Disorders Related to Substance Use

Prof.Bahagia Loebis, Psychiatrist Psychiatric Department FK USU

1. Substance Use Disorders

A. Substance abuse B. Substance dependence

2. Substance-Induced Disorder could generate

A. substance intoxication B. substance withdrawal C. substance-induced delirium D. substance-induced persisting dementia E. substance-induced persisting amnestic disorder
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F. substance-induced psychotic disorder G. substance-induced mood disorder H. substance-induced anxiety disorder I. substance-induced sexual dysfunction J. substance-induced sleep disorder

According to Ausubel there are 3 types of dependence :

1. Primary dependence : marked with

the existence of anxiety & depression which is generally at people with inadequate personality.
2. Symptomatic dependence : substance abuse as one of the underlying personality disorder symptoms; generally at people with antisocial personality, criminal and substance use for the pleasure reason.
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3. Reactive dependence : especially at adolescence, because of the inquiring motivation, environmental influence and peer group pressure.

Evans divided substance abuse from psychological point of view

1. Substance abuse as incarnation of personality disorder; marked with disability to solve various problem and unable to learn from experience. 2. Substance abuse because experiencing personal conflict, for example anxiety or depression.

3. Substance abuse because of peer group pressure.

Psychoactive Substances
1. Alcohol 2. Opioida 3. Cannabinoida 4. Sedative & hypnotic 5. Stimulantia; including caffein 6. Coccaine 7. Hallucinogenic 8. Tobacco 9. Solvent 10. Multiple substance; or other psychoactive substances
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Substance Abuse
1. Existence of pathological pattern of usage, could generate :
- all day long intoxication - continue to use substance - existence of uncomplication episode, in the form of substance intoxication

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2. Damage in social or occupational function because of pathologic use; and existence of failure to fulfill duty, as worker or student; and existence of failure to fulfill duty for environment and family, because of the strange & impulsive behavior.

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- difficulties from law facet, conducting criminal behaviour; in a intoxication condition could experience a traffic accident, fallen down. - reduced occupational function or can't function effectively, because of the intoxication; and followed with trouble in social function.

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3. Duration : at least 12 months.

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For substance dependence :

The condition equal to substance abuse, only added with : 1. Substance tolerance : a need for
markedly increased amounts of the substance to achieve desired effect; or markedly diminished effect with continued use of the same amount of the substance.

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2. Withdrawal syndrome = abstinence syndrome

Is a specific substance syndrome which arise because of the reducing or stopping substance use; which the substance had been used for a long time period, continuous or periodical, to get the physiologic intoxication effect.
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Medical treatment
1. Phase I: crisis service (1-2 days) treatment of overdosage, acute withdrawal syndrome, acute medical problem 2. Phase II: short term stabilization (1-4 weeks) detoxification process

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3. Phase III : long term stabilization ( 4-24 weeks) evaluation & treatment for chronic medical problem 4. Phase IV : rehabilitation (6 months-2 yrs) medic & psychiatric care, religious & cultural approach

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Many expert describe, patient which have free oftentimes fall again & become dependence to substance, because of :
- easy to persuaded by group of friend with substance user . - and when he face problems, he returns to use the substance.

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Prevention in order not to become a substance abuser :

1. Get an explanation concerning substance abuse & dependence 2. The condition in the family are good & healthy 3. Religious life in family 4. Choose peer group friend with none of them are substance abuser
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5. Had activities to fill the leeway The substance arent easy to get, so the substance abuse or dependence are difficult to happened

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Common substance that had been used in Indonesia :

1. Alcohol

- whiskey, kamput, tuak, etc

2. Sedative & hypnotic

Sedative : bromazepam, alprazolam, lorazepam Hypnotic : nitrazepam, flurazepam, triazolam - tetrahidrocannabinol (=THC)

3. Cannabis

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4. stimulantia
- amphetamin, methamphetamin - coccaine, shabu-shabu

5.opiate & opioida

-morphine - heroine, putaw

6. etc
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Alcohol intoxication
Recently ingestion of alcohol There are maladaptive behavior, for example : quarreling, impairment in judgment, social & occupational function.

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At least 1 of these physiological symptoms :

1. Slurred speech 2. Incoordination 3. Unsteady gait 4. Nystagmus 5. Flushed face

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At least 1 of these psychological symptoms :

1. Change of affect 2. Instability 3. Talkative 4. Impairment in focusing attention

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Alcohol withdrawal
Cessation or reduction of prolonged heavy alcohol consumption; discovered the present of harsh tremor at hand, tongue, eyelid and at least one of the following symptom:
1. nausea & vomiting 2. Iethargy or weakness

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3. Autonomic hyperactivity, eg tachycardia, sweating, increased blood pressure 4. Anxiety 5. Depressive affect or irritable 6. Orthostatic hypotension

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Opioida intoxication
Recently used opioida Pupil constriction (or pupil dilatation because of anoxia from overdosage) At least 1 psychological symptoms : 1. euforia 2. disforia 3. apathy 4. psychomotor retardation
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At least 1 neurologic symptoms :

1. Drowsiness 2. Slurred speech 3. Impaired attention or memory

Effect on maladaptive behavior, eg impaired judgment, social or occupational

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Opioida withdrawal syndrome (eg : morphine, heroine, pethidine, etc)

Prolonged & heavy used of opoida At least 4 of the following symptoms because of the cessation or reduction in the use of opioida : 1. lacrimation 2. rinorrhea 3. pupil dilatation 4. pilo erection
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5. sweating 6. diarrhea 7. yawning 8. mild hypertension 9. tachycardia 10. fever 11. inability to fall asleep
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Amphetamine intoxication
A. Recently used of amphetamine or other sympatomimetic/same effect B. Within 1 hour after the use, at least 2 of the following psychological symptom : 1. Psychomotor agitation 2. Elation 3. Grandiosity 4. Talkative 5. Hypervigilance
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C. Within 1 hour after the at least 2 of the following physical symptoms : 1. tachycardia 2. pupil dilatation 3. increased blood pressure 4. sweating or feeling cold 5. nausea or vomiting D. maladaptive behavior effect; eg quarreling, impaired judgment, social & occupational function

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Amphetamine withdrawal syndrome

A. Prolonged & heavy used of amphetamine or other sympatomimetic that had the same mechanism of action or effect B. Present of depressive affect & at least 2 of the following symptoms after cessation or reduction of the substance : 1. fatigue 2. sleep problem 3. increased dreams
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Opiate & Opioida

Opioid receptor consist of
mu receptor : responsible for craving kappa receptor delta receptor sigma receptor epsilon receptor lamda receptor

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Treating overdosage (OD)

Give naloxon (NarcanR/) 0,8 mg IV; wait 15 minutes, not yet improvement, give again naloxon 1,6 mg IV; wait again 15 minutes; still no response add naloxon 3,2 mg IV Signs if there a response, increased respiratory rate, systolic blood pressure & pupil dilatation

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Mirin & Weiss suggest interval for 5 minutes If overdosage is treated continue to give naloxon 0,4 mg/hour/iv until the patient awake

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Cessation the use of opiate & opioida

Detoxification process could be : 1. Natural : cold turkey, very suffered, duration 10-20 days 2. Detoxification by giving symptomatic drugs to treat the withdrawal syndrome 3. Methadone substitution begin with 30 mg (must not be more than 40 mg/day). Some suggest must not be more than 60 mg/day. At day 3 the dosage reduce 5 mg/day; & give symptomatic drugs to treat the symptoms
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4. Clonidine & naltrexon clonidine given 0,1-0,2 mg/3-4 hours, not more than 0.8 mg/day; reduce slowly, & at day 3 give 50 mg/day 5. buprenorphine partial agonist receptor opioid. Give with dose 6-20 mg/day/sublingual (target dosage 16 mg/day) Rapid opioid detoxification giving the naloxon & patient in anesthetic condition; duration 4-8 hour
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Using naltrexon 50 mg at day 1: tablet day 2: tablet day 3: 1 tablet Can be added clonidine & symptomatic treatment to the withdrawal opioida syndrome Note : opioida withdrawal, eg heroine, begin 6-8 hour & reach the peak at day 2-3, & continued for 7-10 days

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