Substance+Abuse

=Reading= Andreasen =Goals=

7. Know the course of treated alchoholism and that treatment works
=Specific Durgs= Andreason Reading

=Goals=

5. Know the neurochemical emchanisms of action for aphetamines, caffeine, cannabis, cocain,e hallucinoge,ns, PCP, and steroids
depression most common mental disorder substance abuse second most common combined --> higher rates

epidemiology risk factors screening & diagnosis treatment & outcomes

U of M has addiction treatment survces..... subspecialty of psychiatry 4 year residency

old data: alchohol 13.7 lifetime prevalence nay other drug 6.2 cannabs stimulents sedatives opioids hallucinogen cocailne

alchoholism rate higher in hospital excessive drinking going to develop medical problems psych 30% OB/GYN: 12.5 % because of gender difference medicne 25% surgery 23%

27% alchoholism rate from medicla & surgical units deaths from su bstanes: tobacco: 400,000 alcohol 100,000 other drugs: 20,000 24% of total deaths in 2000, was about the same, 22%

ECONOMICS: POLICE, SOCIAL SERVICES, PROPERTY DAMAGE dIRECt medical costs: 26.3 billion Lost productivity
 * 24.1 ILLION
 * 134.2 billion

risk factors: genetics demographics level of consution other substance abuse other mental disorders

an alcoholic biological prent increases the risk by about 2.5 fold, regardless of the home environment twin studies comparing identical twins adoption studies other drug dependence: 50-80% of liability due t genetis similar for men &Y& omen family environment may play main role in starting drug use use->abuse->dependence more influenced by genetic factors

Demographics rates in men > women young people > old people mostly younger males, everyone at some risk why decrease with age? people die prematurely prohibition may have had an effect

other drugs of abuse...\ trends still present men still > women

level of consumption: risk factor guidelines for low risk drinking easy to remember, **like to remember** 0 3 4 7 14

0: pregnatnt, medications, medical illness 3: < 3 drinks per day for women 4: < 4 drinks per day for men 7: < 7 drinks in 1 week for women 14: < 14 drinks in 1 week for men

80% binged in last 2 weeks once exceed limits, medical, psychosocial problems HTN, liver disease MVA goes up suicide goes up average threshold values averages are across age groups

no more than 1 drink per hour no drinking on an empty stomach 55 limit....Bal < 55 mg/dL no drinking before driving

100 mg/dL = legal intoxication 80 mg/dL is legal limit in MI

Righ-Risk Preciiption Drug Use Using more than precribed, self-prescribed, or using for reasons other than prescribed

Illicit drug us: Any use is hazardous Legal risks, impurities don't know what you're getting

Other substance abuse other mental idorders

Other subatnce use increases risk of other substances abuse of alcohol or illicit drugs increases risk for abuse of presciption drugs alcohol/marijuana/cocaine opiods/benzodiazepines

single dependence is less common

mental disorder other than subtance abuse increases ods ratio... schizophernia, bipolar....about 1/2 will be diagnosed with substance use disorder if you have schizophernia, 4.6x more likely to have substance abuse disorder antisocial personality disorder has 30x risk about 84% of antisocial personality disorder have substance abuse however...not all people with substance abuse disorders are sociopaths

screening & diagnosis

1st, do no harm not screening for & treating substance use disorders is doing harm responsible for large numbers of deaths, suicides not to screen...

substance use disorders... subsane abuse and substance dependence are separate disorders diagnostically....mutually exclusive diagnoses "One individual uses a drug in a way another group of people disapprove of" if child uses marijuana once, parent may think it is abuse

substance abuse: use depsite social consequences or when physically hazardous

Substace dependence: imparied contorl, tolerance/withdrawal, use despite knwing of adverse consequences

physical dependence: tolerance/withdrawal body adapts to substance

can have physical dependence on b-blockers, etc dont see abuse or dependence patterns

likewise, I could give any of you a prescription for valium, 10 mg/day for 30days, at beginning will knock you flat, at end, going to be tolerating dose if stop suddenly, going to have withdrawal physically dependent, but not DSM-IV dependent, or an abuser

Substance dependence --> addiction

other people feel addict is stigmatizing term

Crieriance for DSM dependence 7 criteria, need 3 or more in same year for substance dependence Physical: 1) tolerance 2) withdrawal Impaired control: 3) more taken than intended 4) desire to cut down, but unable to Life organized around drugs: 5) Much tie spendt on substance-related activity 5) Social, work, or leisure activities replaced by substance use 7) continued substance use despite knowing physical or psycholgcal problems are caused or worsened vby use

desire, yet unable to control use 'it's easy to quit. I've quit 1000 times' -Mark Twain

sustance ause is ontinued use despite adverse consequences or when physically hazardous in the absense of impaired control, organizing life around drugs, &^ tolerance/withdrawal

4 criteria... COntinued use despite adverse soial consequences or use when physically hazardous

a diagnosis of substance abuse or dependence can be made without knowing anything about how much person drinks/uses quantity is not criteria for use, except tolerance

what happens when you do use? What happens when you stop using?
 * What is critial is**

how to screen?

how not to screen: How much do you drin? how often do you drink? 'just one or two, not that much, no more than anyone else does' people w/ problem minimize amount using more specific: How many days a week do you drink? How many drinks do you drink on days that you do drink? What is the most drins you ever had in one day in the past one month?

more specific usually in psych, open ended questions...but now, close-ended may be better

CAGE questions: Cut down on drinking? have you ever felt like you should cut down on your drinking? Annoyed at people who criticize your drinking? Guilty about drinking? Eyeopener? drink first in morning to steady your nerves?

2 or more positive --> positive screen

sensitivity 76%, specificity 94%

not perfect, but good screen

Treatment outcome: treatsomeone, 1/3 get better, 1/3 are cured, 1/3 treatent resistant but, 2/3 improve

worst at tertiary care centers

imparied professionals tend to have better recovery rate than general population

will compare treatment outcomes to any other chronic disorder similar to rates of diabetes, HTN, ashtma


 * Cross-toleraance: tolerance to 1 gives tolerance to second**


 * Cross-dependence:

Alchohol/bezodiazepine/barbituates(GABA)

amphetamines/cocaine (dopamine) enhance dopamine activity

LDS/Psilocybin (5H2T) enhance 5HT2 activity


 * KNOW MECHANISMS OF ACTION**
 * DRUG||MECHAMISM||
 * Amphetamine||Increase dopamine release, reuptake||
 * Cocaine||Blocks reuptake of DA, NE< 5HT||
 * Caffeine||Blocks adenosine receptors||
 * Cannabis||Binds cannabinoid receptors||
 * Hallucinogens||Binds 5HT2 receptor agonists||
 * PCP||Blocks NMDA Receptors||
 * ANabolic Steroids||Bind to intracellular steroid receptors||
 * Opiods||Opioid receptors||
 * nicotine||Nicotine receptors||

adenosine receptors caffeine doesn't cause social consequences, mortality may change no category for caffeine withdrawal cannabinoid receptors found endogenous cannabinoids we don't know what they do

phencyclidine, ketamine are cross-tolerant ketamine used in veterinary, human medicine in pediatric anaesthesia dissociative anaestheics

MDMA methamphetamine amphtemine methylenedioxy ringe methylenedioxymethamphetamine structurally similar to amphetamines, but also hallucinogenic properties sometimes called stimulant/hallucinogen

Amphetamines: intoxication, withdrawawalenarly denticalto cocaine, but last longer block reuptake of DA and cause its release. Similar effects on NE and 5HT but less so. longe racting than cocaine larger problems in western parts of our states.
 * ice is a smokeable form

Prescrition amphetamines are schedule I conorlled subtances indicated for DHD and narcolepsy mixed amphetamines-d andl: adderal Dextroamphetamine slfate: d isomer methamphetamine: Desoxyn: ADHD & obesity

indiginous to South America About 1% weight cocaine coca lief long history.... indiginous to south america... Vin Mariani...had it Vin Mariani endorsed by the pope, and Jules Verne
 * Cocaine**

Pemberton from the south... Vin Mariani was so successful.... his coca wine was a failure until 1903 did contain cocaine Sigmund Freud early psychopharmacologist experimented on self local anaesthetic... treat morphine addiction

Should know: Comes in two forms: two chemically dfferent forms Salt, base forms each form has different properties salt: cocaine hydrochloride distinguished from base by hidrochloride moiety pharmaceutical cocaine topical anaesthetic in ENT surgery largely replaced by other anaesthetics...lidocaine etc property of cocaine good for anesthesia also vasoconstrictor lidocaine have to add epinephrine to get vasoconstriction Schedule II....legitimate medical value Has electric charge, soluble in water, snsoluble in organic

Schedule I: MDMA, LSD, Psylocybin, Heroin

Base: base form without salt doesn't dissolve in water soluble in organic solvents but, can smoke it 'base of cocaine freed from salt portion' IV cocaine users prefer cocaine hydrochloride

Freebase, crack are identical chemically users identify differently freebase conversion used ether...

four ways to use cocaine: Swallow > 20 min onset Sniff > 2-5 min onset Shoot > 15 s onset Smoke > 8 s onset quicker onset makes more addictive only thing faster is to inject directly into carotid artery

rapidly metabolized in blood stream by choleintesrease urine metabolite is benzoecgolinine 1/2life is ~ 1 h

other peice: tract2: mesolimbic tract from VTA to TA common denomenator in all addictions: 4 dopamine tracts in brain believed to be tract in midbrain ventral tegmental area of midbrain projects to nucleus accumbens mesolimbic dopamine tract ventral tegmental area (VTA) to nucleus accumbens (NA) believed to be reinforcement circuit

other reptors that connect....

GABA, Opiod, cannabinoid

Cocaine intoxication: psychoactive effects increased alertness, energy decreased sleep decreased sleep increased confidence sweats high doses->seizures
 * mania**

withdrawal low energy, fatigue depression, suicidal thoughts sleep disturbance increase in appetatie

Know cocaine intoxication & withdrawal

Other cocaine toxicities: arrhytmias, MI, cardiorepipirator arrest stroke convulsions spontaneous abortion, formication 'ants on skin'

cannabis active ingredients cananbinoids oral or smoked route oral is longer onset, slower peak, longer duration smoked onset iwthin minutes, peak 203 min, duration 203 hr elimination 30-60 hours 1 dose: in urine 8 days use daily: stay in urine 1 month or longer

psychoactive effecst: slowed time impaired judgeent euphoria, anxiety altered perceptions

Cannabis withdrawal

may begin within 12h and last 3-5 days after stopping high dose, chronic use insomnia restlessnesss irritability hot flashes, anorexia, hiccoughs, mild tremors sweating

Cannabis more carcinogenic than tobacco pharyngitis, bronchitis low testosterone levels & sperm counts amotivation syndrome caused or associated?

Dronabinol *Marionl) chemically identical to delta-9-THC approved by FDA in 1975 to treat N&Vomiting associated with cancer chemo marijuana increases appetite approved in 1992 to treat anorexia in AIDS pts reclassified as schedule III drug in 1999

Hallucinogens indoleamine methamphetamines Ecstacy mechanisms....5HT2 receptor agonists not much of a withdrawal, ecept MDMA, hangover of headache, fatigue, sore jaw muscles causes bruxism

Hallucinogen flashbacks....reality testing intact...hallucinogen persising perception disorder

when intoxicated, have hallucinations after intoication, users reports days to years afterwards as reexperiencing hallucinations

Anabolic Steroids: mechanism of action