Back to Basics Substance Abuse_2011 Dr Lau_compressed

CASE 1• 35 year old man whose alcohol consumption started in his teens.. • He is not sure what happened first but he began having problems with his wife and his work.. • He has been hav

Substance Use

Disorders

REVIEW OF PSYCHIATRY

T Lau, MD, FRCPC [psych], Director of Undergraduate Education Faculty of Medicine, Department of Psychiatry, UNIVERSITY OF

OTTAWA

CASE 1

• 35 year old man whose alcohol consumption started in his teens For

many years, he drank alcohol mostly on social occasions

• He is not sure what happened first but he began having problems with his

wife and his work It was during this time that his alcohol consumption

increased

• Although he doesn’t drink everyday he often drives to work somewhat

intoxicated and his coworkers have noticed that he has not been himself lately

• He has been having problems with intimacy with his wife and she had been

wondering if it was related to alcohol he had been consuming more of

• What is the diagnosis?

• What treatment options exist?

CASE 2

• 58 year old divorced man with alcohol problems who drinks

everyday, needing an “eye opener” to get going in the

morning and to avoid feeling shakey He sometimes

consumes more than 10 drinks at a time

• He has lost several jobs over the years and is estranged from

his wife and 3 children largely because of his drinking and

behaviour

• He has had a heart attack, has hypertension and is obese He

saw his family physician who tells him his bloodwork and MRI abdomen is consistent with cirrhosis.

• What is the diagnosis?

• What blood work would be consistent with this picture?

• What treatment options would you offer?

CASE 3

• 38 year old female who lives with her husband and 3 year old

daughter She suffers from chronic pain following a MVA 2

years ago

• She was treated at that time with Percocet, however her GP

“cut her off” after 6 months of medications and now will only prescribe her NSAIDs

• She works as a purchasing agent in the civil service but is

getting in trouble at work for repeated work absences.

• She is currently using 2x80 mg oxycontin which she gets from a

friend who refers to them as “oxys” She is paying $80 per day for these narcotics and can’t really afford to continue like this

CASE 3

• You ask her when her last “oxy” was and she

states 2h ago Which of the following are

symptoms of opiod intoxication?

CASE 3

• She states that when she doesn’t take the

pills she feels sick Which of the following are symptoms of opiod withdrawal.

CASE 3

• What pharmacologic options are suitable for

Case 4

• The patient was a 20-year-old man who was brought to the hospital,

trussed in ropes, by his four brothers This was his seventh hospitalization

in the last 2 years, each for similar behavior

• One of his brothers reported that he “became home crazy,” threw a chair through a window, tore a gas heater off the wall, and ran into the street The family called the police, who apprehended him shortly thereafter as

he stood, naked, directing traffic at a busy intersection

• He punched two of the officers and appeared to have no pain He

assaulted the arresting officers, escaped from them, and ran home

screaming threats at his family There, his brothers were able to subdue him.

• One of his brothers also suggested that “he gets dusted every day.”

Case 4

• On admission, the patient was observed to be agitated, with his mood fluctuating between anger and fear He had slurred speech and staggered when he walked He had visible nystagmus,

tachycardia, was hypertensive, and febrile He was particularly sensitive to noise.

• He remained extremely violent and disorganized for the first

several days of his hospitalization, then began having longer and longer lucid intervals, still interspersed with sudden,

unpredictable periods in which he displayed great suspiciousness,

a fierce expression, slurred speech, and clenched fists.

• After calming down, the patient denied ever having been violent

or acting in an unusual way (“I’m a peaceable man” ) and said he ) and said he could not remember how he got to the hospital DSM IV Case

Manual.

Case 4

• What is the most likely substance abused?

a) Amphetamines b)Cocaine

c) Speak K d)PCP

e) LSD

CASE 5

• 38year old male advertising executive, who presents with a history

of altered behaviour His girlfriend who accompanied him

describes that he has been behaving like Jeckyl and Hyde.

• Lately she has been hearing a crackling sound when he is in the

bathroom and strange smells that linger afterwards He sometimes acts like he’s energized, outgoing, hypervigilant, talkative and

becomes interpersonally sensitive

• These periods that last several hours are often followed by intense and unpleasant feelings of lassitude and depression with increased appetite generally requiring several days of recuperation During this crash, he sleeps much more and often has nightmares and

vivid dreams He has also expressed feeling suicidal during these lows.

• What is the most likely offending substance?

CASE 5

• Which of the following is the most

addictive method of abuse

CASE 6

• 23 year old student who began using diet pills to stay awake to

study This helped him stay up for days at a time He later found a friend of a friend who offered other pills that were more potent

• He called some of these pills: Black Beauties, Glass, Bikers Coffee,

Chicken Feed, Shabu, Stove Top, Trash, Go-Fast, Yaba, and Yellow Bam.

• After he took them orally and found that his wakefulness improved

as did his energy level but his appetite went down The next day however he would feel irritable, unhappy and paranoid.

• Over time these runs of energy where followed by increasing

paranoia, visual and auditory hallucinations, and out-of-control

rages that can be coupled with extremely violent behavior.

• What is the most likely substance?

CASE 7

• 17 year old female who was at a party Her friends

pressured her into trying some strange drug Shortly after consuming them she started seeing radiant colors and she felt that some of the things she was looking at appeared to ripple or “breathe” She described seeing colored patterns behind her closed eyelids She also started describing a

sense that time was stretching, repeating itself, or changing speed and stopping

• Her friends then described that she started to freak out and

have “a bad trip” She felt she was going insane and

became intensely anxious, depressed, and suicidal After a week the depressive symptoms subsided but she continued

to periodically have “flashbacks of the same symptoms she had during her “bad trip”.

• What is the most likely substance?

CASE 8

• 25 year old female university student who went to a party

Somebody slipped something in her drink and her personality changed Although she had always been a chronic worrier she suddenly became more relaxed and euphoric

• She began touching people and described feeling very close to

everyone stating that she had compassion for all of mankind and was willing to forgive everyone

• She went with some of her new friends to a club where loud

electronic music was being played Eventually she passed out from heat exhaustion.

• Over the next few days she felt depressed, irritable, tired with a

loss of appetite She continued for awhile afterwards to feel a sense of closeness to others She had problems sleeping as well with aches, pains and jaw tightness.

• What is the drug that someone slipped her?

CASE 9

• 24 year old female medical student

Drinks 6 cups of starbucks each day

When she gets up in the morning she feels

a bit shakey and needs coffee to think

clearly The coffee clears her head and

calms her but at the same time wakens

her up

• How much caffeine is in a Starbuck’s

Verona or a Pepsi MAX?

• Are you one of us that needs coffee

everyday?

What is the connection between substance abuse and mental

illness?

ECA Lifetime prevalence

Regier et al JAMA 1990

Substance Abuse % w Psych

• DSM IV

• Substance use disorders

• Abuse (COLD) & dependence (TWISTED)

• Substance induced disorders

• Intoxication & withdrawal

• Mood / Anxiety / Psychotic / Sexual dysfxn /

Sleep disorder / Delirium / Persisting dementia / amnestic disorder / Hallucinogen persisting

perception disorder

What is the difference between

abuse and dependence?

• Which of the following is the most true?

a) Abuse is more harmful to the person

b) Dependence means physiological

dependence c) Clinically significant impairment or

distress is part of dependence not abuse d) Dependence is a more severe problem

e) Criteria for both can be met

simultaneously

• Generally M>F, low SES, unemployed,

minority THC most common illicit drug

• ETOH, nicotine, caffeine common

• Suicide risk inc 20x

• Etiology

• Bio- ML VTA-NA (reward pathway), LC (NA

somatic sx) Family studies

• Psy- dynamic fixation @ oral stage,

• Soc- codependence, learned social

behaviour, cues from environment trigger relapse

–Early >1<12, partial remission =

abuse, full no abuse/dependence

Full > 12 months

–with and without physiological

dependence

How addicting?

• Probability of becoming dependent

when you have tried the substance at

Cannabinoids

Pleasure pathway

• Mesolimbic dopaminergic tract from the ventral

tegmental area to the nucleus accumbens

• VTA releases dopamine not only into the

nucleus accumbens, but also into the septum,

the amygdala, and the prefrontal cortex The

nucleus accumbens then activates the

individual’s motor functions, while the

prefrontal cortex focuses his or her attention

• Mesocortical/limbic median forebrain bundle

MFB forms pleasure reward bundle whose

activation leads to the repetition of the

gratifying action to strengthen the associated

pathways of the brain (Olds and Milner)

• All drugs of abuse have either receptors directly

on (eg mu opiods) or indirectly through

interneurons (GABA)

• 35 year old man who has been drinking since

he was in his teens He usually had alcohol on mostly social occasions He began having

problems with his wife and his work and his

alcohol consumption increased Although he doesn’t drink everyday he often drives to work somewhat intoxicated He has been having

problems with intimacy with his wife and she had been wondering if it was related to alcohol

he had been consuming more of.

• What is the diagnosis?

• 58 year old divorced man with alcohol problems who

drinks everyday, needing an “eye opener” to get

going in the morning He consumes more than 10 drinks at a time He has lost several jobs and is

estranged from his wife and 3 children largely

because of his drinking and behaviour He has had a heart attack, has hypertension and is obese He saw his family physician who tells him his bloodwork and MRI abdomen is consistent with cirrhosis.

• What is the diagnosis?

• What blood work would be consistent with this

picture?

• Low-Risk Drinker:

• Men: 3-4/day max & 15/wk max

• Women: 2-3/day max & 10/wk max

• "1 drink"

• = 12-oz beer

• = 5-oz wine

• = single mixed drink

• Clues of problem drinking

• Trauma, falls, MVAs

• Prescription drug abuse

• Chronic abdominal pain

• Tobacco use

• Illicit drug use

ETOH

• Epid

• 5% F, 10% M dependence 10% F, 20% M abuse.

• Inc ETOH w education (differs from illicit drugs)

• Inc risk of ASPD, MDD (30-40%), anxiety: phobias&PD (25-50%), suicide

10-15%

• Etiology

• Bio-genetics: 3-4x inc risk & inc severe use w 1MZ>DZ Adoption studies support genetic link.st degree relative MZ 60%,

• Psychol- neuro deficits Dec P300, EEG abn, fixated @ oral stage

• Social- reward, social learning theory

• Subtypes of dependency:

• Type A late onset, dec childhood RF’s, few problems B: early onset, severe

dependency, strong FHx, poly, severe psychopathology, inc # stressors

• Labs:

• GGT sensitive, not specific MCV (60%, F>M), TG, UA, AST/ALT also

CHO-deficient transferrin γ-glutamyltransferase

• Sleep effects:

• dec sleep latency, dec REM, dec stage 4, inc # of awakenings.

• Intoxication (GAS-IN)

• Gait abnormality, attentional, stupor/coma (risk of asp pneum), slurred speech,

incoordination, nystagmus Also mood lability, dec judgement, inappropriate

physical/sexual fxn

• Withdrawal (PINT ASA)

• Perceptual abn, insomnia, nausea, tremor, onset (hrs-days), facial flushing, agitation,

seizures, anxiety (ANS hyperactivity: inc HR, HTN)

• Shakes 6-12h, hallucinations 8-12, sz 12-24, DT’s >72h

• Inc risk w malnutrition, physical illness, depression, fatigue

• Short term Complications

• Withdrawal, sz’s, blackouts, DT’s, psychotic sx, depression, suicide, coma / pneumonia

• Long term Complications:

• Medical: cirrhosis, CHAOS, malnutrition, ETOH persisting amnestic disorder ataxia, confusion, nystagmus: Rx thiamine, Korsakoff’s: 20% irreversible anterograde amnesia due to thiamine deficiency in the mammilary bodies) / ETOHlic dementia

Alcohol dependence tx

AJP Editorial June 2010

• Identification of at-risk drinkers:

• Alcohol Use Disorders Identification Test (AUDIT) recommended by the National Institute on Alcohol Abuse and Alcoholism Clinicians Guid

• For at-risk drinkers, a more detailed history about the pattern of drinking, associated medical and psychiatric comorbidities, family history, and

sufficient clinical information to make a DSM–IV diagnosis should be

obtained

• In the case of the middle-aged man who has severe chronic alcohol

dependence with regular and frequent heavy drinking and medical

complications, a trial with topiramate (25–300 mg/day with a target dose of

• Finally, for an elderly, recently retired woman who feels gloomy and is

drinking to alleviate her low mood, long-acting injectable naltrexone, 380 mg once a month for 4 months, is recommended along with brief intervention

Alcohol Dependence

• Topiramate

• JAMA Oct 2007

Case

• 23 year old student who began using diet pills to stay awake to

study This helped him stay up for days at a time He later found

a friend of a friend who offered other pills that were more potent

He called some of these pills: Black Beauties, Glass, Bikers

Coffee, Chicken Feed, Shabu, Stove Top, Trash, Go-Fast, Yaba, and Yellow Bam.

• After he took them orally and found that his wakefulness

improved as did his energy level but his appetite went down The next day however he would feel irritable, unhappy and paranoid.

• Over time these runs of energy where followed by increasing

paranoia, visual and auditory hallucinations, and out-of-control rages that can be coupled with extremely violent behavior.

• What is the most likely substance?

• AKA:

• Speed, Meth, Ice, Crystal, Chalk, Crank, Tweak, Uppers, Black Beauties, Glass, Bikers Coffee,

Methlies Quick, Poor Man's Cocaine, Chicken Feed, Shabu, Crystal Meth, Stove Top, Trash, Go-Fast, Yaba, and Yellow Bam

• Intoxication like cocaine (24-48 h)

• As a powerful stimulant, methamphetamine, even in small doses, can increase wakefulness and physical activity and decrease appetite A brief, intense sensation, or rush, is reported

by those who smoke or inject methamphetamine Oral ingestion or snorting produces a

long-lasting high instead of a rush, which reportedly can continue for as long as half a day.

• Withdrawal (see cocaine-peak 2-4d-wk)

• Less addictive than cocaine

• no physical manifestations of a withdrawal syndrome

• Other sx include depression, anxiety, fatigue, paranoia, aggression, and an intense craving

for the drug.

• Methamphetamine has toxic effects In animals, damages nerve terminals in the containing regions of the brain High doses can elevate body temperature to dangerous,

dopamine-sometimes lethal, levels, as well as cause convulsions