Substance abuse Lourens - PowerPoint Presentation

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Substance abuse

Lourens

Botes

,

Faatima

Cachalia

,

Anjeli

Desai

definitions

Substance use disorders: inappropriate use of a

substance

Substance related disorders are divided into 2 groups

1) Substance use disorders

2) Substance induced disorders:

a)

Intoxication

(reversible set of symptoms due to recent use/exposure to a substance)

b)

Withdrawal

(behavioural, physical, and cognitive symptoms that occur due to the abrupt reduction or cessation of a substance)

c)

Substance/ medication induced mental disorders

(e.g. psychotic disorders, bipolar and related disorders, depressive disorders, anxiety disorders, sleep disorders, sleep disorders, delirium, neurocognitive disorders)

DSM-5 recognises 10

substance related disorder

classes:

Alcohol, Caffeine, Cannabis, Hallucinogens (separate categories ), inhalants, opioids, sedatives, hypnotics, anxiolytics, stimulants, tobacco and

other

Each

class of drug has its own criteria set for a use disorder

.

DSm-5diagnosis

The substance use disorders follow a standard set of criteria

Require 2 or more of 11 problematic behaviours occurring in a 12 month period leading to clinically significant impairment or distress

11 symptoms involve overall groupings of impaired control, social impairment, risky use and evidence of tolerance or withdrawal.

Rated for severity : mild (2-3 symptoms) moderate (4-5 symptoms ) , severe (6 or more )

Prevalence and social impact

According to WHO – harmful alcohol use was

responsible

for 5.3% of deaths and 5.1% of the burden of disease and injury, equivalent to 132.6 million disability-adjusted life years (

DALY).

Alcohol remains a primary substance of abuse in South Africa and 1 in 10 deaths are associated with alcohol use.

Between 7.5-31.5%

of our population have

an alcohol problem or are at risk of developing one.

Currently we are ranked 6

th

in the world for the most alcohol consumption

Of

those who consume alcohol in SA, 48% of men and 32% of women binge

drink

Substance use is associated with an increased exposure to violent crime (as either a victim or perpetrator), gender based violence, unemployment, school dropout, and being in conflict with the law.

Aetiology of substance related disorders

Combination of genetics, the individual’s biology, person’s environment and the substance

itself contribute to substance use disorders

Genetic factors are estimated to contribute 40-60 % of the variability of the risk for

addiction

Family background – raised in homes affected by mental illness and/or substance usePharmacological properties of the drug itself contribute to abuse.

E.g

. alcohol, opioids and anxiolytics can produce rapid relief of anxiety

Stimulants relieve boredom and fatigue an provide a sense of energy and increased mental alertness

Hallucinogens provide a temporary escape from reality

The above properties contribute to misuse.

Reward pathways of substances

Mesolimbic pathway synonymous with the reward pathway

Release of dopamine from ML pathway into the nucleus

accumbens

regulates motivation and desire for rewarding stimuli and facilitates re-

e

nforcement and reward related motor function learning

May also play a role in the subjective perception of pleasure

Dysregulation of this pathway plays a significant role in the development and maintenance of addiction.

Common substances have been shown to increase extra cellular levels of dopamine within the ML pathway, these activations are accompanied by the perception of reward

This creates increased motivation to repeat the same behaviour which caused it.

Case scenario

66 year old male, known hypertensive on treatment. Brought in by family members with a history of confusion, nausea and vomiting.

Significant findings on examination:

patient appeared dehydrated with a tachycardia

of 115

, an HGT of 2.6, and smelled of alcohol. All other systems examined wellEmergency management included fluid resuscitation and correction of hypoglycaemia.

Further history from the family revealed that he has been drinking 8-10 beers per day since the passing of his wife. He has lost interest in daily activities, struggles to sleep,

is always

irritable

, skips meals and is poorly groomed. He has had 2 previous similar presentations.

What’s the next step?

CAGE questionnaire

Simple screen used to assess presence of alcohol use disorder

Can be easily incorporated into consultation and is quick to perform.

Any positive response or overly defensive answer suggests problematic use

DSm-5diagnosis

The substance use disorders follow a standard set of criteria

Require 2 or more of 11 problematic behaviours occurring in a 12 month period leading to clinically significant impairment or distress

11 symptoms involve overall groupings of impaired control, social impairment, risky use and evidence of tolerance or withdrawal.

Rated for severity : mild (2-3 symptoms) moderate (4-5 symptoms ) , severe (6 or more )

DSM-V- alcohol use disorder

A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 or more of the following, occurring at any time in the same 12-month period:

Alcohol 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 alcohol use.

A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.

Craving, or a strong desire or urge to use alcohol.

Recurrent alcohol use resulting in a failure to

fulfil

major role obligations at work, school, or home.

Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.

Important social, occupational, or recreational activities are given up or reduced because of alcohol use.

Recurrent alcohol use in situations in which it is physically hazardous.

Alcohol 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 alcohol.

Tolerance, as defined by either of the following:

A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.

A markedly diminished effect with continued use of the same amount of alcohol.

Management – levels of prevention

Primary Prevention

Educational campaigns

Community and family interventions

Careful prescribing and education

LegislationPolicing of illegal drug trafficking

Management - Levels of prevention

Secondary prevention

Early identification and effective management of prevent harm from substance misuse

Bio-psycho-social approach

Early recognition:

Withdrawal

: symptoms range from anxiety, tremors, nausea and vomiting to seizures and

hallucinosis

.

Delirium tremens occurs in 5% of hospitalized patients and includes confusion, agitation, perceptual disturbances, mild fever and autonomic hyper arousal.

Managing withdrawal:

G

eneral

supportive measures, nutritional supplementation (including thiamine, folic acid and multivitamins) and the use of benzodiazepine’s.

Benzo of choice in withdrawal = Diazepam

Dose: 10mg stat. then 5mg in 15- 30 minute intervals till calm. Tapered over a few days

Haloperidol 2-5 mg per day in patients with alcoholic

hallucinois

Treatment of alcohol dependence (carefully selected patients who are fully co-operative)

Disulfaram

Naltrexone

Acamprosate

Management - Levels of prevention

Psychosocial

approach

Depression

and anxiety

are

often associated with substance use – therefore it is important to identify co-existing psychological illness’s and manage as appropriate.Involvement of social worker and support groups to aid rehabilitation.To put in place adequate support structures

(family and friends)

**Challenges

in our setting: rehabilitation facilities are not easily

accessible**

Management - Levels of prevention

Tertiary prevention

Overlap on above

Inpatient/outpatient care

Psychosocial rehabilitation

Self help organisations (AA, NA)

Management continued

Motivational interviewing has also been shown to help persuade patients to make their own case for change

Complications

Neuropsychiatric :

Wernike

korsakoff

syndromeCortical atrophyAlcohol induced dementiaMyopathyDepression and suicide

Peripheral neuropathy

Alcohol Withdrawal

Gastrointestinal

Pancreatitis

Liver disease

Oesophageal bleeding

Gastritis

Intestinal malabsorption

Cardiovascular

Cardiomyopathy

Malignancy

Oral cavity

oesophagus

Lage

intestine

Liver and pancreas

Birth defectsFoetal alcohol syndromePsychosocialMVA/PVACrimeViolenceSpouse and Child abuseJob lossDivorce

WERNICKE KORSAKOFF SUNDROME (thiamine/B1 deficiency )

Wernicke encephalopathy : confusion/

opthalmoplegia

/ataxia

Korsakoff

psychosis : amnesia/confabulation/psychosis

references

Black, D.W. and

Andreasen

, N.C. (2014).

Introductory textbook of psychiatry : [DSM-5 ed.]

. Washington, Dc: American Psychiatric Publ.Masiko, N &Selby, X. 2017. Substance Abuse in South Africa, its linkages with Gender Based Violence and Urban violence. CSVR Fact

sheeton

Substance Abuse in south

africa

.

Available : <https://www.saferspaces.org.za/uploads/files/Substance_Abuse_in_SA_-_Linkages_with_GBV__

Urban_Violence.pdf>

Psychiatry - DSM-V

Probst C, Parry CD,

Wittchen

H-U,

Rehm

J. The socioeconomic profile of alcohol-attributable mortality in South Africa: a modelling study. (2018) 

BMC Med

. 16:97.

doi

: 10.1186/s12916-018-1080-0

Schneider M, Norman R, Parry C, Bradshaw D, Pluddemann A, Collaboration SACRA. Estimating the burden of disease attributable to alcohol use in South Africa in 2000. S Afr Med J. (2007) 97:664–72. Available online at: https://www.ajol.info/index.php/samj/article/view/127295