Substance misuse and addictions can be attributed to many reasons other than just an aim of getting high. Studies show that only 20% of individuals who make use of drugs do so with the primary aim of seeking pleasure. Other reasons for substance misuse and addictions include anxiety, depression, anger, boredom, peer pressure, lack of self confidence and lack of self control.
Substance misuse is more probable where there is availability and peer pressure. It is usually obtained either in an illicit way, or else through the chemist (certain drugs such as codeine), shops (such as solvents) and doctors (such as benzodiazepines).
Terminology related To Substance Misuse and Addictions
Acute Intoxication – a transient condition which follows alcohol or psychoactive substance misuse, resulting in disturbances in the individual’s level of consciousness, cognition, perception, judgment, affect or behavior, or other psycho-physiological functions and responses.
Harmful Use – damage incurred by psychoactive substance misuse in the individual as well as the implicated negative effects on the individual’s family and surrounding society eg. at work, in health, etc.
Physiological Dependence – withdrawal symptoms (eg. urgent need for more) and drug tolerance (needing more than before to experience the same ‘high’ effect).
Psychological Dependence – a sense of urgency to take a substance experienced by a drug-dependent individual, even when knowing of its related consequences; social, occupational and recreational activities are usually neglected by an individual with substance psychological dependence. A person with psychological dependence usually becomes addicted to the whole drug-taking process itself – including making sure they’re not being followed.
Diagnosis
Dependence diagnosis requires 3 of the following to be present for at least a year:
- increased tolerance to a psychoactive drug
- physiological withdrawal symptoms exhibited when drug is reduced or stopped
- a sense of urgency to make use of the drug
- inability to control substance misuse behaviour
- neglecting other social, occupational and recreational activities
- increased amount of time required to obtain and make use of the drug, and to recover from its effects
- persistent use of drug despite knowing its attributed negative consequences
Experimentation/Recreation Drug Use vs Addiction
A recreational drug user is an individual who has tried the drug, enjoyed its use, may want to re-use it, but does not treat it as a priority.
On the other hand, for a drug addict, the drug becomes the main focus of attention, to a point in which other necessities such as nutrition become unimportant compared to the drug. Addiction is a chronic disorder.
The Pharmacology of Drugs
Drug pharmacology can be divided into 2 components: desired effects and unwanted effects. Most drug users do not become addicted, dependent or tolerant to the drug. All drugs cause dopamine to be released within the brain‘s nucleus accumbens, which leads to a pleasurable effect. However, it is motivation that may cause cravings for a drug, and drug-seeking behaviour.
Opiates
Opiates such as heroin (illegal), codeine, morphine, and methadone, are analgesic agents which bind to opioid receptors in the central nervous system, causing pain to be reduced or eliminated.
Opiates create a rush sensation of peace followed by CNS depression. Withdrawal symptoms, such as craving, sweating, yawning, diarrhoea, agitation, goose-flesh, abdominal cramping, and flu-like symptoms, can start developing from as early as 24 hours following dose administration.
Opiate Replacement Therapy
Methadone is an opiate receptor agonist which is given as a replacement to heroin and other opioids in the case of addiction. Methadone has a longer half-life when compared with heroin, which means that withdrawal symptoms and cravings are reduced without providing the same euphoric effect that heroin provides, giving opioid users a better chance of weaning off or reducing their dose of opioids.
Buprenorphine is an opiate partial agonist. Together with naloxone, which is an antagonist that blocks the euphoric effect related to opioids, buprenorphine is given in tablet form as Suboxone, with the aim of preventing relapse.
An opioid overdose may cause miosis (pinpoint pupils) and respiratory depression (hypoventilation). Naloxone may be required to rapidly reverse opioid overdose by binding to opioid receptors, thus blocking the effects of the other opioids.
Hallucinogens
Hallucinogens – drugs (such as LSD) which cause dilated pupils, increased temperature, vasoconstriction, and hallucinations (distortions in an individual’s perception of reality), can be found in some plants and mushrooms (or their extracts) or can be man-made.
Hallucinogens do not cause physiological dependence, but rare adverse effects may include flashbacks, psychosis, and seizures.
Ecstasy (MDMA in powder form) can induce hyperactivity, and dehydration which can be fatal.
Flakka is a synthetic drug which has been changing in the past. It is very common, yet very dangerous. Psychosis is a common effect of Flakka.
Magic Mushrooms are similar to LSD with regards to effects.
Stimulants
Amphetamines (stimulant drugs eg. speed) cause euphoria, increased concentration, increased energy, mydriasis (pupil dilation), tachycardia, and hyperreflexia, followed by depression, fatigue and headache.
Cocaine can be sniffed, chewed, or taken through the IV route. Its effects are similar to hypomania, and may include visual and tactile hallucinations. Crack cocaine is a highly addictive form of cocaine with a relatively short ‘high’ effect, which may cause persecutory delusions as a withdrawal symptom.
Cannabis
One of cannabis’s active components is THC, which produces psychological effects such as euphoria, relaxation, an overall well-being sensation, omnipotence and hallucinations. Physiologically, THC causes increased appetite and lowered body temperature.
Cannabis is also associated with depression and schizophrenia. However, to develop schizophrenia, the person using cannabis needs to be at a higher risk of developing it due to factors such as genetic predisposition.
Cannabis may also cause adverse effects such as conjunctival (eye) irritation, decreased sperm production, lung disease, transient psychosis, and apathy. It also causes psychological dependence.
Sedatives and Hypnotics
Benzodiazepines such as Ativan and Valium are commonly used addictive drugs which can cause dependence, withdrawal symptoms, and tolerance. They also carry a risk of seizures and respiratory depression. In the hospital setting, Ativan and Valium are two medications that fall under the Dangerous Drug Act (DDAs).
Solvents
Solvents are typically sniffed with the intention of getting high due to the initial euphoria it causes. This however is followed by drowsiness. Chronic solvent sniffing can lead to weight loss, nausea and vomiting, polyneuropathy (widespread malfunction of peripheral nerves), cognitive impairment, and aplastic anaemia (body ceases to produce new blood cells).
Sniffing solvents may cause a red rush around the mouth and nose – this is a good way of detecting sniffing solvent abuse.
Khat
Khat is commonly used by Somali and Yemeni men. It contains cathionone, which is an amphetamine-like stimulant which causes excitement and euphoria. It is typically consumed through chewing.
Alcohol
Alcohol safe drinking limits are 31 units per week in men, 14 units per week in women, with at least 2 drink-free days per week. Whilst rates of alcohol consumption by women and adolescents are increasing rapidly, younger people are more prone to exceed the stipulated safe limits.
Detecting alcohol abuse is important so as to avoid long-term complications and acute withdrawal effects. A good way to detect alcohol abuse is through screening questionnaires such as FAST and CAGE. CAGE is an ideal questionnaire when alcoholism is suspected. Once detected, an alcoholic individual should be referred for counseling.
Alcoholism-related terminology
Acute Intoxication – a state in which an individual shows signs of slurred speech, impaired coordination, impaired judgement, and labile affect (inappropriate emotion expression). More severe repercussions include hypoglycaemia, stupor and coma.
Acute Withdrawal – following 1-2 days of abstinence, the individual experiences malaise, nausea, autonomic hyperactivity, tremor, labile mood (uncontrollable crying or laughing at an improper time or situation), insomnia, transient (mostly visual) hallucinations, and seizures. In the worst case scenario, delirium tremens, which is a severe withdrawal symptom related only to alcohol withdrawal, may be experienced. This is characterised by altered mental status and sympathetic overdrive that may progress to cardiovascular collapse. Delirium Tremens carries a 15% mortality rate.
Alcohol Dependence – individual experiences cognitive, behavioural and psychological features with compulsion to drink, preoccupation with alcohol, stereotyped drinking pattern, loss in drinking regulation, and tolerance of alcohol intoxicant effect.
Psychotic Disorders – hallucinations with 2nd person threatening voices and at times pathological or morbid jealousy.
Amnesic Syndrome – Korsakoff’s psychosis: a severe, diencephalic amnesia caused by thiamine deficiency, which is typically noted in alcoholic patients with very poor diets.
Alcohol Abuse Residual Problems – residual depression and dementia.
Alcohol Abuse Detection and Screening
- collect collateral history
- look for signs of alcohol disease eg. jaundice, palmar erythema (a skin condition that makes the palms of your hands turn red), gynaecomastia (a common condition that causes boys’ and men’s breasts to swell and become larger than normal), and spider naevi (swollen spider-like blood vessels on the skin often containing a central red spot and deep reddish extensions)
- blood tests should be performed to check for macrocytosis (red blood cells that are larger than normal), high gamma-glutamyltransferase (GGT – indicative of liver disease), and high blood alcohol levels
Complications related to alcoholism are usually encountered in the acute setting. These include:
- gastrointestinal complications
- haematological complications
- cardiovascular complications
- wernicke’s encephalopathy (a life-threatening illness caused by thiamine deficiency, which primarily affects the peripheral and central nervous system)
- korsakoff’s psychosis
- peripheral neuropathy
- cerebellar degeneration (a condition in which cerebellar cells a.k.a. neurons, become damaged and progressively weaken in the cerebellum)
- erectile dysfunction
- social complications
- fetal alcohol syndrome (in pregnancy)
Management
- motivational interviewing
- detoxification (possibly including hospitalisation with administration of benzodiazepines and thiamine)
- learning relapse-prevention strategies
- referral to self-help groups such as Alcoholics Anonymous
- administration of Disulfiram, which causes an unpleasant reaction if the individual consumes alcohol, and Acamprosate, which reduces cravings
- public health measures eg. taxation
Synthetic Drugs
Synthetic drugs are manufactured to chemically resemble illicit drugs such as cocaine, LSD, MDMA, or methamphetamines, yet can be purchased legally as the manufacturers continuously change the chemical structure to circumvent drug laws. They are usually not detected in urine tests.
Synthetic Cannabinoids, which are commonly used in Malta, are products that mimic the effect of Cannabis in a more potent way. These can be found as solids or oils. Smoking mixtures with added cannabinoids are mostly sold in metal-foil sachets.
Synthetic Cannabinoids cause psychotic symptoms such as extreme anxiety, confusion, paranoia, and hallucinations.
Other synthetic drug names include:
- Spice – synthetic marijuana / cannabinoids
- Ecstasy – Molly
- Bath Salts – contain one or more synthetic chemicals related to cathinone
- Mephedrone – Meow Meow: commonly found in bath salts
- Krokodil – cheaper heroin substitute which is a synthetic morphine derivative, commonly used in Russia
NOTE: Psychosis following intoxication can usually be reversed.
The Stages of Change Model
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