One night, while returning from the club, me and my friends decided to sit at the river bank for some time. We sat for sometime silently enjoying the beauty of the full moon light on the clear river water. Suddenly Rahul said- “Hey, Did you notice the group sitting behind us at the club? I was astonished at the amount of drinks they were consuming.” Ravi gave a mischievous smile and said- “I bet, I even noticed the mouth watering Tandooris, Tikkas, Kababs and also their bellies trying to burst the buttons of their shirts.” We all had a hearty laugh. On a serious note, David said- “A close family friend of ours drinks a lot. His family has suffered a lot because of his drinking habit. I really don’t understand why people drink?”
I said “Well, most people start drinking casually. Some drink to get over their stress while others to get over their failures, as in work, love, business etc. Initially they drink in small amounts. Gradually it becomes a habit and they get addicted.” Rahul said-“Some affluential people start the habit as social drinking in parties, hotels and clubs, but I really don’t understand how the middle class and poor also develop the habit?” I said “Those who don’t have enough money, they take low quality local alcohol. Few people start drinking on their own. But most of them develop the habit because of friend circle and social drinking. Slowly, it becomes an addiction. Some even go the extent of selling their household things, jewellery etc. to arrange money for drinking. These people start their day with drinking and end with it. Inspite of repeated persuasion they are not able to stop drinking because when they do so, they develop hand tremors, palpitations, restlessness etc. Some even leave their families because of their repeated advice to stop drinking. Quantity and frequency of drinking increases day by day. They get out of control, have frequent fights with people, behave abnormally and lose consciousness at many places, still don’t stop drinking. Because of this excessive drinking, they also develop many liver, kidney and heart problems. They have repeated vomiting due to gastritis. In spite of repeated warnings from the doctor, they don’t stop drinking.
Ravi said- “There are many people who are also addicted to tobacco chewing, cigarette, brown sugar, cannabis, (Bhang, charas, Ganja) etc. Are these substances not harmful to the body?” I said- “Any type of addiction is harmful to the body. If excessive amount of any addictive substance is taken regularly, then it’s very difficult to control and cure the health problems arising out of it?”
Rahul said- “Can these addictions be controlled if a person goes to doctor early?” I said “yes there are many medicines to help a person to stop drinking. Some act by decreasing the withdrawal symptoms, while some decrease the craving of a person for alcohol. There are even some drugs which cause vomiting and headache whenever the patient takes alcohol. By this, the patient himself starts to avoid alcohol.” After listening to all this, Ravi and David turned towards Rahul and said “ Have you tried any medicines to stop your tobacco chewing and cigarette habit? If not, do so immediately.” I said “yes, even for this, there are many drugs and still new drugs are being searched for. Only you have to make up your mind to stop these addictions and get over it with the help of medicines.” By then, it was almost midnight and we all were sleepy. We got up, said bye to each other and left for our homes.
1.What is substance abuse disorder, addiction, and dependence?
Loss of control, compulsion to use, and continued use despite adverse consequences are indicative of psychoactive substance use disorder. Addiction implies the psychological compulsion to use a substance, whereas the term dependence implies the physiologic components of withdrawal or tolerance.
The symptoms of dependence are-persistent efforts to cut down or stop use; using more or for a longer time than intended; filling one’s time with drug or alcohol activities, such as intoxication or drug procurement; giving up important life activities, such as work or family; and continued use despite knowledge that it will cause or worsen physical or psychological problems.
3.Does addiction run in families?
Yes. The risk of addiction is 3–4 times higher for children of substance abusers than for children of non-substance abusers. The cause may be genetic, environmental, or a combination of factors.
- When do you suspect a person is alcohol dependence?
The CAGE questionnaire, which has 4 questions, is easier to use
- Have you tried to Cut down on alcohol?
- Have you been Annoyed when someone criticized your drinking?
- Have you felt Guilty about your drinking?
- Have you used alcohol as an Eye-opener by having a drink in the morning?
Two or more positive answers suggest alcohol problems with high sensitivity and specificity. We may substitute or add the word drug to get a similar screen of drug problems.
4.What is the relationship between substance use disorders and psychiatric illnesses?
chronic use may induce psychiatric symptoms; for example, depression from alcohol dependence. In substance use disorders secondary to psychiatric illnesses, patients may self-treat their symptoms; for example, alcohol may be used to relieve anxiety or to decrease manic symptoms. In addition, patients may have independent syndromes of substance abuse and major mental illness.
patients with schizophrenia, anxiety disorders, Biploar disorder and antisocial personality disorder are prone to have substance use disorder.
5.Does treatment work?
Yes, but no one treatment works for all patients. Some people stop alcohol use without formal treatment or with brief interventions, such as advice from their physician. In general, substance use disorders are chronic and relapsing; the treatment goal is to decrease the frequency and duration of relapses as well as morbidity and mortality.
Once the patient is abstinent, the focus is prevention of relapse, which includes reducing accessibility of the substance, identifying stimuli that may trigger cravings, understanding feelings, and developing coping responses and improved social skills.
Relapse is high during the first year of treatment, but as periods of abstinence lengthens, the likelihood of relapse decreases. Ongoing treatment should involve a treatment of health and psychiatric problems as well as marital, occupational, legal, financial, and social functioning. For any substance use disorder, a worse prognosis is associated with unemployment, lack of social support system, and presence of psychological problems
6.Is inpatient treatment required?
Patients with complicated medical or psychiatric problems,
severe withdrawal, suicidality, or risk of seizure require inpatient treatment.
7.Should patients be completely abstinent? Or can they learn to control their use?
At this time little evidence suggests that controlled use can be achieved; abstinence should be the goal for most patients. Some patients want to abstain from their drug of abuse but use other substances in moderation; this practice is a potential trigger for relapse.
8.Should family members be included in alcohol or drug treatment?
Yes. Behavior associated with substance use disorders significantly affects family members, who may participate indirectly or directly in maladaptive patterns. They should be included in the patient’s treatment, both for themselves and to help monitor and provide external control for the patient. Part of relapse prevention should be an agreement that the spouse will contact the treatment provider if concern develops about relapse.
9.What are the signs and symptoms of alcohol intoxication?
A person intoxicated by alcohol may have slurred speech, mood lability, decreased concentration and memory, poor judgment, facial flushing,ataxia, enlarged pupils, and nystagmus. Although alcohol initially has a stimulant effect, increasing levels result in depression of respiration, reflexes, blood pressure, and body temperature, potentially followed by stupor, coma, and death.
10.What are the usual symptoms and time course of alcohol withdrawal?
In someone dependent on alcohol, stopping or suddenly decreasing the amount of alcohol intake may result in withdrawal symptoms, which reflect central nervous system and autonomic hyperactivity. Symptoms begin to appear in 4–24 hours, usually peak at 36–48 hours, and subside in about 5 days. Symptoms typically are in proportion to duration of drinking, but the presence of medical illness may increase the severity.
Mild withdrawal may manifest as insomnia, irritability, anxiety, and mild gastrointestinal problems that start a few hours after stopping alcohol and last up to 48 hours.
Symptoms may progress first to tremor, sweating, tachycardia, elevated blood pressure, nausea, vomiting, and diarrhea and then to fever, hallucinations, delusions, confusion, agitation, and grand mal seizures. Hallucinations may appear within 24–96 hours and may be auditory, tactile, or visual (most common). Delirium tremens usually appears between 24 and 72 hours and may have a mortality rate of 5–15%; this syndrome, which is characterized by extreme agitation, delirium, psychosis (delusions and hallucinations), and fever, may last up to 5 days.
11.What about alcohol withdrawal seizures?
Alcohol withdrawal seizures (“rum fits”) most often occur 6–48 hours after stopping or reducing alcohol and may occur in 5–10% of patients in alcohol withdrawal. The seizures generally stop within 6–12 hours; they may be multiple and are usually grand mal.
12.What are the medical complications of chronic alcohol use?
Gastrointestinal problems include gastritis, peptic and gastric ulcer, esophagitis, esophageal varices, alcoholic hepatitis, cirrhosis, and pancreatitis.
Peripheral neuropathy is usually symmetrical and in the lower extremities. With prolonged drinking, alcohol dementia may occur with memory defects and difficulty with abstract thinking and new learning. Cerebellar degeneration, which causes a wide-spread gait, may be associated with Wernicke-Korsakoff syndrome
Hypertension , Alcoholic cardiomyopathy , sinus tachycardia.
Alcoholics show increased incidence of tuberculosis and bacterial pneumonias
Macrocytosis , Iron deficiency anemia
Alcohol impairs the production and function of white blood cells, both neutrophils and lymphocytes, and increases the risk of infection.
Alcohol suppresses testosterone levels in men by effects on the pituitary gland and the testicle, and impaired metabolism of estrogen by the liver increases estrogen levels. Both events may result in signs of feminization, such as gynecomastia and feminine fat distribution; decreased libido; testicular atrophy; and impotence.
Women experience menstrual irregularities, ranging from cessation of menses to excessive bleeding.
13.Are there any useful pharmacologic approaches in the treatment of alcohol abuse and dependence after withdrawal?
Disulfiram (Antabuse) has been used as a deterrent to drinking;
Naltrexone has been approved for use in the treatment of alcohol problems; it decreases craving, and reduces likelihood of continued drinking if the patient relapses.
Acamprosate has produced higher continuous abstinence rates and fewer drinking days.
14.What drugs are considered sedative-hypnotics?
Sedative-hypnotic drugs include the barbiturates, barbiturate-like drugs, and benzodiazepines. They are a diverse group of synthetic drugs with clear medical uses and may be prescribed as anxiolytics (tranquilizers), hypnotics (to induce sleep), anticonvulsant medications, and muscle relaxants.
15.Who abuses sedative-hypnotics?
Sedative-hypnotics are abused by both street addicts and patients who are receiving them by prescription. Street addicts may use them as adjuvants to boost the effect of drugs, to take the edge off stimulants, or to help manage drug or alcohol withdrawal. Prescription addicts may use the drugs alone, seeking sedation or euphoria, but usually combine them with other substances.
16.Are muscle relaxants addictive?
Muscle relaxants may be abused, usually for their sedative properties.
17.What forms of cocaine are available? What are the routes of administration?
Cocaine is available illicitly in either powder or crystallized
(“rock” or “crack”) forms.
Cocaine is snorted, injected, and smoked. “Crack” is the smokable form of cocaine. Smoking is the most rapid route of delivery to the brain and thus the most reinforcing; however, dependence can occur with all routes of administration. A stimulant and a depressant injected together, most frequently cocaine and heroin, is called a “speedball.”