Substance Related Disorders: Alcohol, Opioids, Cannabis

Substance related disorders are an important topic in psychiatry. Substance abuse and dependence are prevalent conditions that are commonly encountered by physicians. It is estimated that 10-15% of the population struggles with substance abuse or dependence, making it a significant public health concern.

In this blog we’ll cover dependence, alcohol, alcohol induced neurocognitive disorders, opioids, cannabis, cocaine, and tobacco.

Dependence

Important Information

• ICD uses the term Dependence
• DSM uses the term substance
• Tolerance (Physical dependence)
  • Increasing amount of substance is required to get the desired effect
  • E.g.: If someone easily got intoxicated by 2 drinks earlier, would now need 4 drinks to get the same effect as he has become intolerant.
•  Withdrawal symptoms (Physical dependence)
  • They are the characteristic symptoms that develop if the substance intake is stopped
  • E.g.: If someone who has been using alcohol regularly, suddenly stops, he will develop symptoms like tremors, vomiting, nausea, etc.
• Important Information
• Tolerance and Withdrawal symptoms are suggestive of Physicsl dependence (The body is dependent on a particular substance)
• Hallucinogens (LSD etc.) are not associated with physical dependence.
• Craving
  • An intense urge to take the substance which is often difficult to ignore/resist
• Inability to control substance taking behavior
  • The person is not able to stop himself from taking/consuming the substance
• Progressive neglect of alternative ways of pleasure
  • The person will stop doing other activities that he used to do earlier
• Continued use despite clear harmful consequence
  • In Spite of knowing the consequences, he still cannot stop the use

ALCOHOL

• M/C Used/Abused Substance in the World
• Important Information
  • Intoxication Symptoms
    • The symptoms that appear when a person ingests a particular substance
    • Intoxication symptoms of alcohol depend on Blood Alcohol Concentration (BAC)

Acute Intoxication

• 30 mg/dl: Legal limit
• 200-300 mg/dl: Alcoholic blackouts
• Important Information
• Alcoholic blackouts
  • When alcohol consumption is 200-300 mg/dl, the person will not be able to recall anything the next day
  • In other words – Anterograde Amnesia – The person was not able to make memories when BAC was 200-300 mg/dl

Alcohol Withdrawal Symptoms

• They depend on the duration since the last alcohol intake
  • After 6-8 hours: Tremors (M/C), nausea, vomiting, anxiety, hypertension, mydriasis ()
  • After 12-24 hours: Alcoholic hallucinosis
    • Patient may start developing hallucinations without any disturbance of consciousness (he is well alert and awake)
    • M/C: Auditory hallucinations
  • After 24-48 hours: Alcohol withdrawal seizures (GTCS – Generalized Tonic-Clonic Seizures, Cluster seizures)
  • After 48-72 hours: Delirium tremens (high mortality)
    • May be triggered by Surgery/Infection
• Important Information
• Delirium Tremens
  • It is the most dreaded complication because even after treatment Mortality rate is 5-10%
  • It usually presents with 3 symptoms
    • Disturbance of consciousness (confusion)
    • Disorientation (of Time/Place/Person)
    • Hallucinations (Visual Hallucinations)
• It can be precipitated by
  • Acute infections
  • Surgery
  • Use of drugs (Cholinergic drugs)

Diagnosis of Alcohol use disorder

• Screening Questionnaire
  • CAGE 
    • If the patient says yes to >-2 (More than/equal to 2), then he has Alcohol use disorder
    • C - Cut down
    • A - Annoyed
    • G - Guilt 
    • E - Eye opener
  • AUDIT
    • Alcohol
    • Use
    • Disorder
    • Identification
    • Test 
• Important Information
• Both AUDIT and CAGE are screening test for alcohol use disorder
• SADQ
  • Severity of Alcohol Disorder Questionnaire

Also Read: Binge-Eating Disorder: Causes, Symptoms, Risk Factors, Diagnosis, Treatment, Prevention And Complications

ALCOHOL INDUCED NEUROCOGNITIVE DISORDERS

Wernicke-Korsakoff Syndrome

• Neuropsychiatric complication
• It has 2 parts
  • Wernicke’s Encephalopathy
  • Korsakoff Syndrome
• 1. Wernicke’s Encephalopathy
  • Acute neurological complication caused by thiamine (Vitamin B1) deficiency
  • Presentation
    • Global confusion
    • Ophthalmoplegia (First symptom to improve after thiamine administration followed by confusion and lastly Ataxia)?
    • Ataxia (Can be residual symptoms even after treatment)?
  • Important Information
  • Ophthalmoplegia
  • Paralysis of extraocular muscle: Caused by the palsy of 6^th nevre (M/C), 3rd nerve (2^nd M/C)
• 2. Korsakoff Syndrome
• Chronic neurological complication caused by thiamine (Vitamin B1) deficiency
• Anterograde amnesia > Retrograde amnesia
• Confabulations (False stories made to fill memory gaps)
• Important Information
• Anterograde amnesia: Inability to make newer memories/Going to forget things in future
  • Patient will have learning difficulty
• Retrograde amnesia: Forgetting older memories

Pathophysiology for both

• Thiamine deficiency
• Mammillary bodies: Mostly affected brain area

Treatment

•  Wernicke’s encephalopathy: High dose of parenteral thiamine
• Korsakoff: Oral thiamine (Long term)

Also Read: Nymphomania: Causes, Symptoms, Risk Factors, Diagnosis, Treatment

Treatment of Alcohol Dependence

Detoxification (1st Stage)

• Management of withdrawal symptoms
• DOC is Benzodiazepines
• If the patient has compromised liver status, then
  • Short acting benzodiazepines: Lorezapam/Oxazepam
• Gradually decrease the dose, stop Benzodiazepines after 7-10 days
• Important Information
  • Alcoholic anonymous (12 step self-help group, no incentives are given)

Maintenance of Abstinence (2^nd Stage)

• To ensure that the patient does not go back to drinking (Stop the craving of the patient)
• Anticraving agents: Naltrexone (mostly used), Acamprosate, Topiramate
• Important Information
  • Naltrexone 
    • It is metabolized by liver
    • If the liver is compromised, we do not give naltrexone
• Deterrent agents (Aversive agents): Disulfiram
  • It was used in the past
  • If the patient on disulfiram consumes alcohol, he will have – Nausea, vomiting, palpitations and anxiety and thus shall avoid alcohol
  • But in reality cravings do not stop so instead the patient stops taking medications.
  • After few days patient starts consuming alcohol again

Alcoholic anonymous 

• A 12-step self-help group (Where people gather together to help each other by sharing their past experiences)
• No incentives are given

OPIOIDS

•  Heroin 
  • M/C abused opioid 
  • Street names: Smack, brown sugar
• Other opioids: Morphine, codeine etc.
• Important Information
  • Over dosage of Opioids can cause respiratory depression (can be fatal)
  • T/t: I.V. Naloxone (Opioid antagonist)

Also Read: Narcissistic Personality Disorder: Causes, Symptoms, Diagnosis, Treatment, Prevention and Complications

Withdrawal Symptoms of Opioids

• Flu-like syndrome
• Lacrimation, rhinorrhea, sweating, diarrhea
• Yawning and piloerection (goosebumps)
• Mydriasis
• Body ache and insomnia

Treatment of withdrawal Symptoms of Opioids

Detoxification (Management of withdrawal symptoms)

• Long acting opioids like: Methadone, Buprenorphine, Dextropropoxyphene
• Alpha 2 agonist like: Clonidine, Lofexidine 
  • Not as active as Long acting opioids

Maintenance of Abstinence

• Opioid substitution therapy: Methadone, Buprenorphine. 
• Important Information
  • Benefit of methadone over heroine (Harm reduction technique)
    • In patient using heroine intravenously, risk of other diseases like hepatitis, HIV, etc is high due to sharing of syringes
    • Element of crime may be involved
    • Methadone is administered orally
    • It is dispatched in government approved centers: No crime
  • Naltrexone
    • It is an opioid antagonist
    • It will block all the receptors, even if the person takes heroine, there will be no high (intoxication)
    • But in real world it does not work that well
• In cases where patient is highly motivated to leave the opioids, we can use Naltrexone

Narcotic anonymous

• A 12-step self-help group (Where people gather together to help each other by sharing their past experiences)

Cannabis

(M/C Used Illegal Drug in India / Worldwide) 

• Derived from cannabis sativa
• Active ingredient is (Delta) 8-9 Tetrahydrocannabinol (THC)
• Street names: Joints, marijuana, grass, pot, weed, etc.

Cannabis related Disorders

• Flashback phenomenon: Recurrence of cannabis use experience in the absence of any current use 
• Running amok
  • Extreme rage develops
  • Patient may injure others indiscriminately
  • Homicide is the most common
• Bad trips
  • Unpleasant experiences after using cannabis
  • Patients may experience anxiety, hallucination, panic attacks, delusions, etc.
  • Sometimes have to give Benzodiazepines, Antipsychotics
• Important Information
  • Cannabis can cause mild withdrawal symptoms like irritability

Psychiatry Articles:

Hallucinations

• They primarily cause hallucinatory experiences
• LSD (Lysergic acid diethylamide), mescaline, psilocybin, methylenedioxyamphetamine (MDMA, ecstasy), phencyclidine (Angel dust), ketamine

Hallucinogens Related Disorders

• No physical dependence (No tolerance, no withdrawal symptoms)
• Flashback phenomenon, reflex hallucinations
• Bad trips

COCAINE

• Derived from “Erythroxylum Coca” plant.
• It was prepared as a LA 
  • It blocks fast Na+ channel
  • It can block the nerve transmission
  • It is a vasoconstrictor- used for ENT surgery
• It works by blockade of reuptake of dopamine and norepinephrine receptors. It causes
  • Vasoconstriction: Causing HTN, MI
  • Nasal septal perforation: Due to prolonged constriction of vessels (Due to snorting) 
  • Seizures (Due to ↑ level of neurotransmitter)
  • Jet black pigmentation of tongue

Cocaine Intoxication

• Paranoid ideations (delusions) + auditory hallucinations, the symptoms resemble paranoid schizophrenia

Tactile Hallucinations

• Cocaine bugs or magnan phenomenon or formication, scratch mark.
• Feeling like bugs are crawling inside the skin.

TOBACCO

• M/C Used/Abused Substance in India
• Withdrawal symptoms of nicotine
  • Irritability
  • Poor concentration
  • Anxiety, restlessness
  • Bradycardia
  • Drowsiness but paradoxical insomnia (Not able to fall asleep)
  • Increased appetite, weight gain
  • Depression
  • Constipation

Treatment

• Nicotine replacement therapy
  • Nicotine patches
  • Nicotine gum
  • Nicotine lozenges
  • Nicotine sprays  
• Medications
  • Varenicline: Partial agonist at α4β2 nicotinic acetylcholine receptors and α7 nicotinic acetylcholine receptor (Good efficacy). 
    • Rare and important side effect: Suicidal thought
  • Bupropion (Anti-depressant)

Important Information

• Rave drugs: LSD, amphetamines, GHB (Gamma hydroxy butyric acid), ketamine.
• Date Rape Drugs: Flunitrazepam, GHB and Ketamine (dissociative amnesia).

Also Read: Absence Seizures: Causes, Symptoms, Risk Factors, Diagnosis, Treatment and Complications

Previous year Question

Q. A patient presented with history of visual hallucinations and disorientation. He was a chronic user of alcohol and last intake was a day’s back? what is the likely diagnosis? Alcohol withdrawal delirium?   (FMGE Aug 2020)

A. Alcohol withdrawal seizures

B. Alcohol withdrawal Delirium

C. Alcoholic hallucinosis 

D. Schizophrenia

Q. Freud’s theory of dream work, includes all except? (NEET Jan 2018)

A. Displacement

B. Condensation

C. Symbolization

D. Confabulation

Q. Disulfiram is a type of? (FMGE Nov 2017)

A. Aversion therapy 

B. Anticraving therapy 

C. Detoxification 

D. Opioid management therapy.

Q. Which of the following drug is known to cause dependence is most commonly abused? (NEET Jan 2020) 

A. Cocaine

B. Heroin 

C. Amphetamine 

D. Cannabis

Q. Jet black pigmentation of tongue with tactile hallucinations is a feature of?  (FMGE June 2018)

A. Heroin 

B. Opium 

C. Alcohol

D. Cocaine

Q. Magnan Symptom are associated with which substance? (NEET Jan 2020) 

A. Cocaine

B. Cannabis 

C. Amphetamine 

D. Alcohol

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