Substance

• Dejla college for dentistry provides education on substance misuse
• Substances covered


  • Prescription and over-the-counter medicines
  • Volatile chemicals
  • Street drugs
  • Alcohol
• Problems caused by substance misuse


  • Mental and physical illnesses
  • Family, housing, employment, and legal difficulties
• Treatments for substance misuse

  • Psychological interventions
  • Pharmacological interventions
  • Detoxification
  • Substitute prescribing
• Reasons for substance use


  • Search for a 'high'
  • Repeat of initial pleasurable effects
  • Cultural norm in some subcultures
  • Self medication for anxiety, social phobia, insomnia, and symptoms of psychotic illness
  • To prevent the development of withdrawal symptoms
• There is evidence for vulnerability to substance use in those with a family history of substance misuse, and the role of environmental stressors in perpetuating use
• Substance misuse


  • Gives rise to health risks beyond the effect of the drug (e.g. drink-driving deaths, HIV infection)
  • Is a community problem, leading to lost productivity, crime, road accidents, violence, and family break-up
  • Patterns are susceptible to political manipulation (e.g. licensing hours, criminalization, legalization, availability of treatment services)
• Withdrawal


  Where there is physical dependence on a drug, abstinence will generally lead to features of withdrawal
• Withdrawal symptoms


  Often the 'opposite' of the acute effects of the drug
• Harmful use


  The continuation of substance use despite evidence of damage to the user's physical or mental health or to their social, occupational, and familial well-being
• Dependence


  Includes both physical dependence and psychological dependence
• In some drugs (e.g. hallucinogens), no physical dependence features are seen
• Common effects of substance misuse

  • Substance-induced psychiatric illness
  • Persisting cognitive impairment
  • Residual disorders
  • Exacerbation of pre-existing disorder
• Opioids


  Natural opium alkaloids and the semi-synthetics derived from the alkaloids
• Opioids


  • Potent analgesic, euphoriant and anxiolytic effects for which they are abused
  • Heroin is the most commonly used opioid and it is most commonly smoked
• Intoxication effects of opioids

  • Initial euphoria & dysphoria
  • Psychomotor agitation
  • Pupillary constriction
  • Drowsiness or coma
  • Slurred speech
  • Impairment in attention or memory
• Withdrawal symptoms of opioids (cold turkey)

  • Dysphoric mood
  • Nausea or vomiting
  • Muscle aches
  • Lacrimation or rhinorrhea
  • Pupillary dilation
  • Piloerection (gooseflesh)
  • Sweating
  • Diarrhea
  • Yawning
  • Fever
  • Insomnia
• Pharmacotherapy for opioid withdrawal

  • Methadone
  • Buprenorphine
  • α2 adrenergic agonists
• Cannabis


  Obtained from the plant Cannabis sativa, e.g. tetrahydracannabinol, cannabidiol, cannabigerol
• Withdrawal symptoms of cannabis

  • Irritability
  • Insomnia
  • Anorexia
  • Mild nausea
• Cannabis intoxication


  • Heightened perceptual sensitivity, depersonalization and derealization
  • Impairment in motor skills may remain long after the euphoriant effects are gone
• There is no evidence of drug benefit for cannabis treatment
• Benzodiazepines


  Sedatives/Hypnotics, e.g. diazepam, librium, lorazepam, alprazolam
• Symptoms of benzodiazepine intoxication

  • Slurred speech
  • Incoordination
  • Nystagmus
  • Impairment in attention or memory
  • Coma
  • Behavioural changes such as inappropriate sexual or aggressive behaviour
  • Mood lability
  • Impaired judgment
• Symptoms of benzodiazepine withdrawal

  • Prominent anxiety and autonomic hyperactivity
  • Increased tremor
  • Insomnia
  • Nausea or vomiting
  • Hallucinations
  • Seizures
• Management of benzodiazepine dependence

  • For non-abusing patients with early/mild dependence, minimal interventions such as advisory letters or short courses of relaxation
  • For established dependence, graded discontinuation of prescribed benzodiazepine should be tried, with the goal of cessation after safe withdrawal
  • Carbamazepine may be used instead of benzodiazepines to control withdrawal symptoms from high doses of benzodiazepines
• Amphetamines


  Block catecholamine (DA & NEN especially) reuptake and stimulate their release from vesicles, e.g. methamphetamine, ritalin, dexedrine, atomoxetine, modafinil
• Intoxication effects of amphetamines

  • Tachycardia or bradycardia
  • Elevated or lowered blood pressure
  • Nausea or vomiting
  • Evidence of weight loss
  • Chest pain
  • Confusion
  • Seizures
  • Euphoria and impaired judgment
• Withdrawal effects of amphetamines

  • Dysphoric mood (crash) sometimes with suicidal ideation
  • Fatigue
  • Vivid, unpleasant dreams
  • Increased appetite
• Cocaine


  A powerful stimulant, an alkaloid derived from the coca plant, with a potent dopamine reuptake blockade effect
• Cocaine


  • The duration of cocaine's euphoric effects ('high') depends upon the route of administration, with faster absorption leading to more intense 'high'
• Intoxication effects of cocaine

  • Increased energy
  • Increased confidence
  • Diminished need for sleep
  • Agitation
  • Impaired judgment
  • Sensation of bugs crawling beneath the skin
• Withdrawal effects of cocaine

  • Intense cravings
  • Dysphoria (crash)
  • Anhedonia
  • Anxiety
  • Irritability
  • Hypersomnolence
  • Agitation
• Physical adverse effects of cocaine

  • Nasal perforation on snorting
  • Nonhemorrhagic cerebral infarctions
  • Subarachnoid, intraventricular hemorrhages
  • Seizures
  • Myocardial infarctions and arrhythmias
• The evidence supporting pharmacological treatment for amphetamine and cocaine dependence is weak, and psychosocial treatments such as cognitive behaviour therapy are most effective
• Inhalants


  Easily available, legal, and inexpensive substances, often solvents for glues and adhesives, propellants for aerosol sprays, and fuels
• Signs of inhalant intoxication

  • Dizziness
  • Nystagmus
  • Incoordination
  • Slurred speech
  • Unsteady gait
  • Lethargy
  • Psychomotor retardation
  • Tremor
  • Generalized muscle weakness
  • Blurred vision
  • Rashes around nose and mouth
  • Unusual breath odours
• No dependence syndrome or reliable withdrawal syndrome has been described for inhalants
• Other drugs of abuse

  • Androgenic and anabolic steroids
  • Clenbuterol
  • Chorionic gonadotrophin
  • Somatotropin
• Anabolic steroids


  • Associated with increased risk of aggression, violence, depression and endocrine abnormalities resulting in acne (~50%), testicular atrophy and/or gynaecomastia