ADDICTION

PSYCHIATRY

RAINIER B. UMALI, M.D.

IMPLICATIONS:
It affects both mood and
behavior;

Can cause symptoms

indistinguishable from the
primary psychiatric disorders;

Provides fertile ground for brain

research
 Medical Model of Addiction
-Expression of addiction is based on a
genetic predisposition that is influenced
by environmental factors

-Well-studied biological mechanism

-Treatment compliance is similar to other

chronic medical conditions (diabetes,
hypertension, asthma)
Medical Model of Addiction
- Follows a relapsing and remitting
course

- Most effectively managed as a

chronic disease

- Both medical and behavioral

interventions are used
 TERMINOLOGIES:
1. ADDICTION
- repeated use of a psychoactive substance/s,
to the extent that the user (addict) is
periodically or chronically intoxicated,
shows a compulsion to take the preferred
substance

- has great difficulty in voluntarily ceasing or

modifying use, and exhibits determination to
obtain psychoactive substance to almost any
means.

-WHO
2. DEPENDENCE

- The repeated use of a drug or chemical

substance, with or without physical
dependence.
A. Physical dependence: indicates an
altered physiologic state, the cessation of
which results in a specific syndrome.

B. Psychological dependence: also

referred to as habituation, is
characterized by a continuous or
intermittent craving for the substance to
avoid a dysphoric state.
3. Abuse
-Use of any drug, usually by self-
administration, in a manner that deviates
from approved social or medical patterns.

4. Misuse
-Similar to abuse, but usually applies to
drugs prescribed by physicians that are
not used properly.
5. Intoxication
- A reversible syndrome caused by
a specific substance (e.g., alcohol)
that affects one or more of the
following mental functions:
- memory
- orientation
- mood
- judgment
- behavioral
- social or occupational
functioning
6. WITHDRAWAL

- A substance-specific syndrome that

occurs after stopping or reducing the
amount of the drug or substance that has
been used regularly and heavily over a
prolonged period of time.
- The syndrome is characterized by
physiologic signs and symptoms in
addition to psychological changes, such as
disturbances in thinking, feeling, and
behavior. Also called abstinence
syndrome or discontinuation
syndrome.
7. Tolerance
- Phenomenon in which, after repeated
administration, a given dose of drug
produces a decreased effect or
increasingly larger doses must be
administered to obtain the effect observed
with the original dose.
Behavioral tolerance reflects the ability of
the person to perform tasks despite the
effects of the drug.
8. Cross-tolerance

- Refers to the ability of one drug to

be substituted for another.
- Each drug usually produce the same
physiologic and psychological effect
(e.g., diazepam and barbiturates).
- Also known as cross-dependence.
9. Neuroadaptation

- Neurochemical or neurophysiologic
changes in the body that result from
the repeated administration of a drug.
- Neuroadaptation accounts for the
phenomenon of tolerance.
ETIOLOGY
BIOLOGICAL
-GENETICS
- NEUROTRANSMITTERS
- dopamine
-endorphins
-GABA
*Brain-Reward Circuitry
- NEUROADAPTATION
 Genetics: Pedigree
-Monozygotic twins have higher
concordance of addiction than dizygotic
twins (the more genes you share, the
more similar your addiction propensity)

-Men whose parents were alcoholics have

an increased likelihood of alcoholism even
when adopted and raised by non-alcoholic
parents from birth
Genetics: The Genome
- The minor (A1) allele of the TaqIA D2
dopamine receptor gene has been linked
to severe alcoholism and polysubstance
dependence

- A single nucleotide polymorphism in the

gene encoding fatty acid amide hydrolase
has been associated with increased
recreational and problem use of drugs or
alcohol
How it Works: The Reward
Pathway
- Many parts of the brain work together
to maintain homeostasis

- The “mesolimbic” pathway uses reward

(often a sense of well-being or
pleasure) to promote life sustaining
and life fulfilling behaviors
- eating
- drinking
- sex
- nurturing, etc.
How it Works: The Reward
Pathway

- addiction occurs by dysregulation of

this natural function
The Reward Pathway

1. Drugs of addiction are identifiable by their

ability to stimulate dopamine secretion in
this pathway

2. Addicts are identifiable by their unique response

to addictive chemicals by hypersecretion of
dopamine in this brain pathway
 The “Switch”
- Frequent drug use in a person with biological
predisposition alters the hedonic set-point and
creates a starvation or craving response.

- The drug loses its pleasurable effects but

becomes pathologically “wanted”

- Cravings may continue or even increase despite

satiation or drug use
 Hedonic Homeostatic
Dysregulation
- The patients are logically aware they do
not “need” the drug, but survival drives
tend to take precedence over logic and
judgment
- Continued substance use slowly takes
“survival precedence” over life goals, self
esteem, relationships, stability, safety,
and health
 Chronic Use: Hedonic
Homeostatic
Dysregulation
Hedonic Set Point is Altered with Chronic Drug Use
“Feel good” Normal Affective Response
Hedonic Scale

to Drugs/Alcohol

Initially use
to
get high…
“Cravings” Now use to
“get normal”

“Feel bad”
Altered Dysregulated Set-Point
(Koob, Science, 1997)
following chronic drug use
Slide from Pating,D.
 PSYCHOLOGICAL:

- Co-morbidities

> 35 – 60% with Antisocial PD

> 40% of alcohol abusers/dependents meet

criteria for Major Depressive Disorder (MDD)

> Substance use is a major precipitating

factor for suicide; 20x more likely to die by
suicide; 15% of alcohol abusers commit
suicide;
PSYCHOLOGICAL:

- Psychodynamic theories
- masturbatory effect
- defense against anxious
impulses
- manifestation of oral aggression
- disturbed ego functions
- Self-medication
SOCIAL:
- Learning and Conditioning

- Environmental
- peer pressure
- social acceptability
- drug availability
 The “Formula” for Addiction
- Genetic or biological predisposition
- A specialized response to addictive
chemicals
- Risk factors (mood disorders, life
trauma, environmental factors, drug
availability)
- Practice (“experimentation”)
- The “Switch”: hypersensitization and
hedonic dysregulation
Phases of Addiction:

- Abstinence
- Experimentation
- Social/Recreational - start
of pattern use
- Habituation –a glass a day
- Abuse
- Dependence
DRUG ABUSE TRENDS
- 1999 survey estimated 1.8
million regular users and 1.6
million occasional users

- 2001 – there were 2.2 – 9.3

million drug users estimated
at that time

- 2004-2005 study projects

6.7 million users in the
country
COMMON DRUGS OF
ABUSE
Types of Substances
1. Stimulants
- Shabu (methamphetamine)
Cocaine, Ecstasy, Morphine
2. Depressants
- Alcohol
- Heroine
- Opium
- Ketamine
3. Hallucinogens
- Marijuana (Cannabis)
4. Inhalants
 Designer drugs
1. Club Drugs
- used by teenagers and young adults at bars,
nightclubs, concerts, and parties.

- Club drugs include:

- GHB - used as a recreational intoxicant like
alcohol
- ketamine
- Ecstasy
- Methamphetamine
- LSD Acid
These are considered club drugs and are covered in
their individual drug summaries
 Designer drugs

2. Raves and circuit parties

- Used in nightclubs, all night dance
parties
- Induces some form of psychomotor
agitation that can be pleasurably
relieved by dancing thus making it an
ideal party drug
Designer drugs

Ketamine
- Street names:
- Special K
- Super K
- Vitamin K
Mild Effects

- Dissociative anesthetic
- Induces feeling of
detachment
- Lack of responsive
awareness
Severe Effects
- Altered mental status
- Hyperthermia
- Convulsions
- Hypertension
- Acute renal failure
- Dehydration
- Death
Alcohol

- Average alcohol – dependent person decreases

life span by 10 – 15 years

- Third largest health problem in the US

- Intoxication and withdrawal mimic many major

psychiatric disorders

- Contributes to 22,000 deaths and 2M non-fatal

injuries.
Alcohol

- Common causes of death includes suicide, CA,

heart disease and hepatic disease.

- Leads all other substances in substance-related

deaths

- 10 – 15% prevalence of suicide among persons

with alcohol related disorders.

- Legal definition of intoxication = 80 or 100 mg/dl

 Table 12.2-2 Epidemiological Data for
Alcohol-Related Disorders

Race and •Whites have the highest rate of alcohol use (56%)
Ethnicity •Hispanics and blacks have similar rate of binge use,
but is lower among blacks than among whites

Gender •Men are much more likely than women to be binge

drinkers and heavy drinkers

Region and •Alcohol use is highest in western states and lowest in

Urbanicity southern states
•North central and northeast regions are about the same
•The rate of past month alcohol use was 56 percent in large
metropolitan areas, 52 percent in small metropolitan
areas, and 46 percent in non-metropolitan areas.
•Little variation seen in binge and heavy alcohol use rates
by population density.
 •About 70 percent of adults with college degrees
are current drinkers, compared with only 40
Education percent of those with less than a high school
education.
•Binge alcohol use rates are similar across
different levels of education.

•Alcohol-related disorders appear among persons of

all socioeconomic classes.
Socioeconomic •Persons who are stereotypical skid-row alcoholics
Class constitute less than 5 percent of those with
alcohol-related disorders.
 COMORBIDITY:
- Antisocial Personality Disorder

- Mood Disorders – 30 – 40%

- Depression is more common in women
than in men with these disorder.

- great risk for attempting suicide

- Bipolar I disorder may self-medicate

manic symptoms with alcohol
- Anxiety Disorders
- 25 – 50% also meet criteria for an
anxiety disorder
- Phobias and panic disorders
- Suicide = 10 – 15% prevalence
- Factors: presence of MDD, weak
psychosocial support system,
serious coexisting medical
condition, unemployment and
living alone.
 ABSORPTION:

- 10% - stomach; the rest – small intestines

- Empty stomach = increase abs
- full stomach = decrease abs
- Peak blood concentration= 30 – 90 min
rapid drinking = increase time
slow drinking = decrease time
- Absorption is most rapid in those containing
15 – 30% alcohol (30 – 60 proof)
 METABOLISM:

- 90% of absorbed alcohol is metabolized thru

oxidation in the liver; 10% excreted by lungs and
kidneys

ALCOHOL + alcohol dehydrogenase=acetaldehyde

Acetaldehyde + aldehyde dehydrogenase = acetic acid

 EFFECTS ON THE BRAIN:

- Inhibits glutamate receptor function:

- muscular relaxation
- discoordination
- slurred speech
- staggering
- memory disruption
- black- outs
- Enhances GABA receptor functions

- calm feeling

- anxiety-reduction

- sleep
- Increases dopamine levels
- excitement and stimulation

- Raises endorphin levels

- kills pain
Impairment Likely to be Seen at Different
Blood Alcohol Concentrations

Level Likely Impairment

20 - 30 Slowed motor performance and decreased
mg/dL thinking ability
30 - 80 Increases in motor and cognitive problems
mg/dL
80 -200 Increases in incoordination and judgment
mg/dL errors
Mood lability
Deterioration in cognition
200-300 Nystagmus, marked slurring of speech, and
mg/dL alcoholic blackouts
>300 mg/dL Impaired vital signs and possible death
OTHER PHYSIOLOGICAL
EFFECTS:

- LIVER DAMAGE
- ESOPHAGITIS, GASTRITIS
- ACHLORYDIA ( dec. gastric acid production)
- GASTRIC ULCERS
- VITAMIN DEFICIENCIES
- INC. BLOOD PRESSURE
- DYSREGULATION OF LIPOPROTEIN AND TG
METABOLISM
- HYPOGLYCEMIA- acute intoxication
- INCREASES INCIDENCE OF CANCER
 DISORDERS:

- Alcohol Dependence and Alcohol abuse

- a need for daily use of alcohol for adequate functioning

- regular pattern of heavy drinking limited to weekends
- long periods of sobriety interspersed with binges of
heavy drinking lasting for weeks or months
- binge periods
- social and occupational dysfunction
- current rate is 5%
ALCOHOL INTOXICATION:

- In extreme cases, may lead to coma,

respiratory depression, and death due to
respiratory arrest or aspiration of vomitus;

- Treatment: mechanical ventilatory support,

acid-base balance, electrolytes, temperature.

- Medical complications: subdural hematoma,

fractures, suppressed immune system
DSM-IV-TR Diagnostic Criteria for Alcohol Intoxication

A.Recent ingestion of alcohol.

B.Clinically significant maladaptive behavioral or psychological
changes (e.g., inappropriate sexual or aggressive behavior,
mood lability, impaired judgment, impaired social or
occupational functioning) that developed during, or shortly
after, alcohol ingestion.
C.One (or more) of the following signs, developing during, or
shortly after, alcohol use:
1. slurred speech
2. incoordination
3. unsteady gait
4. nystagmus
5. impairment in attention or memory
6. stupor or coma
D.The symptoms are not due to a general medical condition
and are not better accounted for by another mental
disorder.
Alcohol Withdrawal:

- Conditions that aggravate or predispose:

fatigue, malnutrition, physical illness,
depression
- Classic sign : TREMULOUSNESS (shakes or
jitters); develop 6 – 8 hours after
cessation
- Psychotic symptoms develop 8-12 hours
after cessation
- Seizures develop 12-24 hours after cessation
- Delirium tremens = during 72 hours up to
first week
DSM-IV-TR Diagnostic Criteria for Alcohol Withdrawal

A.Cessation of (or reduction in) alcohol use that has been heavy and
prolonged.
B.Two (or more) of the following, developing within several hours to a
few days after Criterion A:
1. autonomic hyperactivity (e.g., sweating or pulse rate
greater than 100)
2. increased hand tremor
3. insomnia
4. nausea or vomiting
5. transient visual, tactile, or auditory hallucinations or
illusions
6. psychomotor agitation
7. anxiety
8. grand mal seizures
C.The symptoms in Criterion B cause clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
D.The symptoms are not due to a general medical condition and are
not better accounted for by another mental disorder.
Treatment for Alcohol Withdrawal:
Clinical
Problem Drug Route Dosage Comment
Tremulousness Chlordiaze Oral 25-100 mg Initial dose can be repeated every
poxide every 4-6
and mild to 2 hr until patient is calm;
hr
moderate subsequent doses must be
agitation Diazepam Oral 5-20 mg individualized and titrated
every 4-6
hr

Hallucinosis Lorazepa Oral 2-10 mg

m every 4-6
hr

Extreme Chlordiaze IV 0.5 mg/kg Give until patient is calm;

poxide at 12.5
agitation subsequent doses must be
mg/min
individualized and titrated
Withdrawal Diazepam IV 0.15 mg/kg
at 2.5
seizures
mg/min

Delirium Lorazepa IV 0.1 mg/kg

m at 2.0
tremens
mg/min
ALCOHOL WITHDRAWAL DELIRIUM

- Delirium tremens (DT)

- Most severe form of alcohol withdrawal
- Medical emergency
- 20% mortality rate
- Delirium occurs within 1 week after a
person stops drinking
- 5% of all Alcohol-related disorder has DT
- Physical illness predisposes to DT
Treatment:

- PREVENTION
Benzodiazepines (e.g. valium)
Fluids
Antipsychotics should be avoided
Psychotherapy
ALCOHOL-INDUCED PERSISTING AMNESTIC
DISORDER:

- Disturbance in short-term memory caused by prolonged

heavy use of alcohol.
a.) Wernicke Encephalopathy – reversible with
treatment
- alcoholic encephalopathy
- ataxia, vestibular dysfunction, confusion and ocular
motility abnormalities;
- may clear spontaneously or progress to Korsakoff”s
syndrome.
TX: Thiamine 100mg p.o. BID/TID x 1-2 weeks.
b.) Korsakoff Syndrome – chronic amnestic
syndrome

- impaired recent memory and anterograde amnesia

in an alert and responsive patient.

- +/- confabulation

TX : Thiamine 100 mg. p.o. BID/TID x 3 – 12 months

c.) Blackouts
- discrete episodes of anterograde
amnesia that occur in association with
alcohol intoxication;
- there is relatively intact remote memory
- unable to recall events that happened in
previous minutes.
- Alcohol blocks the consolidation of new
memories into old memories;
ALCOHOL-INDUCED PSYCHOTIC DISORDERS:

- With temporal association with alcohol use

- Most common are auditory hallucinations

- Usually resolve after a week

TREATMENT: benzodiazepines, adequate

nutrition, fluids
antipsychotics
ALCOHOL-RELATED USE DISORDER NOS:

- Idiosyncratic Alcohol Intoxication

- severe behavioral syndrome develops rapidly
after a person consumes a small amount of
alcohol that would have minimal behavioral
effects on most persons

- confused, oriented, visual hallucinations, increased

psychomotor activity, impulsiveness, aggression

- most common in persons with high levels of anxiety

- Alcohol pellagra encephalopathy
do not respond to thiamine
treatment

- They respond to niacin 50 mg QID

FETAL ALCOHOL SYNDROME:

- Leading cause of MR in the US

- Alcohol inhibits intrauterine growth and
postnatal development
- microcephaly, craniofacial malformations,
limb and heart defects, short stature
REHABILITATION:

3 major components:

1. continued efforts to increase and

maintain high levels of motivation for
abstinence

2. work to help the patient readjust to a

lifestyle free of alcohol

3. relapse prevention
MEDICATIONS:

- DISULFIRAM - used to support the treatment

of chronic alcoholism by producing an acute
sensitivity to alcohol

- NALTREXONE – opioid antagonist; decrease

craving or blunt the rewarding effects of
drinking

- ACAMPROSATE – acts directly or indirectly at

GABA receptors alters the development of
tolerance or physical dependence
 MEDICATIONS:

-Buspirone - is an anxiolyticpsychotropic
drug. It is primarily used to treat
generalized anxiety disorder (GAD).
Unlike most drugs predominantly used
to treat anxiety, buspirone‘s pharmacology
is not related to benzodiazepines or barbiturates,
to benzodiazepines or barbiturates,
so does not carry the risk of physical dependence
and withdrawal symptoms for which those drug
classes are known.
 Amphetamines

- most widely used illicit substances,

second only to cannabis, in the United
States, Asia, Great Britain, Australia,
and several other western European
countries
-1937 - amphetamine sulfate
tablets were introduced for the
treatment of:
-narcolepsy,
-postencephalitic parkinsonism
-depression
-lethargy
- attention-deficit/hyperactivity disorder (ADHD)
and narcolepsy are current US
Food and Drug Administration (FDA)- approved
indications. Also used in the treatment of:
-obesity
-depression
-dysthymia
-chronic fatigue syndrome
-acquired immune deficiency syndrome (AIDS)
-dementia
-neurasthenia
-Small doses generally improve attention
and increase performance on written,
oral, and performance tasks
major amphetamines :

- dextroamphetamine (Dexedrine)
- methamphetamine (Desoxyn)
- mixed dextroamphetamine-amphetamine
salt (Adderall)
- amphetamine-like compound
methylphenidate (Ritalin)
 Other names:
- ice
- crystal
- crystal meth
- speed

Feel good substances:

analeptics - is a central nervous system
stimulant medication.
Sympathomimetics- are stimulant compounds
which mimic the effects of neurotransmitter
substances of the sympathetic nervous system
such as catecholamines.

Stimulants and Psychostimulants –

are psychoactive drugs that induce temporary
improvements in either mental or physical
functions or both.
 Amphetamine Intoxication
Psychological:
- euphoria or affective
blunting
- changes in sociability
- hypervigilance
- interpersonal sensitivity
- anxiety, tension, or
anger
- stereotyped behaviors
- impaired judgment
- impaired social or
occupational functioning
Physical:
- tachycardia or bradycardia
- capillary dilation
- elevated or lowered blood
pressure
- perspiration or chills
- nausea or vomiting
- evidence of weight loss
- psychomotor agitation or
retardation
- muscular weakness,
respiratory depression,
chest pain, or cardiac
arrhythmias
- confusion, seizures,
dyskinesias, dystonias, or
coma
Amphetamine Withdrawal

Crash
- anxiety - Headache
- tremulousness - profuse sweating
- dysphoric mood - muscle cramps
- lethargy - stomach cramps
- fatigue - insatiable hunger
- nightmares
- (accompanied by
- rebound rapid eye
movement [REM]
sleep
Amphetamine Withdrawal

- peak in 2 to 4 days and are resolved

in 1 week

- most serious withdrawal symptom is

depression
Amphetamine Intoxication Delirium

- results from high doses of amphetamine

or from sustained use

- combination of amphetamines with other

substances

- use of amphetamines by a person with

preexisting brain damage
Amphetamine-Induced Psychotic
Disorder

- hallmark is the presence of paranoia.

- vs. Paranoid Schizoprenia:
- predominance of visual hallucinations
- generally appropriate affects
- Hyperactivity
- Hypersexuality
- confusion and incoherence
 little evidence of disordered thinking (e.g.,
looseness of associations).
Adverse Effects
-Life-threatening - Non- life threatening
- myocardial infarction - Flushing
- severe hypertension - Pallor
- cerebrovascular disease - Cyanosis
- ischemic colitis - Fever
- HIV and hepatitis - Headache
- lung abscesses - Tachycardia
- Endocarditis - Palpitations
- necrotizing angiitis - Nausea
- twitching to tetany to - Vomiting
- seizures to coma and - bruxism (teeth
death grinding)
- shortness of breath
- Tremor
- ataxia
Psychological Effects

- restlessness - generalized
- Dysphoria anxiety disorder
- Insomnia - panic disorder
- Irritability - ideas of reference
- Hostility - Paranoid delusions
- confusion - hallucinations
Caffeine

- most widely consumed psychoactive substance

in the world.
- cup of coffee generally contains 100 to 150 mg
of caffeine
- methylxanthine – active ingredient in caffeine
half-life =3 to 10 hours
- readily crosses the blood-brain barrier
- Caffeine acts primarily as an antagonist of the
adenosine receptors
Caffeine Intoxication

in excess of 250 mg.:

- restlessness - muscle twitching

- nervousness - rambling flow of
- excitement thought and speech
- insomnia - tachycardia or
- flushed face cardiac arrhythmia
- diuresis - periods of
- Gastrointestinal inexhaustibility
disturbance - psychomotor
agitation
Caffeine Withdrawal

most common symptoms are:

- headache - nausea
- fatigue - vomiting
- anxiety - craving for caffeine
- irritability - muscle pain and
- mild depressive symptoms stiffness
- impaired psychomotor
performance
Sought-after Effects of Caffeine:

- 50 to 100 mg of caffeine
- increased alertness
- a mild sense of well-being
- sense of improved verbal and motor
performance

- Other Effects:
- Diuresis
- cardiac muscle stimulation
- increased intestinal peristalsis
- increased gastric acid secretion
- increased blood pressure.
Cannabis
Other names:

- marijuana
- grass
- pot
- weed
- tea
- Mary Jane
Cannabis

- Cannabis Sativa- marijuana plant

Effects:
- When smoked - euphoric effects appear within
minutes, peak in about 30 minutes, and last 2
to 4 hours.
- most common physical effects of cannabis are
dilation of the conjunctival blood vessels (red
eye) and mild tachycardia
Cannabis Intoxication

- heightens sensitivities to external stimuli

- reveals new details
- makes colors seem brighter and richer
than in the past
- subjectively slows the appreciation of time
- depersonalization and derealization
Cannabis-Induced Psychotic Disorder

- rare

- transient paranoid ideation is more

common

- hemp insanity
Amotivational Syndrome

-characterized by a person's unwillingness

to persist in a task be it at school, at
work, or in any setting that requires
prolonged attention or tenacity.

- associated with long-term heavy use

- apathetic and anergic, usually gaining

weight, and appearing slothful.
Cocaine

- Erythroxylon coca
- first used as a local anesthetic in 1880.
- active ingredient in the beverage Coca-
Cola until 1902.
- competitive blockade of dopamine
reuptake by the dopamine transporter
- behavioral effects of cocaine are felt
almost immediately and last for a
relatively brief time (30 to 60 minutes)
 Cocaine
- most common method of using cocaine is
inhaling the finely chopped powder into
the nose – snorting or tooting

- Freebasing - mixing street cocaine with

chemically extracted pure cocaine
alkaloid (the freebase) to get an
increased effect.

- Crack - a freebase form of cocaine, is

extremely potent. “rocks “
Effects:

- Elation

- Euphoria

- heightened self-esteem

- perceived improvement on mental and

physical tasks
Cocaine Intoxication

- tachycardia or bradycardia - confusion

- pupillary dilation - seizures
- elevated or lowered blood - dyskinesias, dystonias or coma
pressure - agitation
- perspiration or chills - irritability
- nausea or vomiting - impaired judgment
- evidence of weight loss - impulsive
- psychomotor agitation or - potentially dangerous
retardation sexual behavior
- muscular weakness - aggression
- respiratory depression
- chest pain or cardiac
arrhythmias
Cocaine Withdrawal

- Postintoxication Depression (crash)

- Dysphoria
- Anhedonia
- Anxiety
- Irritability
- Fatigue
- Hypersomnolence
- Agitation
Cerebrovascular Effects

- nonhemorrhagic cerebral infarctions – most

common
- Transient ischemic attacks
- Cocaine is the substance of abuse most
commonly associated with seizures
Cardiac Effects:

- Myocardial infarctions and arrhythmias are

perhaps the most common cocaine-induced
cardiac abnormalities

- Cardiomyopathies

- Cardioembolic cerebral infarctions

Opioids
Initial euphoria followed by:

- apathy - Pupillary constriction (or

- dysphoria pupillary dilation due to
- psychomotor agitation anoxia from severe
or retardation overdose)
- impaired judgment - drowsiness or coma
- impaired social or - slurred speech
occupational - impairment in attention
functioning or memory
associated symptoms:

- feeling of warmth
- heaviness of the extremities
- dry mouth
- itchy face (especially the nose)
- facial flushing.
- nodding off
- Skin popper
Opioid Withdrawal

- dysphoric mood
- nausea or vomiting
- muscle aches
- lacrimation or rhinorrhea
- pupillary dilation
- piloerection
- sweating
- diarrhea
- yawning
- fever
- insomnia
Thank you and good
day !