Abused substances

Manic-like Mood liability Depersonalization/de realization Formication Hallucinations (non-specific) Ideas of reference Impulsiveness Inappropriate sexual behavior 

Paranoid delusions Paranoid ideation Distorted space/time perception Stereotyped behavior Synesthesias Non-specific anxiety Anxious Panic-like attacks Phobias 

Hypervigilance Impaired social/occupational skills Interpersonal sensitivity Psychomotor agitation/retardation Tension, anger 

More frequently observed symptom Less frequently observed symptom Practically not observed Can decrease 

Anxiety Appetite (decreased) Appetite (increased) Autonomic hyperactivity Autonomic hypoactivity Impaired concentration Delirium Dysphoria Diarrhea Dreams (unpleasant) Fatigue Fever 

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Cowley DS Alcohol abuse, substance abuse, and panic disorder. Am J Med 92(suppl) 41S 8S, 1992... 

Comparable findings for lifetime prevalence of psychiatric disorders were obtained in another study of 133 persons, which also found that 47% received a concurrent DSM-III diagnosis of substance abuse or dependence (Khantzian and Treece 1985). The most frequently abused substances were sedative-hypnotics (23%), alcohol (14%), and cannabis (13%). Similar rates of psychiatric disorders were found in other studies of drug abusers (Mirin et al. 1986 Woody et al. 1983). Although such diagnoses do not imply causality, and, in many cases, opioid dependence causes or exacerbates psychiatric problems, some causal link seems likely (Regier et al. 1990). 

Other anesthetics susceptible to abuse, such as ether and chloroform, have received far less attention, because they are considered to be less commonly abused substances. Nonetheless, when inhaled, ether and chloroform are also rapidly absorbed and distributed in the central nervous system (CNS), inducing a rapid euphoria. Ether and chloroform inhalation is facilitated by the fact that they have a low boiling point (i.e., approximately 34°C) (Delteil et al. 1974). 

SELF-ADMINISTRATION OF ABUSED SUBSTANCES METHODS FOR STUDY. 

Explain the commonalities of action of abused substances on the reward system in the brain. 

Virtually all abused substances appear to activate the same brain reward pathway. 

While activation of the reward pathways explains the pleasurable sensations associated with acute substance use, chronic use of abused substances resulting in both addiction and withdrawal may be related to neuroadaptive effects occurring within the brain. 

Individuals with a pattern of chronic use of commonly abused substances should be assessed to determine if they meet Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria for substance dependence (addiction). 

The abused substances covered in this chapter include nicotine, alcohol, cocaine, amphetamines, cannabis, and opioids. While many more substances can be and have been abused, these drugs are among the most popular. 

O Virtually all abused substances appear to activate the same brain reward pathway. Key components of the reward pathway are the dopamine (DA) mesocorticolimbic system that projects from the ventral tegmental area (VTA) and the nucleus accumbens (NA) to the prefrontal cortex, the amygdala, and the olfactory tubercle (Figs. 33-3 and 33-4).5 Animal studies... 

FIGURE 33-4. Where different abused substances interact with the reward system in the brain. Data from reference 5. (From h ttp //www.drugabuse.gov/pubs/Teaching/)... 

Unfortunately, unlike some medical diseases, substance dependence cannot be cured with medications alone. However, we can sometimes alleviate the effects of drug intoxication, attenuate the adverse effects of withdrawal, or use agents that may somewhat decrease craving for, and relapse to, abused substances. 

The intoxicating effects of opioids appear to be due to their action as agonists on mu (p) receptors of the opioid neurotransmitter system. Competitive p opioid antagonists such as naloxone and naltrexone acutely reverse many of the adverse effects of opioids. To date we do not have specific antagonists for most other abused substances, so rapid pharmacologic reversal of intoxication is usually not possible. 

Alterations in dopamine (DA) levels are associated with the rewarding effects of abused substances including cigarettes. Specifically, the mesolimbic DA pathway, which originates in the... 

Chiang CN and Hawks RL (eds) (1990). Research Findings on Smoking of Abused Substances (p. 72). National Institute on Drug Abuse, Bethesda, MD... 

The types of medical data that help accident investigations include (1) type and level of toxic or abusive substances in the blood, (2) location and magnitude of injuries, (3) type of poisoning (carbon monoxide, toluene, etc.), (4) signs of suffocation, (5) signs of heat exposure or heat exhaustion, and (6) signs of eye irritation. 

Epidemiological research suggests that probably 10 to 20% of the population of the United States may have problems related to substance use, with approximately 5 % of the population having problems with drugs other than alcohol (Substance Abuse and Mental Health Services Administration [SAMHSA], 2003). The most widely abused substances in the United States are alcohol, tobacco, and marijuana, but the typical pattern is for a person to abuse more than one substance at a time. An example might be that a person may smoke both cigarettes and marijuana, or may use both cocaine and heroin. 

Le Houezec J. (1998). Nicotine abused substance and therapeutic agent. J Psychiatry Neurosci. 23(2) 95-108. 

Substance-Induced Mood Disorder. Many prescription medications and abused substances cause depression (see Table 3.5). This idea is not new. In fact, recognizing that certain medications cause depression has helped us to understand the biology of depression better. 

As for abused substances, the question is usually, Which came first Is the alcoholic depressed because of his drinking or does he drink because he is depressed The answer is usually both. The key is that to treat one you must treat the other. Simply giving an antidepressant to a depressed substance abuser accomplishes little. 

The assessment of dysthymic disorder is identical to that nndertaken for MDD. Causative factors such as medical illnesses, depression-indncing medications, or abused substances must be ruled out. Mild depressive symptoms in the context of other psychiatric disorders must also be ruled out. 

Does applying the illness model to addiction provide a crutch for the addict In a word, no. When properly implemented, this model, in fact, readily explains the addict s vulnerability to abusing substances, predicts the course of illness should treatment either be sought out or not, and helps to guide rational therapy decisions that will increase the probability of keeping the illness in remission. 

Reward Therapy. A similar (yet nonspecific) approach is to use a medication that stimulates the brain s reward centers. Reward medications usually do not work in quite the same way as the substance of abuse however, the net effect in the final common pathway (i.e., the reward centers) may be the same. For the most part, these reward centers are activated by either dopamine or endogenous opioid agonists. One common feature of most abused drugs is that they stimulate these reward centers. This lies at the heart of their addictive potential. Some attempts have been made to use medications that activate these reward centers in place of the abused substance. The hypothesis is that the addict will have less intense craving for his/her preferred substance of abuse in the presence of these other agents. This is, of course, a relatively nonspecific approach that could theoretically be used to treat the abuse of many different substances. It has not yet, however, demonstrated any utility in the treatment of substance abuse. 

Abused Substance Medications Recommended During Each Treatment Stage ... 

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