IT 8 - MTK Drug Abuse

Gangguan Terkait Zat dan
Drug Abuse
Prof.Dr.dr.M T Kamaluddin,M.Sc.,SpFK
Bagian Farmakologi
Fakultas Kedokteran Unsri
2012
SUBSTANCE ABUSE
- What, why and how to

- Scope dealing with genetic and
environment
- How to handle
- Is there any chance for doctor to do..
Drug Abuse
Self administration of drug or

drugs in manner not in accord with
accepted medical or social
patterns
Six reasons why today drug use
and abuse is a serious problem
• since 1960 to the present, drug use,

and/or abuse has increased
dramatically
illicit drugs are more potent than in
the past
drugs have become commonplace
and a multibillion-dollar-a-year
business
Manjadda wajadda dr.Choiriah 4
Six reasons why today drug
use and abuse is a serious
problem
 drug use physically harms members
of society
 drug use and drug dealing by violent
gangs are steadily increasing at an
alarming rate
 serious accidents caused by drug
users is greater as people become
more dependent on technology
Biology/Genes Environment
DRUG
Neurobiology
Behavior
Manjadda wajadda
Addiction
dr.Choiriah 6
Rethinking the Social Environment: Integrating
Social and Genetic Epidemiology
Social Epi Genetic Epi

November 2002: Sum mer-Fall 2004:
Understanding the social Portfolio & literature review
epidemiology of drug abuse Fall 2004:
January 2007: Small m eeting
Special Supplem ent AJPM Spring 2005: Phenotype Special
Fall 2006: Neuroscience Issue JSA
Mapping the social environment
2007:
Recom mendations from
participants
?
Social Epi Transdisciplinary Meeting Genetic Epi
Future Initiative?
• A person’s social environment
includes their human relationships,
living and working conditions, income
level, educational background and
the communities they are a part of.
All of these are shown to have a
powerful effect on health.
Epidemiological Triad
Host
Drug Abuse
Social Agent/Vector
Environment
time/history
Berkman and Kawachi social epidemiology as the study of the distribution of health
outcomes and their social determinants. This definition builds on the classic
epidemiologic triangle [SWITCH TO SLIDE] of host, agent, and environment to focus
explicitly on the role of social determinants in disease transmission and progression.
Nancy Krieger
Manjadda describes these determinants
wajadda are the “features and pathways by 10
dr.Choiriah which
societal conditions affect health.
Biological explanations for
the use and abuse of drugs.
 Genetic theory
– predisposition to drug use can be
found in the gene structure
 “Addiction to pleasure”
 it is biologically normal to continue a
pleasure stimulation when drugs are
proven to be a pleasurable experience
Q. All the major biological explanations
related to drug abuse assume that
these substances exert their
psychoactive effects by altering brain
chemistry. Drugs of abuse interfere
with chemical messengers of the
brain called .
A. neurotransmitters
Q. It is generally believed that
most drugs with abuse potential
enhance the pleasure centers by
causing the release of what
specific brain neurotransmitter?
A. dopamine
Drugs can be “Imposters” of
Brain Messages

How are drugs able to affect brain
chemicals? Often, the chemical structure
of drugs is similar to brain chemicals or
neurotransmitters. Similarity in structure
allows them to be recognized by neurons
and to alter normal brain messages.
Illustrated in this slide is THC, the active
ingredient found in marijuana. It’s
chemical structure is highly similar to
anandamide, which is involved in a variety
of functions including regulation of pain,
appetite, memory, and mood.
Movement
Motivation
Dopamine
Addiction
Manjadda wajadda dr.Choiriah Reward & well-being21
Dopamine is a brain chemical
involved in many different
functions including movement,
motivation, reward — and
addiction. Nearly all drugs of abuse
directly or indirectly increase
dopamine in the pleasure and
motivation pathways and in so
doing, alter the normal
communication between neurons.
The Neuron: How the Brain’s
Messaging System Works
Dendrites
Cell body Axon

(the cell’s
life Terminal
support branches
center) of
Neuronal Impulse axon
Myeli
n
Manjadda wajadda
shea
dr.Choiriah 23
Donald Bliss, MAPB, Medical Illustration th
Neurons are the brain’s messaging system. How do they communicate
with each other? The brain consists of billions of neurons, or nerve cells,
that communicate via chemical messages. This is a schematic drawing of a
neuron. Towards the left of the diagram is the cell body, where
neurotransmitters are made. Extending outward from the cell body are
dendrites, which receive information from other neurons. When the cell body
is sufficiently stimulated, an electric pulse called an action potential is
generated and subsequently travels down the axon to the terminal region of
the cell. Fast transmission of this electrical message is aided by an insulator
material covering the axon called myelin. Once the impulse reaches the
nerve terminal, neurotransmitters, such as dopamine are released into the
synapse or gap between neurons. These chemicals can then attach to
receptors located on the dendrites of neighboring neurons, thus transmitting
information from one cell to the next within the brain and other parts of the
body. Some axons can travel a long distance, extending all the way from
your brain to your toes!

This slide and the one that follows show how
neurotransmission works specifically for
dopamine. What is schematically illustrated in this
slide is a nerve terminal (top), the synaptic cleft or
space between the neurons, and the post-synaptic
or receiving portion of a dendrite on a neighboring
neuron. Dopamine is contained in vesicles (round
storage sites) in the nerve terminal; dopamine
receptors are present on the receiving (bottom)
neuron.

dopamine
transporters

When a signal comes down the axon,
dopamine (shown in orange) is released
into the synapse. It then crosses the
synaptic cleft to the second neuron, where
it binds to and stimulates dopamine
receptors (shown in blue), generating a
signal in the second neuron. The dopamine
is then released from the receptor and
crosses back to the first neuron where it is
picked up by dopamine transporters
(reuptake molecules; shown in purple) for
re-use.

Natural Rewards Elevate
Dopamine Levels
Food Sex
DA Concentration (% Baseline)
200 200
NAc shell
% of Basal DA Output
150 150
100 100
Empty
50
Box Feeding
Female Present
0
0 60 120 180 Sample 1 2 3 4 5 6 7 8
Time (min) Number
Di Chiara et al., Neuroscience, 1999.,Fiorino and Phillips, J. Neuroscience, 1997.

Natural rewards stimulate dopamine
neurotransmission. Eating something that you
enjoy or being stimulated sexually can cause
dopamine levels to increase. In these graphs,
dopamine is being measured inside the brains of
animals. Its increase is shown in response to
food or sex cues. This basic mechanism of
controlled dopamine release and reuptake has
been carefully shaped and calibrated by
evolution to reward normal activities critical for
our survival.

But what happens when a person takes a drug? This
slide shows how cocaine is able to alter activity in the
synapse. Cocaine (shown in green), attaches to
dopamine transporters (shown in purple), thereby
blocking dopamine from being taken back up by the first
neuron. Thus dopamine can continue to stimulate
(maybe over-stimulate) the receptors of the second
neuron because it remains in the synapse for a longer
period of time. This duration of stimulation and amount of
dopamine in the synapse is far greater than what
normally occurs when a person engages in an enjoyable
activity (e.g., eating, sex, etc), and is what produces
cocaine’s intense euphoria and potential for abuse.

Effects of Drugs on Dopamine Release
Amphetamine Cocaine
1100 Accumbens 400 Accumbens
1000
% of Basal Release
900 DA
% of Basal Release
300 DOPAC
800 DA HVA
700 DOPAC
600 HVA 200
500
400
300 100
200
100
0 0
0 1 2 3 4 5 hr 0 1 2 3 4 5 hr
250 Nicotine Morphine

250 Accumbens
Dose
200
% of Basal Release
Accumbens 0.5 mg/kg
% of Basal Release
Caudate 200
1.0 mg/kg
150 2.5 mg/kg
150 10 mg/kg
100
100
0
0 1 2 3 hr 0
0 1 2 3 4 5 hr
Manjadda wajadda
Time After Drug dr.Choiriah 33
Time After Drug
Di Chiara and Imperato, PNAS, 1988
Nearly all drugs of abuse increase dopamine
neurotransmission. This slide shows the increase
in brain dopamine (DA) levels (measured in
animals) following exposure to various drugs of
abuse. All of the drugs depicted in this slide have
different mechanisms of action, however they all
increase activity in the brain reward pathway by
increasing dopamine neurotransmission. It is
because drugs activate these brain
regionsusually more effectively and for longer
periods of time than natural rewardsthat they
have an inherent risk of being abused.

But Dopamine is only Part of the
Story
• Scientific research has Dopamine is an important
shown that other brain chemical in drug abuse
neurotransmitter and addiction, but other brain
systems are also systems and brain chemicals
are also involved. Serotonin
affected:
and glutamate neurotransmitter
– Serotonin systems, for example, are
• Regulates mood, sleep, among those affected. These
etc.
neurotransmitters are important
– Glutamate regulators of mood, sleep,
• Regulates learning and learning and memory, and more.
memory, etc.

Brain pathways affected by drugs
of abuse. The dopamine and
serotonin pathways are two brain
systems affected by drugs of abuse.
They are illustrated here. By altering
activity in these pathways, abused
substances can influence their
function. Dopamine neurons (shown in
yellow) influence pleasure, motivation,
motor function and saliency of stimuli
or events. Serotonin (shown in red)
plays a role in learning, memory, sleep
and mood.
Genetic explanations for
contribution to drug abuse
vulnerability
 psychiatric disorders that are
genetically determined may be
relieved by drugs of abuse, this
encouraging their use
 in some people, reward centers of
the brain may be genetically
determined
Genetic explanations for
contribution to drug abuse
vulnerability
 character traits, such as insecurity
and vulnerability, may be genetically
determined
 factors that determine how difficult it
will be to break a drug addiction may
be genetically determined
Psychological explanations
for the use and abuse of
drugs.
 The American Psychiatric
Association classifies severe drug
dependence as a form of psychiatric
disorder.
 Drugs that are abused can cause
mental conditions that mimic major
psychiatric illnesses.
drugs.
Because of the similarities between,
and coexistence of, substance-
related and psychiatric disorders, it is
sometimes difficult to distinguish
between the two problems.

drugs.
 substance use (or abuse) disorder
can be identified by the presence of
the following features and their
associate criteria:
 substance dependence
– substance abuse
– substance intoxications
– substance withdrawal
drugs.
 personality and drug use
introversion extroversion

Bringing the
Full Power of Science
to Bear on
Drug Abuse
& Addiction

NIDA's mission is to lead the
nation in bringing the power of
science to bear on drug abuse
and addiction. Recent scientific
advances have revolutionized our
understanding of drug abuse and
addiction, which is now recognized
as a chronic relapsing brain disease
expressed in the form of compulsive
behaviors. This understanding has
improved our ability to both prevent
and treat addiction.

Neurotoxicity
AIDS, Cancer
Mental illness
Homelessness Health care

Crime Productivity
Violence
Manjadda wajadda dr.Choiriah
Accidents 46
The effects of drug abuse are wide
ranging and affect people of all ages.
Besides addiction, drug abuse is linked to
a variety of health problems, including
HIV/AIDS, cancer, heart disease, and
many more. It is also linked to
homelessness, crime, and violence.
Thus, addiction is costly to both
individuals and society.

What is Addiction?
Addiction is A Brain Disease
• Characterized by:
– Compulsive Behavior
– Continued abuse of drugs despite negative
consequences
– Persistent changes in dr.Choiriah
Manjadda wajadda
the brain’s structure and 48
function
Decades of research have revealed addiction
to be a disease that alters the brain. We now
know that while the initial decision to use drugs is
voluntary, drug addiction is a disease of the brain
that compels a person to become singularly
obsessed with obtaining and abusing drugs
despite their many adverse health and life
consequences.

Advances in science have
revolutionized our fundamental
views of drug abuse and
addiction.
Science has come a long way in helping us understand
how drugs of abuse change the brain. Research has
revealed that addiction affects the brain circuits involved in
reward, motivation, memory, and inhibitory control. When
these circuits are disrupted, so is a person’s capacity to freely
choose not to use drugs, even when it means losing
everything they used to value. In fact, the inability to stop is
the essence of addiction, like riding in a car with no brakes.

Your Brain on Drugs Today
YELLOW
shows places in
brain where
cocaine binds
(e.g., striatum)

Fowler et al., Synapse, 1989.
We can now measure the brain’s
response to drugs of abuse in real
time. This slide depicts images of a
human brain taken at different intervals
following administration of radioactive
cocaine. Because the drug was
“radiolabeled,” scientists can see precisely
where cocaine binds in the brain (yellow
signal) and for how long. Studies such as
these teach scientists more about how
cocaine exerts its devastating effects, and
can illustrate to people in real time what
happens to their brains on drugs.

Addiction is Like Other Diseases…
 It is preventable
 It is treatable
 It changes biology
 If untreated, it can last a lifetime
Decreased Brain Metabolism Decreased Heart Metabolism
in Drug Abuser in Heart Disease Patient
High
Low
Healthy Brain Diseased Brain/ Healthy Diseased Heart
Cocaine Abuser Heart
Research supported by NIDA addresses all of these

components of addiction.
Addiction Involves Multiple Factors

Addiction Is A Developmental Disease
that starts in adolescence and childhood
1.8%
1.8%
TOBACCO
develop first-time dependence
1.6%
1.6% CANNABIS
% in each age group who
1.4%
1.4% ALCOHOL
1.2%
1.2%
1.0%
1.0%
0.8%
0.8%
0.6%
0.6%
0.4%
0.4%
0.2%
0.2%
0.0%
0.0%
55 10
10 15
15 21
21 25
25 30
30 35
35 40
40 45
45 50
50 55
55 60
60 65
65
Age
Age at tobacco, alcohol, and cannabis dependence per DSM IV

National Epidemiologic Survey on Alcohol and Related Conditions, 2003.
definition of drug dependence
• Unusual mental state
• Constraint
• Continuity or regularity
• mental effect
• to avoid malaise
• toleration

• Narrow definition of drug abuse:
psychological dependence
physiological dependence
mental disorder
aberrant behavior

Key Concepts and Terms
• physical dependence/ physiological

dependence
• psychic dependence/ psychological
dependence
• cross-dependence

Danger signals of drug
abuse
 Do those close to you often ask
about your drug use? Have they
noticed any changes in your
moods or behavior?
 Are you defensive if a friend or
relative mentions your drug or
alcohol use?
 Are you sometimes embarrassed or
frightened by your behavior
Effects on society
• National health problem
• More deaths,illness,accidents,disabilities than
any other health problem
• 15 million dependent on alcohol
• 500,000 between ages 9-12
• 7 million persons between 12-20
binge drink
(Narconon,2005)

Effects on the family
• # of babies born with physiologic &
emotional consequences of crack &
alcohol ---Increasing at an alarming rate
• 43% of US families exposed to alcoholism
• 50% persons who seek tx have at least
one parent w/ alcoholism hx.

Culture and Substance abuse
• Attitudes vary in cultures
• Muslims – no alcohol consumption
• Jewish – use wine for religious rites
• Native Americans – use payote (religious
ceremonies)
• Genetic traits found – predispose or
protect
• Flushing reaction – Asians
Genetics & substance abuse
• Variations is structure & activity levels of
enzymes involved in metabolism of ETOH
• Variations among Asians, Africian Americans
and whites
• Japanese – enzyme produces faster elimination
of alcohol
• Native Americans- etoh use –one of five leading
causes of death(75% accidents)
• Japan – ETOH consumption quadrupled since
1960

Effects of addiction
• Abuse
• Tolerence
• Physical dependence - addiction
• Psychologic dependence –mind-body
connection
• Alcoholism – chronic progressive
potentially fatal
• Blackouts

WHO classification
• Suppressant of central nerve
• Nicotine or tobacco
• Opioid
• antimelancholic
• cannabis
• hallucinogenic drug
• Fugitive compound

drug tolerance
Definition
• Repeated medication
Characteristic
• Different tolerance
• Reversability
• Cross resistance :
analogic chemcial constitution
mechanism of action
• drug dependence toleration

Classification of drug to cause
dependence
• narcotic drug
• psychotropic drug

Narcotic drug
• Consecutive application to bring about

physiological dependence and addiction
• Including:
• opioids, cocaine, cannabis

psychotropic drug
Definition
• Repeated medication,
• Affect C.N.S excited/inhibited
• to bring about psychological dependence
（1） Sedativehypnotics / antianxietic:
Barbiturates, benzodiazepines
（2） psychostimulant ：
Amphetamines, ritalin, caffeine
（3）psychodelic ：
Cannabinol, cannabidiol

Appearance of drug dependence
• Craving re-medication
• Constraint drug seeking behavior
• Withdrawal reaction

Characteristic of drug
dependence
Opioid
• discontinuation 8-16h, 24-36h
Suppressant of central nerve
• Benzodiazepine withdrawal 36h
• Barbiturates withdrawal 12-24h
Cannabis
Antimelancholic
#phenamine
#Cocaine

Disservice of drug abuse
Individual
• physical and mental health
• Intoxation death
• immunity infection
Society
• Common family life destroy
• Criminality
• hold-back development

Control of drug abuse
• International
• 1961 convention
• 1971 convention
• 1981 strategy
• National
• institute system
• Education
• medical establishment of withdrawal
Drug Abuse
• Psychological Dependency (Habituation)
– Drug necessary to maintain user’s sense of
well-being
• Physical Dependency
– Physical symptoms if intake reduced

Drug Abuse
• Compulsive Drug Use
– Preoccupation with obtaining drug
– Rituals of preparing, using drug as
important as drug effects
• Tolerance
– Increasing doses needed to obtain drug
effect

Drug Abuse
• Addiction
– Includes
• Psychological dependence
• Physical dependence
• Compulsive use
• Tolerance
– Plus, complete absorption with obtaining,
using drug to exclusion of all else

Drug Abuse
• Suspect drug-related problem in patients
with:
– Altered LOC
– Bizarre behavior
– Seizures

Drug Abuse
• Ask EVERY patient about recreational drugs.
• Be non-judgmental.
• Keep drug box/cabinet secured.
• Use discretion.
• If held up, give them what they want!

Narcotics
• Opium
• Opium derivatives
• Synthetic opium substitutes

Narcotics
• Examples
– Opium
– Oxycodone
– Morphine
(Percodan)
– Heroin
– Meperidine (Demerol)
– Codeine
– Propoxyphene
– Dilaudid (Darvon)
– Talwin
– Fentanyl

Narcotics
• Effects
– Analgesia
– CNS depression
• Euphoria
• Drowsiness
• Apathy
– Antidiarrheal action
– Antitussitive action

Narcotics
• Overdose
– Mild to Moderate  Severe
• Lethargy  Respiratory depression
• Pinpoint pupils  Coma
• Bradycardia  Aspiration
• Hypotension  Seizureswith certain

• Decreased compounds (meperidine,
bowel sounds propoxyphene, tramadol)
• Flaccid muscles

Narcotics
• Overdose
– Management
• Support oxygenation/ventilation
• Vascular access
• D50W 50cc
• Narcan 0.4 to 2.0 mg
–Improve respirations
–Do NOT awaken completely
–Restrain before giving
Narcotics
• Associated Dangers
– Skin abscesses – Adulterant toxicity
– Phlebitis – “Cotton fever”
– Sepsis – Malnutrition
– Hepatitis – Tetanus
– HIV – Malaria
– Endocarditis

Narcotics
• Withdrawal
– Insomnia – Watery eyes
– Restlessness – Yawning
– Irritability – Rhinorrhea
– Anorexia – Sneezing
– Tremors – Diarrhea
– Back, extremity pain – Diaphoresis
Resembles Severe Influenza

Narcotics
• Withdrawal
– Lasts 7 to 10 days
– NOT life threatening

Sedative-Hypnotic Drugs
Categories
• Barbiturates
• Benzodiazepine
• Barbiturate-like non-barbiturates
• Chloral hydrate

Mechanism of Action
• Most overdoses of sedative-hypnotics are
from benzodiazepines, barbiturates
• Both enhance effects of gamma-
aminobutyric acid (GABA)
• GABA enhancement results in down-
regulation of CNS activity

Sedative-Hypnotics
• Use more then a week leads to tolerance
to effects on sleep patterns
• Withdrawal after long term results in
“rebound” increase in frequency of
occurrence, duration of REM sleep.
• In high doses, sedative-hypnotics depress
CNS to point of Stage III or general
anesthesia

Sedative-Hypnotics
• Tolerance
– Happens with all sedative-hypnotics
– Appears very quickly even during short-
term use.
– Discontinuation will bring receptor
response back to normal after drug has
been metabolized
– Withdrawal symptoms may take up to a
week to see in some patients
Chloral hydrate
• “Micky Finn” when mixed with alcohol
• Rapidly absorbed, acts quickly
• Drowsiness, sleep
• Alcohol, chloral hydrate compete for
metabolism by same enzyme
• Prolonged action for both when mixed
• Not commonly abused
Barbiturates
• Introduced in 1903
• Replaced older sedative-hypnotics
• Quickly became major health problem
• In 1950’s-60’s barbiturates were
implicated in overdoses; were responsible
for majority of drug-related suicides

Barbiturates
• Short-acting
– Amytal
– Pentathiol
• Intermediate-acting
– Nembutal
– Seconal
– Tuinal
• Long-acting
–
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Phenobarbitaldr.Choiriah 94
Barbiturates
• Initial overdose presentation
– Slurred speech
– Ataxia
– Lethargy
– Nystagmus
– Headache
– Confusion

Barbiturates
• As overdose progresses
– Depth of coma increases
• Patient anesthetized with loss of neurologic
function
• EEG may mimic brain death
– Respiratory depression occurs
– Peripheral vasodilation occurs
• Hypotension, shock
• Hypothermia
– Blisters (bullae) form on skin
Barbiturates
• Early deaths
– Respiratory arrest
– Cardiovascular collapse
• Delayed deaths
– Acute renal failure
– Pneumonia
– Pulmonary edema
– Cerebral edema
Barbiturates
• Overdose management
– Secure airway
– Support oxygenation/ventilation
– IV with LR or NS
– Prevent heat loss secondary to
vasodilation
– Bicarbonate to alkalinize urine (long-acting
only)

Barbiturates
• Withdrawal signs/symptoms
– Apprehensiveness
– Anxiety
– Tremulousness
– Diarrhea
– Nausea
– Vomiting
– Seizures
Barbiturate-like, non-
barbiturates
• Examples
– Doriden (glutethimide)
– Quaalude (methaqualone)
– Placidyl (ethchlorvynol)
– Noludar
• Overdose produces sudden, prolonged
apnea
• Highly addictive
• Withdrawal resembles barbiturate withdrawal
• Only Placidyl, Doriden remain available in
U.S.
Placidyl (ethchlorvynol)
• “Pickles”, “jelly beans”, “Mr. Green Jeans”
• Produces vinyl-like odor on breath
• Concentrates in CNS, slow hepatic
metabolism
• Half-life >100 hrs
• Prolonged deep coma (100 to 300 hrs),
hypothermia, respiratory depression,
hypotension, bradycardia
• EEG is flatline
• Keep patient on life support for a few days;
they wake up, are ok
Doriden (gluthethimide)
• Abused in combination with codeine
• “sets”, “hits”, “loads”, “fours and doors”
• Prolonged coma (average 48 hours)
• Hypotension, shock common
• Anticholinergic signs: dilated pupils,
tachycardia, dry mouth, ileus, urinary
retention, hyperthermia

Benzodiazepines
• Developed due to overdoses, deaths
related to barbiturates, barbiturate-like
non-barbiturates
• Relatively few deaths
• In 1993, prescription rate for
barbiturates dropped to one-sixth that of
benzos

Benzodiazepines
• Examples
– Valium (diazepam)
– Ativan (lorazepam)
– Versed (midazolam)
– Librium (chlorodiazepoxide)
– Tranxene (chlorazepate dipotassium)
– Dalmane (flurazepam)
– Halcion (triaxolam)
– Restoril (temazepam)
Benzodiazepines
• Adverse Effects
– Weakness
– Headache
– Blurred vision
– Vertigo
– Nausea
– Diarrhea
– Chest pain

Benzodiazepines
• Overdoses
– Relatively safe taken by themselves, even in
overdose
– Can be lethal with other CNS depressants
especially alcohol
– Look like other CNS depressant overdoses
– Antidote is Romazicon ( flumazenil )
• Only recommended in known, controlled
situations
• Can lead to seizures that cannot be controlled

Benzodiazepines
• Produce withdrawal syndrome similar to
barbiturate withdrawal

Benzodiazepine-like non-
benzos
• BuSpar (buspirone)
– Used for generalized anxiety disorder
– Less sedating than diazepam
– Less potentiation by other CNS depressants
• Ambien, Stilnox (zolpidem)
– Used for short-term insomnia treatment
– Toxic effects similar to benzos

Neuroleptics
• Antipsychotics, major tranquilizers
• Used in treatment of schizophrenia,
other psychoses
• Examples
– Haldol
– Mellaril
– Thorazine
– Stellazine
– Compazine
Neuroleptics
• Extrapyramidal muscle contractions
(dystonias)
– Bizarre, acute, involuntary movements,
spasms of skeletal muscles
– Reversible with Benadryl

Neuroleptics
• Acute Overdose Presentation
– CNS depression
– Hypotension
– Anticholinergic symptoms: flushing, dry
mouth, hyperthermia, tachycardia, urinary
retention
– Ventricular arrhythmias, including
Torsades
– Seizures
Neuroleptics
• Acute Overdose Management
– ABCs
– Fluid, vasopressors for hypotension
– Lidocaine, phenytoin for ventricular
arrhythmia
– Magnesium, isoproterenol for Torsades
– Benzodiazepines, phenobarbital for
seizures

Neuroleptics
• Neuroleptic malignant syndrome
– Life-threatening reaction
– Signs, symptoms
• Hyperthermia
• Muscular rigidity
• Altered LOC
• Tachycardia, hypotension

Neuroleptics
• Neuroleptic malignant syndrome
– Management
• ABCs
• Oxygen
• Assist ventilation, as needed
• Benzodiazepines
• Rapid cooling
• Volume for hypotension

Stimulants
• Examples
– Cocaine
– Amphetamines
• Benzedrine (bennies)
• Dexedrine (dexies, copilots)
• Methamphetamine (ice, black beauties)
– Ephedrine
– Caffeine
– Ritalin
Stimulants
• Produce
– euphoria
– hyperactivity
– alertness
– sense of enhanced energy
– anorexia

Stimulants
• Overdose signs/symptoms
– Euphoria, restlessness, agitation, anxiety
– Paranoia, irritability, delirium, psychosis
– Muscle tremors, rigidity
– Seizures, coma
– Nausea, vomiting, chills, sweating,
headache
– Elevated body temperature
– Tachycardia, hypertension
– Ventricular arrhythmias
Stimulants
• Overdose complications
– Hyperthermia, heat stroke
– Hypertensive crisis
– CVA
– Acute MI
– Intestinal infarctions
– Rhabdomyolysis
– Acute renal failure

Stimulants
• Chronic effects
– Weight loss
– Cardiomyopathy
– Paranoia
– Psychosis
– Stereotypic behavior: picking at skin
(“cocaine bugs”)

Stimulants
• Overdose management
– Oxygen, monitor, IV
– Activated charcoal for decontamination in
first hour
– Valium for sedation
– Hypertension control
• Nipride
• Phentolamine
• Avoid beta-blockers, including labetolol (Why?)
– Body temperature reduction
Stimulants
• Withdrawal
– Drowsiness
– Profound depression (“cocaine blues”)
– Increased appetite
– Abdominal cramps, diarrhea, nausea
– Headache

Hallucinogens
• Examples
– Indole hallucinogens – Amphetamine-like
• LSD (acid) hallucinogens
• Morning-glory • Peyote
seeds • Mescaline
• Psilocybin • DOM
• DMT • MDA
• MDMA (ecstasy)

Hallucinogens
• Produce altered/enhanced sensation
• Effects highly variable depending on
patient
• Increased dose does not intensify effect
• Toxic overdose virtually impossible

Hallucinogens
• Some patients may experience “bad
trips”
• Depends on surroundings, emotional
state
• Signs and symptoms
– Paranoia, fearfulness, combativeness
– Anxiety, excitement
– Nausea, vomiting
– Tachycardia, tachypnea
– Tearfulness
– Bizarre Reasoning
Hallucinogens
• Moderate Intoxication
– Tachycardia
– Mydriasis
– Diaphoresis
– Short attention span
– Tremor
– Hypertension
– Hyperreflexia
– Fever

Hallucinogens
• Life-threatening toxicity (rare)
– Seizures
– Severe hyperthermia
– Hypertension, arrhythmias
– Obtunded, agitated, or thrashing about
– Diaphoretic, hyperreflexic
– Untreated hyperthermia can lead to hypotension,
coagulopathy, rhabdomyolysis and multiple organ
failure

Hallucinogens
• Management of “bad trip”
– Rule out other causes of hallucinations
• Hypoglycemia
• Alcohol, drug withdrawal
• Infection
– Quiet, supportive environment
– Benzodiazepines, haldol for agitation,
anxiety

Phencyclidine (PCP)
• Street names
– Angel dust
– Peace Pill
– Hog
– Krystal
– Animal tranquilizer
• Used as veterinary anesthetic

Phencyclidine (PCP)
• Actions
– Dissociative anesthesia
– Generalized loss of pain perception
– Little or no depression of airway reflexes or
ventilation
– CNS-stimulant, anticholinergic, opiate, and
alpha-adrenergic effects

Phencyclidine (PCP)
• Low Doses
– Lethargy, euphoria, hallucinations
– Slurred speech
– Blank stare
– Insensitivity to pain
– Midposition to dilated pupils
– Vertical and horizontal nystagmus
– Occasionally bizarre or violent
behavior
Phencyclidine (PCP)
• High Doses
– Diaphoresis • Localized dystonic
– Salivation reactions
– Hypertension • Wide-eyed coma
– Tachycardia • Rigidity
– Hyperthermia • Seizures

Phencyclidine (PCP)
• Treatment
– Maintain airway
– Assist ventilations, as needed
– Treat coma, seizures, hypertension,
hypothermia as needed
– Quiet environment
– Sedation if needed to control agitation
• Haldol
• Benzodiazepines
Inhalants
• Examples
– Hydrocarbons (solvents, paints, aerosols)
– Gases (freon, halon fire extinguishing
agent)
– Metallic paints (“huffing”)

Inhalants
• Effects
– Dysrhythmias including VF
– CNS depression
– Seizures
– Respiratory irritation
– Epinephrine may increase risk of
dysrhythmias
• Treatment
– Oxygen
– Treat symptomatically
“Date rape” drugs
• Flunitrazepam (Rhohypnol)
• Gamma hydroxybutyrate

Flunitrazepam (Rhohypnol)
• Street names
– Rophies – Roche
– Roofies – Roachies
– R2 – La rocha
– Roofenol – Rope
– Rib

• Benzodiazepine
• Similar to Valium but 10x more potent
• Produced, sold legally in Europe, South
America
• Uses
– Short-term treatment of insomnia
– Sedative hypnotic
– Preanesthetic medication

• Effects
– Disinhibition and amnesia
– Onset within 30 minutes, peak within 2
hours, may persist 8 hours or more
– Frequently abused with alcohol or other
drugs
– Enhances high produced by heroin

• Adverse Effects
– Drowsiness
– Dizziness
– Confusion
– Decreased BP
– Memory impairment
– GI disturbances
– Excitability, aggressive behavior

• Management of overdose
– Lethal overdose very unlikely
– Oxygenate, ventilate
– Intubate if necessary to control airway
– Vascular access
– ECG
– Fluid for hypotension
– Dextrostick (rule out hypoglycemia)
– Treat trauma resulting from assault
• Withdrawal
– Headache – Hallucinations
– Anxiety, tension – Delirium
– Numbness, tingling – Seizures (up to a
of extremities week after cessation)
– Restlessness, – Shock
confusion – Cardiovascular
– Loss of identity collapse

• Management of withdrawal
– Oxygen/ventilation
– Intubate if necessary
– EKG
– Vascular access
– Fluid for hypotension
– Dextrostick
– Diazepam for seizures

Gamma hydroxybutyrate
• Street names
– Cherry meth
– Liquid X
– Liquid ecstacy
• Originally developed as anesthetic
• Banned in 1991 because of side effects
• Promoted as aphrodisiac

Gamma hydroxybutyrate
• Effects
– Odorless, nearly tasteless
– Tremors
– Seizures
– Death

Alcohol and other drugs are
associated with:
• Up to 50% spousal abuse
• 50% traffic accidents
• 49% murders
• 68% manslaughter charges
• 69% drownings
• 38% child abuse
• 52% rapes
• 62% assaults
• 20-35% suicides
(Johnson-1997)
Similarities & Differences
Alcohol
Intended effect Intoxication W/d – detox
Alcohol- CNS Slurred 4-12n hrs. p last
Depressant/relax- speech;loss of drink
ation, loss of coordination; Course hand
inhibition ataxia; decreased tremor,sweating
coordination,  T, P,B/P, R
attention/concen-
tration, memory Insomnia, anxiety,
N/V –
judgment
If no tx.= DT’s 146
Sedatives /Hypnotics
Anxiolytics
Induced effect Intox-OD W/d –detox
Benzodiazapines Benzo’s rarely Ativan-10 hrs
& Barbituates fatal when taken W/d sx’s-6-8 hrs
Use: to produce alone; sx’s = p last dose
Drowsiness, Lethergy, Valium –w/d up
 anxiety Confusion; to 1 wk
Barb’s –fatal in W/d= v/s
OD-coma,resp – Need to taper off
cardiac arrest drug
Stimulants
amphetamines/cocaine
Intended effect Intox- OD W/d – detox
Excite – CNS High-euphoric Occurs-few hrs-
Limited clinical feeling;hyper- days
use – high abuse activity/vigilance C/b marked
potential Talkativeness, dysphoria;
Cocaine-highly grandiosity,hallucin fatigue; vivid &
addictive ations, anxiety unpleasant
Repetitive dreams; hyper or
behaviors, anger , insomnia;
Manjadda wajadda fightingdr.Choiriah psychomotor act.
148
Opioids: morphine,
heroin,meperidine,codeine,hydromorphone,
Induced effect Intox – OD W/d detox
Popular for Intox- develops Drug intake ceases
abuse – quickly c/b apathy, or  markedly; c/b
desensitize user lethergy,listlessness, anxiety/restless.,
to both judgment, psycho- aching back,legs,
physio/psych motor retardation or craving for opioids
pain-induce agiation, constricted
euphoria, well- pupils,slurred speech Heroin –w/d
being Severe o d coma, 6-24 hr;
Resp. arrest/death peak 2-3 days;
Manjadda wajadda dr.Choiriah Ends=5-7 days149
Hallucinogens
Intended Intoxification/OD Withdrawal/Detox
effect Intox= (Psychologic) No withdrawal
Distort users anxiety,depression, symptoms known
perception of Paranoid delusions, -may crave drug
reality hallucinations Produce flashbacks
(Physio)  B/P,T,P May continue up to
dilated pupils,sweating, 5 years after use.
blurred vision,tremors,
decreased coordination
Pharmacologic treatment
substance abuse
• Disulfiram(antabuse)-maintain abstinence
from alcohol
• Teach client to read all labels – avoid any
product containing alcohol
• Lorazepam(ativan) – for w/d fro etoh
Monitor V/S/client safety/assess
effectiveness

Pharmacologic treatment
• Clonidine(catapres) –suppresses opiate
withdrawal symptoms –check B/P prior to
administration – withhold if hypotensive
• Thiamine(vitamin B1) Folic acid (folate),

B12 = tx nutritional deficiencies – teach re:
proper nutrition; darkened urine may result
w/folate.

prevention and cure
Insulate to withdrawal
Substitution therapy
Barbiturates：Phenobarbital
Alcohol：clormethiazole；clorazepate
Opioid：methadone；

Substitution therapy of methadone
• pharmacologic action of methadone
• methadone 1mg
morphine 4mg; heroinreplace
2mg; dolantin 20mg
① detoxification
②convalescent care

Therapy of clonidine
pharmacologic action of clonidine:

• Excitomotor ofα2 adrenoceptor
• Inhibit NC excitation of NE nucleus ceruleus
• to control abstinent symptom
• therapy
① detoxification
②convalescent care

Therapy of the drug abuse
• Detoxification
• to prevent relapse
• Return to social life

The Impact of Addiction Can Be Far
Reaching
•Cardiovascular disease
•Stroke
•Cancer
•HIV/AIDS
•Hepatitis B and C
•Lung disease
•Obesity
•Mental disorders

Continued drug abuse- a voluntary behavior?
The initial decision to take drugs is mostly voluntary.

However, when drug abuse takes over, a person's ability to
exert self control can become seriously impaired. Brain
imaging studies from drug-addicted individuals show
physical changes in areas of the brain that are critical to
judgment, decision making, learning and memory, and
behavior control. Scientists believe that these changes alter
the way the brain works, and may help explain the
compulsive and destructive behaviors of addiction.

How Does the Brain Become Addicted?
Typically it happens like this:

•A person takes a drug of abuse, be it marijuana or cocaine or
even alcohol, activating the same brain circuits as do behaviors
linked to survival, such as eating, bonding and sex. The drug
causes a surge in levels of a brain chemical called dopamine,
which results in feelings of pleasure. The brain remembers this
pleasure and wants it repeated.
•Just as food is linked to survival in day-to-day living, drugs

begin to take on the same significance for the addict. The need to
obtain and take drugs becomes more important than any other
need, including truly vital behaviors like eating. The addict no
longer seeks the drug for pleasure, but for relieving distress.
How Does the Brain Become Addicted?
•Eventually, the drive to seek and use the drug

is all that matters, despite devastating
consequences.
•Finally, control and choice and everything that

once held value in a person's life, such as
family, job and community, are lost to the
disease of addiction.

Repeated drug exposure changes brain function. Positron emission tomography (PET) images are illustrated showing similar brain
changes in dopamine receptors resulting from addiction to different substances - cocaine, methamphetamine, alcohol, or heroin. The
striatum (which contains the reward and motor circuitry) shows up as bright red and yellow in the controls (in the left column), indicating
Manjadda
numerous wajadda
dopamine dr.Choiriah
D2 receptors. Conversely, the brains of addicted individuals (in the right column) show a less intense signal, 161
indicating lower levels of dopamine D2 receptors.
Source: From the laboratories of Drs. N. Volkow and H Schelbert
Addiction is similar to other diseases, such as heart disease.

Both disrupt the normal, healthy functioning of the
underlying organ, have serious harmful consequences, are
preventable, treatable, anddr.Choiriah
Manjadda wajadda if left untreated, can last a lifetime. 162
No single factor determines whether a person
will become addicted to drugs
Scientists estimate that genetic factors account for 40-60% of a person’s
vulnerability to addiction including the effects of environment on these factors
The influence of the home environment is usually most important in childhood.

Parents or older family members who abuse alcohol or drugs, or who engage in
criminal behavior, can increase children's risks of developing their own drug
problems
The earlier a person begins to use drugs the more likely they are to progress to
more serious abuse
Method of administration. Smoking a drug or injecting it into a vein increases its

addictive potential
Some people will never develop diabetes because they never go over a certain
weight –much like some people will never become drug dependent because they
never try drugs. If they did they would in both cases

Does drug abuse cause mental disorders, or vice versa?
Drug abuse and mental disorders often co-exist. In

some cases, mental diseases may precede
addiction; in other cases, drug abuse may trigger or
exacerbate mental disorders, particularly in
individuals with specific vulnerabilities.

2004 National Survey on Drug Use and Health found that
the percentage of the nation's estimated 600,000 monthly
meth users who met the criteria for dependence rose from
27.5 percent (164,000) in 2002 to 59.3 percent (346,000)
in 2004
• The first meth epidemic occurred in Japan following
WWII when the government released large stockpiles of
meth that had been held for use by factory workers during
the war
• Amphetamines were used by Allied and Axis armed forces
during WWII and 1991 Operation Desert Storm
• In Japan, meth use has surpassed that of all other drugs -
meth users exceed users of all other substances combined
• Worldwide, amphetamine and methamphetamine are the
most widely abused illicit drug after cannabis- more use
than cocaine or heroin
• From the WHO- over 35 million individuals regularly
use/abuse amphetamine/meth
• As of 2003, according to the National Survey on Drug Use
and Health, 12.3 million Americans had tried meth at least
once -up nearly 40% over 2000 and 156% over 1996
Methamphetamine – The Drug
• Speed, Ice, Meth, Crystal, Crank

• Clandestine labs
• Easily synthesized
• Readily obtainable
• Sold through networks
• Abusers range widely in age, educational level,
socioeconomic status and ethnic background

Forms of Meth
Speed usually comes in the form of white or yellow powder
People usually sniff it through the nose (snort), smoke or inject it.
It can also be swallowed, in the form of tablets or capsules
Speed is often mixed or ‘cut’ with other things that look the same to make the
drug go further
Some mixed-in
Manjadda wajadda substances can have dr.Choiriah
unpleasant or harmful effects 169
ICE
•Making ice, the smokable form of methamphetamine, from standard quality
methamphetamine HCl is essentially a purification process. Methamphetamine HCl is
added slowly to water that has been heated 80-100°C until a supersaturated solution is
obtained. When the slurry is cooled, pure HCl salt of methamphetamine (ice)
precipitates. Methamphetamine HCl, unlike cocaine HCl, is volatile and can be
smoked. Other solvents, such as isopropanol, have been used in place of water to
speed the process. Uncontrolled variations of this process can result in unreliable
removal or addition of impurities. The physical characteristics of the final product
depend on the quality and type of reagents used and on contaminants that may have
been introduced. The lack of significant further processing of methamphetamine HCl
has resulted in increased availability and popularity of smoking the drug.
•One reason for the popularity of smoked methamphetamine is the immediate
clinical euphoria that results from the rapid absorption in the lungs and deposition
in the brain.
•Smoking methamphetamine HCl powder, crystals, or ice occurs first by placing
the substance into a piece of aluminum foil that has been molded into the shape of
a bowl, a glass pipe, or a modified light bulb and heating it over the flame of a
cigarette lighter or torch. Then, the volatile methamphetamine fumes are inhaled
through a straw or pipe.
From emedincine.com
Methamphetamine
• Toxicity: Moderate • Powerful CNS

• Flammability: Low stimulant
• Reactivity: Very Low • Highly addictive
• Usually smoked or
OH
injected
CHCHNHCH 3
CH
• “High” lasts longer
3
EPHEDRINE than cocaine
CH CHNHCH
2 3
• Prescribed for weight
CH
3
METHAMPHETAMINE
loss, ADD-type
behaviors
Atlanta DEA Seizes Record Amount
of Crystal Meth
…large-scale Mexican drug ring with
members believed to be in the Atlanta
area, involving importation and
distribution of multi-kilogram quantities
of methamphetamine and cocaine from
Mexico, moved through California and
Texas, distributed into the United States…
…41 kilograms of suspected cocaine and
in excess of 187 pounds of suspected
crystal methamphetamine…

How is Methamphetamine Used?
• May be smoked, snorted, orally ingested,

injected or used rectally or vaginally
• Alters moods in different ways depending
on how it is taken

Acute Positive Effects of Meth
• Well-being to Euphoria
• Increased Energy
• Enhanced Mental Activity
• Increased Sex Drive
• Decreased Need for Sleep
• Decreased Appetite
• Increased Sensory Awareness and Alertness
• Feeling of Omnipotence
• Intensify Emotions
• Alter Self-esteem
• Increased aggressiveness
Reasons for First Use of Methamphetamine March 1998- Nov 1998
• Easily Available (strongest reason)

66% females 59% males
• 2nd reported reason

Females: to be more productive
Males: curiosity
• Males more likely because parents use drugs

Review article M. Cretzmeyer, et al J. Substance Abuse Treatment
24(2003) 267-277
Binge Pattern of Abuse Cycle
HIGH (4-16 hrs.)
RUSH
(5-30 Min.) BINGE (3-15 Days )
TWEAKING
(4-25 Hours)
NORMAL NORMAL
(2-14 Days)
WITHDRAWAL
(30-90 DAYS)

CRASH 176
Meth vs. Cocaine
• Man-made • Plant-derived
• Daily use • Recreational use
• Longer binges • Intermittent binges
• Smoking produces • Smoking produces
a high that last 8-24
hours a high that lasts 20-
30 minutes
• 50% of the drug is
removed from the • 50% of the drug is
body in 12 hours removed from the
body in 1 hour
Meth vs. Cocaine Effects on the Brain
Cocaine
Methamphetamine

Measuring Pleasure
Stimulants boost the normal brain levels of the neurotransmitter
dopamine, which produces feelings of pleasure and increases
energy. Methamphetamines causes an excessive spike in
dopamine. Scientists say the excessive release contributes to the
drug's destruction of the brain.
Dopamine Index
Cheeseburger 1.5
Sex 2.0
Nicotine 2.0
Cocaine 4.0
Methamphetamine 11.0
Source: UCLA Integrated Substance Abuse Programs. Michael Mode/The Oregonian
Effects of Methamphetamine Use on the Brain
• Direct dopamine effects: • Suspected serotonin effects:

– Changes in mood – Increase feelings of
– Excitation empathy
– Intensification of – Feelings of closeness
emotions
– Bizarre mood changes
– Elevation of self esteem
– Psychotic behavior
– Sensory perception
– Decreased appetite – Aggressiveness
– Elevation of libido – Bruxism
– Unusual motor – Lack of appetite
movements – Inability to sleep
–Manjadda
Paranoia
wajadda dr.Choiriah 180
Depleted dopamine
transporter levels in
methamphetamine
abusers show recovery
after prolonged
abstinence.
In these brain scans,
high dopamine
transporter levels appear
as red, while low levels
appear as yellow/green.
Dr. Nora Volkow, Director of
NIDA
(National Institute on Drug
Abuse)
Brain Changes with Meth Use
PET scans comparing control, Meth users with 6 mo-5 years

abstinence, and patients with Parkinson’s Disease, showing
decreased dopamine transporter activity in the caudate and
putamen. 25% decrease for Meth users, and 60% for PD.
(McCann 1998)
Cognitive Deficits
• Axons don’t always grow back correctly

• Different parts of brain recover at different rates
• Impairment of word and picture recall
• Impaired ability to manipulate information
• Ignore information
• Inability to filter irrelevant information
• Studies show impairment worse at 12 weeks
of non-use than is evident in current user
• Word recall gets worse, picture recall gets
better
Neurotransmitter Depletion

Behavior Changes –
Psychotic Features
• Paranoia
• Visual and auditory hallucinations
• Mood disturbances
• Delusions (ex. The sensation of insects
creeping on the skin)
• Homicidal thoughts
• Suicidal thoughts
• Out of control rages
• Can persist for years after use discontinued
Other Effects of Chronic Meth Use
• Tooth decay
• Hepatitis B and C
• STD’s : sexually transmitted disease
• HIV : associated with needle use and unprotected sex
• Sexual Impotence
• Cognitive impairment (reduced ability to process
information)
• Unplanned pregnancy, victims of domestic violence

Matrix Institute on Addictions
Cognitive Impairment in Individuals Currently

Using Methamphetamine
Active MA users demonstrate impairments in:

– the ability to manipulate information
– the ability to make inferences
– the ability to ignore irrelevant information
– the ability to learn
– the ability to recall material
Effects of Methamphetamine Use - Addiction
• Chronic, relapsing disease

• Characterized by compulsive drug-seeking and
drug use
• Functional and molecular changes in the brain
• Stronger potential for addiction
– rapid-acting routes of administration
– higher dosages
– higher purity

Effects of Methamphetamine Use - Tolerance
• Take higher doses

• Dose more frequently
• Change their method of drug intake
• “Run” - forego food and sleep while binging
• No tolerance for effects on judgment,
impulsivity, aggression, and susceptibility to
paranoia, delusions, and hallucinations –
opposite reaction
Effects of Methamphetamine Use - Withdrawal
• Physical:
Polyphagia (excessive hunger)
Hypersomnolence (sleepiness)
• Psychological:
Depression
Anxiety/agitation “Free floating” anxiety
Delusional state lasting up to a week
Fatigue/malaise
Paranoia
Hallucinations
Aggression
Intense craving for the drug
Abstinence Syndrome
After awaking from the crash, symptoms continue:
Psychological/Behavioral Symptoms
• Dysphoric mood--that may deepen into clinical depression

and suicidal ideation
• Persistent and intense drug craving
• Anxiety and irritability
• Impaired memory
• Anhedonia--loss of interest in pleasurable activities
• Interpersonal withdrawal
• Intense and vivid drug-related dreams
Abstinence Syndrome
Physiological symptoms
• Thin, gaunt appearance with reported weight loss

or anorexia
• Dehydration
• Fatigue and lassitude, with lack of mental or
physical energy
• Dulled sensorium
• Psychomotor lethargy and retardation--may be
preceded by agitation
• Hunger
• Chills
• Insomnia
Manjadda wajadda followed bydr.Choiriah
hypersomnia 193
Special Issues for Women and Methamphetamine
• Affordable
• Available
• Appetite suppressor
• Energy enhancer
• Weight loss
• Mood elevator
• Libido enhancer
• The growing illicit drug of choice among young
women
• 47% of those presenting for meth treatment females,
other substances 20-25% females
The impact on children may be connected to the
fact that women are more likely to use meth than
other illegal drugs.
For one thing, the drug is associated with weight
loss.
One federal survey of people arrested for all

crimes found that 11.3 percent of women had used
meth within the prior month compared with 4.7
percent of men.

Parenting Issues with Meth Involvement
• Neglect during long periods of sleep

• Inconsistent, paranoid behavior
• Irritability, short fuse, potentially leading to
physical abuse
• Exposure to violence, unsavory characters
• Generally poor parenting skills
• Mental health issues

Substance Abuse Affects Parenting
• Impaired judgment and

priorities
• Inability to provide the
consistent care,
supervision and guidance
children need
• Substance abuse is a
critical factor in child
welfare
[Blending Perspectives and Building Common Ground, A Report to Congress
Manjadda wajadda on Substance Abuse and dr.Choiriah
Child Protection, April 1999] 197
Children of Parents
with Substance Abuse Problems
• Have poorer developmental outcomes

(physical, intellectual, social and emotional)
than other children
• Are at an (eight-fold) increased risk of
substance abuse themselves

Substance Abuse and Child Abuse and Neglect
• Substance abuse causes or exacerbates 7 out

of 10 cases of child abuse and neglect
• Children whose parents use drugs and alcohol
are:
– 3x more likely to be abused
– More than 4x more likely to be neglected

Basic Meth Patient Treatment Considerations
Many stimulant dependent individuals demonstrate…

1. Low Impulse Control
2. Low Tolerance for Frustration
3. High Likelihood of Psychiatric Complications
(paranoia, delusions, agitated depression)
4. High Risk for Explosive, Violent Behavior
5. High Risk of Depression and High Risk of Suicide
6. Very Strong Craving
7. Cognitive and Memory Impairment
8. Brief Attention Span

Implications for practice
Try to find time for a quick phone call or a quick little note of
reassurance and encouragement. This will go a long way in
helping the addict be successful and will help the case move
quicker towards safe case closure.
You can take exception to the person’s behavior but you must
accept the person in order to make progress.
Determine the priorities for intervention in a case and then

move slowly forward to implementation.
Provide parent/child visitation
Provide support and encouragement

If we take away their only solution to life’s problems we need
to follow that up with some other means of coping.
Can addiction be treated successfully?
Yes. Addiction is a treatable disease. Discoveries in the
science of addiction have led to advances in drug abuse
treatment that help people stop abusing drugs and
resume their productive lives.
Can addiction be cured?

Addiction need not be a life sentence. Like other
chronic diseases, addiction can be managed
successfully. Treatment enables people to counteract
addiction's powerful disruptive effects on brain and
behavior and regain control of their lives.

Relapse rates for drug-addicted patients are compared with those suffering from diabetes,
hypertension, and asthma. Relapse is common and similar across these illnesses (as is adherence to
medication). Thus, drug addiction should be treated like any other chronic illness, with relapse
serving as a trigger for
Relapse rates for drug-addicted patients are compared with those suffering from
diabetes, hypertension, and asthma. Relapse is common and similar across these
illnesses (as is adherence to medication). Thus, drug addiction should be treated
like any other
Manjadda chronic illness, with relapse
wajadda serving as a trigger for renewed
dr.Choiriah 203
intervention.
People Can and Do Recover from Meth Addiction
Outcomes data provided by SSAs confirm that people can and do recover from meth
addiction. Examples include:
• Colorado’s Alcohol and Drug Abuse Division reported in FY 2003 that 80% of
meth users were abstinent at discharge.
• Iowa’s Division of Behavioral Health and Professional Licensure found, in a 2003
study, that 71.2% of meth users were abstinent 6 months after treatment.
• Tennessee’s Bureau of Alcohol and Drug Abuse reported in a 2002-2003 study that
over 65% meth clients were abstinent 6 months after discharge.
• The Texas Department of State Health Services examined outcomes data for
publicly funded services from 2001-2004 and found that approximately 88% of meth
clients were abstinent 60 days after discharge.
• Utah’s Division of Substance Abuse and Mental Health reported that in State Fiscal
Year 2004, 60.8% of meth clients were abstinent at discharge.
National Association of State Alcohol and Drug Abuse Directors, Inc.

Pre-Recovery Behaviors/Excuses
Occur with Increased Frequency
• Old playmates and • “I will just stop over at
old playgrounds Jim’s and if they have
• Person not following drugs, I will just
through with AA/NA leave”
meetings or recovery • “I’m too busy/tired to
steps got to a meeting,”
• Cross-addictions • I don’t have a problem
with alcohol so it is
OK for me to drink.”
Reuse
• can be the use of a drug “out of the blue”
• person may be working an excellent
recovery program
• may have had a long period of sobriety
• may be avoiding the old friends and old
playgrounds
• They may be doing everything right but still
have used
Relapse Prevention Steps
• Self-knowledge and identification
warning signs. This process teaches
clients to identify the sequence of
problems that has led from stable
recovery to chemical use in the past, and
then to synthesize those steps into future
circumstances that could cause relapse.

Types of Relapse-Prone Clients
• Transition- does not accept/recognize their
addiction and are not able to accurately perceive
reality due to chemical effects.
• Unstabilized- lacks addiction interruption skills,
recovery program support, and positive lifestyle
change.
• Stabilized- is aware of their addiction and the
necessity for ongoing recovery program to
maintain abstinence. However, they tend to
develop dysfunctional symptoms over time
leading back to substance usage.
Relapse or Reuse?
• It is important to distinguish relapse from

reuse. They are two different things.
• Relapse is a progressive psychological and
behavioral change
• Can start hours, days, weeks or months
before a person uses mood-altering
chemicals

Relapse ≠ Treatment Failure
Recurrence of substance use can happen at any point during
recovery
Recognize the difference between a lapse (a period of substance
use) and relapse (the return to problem behaviors associated with
substance use)
Work with the client to re-engage in treatment as soon as possible

Part of effecting long-term change includes working with clients to
identify the specific factors that preceded their substance use—
What were the emotional, cognitive, environmental, situational, and

behavioral precedents to the relapse?

One element in the process of recovery is to
develop a relapse prevention plan and strategies to
avoid relapse
Plan for the potential of relapse and for ensuring
safety of the child(ren)
Parents who learn triggers can become empowered
to plan proactively for the safety of their children
and to seek healthy ways to neutralize or mitigate
the trigger
Relapse prevention includes: “What can a client do
differently?”
Implications for Practice
• Make sure factors critical for recovery are
addressed by making client accountable.
• Relapse does not necessarily mean the
discontinuation of visitation. Don’t stop visits as
punishment if the child’s safety and well-being
can be assured.
• Provide client with accurate information about
relapse process and the means to avoid it.
• Encourage client through motivational
interviewing and affirmations
Stages of Change in Substance Abuse &
Dependence: Intervention Strategies
Maintenance
Stage
Precontemplation Contemplation Preparation Action

Stage Stage Stage Stage
Relapse
Stage
Motivational
Enhancement Assessment
Strategies & Treatment Relapse
Matching Prevention
& Relapse
Management
Treating a Biobehavioral Disorder Must Go
Beyond Just Fixing the Chemistry
We Need to Treat the
Whole Person!
Pharmacological Behavioral Therapies
Treatments
(Medications)
Medical Services Social Services
Manjadda wajadda In Social Context

dr.Choiriah 217
Basic Research Medication
Opiate agonists stabilize brain Agonist Therapy
Methadone
function in heroin addicts Buprenorphine
CB1 KO mice have decreased

responses to multiple drugs of abuse CB1 Antagonists
Smokers who are poor nicotine Inhibitors of

metabolizers smoke less metabolizing enzymes
Stress triggers relapse in animal models

of addiction and CRF antagonists CRF Antagonists
interfere with the response to stress
Thank you

poppy flower of California (1998.5)

opium
poppy

marijuana

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Gangguan Terkait Zat dan

- What, why and how to

Self administration of drug or

• since 1960 to the present, drug use,

Social Epi Genetic Epi

Social Epi Transdisciplinary Meeting Genetic Epi

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Cell body Axon

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Di Chiara et al., Neuroscience, 1999.,Fiorino and Phillips, J. Neuroscience, 1997.

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250 Nicotine Morphine

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Homelessness Health care

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Research supported by NIDA addresses all of these

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Age at tobacco, alcohol, and cannabis dependence per DSM IV

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• physical dependence/ physiological

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• Consecutive application to bring about

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• Hypotension  Seizureswith certain

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Resembles Severe Influenza

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