SUBSTANCE USE AND ADDICTIVE DISORDERS

Emeryl S. Layugan, MD
- addiction is a "brain disease"

TERMINOLOGY
- Dependence:
1. behavioral dependence
2. physical dependence
3. psychological dependence
- Addiction
- Codependence
- Enabling
- Denial
- Abuse COMORBIDITY
- Misuse - 50 percent of addicts have a comorbid psychiatric disorder
- Intoxication - 35 to 60 percent of patients with substance abuse or
- Withdrawal substance dependence also meets the diagnostic criteria
- Tolerance for antisocial personality disorder.
- Cross-tolerance - Depressive symptoms are common among persons
- Neuroadaptation diagnosed with substance abuse or substance dependence.

EPIDEMIOLOGY (Pacheck na lang) DIAGNOSTIC CLASSIFICATION

- There are four major diagnostic categories in the Diagnostic
ETIOLOGY and Statistical Manual of Mental Disorders, fifth edition
- Drug availability, social acceptability, and peer pressures (DSM-5):
may be the major determinants of initial experimentation (1) Substance Use Disorder
with a drug, but other factors, such as personality and (2) Substance Intoxication
individual biology, probably are more important in how the (3) Substance Withdrawal
effects of a given drug are perceived and the degree to (4) Substance-Induced Mental Disorder.
which repeated drug use produces changes in the central
nervous system (CNS). Substance Use Disorder
Psychodynamic Factors - Substance use disorder is the diagnostic term applied to the
- a masturbatory equivalent (some heroin users describe the specific substance abused (e.g., alcohol use disorder, opioid
initial "rush" as similar to a prolonged sexual orgasm use disorder) that results from the prolonged use of the
- a defense against anxious impulses substance.
- a manifestation of oral regression (i.e., dependency). A maladaptive pattern of substance use leading to clinically
- a reflection of disturbed ego functions (i.e., the inability to significant impairment or distress, as manifested by 2 (or more) of
deal with reality) the following, occurring within a 12-month period:
- alcohol may be used to control panic, opioids to diminish 1. recurrent substance use resulting in a failure to fulfill major role
anger, and amphetamines to alleviate depression. obligations at work, school, or home (e.g., repeated absences or
- Some addicts have great difficulty recognizing their inner poor work performance related to substance use; substance-
emotional states, a condition called alexithymia (i.e., being related absences, suspensions, or expulsions from school;
unable to find words to describe their feelings). neglect of children or household)
2. recurrent substance use in situations in which it is physically
Learning and Conditioning hazardous (e.g., driving an automobile or operating a machine
- Drug use, whether occasional or compulsive, can be viewed when impaired by substance use)
as behavior maintained by its consequences. 3. continued substance use despite having persistent or recurrent
Genetic Factors (blank) social or interpersonal problems caused or exacerbated by the
Neurochemical Factors effects of the substance (e.g., arguments with spouse about
- Receptors and Receptor Systems. consequences of intoxication, physical fights)
1. With the exception of alcohol, researchers have 4. tolerance, as defined by either of the following: a. a need for
identified particular neurotransmitters or markedly increased amounts of the substance to achieve
neurotransmitter receptors involved with most intoxication or desired effect b. markedly diminished effect with
substances of abuse. continued use of the same amount of the substance
5. withdrawal, as manifested by either of the following: a. the
Pathways and Neurotransmitters characteristic withdrawal syndrome for the substance b. the
- The major neurotransmitters possibly involved in same (or a closely related) substance is taken to relieve or avoid
developing substance abuse and substance dependence are withdrawal symptoms
the opioid, catecholamine (particularly dopamine), and y- 6. the substance is often taken in larger amounts or over a longer
aminobutyric acid (GABA) systems. period than was intended
 7. there is a persistent desire or unsuccessful efforts to cut 3. therapeutic communities
down or control substance use 4. short-term inpatient programs
8. a great deal of time is spent in activities necessary to obtain SELECTING A TREATMENT
the substance, use the substance, or recover from its effects
9. important social, occupational, or recreational activities are
given up or reduced because of substance use
10. 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
11. craving or a strong desire or urge to use a specific substance.

Substance Intoxication Treatment of Comorbidity

- the diagnosis used to describe a syndrome (e.g., alcohol - integrated treatment
intoxication or simple drunkenness) characterized by - parallel treatment
specific signs and symptoms resulting from recent ingestion - sequential treatment
or exposure to the substance ALCOHOL-RELATED DISORDERS
A general description of substance intoxication includes the - Alcohol is a potent drug that causes both acute and chronic
following points: changes in almost all neurochemical systems.
- The development of a reversible substance-specific - Thus alcohol abuse can produce serious temporary
syndrome due to recent ingestion of (or exposure to) a psychological symptoms including depression, anxiety, and
substance. Note: Different substances may produce similar psychoses
or identical syndromes
- Clinically significant maladaptive behavioral or EPIDEMIOLOGY
psychological changes that are due to the effect of the - Psychiatrists need to be concerned about alcoholism
substance on the central nervous system (e.g., belligerence, because this condition is common; intoxication and
mood lability, cognitive impairment, impaired judgment, withdrawal mimic many major psychiatric disorders, and
impaired social or occupational functioning) and develop the usual person with alcoholism does not fit the
during or shortly after use of the substance. stereotype
- The symptoms are not due to a general medical condition
and are not better accounted for by another mental
disorder.
Substance Withdrawal
- a substance specific syndrome that results from the abrupt
cessation of heavy and prolonged use of a substance (e.g.,
opioid withdrawal).
A general description of substance withdrawal requires the following
criteria to be met:
- The development of a substance-specific syndrome due to
the cessation of (or reduction in) substance use that has
been heavy and prolonged.
- The substance-specific syndrome causes clinically
significant distress or impairment in social, occupational, or
other important areas of functioning.
- The symptoms are not due to a general medical condition
and are not better accounted for by another mental
disorder.
TREATMENT AND REHABILITATION
- Some persons who develop substance-related problems
recover without formal treatment, especially as they age.
- treatment programs
- individual therapy
- family therapy
- group therapy
- relapse prevention
- pharmacotherapy
- government agencies recently categorized publicly funded
treatment programs for drug dependence as
1. methadone maintenance (mostly outpatient)
2. outpatient drug-free programs
COMORBIDITY Drug Interaction:
- Antisocial Personality Disorder - phenobarbital (Luminal)
- Mood Disorders - Sedatives
- Anxiety Disorders - Hypnotics
- Suicide - drugs that relieve pain
- motion sickness
ETIOLOGY - head colds
- Social - allergy symptoms
- Religious - Narcotics
- psychological factors - Sedative-hypnotic drugs like chloral hydrate (N octec) and
- genetic characteristics benzodiazepines,

Psychological Theories
- use of alcohol to reduce tension, increase feelings of
power, and decrease the effects of psychological pain.
Psychodynamic Theories
- use this drug to help them deal with self-punitive harsh
superegos and to decrease unconscious stress levels.
- classic psychoanalytical theory hypothesizes that at least
some alcoholic people may have become fixated at the oral
stage of development and use alcohol to relieve their
frustrations by taking the substance by mouth.
Behavioral Theories
- Expectations about the rewarding effects of drinking,
cognitive attitudes toward responsibility for one's behavior,
and subsequent reinforcement after alcohol intake all
contribute to the decision to drink again after the first
experience with alcohol and to continue to imbibe despite
problems.
Sociocultural Theories
- it is likely that cultural attitudes toward drinking,
drunkenness, and personal responsibility for consequences
are important contributors to the rates of alcohol-related
problems in a society.
Childhood History
- one or both of their parents are affected
- history of attentiondeficit/hyperactivity disorder (ADHD)
- conduct disorder
Genetic Theories
- Importance of Genetic Influences.

EFFECTS OF ALCOHOL
- The possible beneficial effects of alcohol have been
publicized, especially by the makers and the distributors of
alcohol. Most attention has been focused on some
epidemiological data that suggest that one or two glasses of
red wine each day lower the incidence of cardiovascular
disease; these findings, however, are highly controversial.
- Other Physiological Effects:
1. Liver
2. Gastrointestinal System
3. Other Bodily Systems

Laboratory Tests:
- y-glutamyl transpeptidase levels
- MC
- uric acid
- Triglycerides
- aspartate aminotransferase
- alanine aminotransferase
 - Other alcohol related neurologic disorders
- Fetal Alcohol Syndrome

Prognosis
- Between 10 and 40 percent of alcoholic persons enter
some kind of formal treatment program during the course
of their alcohol problems

TREATMENT AND REHABILITATION

- Detoxification
- Rehabilitation
- Counselling
- Medications

- Alcoholics Anonymous

CAFFEINE-RELATED DISORDERS
- Caffeine is the most widely consumed psychoactive
substance in the world.

Epidemiology
- An adult in the United States consumes about 200 mg of
caffeine per day on average, although 20 to 30 percent of
all adults consume more than 500 mg per day.

Common Sources of Caffeine

COMORBIDITY
- About two thirds of those who consume large amounts of
caffeine daily also use sedative and hypnotic drug
“Withdrawal Seizures” ETIOLOGY
- After exposure to caff eine, continued caffeine
Treatment consumption can be influenced by several different factors,
- Benzodiazepines such as the pharmacological effects of caff eine, caff eine's
- Carbamazepine reinforcing effects, genetic predispositions to caffeine use,
- /3-adrenergic receptor antagonists and personal attributes of the consumer.
- clonidine (Catapres) Diagnosis:
- comprehensive history of a patient's intake of caffeine-
- Delirium Tremens containing products.
- Alcohol- induced Persisting Dementia
- Alcohol-induced Persisting Amnestic Disorder
- Alcohol-Induced Psychotic Disorder
- Alcohol Induced Mood Disorder
- Alcohol Induced Anxiety Disorder
- Alcohol-Induced Sexual Dysfunction
- Alcohol-Induced Sleep Disorder
- Unspecified Alcohol-related Disorder
- Idiosyncratic Alcohol Intoxication
 - Caffeine-Induced Anxiety Disorder
- Caffeine-Induced Sleep Disorder
- Caffeine-Related Disorder Not Elsewhere Classified
TREATMENT
- Aspirin
- benzodiazepines
CANNABIS-RELATED DISORDERS
- Cannabis sativa
Epidemiology
- males was almost twice the rate for females overall among
those aged 26 and older
- at ages 12 to 17, there are no significant differences.
- Among those aged 12 to 17, whites had higher rates of
lifetime and past-year marijuana use than blacks.
- Among those 17 to 34 years of age, whites reported higher
levels of lifetime use than blacks and Hispanics.
- among those 35 and older, whites and blacks reported the
same levels of use.
- The lifetime rates for black adults were significantly higher
than those for Hispanics
 - Cannabis Intoxication Delirium
- Cannabis-Induced Psychotic Disorder
- Cannabis-Induced Anxiety Disorder
- Unspecified Cannabis-Related Disorders
TREATMENT AND REHABILITATION
- abstinence and support.

Medical Use of Marijuana

- remedy for anxiety, depression, and gastrointestinal
disorders
- nausea secondary to chemotherapy, multiple sclerosis (MS)
chronic pain, acquired immune deficiency syndrome (AIDS),
epilepsy, and glaucoma.
sativex
- In 2006, regulatory officials authorized the first U.S. clinical DIAGNOSIS
trial investigating the efficacy of Sativex, an oral spray - Hallucinogen Use Disorder
consisting of natural cannabis extracts, for the treatment of - Hallucinogen Intoxication
cancer pain - Hallucinogen Persisting Perception Disorder
Epidiolex - Hallucinogen Intoxication Delirium
- In 2013, a product called Epidiolex which contains - Hallucinogen-Induced Psychotic Disorders
cannabidiol was granted orphan drug status for the
- Hallucinogen-Induced Mood Disorder
treatment of certain rare, intractable types of epilepsy in
- Hallucinogen-Induced Anxiety Disorder
children.
- Unspecified Hallucinogen-Related Disorder
INHALANT-RELATED DISORDERS
HALLUCINOGEN-RELATED DISORDERS
1. solvents for glues and adhesives
- Intoxicants
2. propellants (e.g., for aerosol paint sprays, hair sprays, and
- Hallucinogens have been used for thousands of years, and shaving cream);
drug-induced hallucinogenic states have been part of social
3. thinners (e.g., for paint products and correction fluids);
and religious rituals
4. fuels (e.g., gasoline, propane)
- Hallucinogens are natural and synthetic substances that are DIAGNOSIS
variously called psychedelics or psychotomimetics because,
- Inhalant Use Disorder
in addition to inducing hallucinations, they produce a loss
- Inhalant Intoxication
of contact with reality and an experience of expanded and
- Inhalant Intoxication Delirium
heightened consciousness
- Inhalant-Induced Persisting Dementia
- the US Food and Drug Administration (FDA) has decreed
- Inhalant-Induced Psychotic Disorder
that they have no medical use and a high abuse potential
- Inhalant-Induced Mood Disorder and Inhalant-Induced
Anxiety Disorder
- Other Inhalant-Induced Disorders
 TREATMENT
- Inhalant intoxication, as with alcohol intoxication, usually
requires no medical attention and resolves spontaneously
- However, effects of the intoxication, such as coma,
bronchospasm, laryngospasm, cardiac arrhythmias, trauma,
or burns, need treatment

OPIOID-RELATED DISORDERS
- Opioid dependence
- Opioid abuse
- In addition to the morbidity and mortality associated
directly with the opioid-related disorders, the association
between the transmission of
- human immunodeficiency virus (HIV) and intravenous
opioid and
- opiate use is now recognized as a leading national health
concern.
COMORBIDITY
- About 90 percent of persons with opioid dependence have
an additional psychiatric disorder.
- The most common comorbid psychiatric diagnoses are
major depressive disorder, alcohol use disorders, antisocial
personality disorder, and anxiety disorders.
- About 15 percent of persons with opioid dependence
attempt to commit suicide at least once
ETIOLOGY
- Psychosocial Factors
- Biological and Genetic Factors
- Inhalant Intoxication Delirium
- Psychodynamic Theory
- Inhalant-Induced Persisting Dementia
- Inhalant-Induced Psychotic Disorder
Morphine and Heroin:
- begins 6 to 8 hours after the last dose, usually after a 1- to
2-week period of continuous use or after the administration
of a narcotic antagonist.
- peak intensity during the second or third day
- subsides during the next 7 to 10 days
Meperidine:
- begins quickly, peak in 8-12 hrs, and ends in 4 to 5 days.
Methadone:
- begins 1 to 3 days after the last dose and ends in 10 to 14
days.
 - Opioid Intoxication Delirium - secobarbital-amobarbital combination (known as "reds and
- Opioid-Induced Psychotic Disorder blues " "rainbows " "double-trouble " and "tooies") are ' ' '
- Opioid-Induced Mood Disorder easily available on the street from drug dealers.
- Opioid-Induced Sleep Disorder and OpioidInduced Sexual DIAGNOSIS
Dysfunction - Sedative, Hypnotic, or Anxiolytic Use Disorder
- Unspecified Opioid-Related Disorder - Sedative, Hypnotic, or Anxiolytic Intoxication
- Sedative, Hypnotic, or Anxiolytic Withdrawal
Other Sedative-, Hypnotic-, or Anxiolytic-lnduced Disorders
- Delirium
- Persisting Dementia
- Persisting Amnestic Disorder
- Psychotic Disorders
- Other Disorders. Sedative and hypnotic use has also been
associated with mood disorders, anxiety disorders, sleep
disorders, and sexual dysfunctions.
- Unspecified Sedative-, Hypnotic-, or AnxiolyticRelated
Disorder

Patterns of Abuse
- Oral Use
- Intravenous Use

TREATMENT AND REHABILITATION TREATMENT AND REHABILITATION

Overdose Treatment: Treat Withdrawal Symptoms
- ensure an adequate airway Detoxification
- Naloxone Treatment of Overdose
Medically Supervised Withdrawal & Detoxification - METHADONE
Other Opioid Substitutes: STIMULANT-RELATED DISORDERS
- LEVOMETHADYL (LAAM)
- BUPRENORPHINE AMPHETAMINES:
Opioid Antagonists: - Amphetamines and amphetamine-like drugs are among the
- Naloxone most widely used illicit substances, second only to cannabis
- naltrexone - Methamphetamine, a congener of amphetamine, has
Psychotherapy : become even more popular in recent years.
- Individual psychotherapy COCAINE:
- behavioral therapy • Cocaine is an alkaloid derived from the shrub Erythroxylum
- cognitive-behavioral therapy coca
- family therapy • 1880-local anesthetic
- support groups (e.g., Narcotics Anonymous [NA]) • 1890’s-cure for many illnesses
- social skills training • 1903-coca cola
- Family therapy
Sedative-, Hypnotic-, or Anxiolytic-Related Disorders
- Their sedative or calming effects are on a continuum with
their hypnotic or sleep-inducing effects.
- these drugs are also used as antiepileptics, muscle
relaxants, anesthetics, and anesthetic adjuvants.
BENZODIAZEPINES:
- diazepam, flurazepam (Dalmane ), oxazepam (Serax), and
chlordiazepoxide (Librium).
- Flunitrazepam (Rohypnol)
- zolpidem (Ambien) zaleplon (Sonata), and eszopiclone
(Lunesta)-the so called Z drugs-have clinical effects similar
to the benzodiazepines and are also subject to misuse and
dependence.
BARBITURATES :
- Secobarbital (popularly known as "reds," "red devils,"
"seggies," and "downers")
- pentobarbital (Nembutal) (known as "yellow jackets,"
"yellows," and "nembies")
Etiology TREATMENT AND REHABILITATION
- Genetic Factors - Inpatient setting and use of multiple therapeutic methods
- Sociocultural Factors - Detoxification
- Learning and Conditioning - Supportive Therapy
- Pharmacological Factors - Treat comorbid conditions
Methods of Use:
- Inhalation TOBACCO-RELATED DISORDERS
- smoking - Tobacco use disorder is among the most prevalent, deadly,
- Oral and costly of substance dependencies.
- Subcutaneous DIAGNOSIS:
- intravenous - Tobacco Use Disorder
DIAGNOSIS AND CLINICAL FEATURES - Tobacco Withdrawal
- Stimulant Use Disorder CLINICAL FEATURES
- Stimulant Intoxication - improved attention,learning, reaction time, and problem-
- Stimulant Withdrawal solving ability.
- Stimulant Intoxication Delirium - Tobacco users also report that cigarette smoking lifts their
- Stimulant-Induced Mood Disorder ` mood.
- Stimulant-Induced Anxiety Disorder Health Benefits of Smoking Cessation
- Stimulant-Induced Obsessive-Compulsive Disorder - Former smokers live longer than those who continue to
- Stimulant-Induced Sexual Dysfunction smoke.
- Stimulant-Induced Sleep Disorder - Smoking cessation decreases the risk for lung cancer and
other cancers, myocardial infarction, cerebrovascular
diseases, and chronic lung diseases.
- Women who stop smoking before pregnancy or during the
first 3 to 4 months of pregnancy reduce their risk for having
low birth weight infants to that of women who never
smoked.
TREATMENT
- Quit smoking
- Set a quit date
- Abupt cessation of smoking
- medication or group therapy
- weight gain concerns
- high-risk situations
- making cigarettes unavailable
ADVERSE EFFECTS - Psychosocial Therapies
- Amphetamines: - Psychopharmacological Therapies
- Physical - Combined Psychosocial and Pharmacological Therapy
- Psychological
- Cocaine: ANABOLIC-ANDROGENIC STEROID ABUSE
- Cerebrovascular Effects - family of hormones that includes testosterone, the natural
- Seizures male hormone, which together with numerous synthetic
analogs of testosterone have been developed over the last
- Cardiac Effects
70 years.
- Death
Therapeutic Indications
Other Agents
- testosterone deficiency (male hypogonadism)
- Substituted Amphetamines:
- hereditary angioedema (a congenital skin disorder)
- MDMA (3,4-methylenedioxymethamphetamine)
- anemia caused by bone marrow or renal failure
- MDEA(3,4-Methylenedioxy-N-ethylamphetamine)
- for metastatic breast cancer
- MDA (3,4-methylenedioxyamphetamine )
- Osteoporosis
- DOB (2,5-dimethoxy-4-bromoamphetamine )
- Endometriosis
- PMA (paramethoxyamphetamine )
- adjunctive treatment of menopausal symptoms
- Khat
- male contraceptive
"Club Drugs"
- major depressive disorder
- LSD
- sexual disorders
- y-hydroxybutyrate (GHB)
- wasting syndromes associated with acquired
- Ketamine
immunodeficiency syndrome (AIDS).
- Methamphetamine
Adverse Reactions
- MDMA (ecstasy)
- Cardiovascular
- Rohypnol or "roofies" (flunitrazepam).
- Hepatic
 - Reproductive
- dermatological systems
Etiology:
- What is the major reason for taking illicit AAS?
- to enhance either athletic performance or physical
appearance
DIAGNOSIS AND CLINICAL FEATURES
- Steroids may initially induce euphoria and hyperactivity
- increased anger
- Arousal
- Irritability
- Hostility
- Anxiety
- Somatization
- Depression
- hypomanic or manic episodes
- psychotic symptoms
TREATMENT
- Abstinence
- therapeutic alliance
AAS Withdrawal
- suicidal depressions COMORBIDITY
- mood disorders
STEROID RELATED DISORDERS - other substance use and addictive disorders
- ANABOLIC STEROID-INDUCED MOOD DISORDERS - ADHD
- ANABOLIC STEROID-INDUCED PSYCHOTIC DISORDER - personality disorders
- disruptive, impulse control, and conduct disorders
OTHER SUBSTANCE USE AND ADDICTIVE DISORDERS Etiology
- y-HYDROXYBUTYRATE - Psychosocial Factors
- NITRITE INHALANTS - Biological Factors
- NITROUS OXIDE DIAGNOSIS AND CLINICAL FEATURES
Other Substances: - Overconfident
- Catnip - Abrasive
- Nutmeg - Energetic
- Betel nut - free spending
- Kava - personal stress
- Over-the-Counter Drugs - Anxiety
- Ephedra - Depression
- Chocolate - lying
TREATMENT AND REHABILITATION Four phases:
- Abstinence - The winning phase
- physical, psychiatric, and psychosocial well-being of the - The progressive-loss phase
patient - The desperate phase
- The hopeless stage
GAMBLING DISORDER TREATMENT
- Gambling disorder is characterized by persistent and - Gamblers Anonymous (GA)
recurrent maladaptive gambling that causes economic - Hospitalization
problems and significant disturbances in personal, social, or - Insight oriented psychotherapy after 3 months
occupational functioning. - Family therapy
- Psychopharmacological Treatment