is spent

• 34 year old woman who procures prescription drugs
  on the internet
• Hours and hours searching sites
• 40 year old man who abuses pain medication
• Unable to find in his communityall the doctors
  and ERs know him
• Drives to 4 other states to obtain prescriptions

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Social and recreational activities are given up

• Too ill from bouts of intoxication and withdrawal
  from alcohol to participate in family activities
• Association with others who are abusing drugs and
  alcohol instead of non partying individuals
• Teen who uses marijuana alone at home instead of
  participating in other activities

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Compulsion to useThe brain is hijacked by
abuse of a psychoactive chemical and use becomes
the only way to experience feeling good

• No one ever starts drinking or using a drug
  intending to become an alcoholic or drug addicted
• The focus of life is on obtaining access to,
  using, and recovering from a chemical that makes
  you high.OR IN THE END TO AVOID WITHDRAWAL OR
  FEEL NORMAL
• Everythingsocial time, job performance,
  recreational opportunitiesare given up or
  reduced because of this focus

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Abuse in spite of consequences

• Drug abuser knows that there are social, physical
  and emotional costs to continued use of the
  substance and continues to consume the substance
  anyway
• Cocaine use in spite of worsening depression
  PSYCHOLOGICAL PROBLEMS
• Continued use of alcohol in spite of worsening
  hepatitis PHYSICAL PROBLEMS
• Abuse of prescription pain medications, bought on
  the street, even though a woman knows she is
  pregnant
• Continued abuse of tobacco, even though an adult
  child has stated that a grandchild cannot visit
  the home where there is cigarette smoking

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Substance Induced Disorders

• Substance intoxication
• Substance withdrawal
• Substance induced mood disorder
• Substance induced psychotic disorder
• Hallucinogen Persisting Perception Disorder
• Alcohol induced Persisting Amnestic Disorder

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Assessment

• Proper assessment requires thorough history with
  corroborating sources due to denial, minimization
  common in the disorder.
• Careful attention to both co-morbid general
  medical and psychiatric disorders.
• Careful examination and screening including UDS
  or other toxicological screening.
• Use of screening questions is good practice due
  to the prevalence of substance use.

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Treatment

• Acute Phase (Medical Withdrawal)
• Carefully constructed plan for medical
  withdrawal.
• Dependent on history and response
• Careful serial assessment for medical stability
  and safety.
• Use of appropriate drugs for treatment if
  withdrawal is potentially life threatening (ex.
  ETOH, Barbiturates)
• Protocols may be helpful
• If in doubt consult with experienced colleagues.

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Important Factors in Treatment of Withdrawal

• Amount of use and last use
• Route of administration
• General medical conditions
• T1/2 of substance of abuse
• Appropriate cross tolerance
• Use of multiple substances which may not be
  revealed by the patient

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Treatment

• Rehabilitation Phase
• Appropriate assessment of patients goals and
  motivation.
• Both inpatient and outpatient programs are
  effective but recidivism is high for all.
• Many programs based on 12 step model
• Various emphasis on spirituality, etc. often
  needs to be a fit for the patient. (ex. AA)

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Treatment

• Relapse Prevention Phase
• High rate of relapse
• Relapse is viewed as an ongoing part of the
  disease.
• Focus on support and prevention of behavioral
  patterns associated with substance use/abuse
• Understanding personal triggers to pattern of
  abuse
• Relapse prevention is an ongoing, continuous part
  of Substance abuse treatment.

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Substance use
Escape Feel Good
Stress
Negative consequences Of Substance use
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Summary

• Substance use is very prevalent in our culture
  (60-70 for ETOH) and occasionally results in
  maladaptive patterns of abuse and dependence.
• Assessment requires careful examination and use
  of collateral sources of information.
• Treatment is frequently best individualized and
  technically administered.
• Even in remission the illness is ongoing with
  significant risk of relapse and requires
  treatment directed at maintenance for long
  periods.