At Home Drug Withdrawal

Sobriety Success

The dependence on sobriety is defined as the state of sobriety. When a person is sober, they can live on a daily basis without their thoughts and behaviors being controlled by substance dependence. They do not feel obliged to use it because they manage to live without it. They see and appreciate so much the benefits of living without substance that they do not feel they have to use drugs or alcohol. Therefore, they refrain from using it to continue enjoying this new, healthier lifestyle. The success product of sobriety is a step-by-step manual for everyone. The product has been said to be beneficial for many people around the world. The reason why the product is gaining so much popularity among individuals. They see and appreciate so much the benefits of life without substance that they do not feel they have to use drugs or alcohol. Therefore, they refrain from using it to continue enjoying this new, healthier lifestyle. This strategy encourages you to maintain the long-term vision of recovery. Recognize that this is not a one-off thing, something you try for a few weeks to several months, then return to your previous life. You will be in recovery if you decide it's the life you want to live for the rest of your life. As such, there is no immediate timeline to which you must adhere, nor should you strive to achieve goals that you are clearly not ready to face. Read more...

Sobriety Success Summary


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Methylenedioxymethamphetamine (MDMA Ecstasy) is a derivative of methamphetamine. It is reported to cause severe damage to the serotonergic neurons in nonhuman primates and decreases in the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in the cerebrospinal fluid of humans who have abused the drug. y MDMA acts as a stimulant and a hallucinogen. It is abused by individuals who wish to intensify their emotional and sensory experiences. MDMA and a close congener, methylenedioxyamphetamine (MDA), are reported to cause changes in the strength of the emotions. Psychiatrists have experimented with these drugs to facilitate psychotherapy, especially in patients who have difficulty in expressing their emotions.

PAC Pontocaine AdrenalineCocaine and TAC Tetracaine AdrenalineCocaine

Pontocaine or tetracaine 2 aqueous epinephrine (adrenaline) 1 1000 cocaine (PAC) is the most commonly used topical agent.3,4 It may be prepared in a 100-mL volume by mixing 25 mL of 2 tetracaine, 50 mL of 1 1000 aqueous epinephrine, 11.8 g of cocaine, and sterile normal saline to a volume of 100 mL.

Drug Or Drug Withdrawal

Drugs, or the withdrawal of drugs, can precipitate seizures. Historically, pentylenetetrazol (Metrazol) was introduced to bring on convulsive seizures for electroconvulsive shock therapy in the 1930s and 1940s. It was later abandoned because of many restrictions on its use. Antiepileptic drug withdrawal is often used during inpatient long-term video EEG monitoring for both diagnostic and therapeutic reasons. Contrary to many patients' understanding, however, drug withdrawal is rarely used in the EEG laboratory outside of the long-term monitoring setting, because the likelihood of seeing interictal discharges, especially focal discharges, is not greatly affected by most antiepileptic drugs (and the risk of seizure is high). In the long-term monitoring setting, concerns raised that medication withdrawal would change the nature of the typical seizures and negate the usefulness for localization has dissipated with studies indicating that seizures may more likely generalize, but clinical...


South and Southwest, transmission is currently most associated with injection use of cocaine and amphetamine (18). The increased prevalence of HIV-seropositive status among cocaine users is apparently linked to two sets of associated behaviors sexuality and injection drug use (33,137). Sexually transmitted disease related to cocaine use appears to be partially dependent on the route of administration of the cocaine. A survey conducted in 1991 showed evidence of higher-risk sexual practices in those who use a freebased, or smokeable, form of cocaine. These individuals reported not only more frequent sex partners but also more drug use surrounding individual sexual acts, and, what might seem intuitive, more frequent unprotected sex. This population also had higher rates of drugs for sex activity than the cocaine hydrochloride group, those primarily using intranasally (138). Similar results were found in a study of inner-city young adult crack cocaine smokers in which high-risk sexual...


Blockade of the uptake of monoamines into the presynaptic terminals is probably responsible for the acute effects produced by cocaine. Depending on the synapse affected, this blockade leads to increased levels of dopamine (DA), norepinephrine, or serotonin. The increase in neurotransmitters can TABLE 39-7 -- SUMMARY OF NEUROLOGIC SIGNS AND SYMPTOMS OF DRUG ABUSE TABLE 39-7 -- SUMMARY OF NEUROLOGIC SIGNS AND SYMPTOMS OF DRUG ABUSE Cocaine can cause strokes when taken either intranasally, intravenously, or intramuscularly. y , y The effects of cocaine on the cerebral circulation are due primarily to direct vasoconstriction, probably related to stimulation of noradrenergic receptors by increased levels of norepinephrine. In addition, cocaine can enhance platelet response to arachidonic acid, thus promoting aggregation. Cocaine-induced strokes may be ischemic or hemorrhagic. Cocaine-ischemic strokes can present as transient ischemic attacks. Infarctions...

Three Giants Of The First Half Of The 20th Century

Concurrently, Sigmund Freud was abandoning his early emphasis with neurological approaches to the mind, including experimentation with drugs such as cocaine for the treatment of opiate addiction, and was setting in motion a dynamic depth psychology that eventually captivated American psychiatry. Unfortunately, Freud's psychodynamic approach, which revolutionized our views of how the mind operates with many unconscious instinctual dimensions and urges, did not foster a robust scientific movement to properly evaluate his own blossoming ideas. That, of course, would have been impossible in his day. Initial theory was built upon rather limited clinical observations, and then theoretical constructs were built upon other theoretical constructs, with no clear empirical operationalization or organic foundations. In the opinion of many, the resulting structure ultimately resembled a Tower of Babel, where one could not readily sift the good ideas from the bad. Freud's thesis that most...

Three Great Phases Of 20thcentury American Psychiatry

Following the decline of German medical influence in 1914, the progression of 20th-century psychiatry emerged largely on the Anglo-American scene, at least until the most recent psychopharmacological era when new agents were discovered, around the world, to have more remarkable and specific effects on the psyche than anything discovered since morphine and cocaine. This history can be conveniently broken down into three phases of about three decades each, with the Kraepelinian approach to diagnostics and pathophysiology providing a sustained background theme for all. His systematics matured when effective medicines were discovered to treat most major disorders with the advent of powerful medications for the treatment of schizophrenia, depression, mania, and anxiety in the 1950s. It remains controversial how much each phase advanced the field relative to the ones that preceded it. Nonetheless, each period was distinctive, reflecting, perhaps, an evolving progression of scientific...

Affective Disorder Syndromes

The differential diagnosis of bipolar disorder includes other psychiatric syndromes including schizophrenia and personality disorders. Medical and neurological conditions that may be associated with mania or may be mistaken for bipolar disorder include CNS masses, infections (neurosyphilis, encephalitis), and hyperthyroidism. Steroids, cocaine, amphetamines, hallucinogens, baclofen, bromocriptine, pergolide, methylphenidate, and levodopa may all cause symptoms consistent with mania. Other neurological disorders that may include mania as part of their presentation include multiple sclerosis, head trauma, stroke, temporal lobe epilepsy, and Wilson's disease.

Alcohol And Depression

Similar relationships between depressed mood and alcohol abuse have been reported in adolescents. In a prospective study of over 1000 adolescents, those with depressive symptoms and heavy drinking were more likely to have low levels of functioning, high levels of childhood externalizing problems and stressful life events, low levels of family social support, and high levels of delinquency (34). Alpert et al. (35) found that childhood and adolescent onsets of depression were risk factors in the development of alcohol dependence and abuse in adulthood. King et al. (36) noted that depressed male adolescents had increased risk of later alcohol and drug abuse.

Social Skills and Daily Living

Modeling by in vivo demonstration is widely used as part of social skills training. Video modeling is the staple of many standard programs. It has been the primary component in a diverse range of training programs, from teaching young, isolated children to overcome their shyness, to providing alternatives to social behavior related to drug abuse, aggression, and other illicit or unhealthy activity. For example, films of age-appropriate students coping with social pressure to smoke cigarettes have been effective in programs at junior high schools. It may be noted that the programs with greatest effectiveness are those that illustrate adaptive coping (resisting coercion without destroying friendships), not negative consequences (early, gruesome death by cancer).

Local Anesthetics Vasoconstrictors and Injection Locations

Local anesthetics 3 and vasoconstrictors 12 also play an important role in minimizing postoperative pain and improving the surgical field during endo-scopic sinus surgery. There are a myriad of mixtures and protocols used for local anesthesia and vasoconstriction. Two basic classes for local anesthetics exist the amino esters and the amino amides. Cocaine, a naturally occurring amino ester, was the first anesthetic to be discovered and was introduced into Europe in the 1800s. Lidocaine, an amino amide, is the most widely used cocaine derivative and was developed during World War II. All esters and amides are vasodilators with the exception of cocaine, which is a vasoconstrictor thus, the combination of anesthesia and vasoconstriction makes cocaine an ideal anesthetic for intranasal surgery 6 . However, the euphoria and highly addictive nature of cocaine have made it one of the most widely abused recreational drugs and thus made it illegal in most countries. As a result, cocaine is...

Stimulants And Depression

Depressive disorders among 298 treatment-seeking cocaine abusers to be about 60 , which declined to approximately 30 during exclusive cocaine use. In characterizing their population, Gawin and Kleber (107) found that 33 had depressive disorders 13 with major depression and melancholia and 20 with dysthymia. Symptoms persisted for more than 10 days after last use and were consistent with previous symptoms during abstinence. Interestingly, the group with psychiatric diagnoses used less cocaine than the remainder of the sample but reported that it produced the same effect. It was postulated that the depressed group might have an increased sensitivity to the effects of cocaine, thereby using it to self-medicate dysphoria. Eight of the authors' 70 subjects reported increased severity of depressive symptoms as intensity and duration of cocaine use increased, for which they postulated an acute depletion of catecholamine neurotransmitters and supersensitivity of dopamine (DA) autoreceptors....

Associated Neurological Findings

Optic disk examination and documentation of increased intraocular or intracranial pressure (papilledema) should be obtained because tumors in the olfactory groove or sphenoid ridge (e.g., meningiomas) can cause the Foster Kennedy syndrome, which is composed of three clinical hallmarks--ipsilateral anosmia or hyposmia, ipsilateral optic atrophy, and contralateral papilledema. Although rare, visual disturbances are caused by some forms of sinusitis, which can also alter chemosensation. For example, optic neuropathy has been reported secondary to cocaine-induced osteolytic sinusitis. y Altered visual contrast sensitivity, color perception, and perception of the visual vertical may provide additional information about a more diffuse chemosensory disorder. Hearing problems may reflect viral or bacterial infections in the middle ear that alter taste function in the anterior tongue via chorda tympani nerve (CN VII) damage or inflammation, as well as more general nasal sinus...

Brainderived Neurotrophic Factor

In neonatal rat pups, 24 hours of maternal deprivation results in substantial decrements in BDNF in the hippocampus and a doubling in the rate of the diffuse neuronal apoptosis that occurs in the 12-day-old animal. Repeated experiences of maternal deprivation for 3 hours in the first 10 days of life result in an animal that is permanently hyperactive and hypercortisolemic, as well as prone to alcohol and cocaine self-administration as compared with its non-deprived litter mates. These biochemical and behavioral defects are reversed by chronic treatment with serotonin-selective antidepressants but return when these treatments are discontinued. While alterations in BDNF or other neurotrophic factors have not been definitively linked to these long-term biochemical and behavioral changes in this psychosocial stressor paradigm, they provide a plausible mechanism.

Substanceinduced Psychotic Disorders That Must Be Excluded Prior To Diagnosing Schizophrenia

Stimulants (e.g., amphetamine, methamphetamine, cocaine), hallucinogens (e.g., lysergic acid diethylamide), and phencyclidine may produce a paranoid psychosis with visual, auditory, and tactile hallucinations. Unlike the insidious onset typical of true schizophrenia, these psychoses tend to have an abrupt onset (e.g., during a several-day course of high In a family study of substance abusers, Tsuang and associates (30) examined whether prolonged psychosis following substance abuse was related to risk factors for schizophrenia. They defined prolonged psychosis as at least 6 months of psychotic symptoms without return to the individual's previous level of functioning. They found that the risk for schizophrenia in the families of 45 substance abusers with prolonged psychosis was 6.5 . This was similar to the risk for families of 46 patients with schizophrenia (6.8 ). In addition, families of substance abusers with prolonged psychosis had increased risk for mood disorder, suggesting that...

Chronology Of Bipolar Disorder And Sud Comorbidity

The association between SUD and bipolar disorder remains unclear. Some have suggested that SUD is a consequence of the mood instability inherent in bipolar disorder, others that SUD is a risk factor for precipitating or perpetuating affective episodes, or an attempt at self-medication of symptoms. Studying the temporal relationship between the onset of SUD and bipolar disorder may be one way of addressing this relationship. Goodwin and Jamison (28) have suggested that SUD may initiate bipolar disorder by way of kindling and sensitization (40). In this model, repeated intermittent exogenous stressors (such as abuse of alcohol or cocaine) may initiate progressively more severe and frequent affective responses, eventually culminating in spontaneous mood episodes (40). With this theory in mind, Ananth et al. (41) have speculated that use of cocaine might contribute to a rapid-cycling pattern in bipolar disorder. For this model to hold true, the age of onset of bipolar disorder with...

Course Of Bipolar Disorder With

Tohen et al. (46), in a 4-year prospective follow-up study of 75 patients who recovered from an index manic episode, reported that a history of alcoholism was a predictor of poor outcome for the bipolar disorder. They found that the presence of SUDs was strongly associated with a shorter time to relapse and poor psychosocial outcome. In addition, in a sample of firstepisode patients (9), the median time to recovery was shorter for persons without drug abuse than those with comorbid drug abuse (43 days vs. 55 days, respectively p 0.045). The presence of comorbid drug abuse was also associated with a lower probability of recovery at 2 years. Recently, Tohen et al. (3) studied the 24-month outcome of 219 patients who were recruited from consecutive inpatient admissions who met DSM-III-R IV criteria for bipolar disorder manic or mixed or unipolar major depression with psychotic features. The authors did not find that substance use disorder was predictive of either syndromic or functional...

Heather Ashton and Allan H Young

Selective serotonin reuptake inhibitors (SSRIs) have considerable advantages over earlier antidepressants, such as most tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs), but like all drugs they also have adverse effects. Advantages of SSRIs include greater tolerability and safety and a wider range of clinical applications, one of which is a potential use in the treatment of drug abuse and some eating disorders (see also Chapter 4). However, recent evidence shows that SSRIs are associated with a withdrawal reaction on discontinuation after regular use. A further emerging problem is that SSRIs may themselves be entering the repertoire of polydrug abusers. Three aspects of SSRIs are considered in this chapter withdrawal effects after chronic administration, potential therapeutic value in the treatment of drug abuse and the possibility of SSRI abuse.

The SSRI Withdrawal Discontinuation Syndrome

Many, if not all, drugs that cause adaptive receptor changes on chronic administration are liable to be associated with symptoms if the drug is abruptly discontinued. Withdrawal symptoms are well documented for TCAs and related compounds,1-8 MAOIs,6 trazodone9 and the serotonin (5-hydroxytryptamine, 5-HT) noradrenaline reuptake inhibitor (SNRI), venlafaxine,10 and it is not surprising that similar symptoms can occur on cessation of long-term treatment with SSRIs. The question of whether the emergence of a withdrawal reaction on drug discontinuation is evidence of drug dependence, as defined for therapeutic dose benzodiazepine dependence, is discussed by Medawar.11

Shared Underlying Pathophysiology Between Schizophrenia and Substance Abuse

Behavioral sensitization also develops following intermittent repeated exposure to stress, which is also mediated via the mesolimbic DA system (92-94). Furthermore, there is cross-sensitization between stress and psychostimulants (and other drugs) (92-94), and the HPA axis appears to mediate this interaction (93,94). Repeated exposure to stress has been reported to increase the behavioral response to psychostimulants and other drugs in rodents (92-94). This stress-induced enhanced sensitivity to addictive drugs is mediated via stress-induced glucocorticoids secretion, which increases the sensitivity of mesolimbic DA neurons to drugs (93,94). For example, metyra-pone, an inhibitor of corticosterone, suppressed stress-induced sensitization of the increase of DA in nucleus accumbens induced by cocaine and sensitization of cocaine-induced locomotion (94). Similarly, suppression of stress-induced corticosterone secretion by adrenalectomy abolished stress-induced sensi-tization of the...

Treatment A Role Of Atypical Antipsychotic Drugs

Haloperidol treatment has been reported to increase smoking in schizophrenia (124) and normals (131). Furthermore, as previously mentioned, chronic treatment with haloperidol enhanced sensitization of the psychomotor effects of cocaine in rodents (65). Atypical antipsychotic drugs have been reported to be more effective than typical neuroleptics to treat positive, as well as negative and depressive symptoms (128-130). In addition, atypical antipsychotics produce significantly fewer extrapyramidal side effects than typical antipsychotic drugs do (130). Furthermore, treatment with atypical antipsychotic drugs reduces frequency of hospitalization (132,133), and treatment with clozapine has been reported to reduce suicidal attempts (134). In addition, atypical antipsychotic drugs have been reported to decrease substance abuse. For example, use of clozapine in substance-abusing schizophrenics has been reported to reduce smoking (121,122), and there have been case reports...

Summary And Future Directions Of Research

And self-medication of symptoms and side effects of neuroleptics. The biological mechanisms underpinning both substance abuse and schizophrenia appear to be a significant factor in the high rate of comorbidity. In contrast to typical neuroleptics, some atypical antipsychotic drugs, such as clozapine and amperozide, appear to decrease drug intake in rodents. In addition, clozapine was reported to improve abuse of alcohol, cocaine, and smoking in schizophrenics, and risperidone was reported to reduce methamphetamine and cocaine craving in nonschizophrenic patients. Future research is needed on biological mechanisms of both substance abuse and schizophrenia, and on effects of atypical antipsychotic drugs in substance-abusing schizophrenics. In addition, substance abuse treatment programs specific for schizophrenic patients need to be developed.

Interaction of Serotonergic Pathways with Reward Systems

Conversely, serotonergic neurons from the raphe nuclei appear to exert an inhibitory effect on dopaminergic neurons in the nucleus accumbens. Thus, lesions of the dorsal and median raphe nuclei in rats increase dopamine turnover in the nucleus accumbens injection of 5-HT into the nucleus accumbens inhibits the locomotor effects of cocaine and apomorphine, and 5-HT depolarizes nucleus accumbens neurons in vitro while dopamine hyperpolarizes them.

HT in Addictive Behaviors

In view of these contradictory actions on dopaminergic reward pathways, it is not surprising that the part played by 5-HT in addictive behaviors is uncertain. However, there is some evidence for decreased serotonergic activity in alcoholics,51 bulimics52 and possibly in opiate and CNS stimulant abusers, although this may be related to depression. It has been suggested that 5-HT deficiency may underlie drug-seeking behavior,51 that it is involved in craving53 and that brain serotonergic activity contributes to satiety47,52 and modulates the reinforcing effect or 'high' produced by other drugs of addiction.54 Trials with drugs that increase serotonergic activity, especially SSRIs, are described below, but it should be noted that these constitute only one of several pharmacological approaches to the treatment of drug addiction. It may be that the combined use of other drugs such as naltrexone, acamprosate,55 clonidine, lofexidine and others56 is more effective in some cases.

Substance Abuse and Personality Disorders in the General Population

Thus, in the general population a strong association has been demonstrated between alcoholism and ASPD. However, a comprehensive and methodologically sound assessment of the comorbidity rates between alcoholism and the full range of personality disorders remains lacking. Furthermore, information on the comorbidity between the personality disorders and drug dependence other than alcohol dependence in the general population is also unavailable at the present time.

Substance Abuse and Personality Disorders Among Treatment Populations

In an inpatient substance abuse treatment population, Nace and colleagues (9) found that 57 of substance abusers had an Axis II personality disorder. ASPD was the most frequently diagnosed personality disorder in this sample. When a sample of cocaine-dependent inpatients was studied, 70 of patients met criteria for at least one personality disorder (10). Comorbidity rates were highest for borderline personality disorder (BPD) (34 ), followed by ASPD (28 ) and narcissistic personality disorder (28 ). In outpatient substance abuse patients, the prevalence rate of personality disorders was at least 60 in alcoholics (13,14) and 48 in cocaine addicts (15). Cocaine Cocaine

Impact Of Personality Disorders On The Course Of Substance Abuse

A multitude of studies have demonstrated that ASPD is associated with an earlier age of onset for alcohol use and dependence (7,27-29) and for cocaine use and dependence (17). Severity of drug dependence is also affected by the coexistence of a personality disorder. Alcoholics with ASPD, for example, exhibit a higher alcohol symptom count and longer duration of alcoholism (4). A distinct pattern of alcohol use characterized by compulsive use, drinking to manage moods and enhance functioning, and pervasive use of alcohol in one's life is seen among alcoholics with personality disorders as compared with those without personality disorders (9). BPD was the largest personality disorder group represented in this study hence, this particular pattern of alcohol use may pertain more to BPD than other personality disorders. Polydrug use, another indicator of severity, is also more likely among substance abusers with a personality disturbance. For example, alcohol-dependent patients with BPD...

Effects of Axis II Diagnosis on Treatment Outcome

Both of these personality-disordered groups showed improvement across a number of areas studied, including employment, social, psychiatric, and legal status. The other personality group excluded patients with ASPD however, the ASPD group did not exclude patients with other personality disorders. Hence, comorbid personality disorders in the ASPD group may have resulted in a failure to detect differences between the two groups. In Cacciola and coworkers' study (40), ASPD was not a negative predictor of treatment response in alcohol- and cocaine-dependent men at 7-month follow-up. Among these patients, ASPD substance abusers and non-ASPD substance abusers showed comparable rates of treatment response in several areas.

Multiple sleep latency tests MSLTs

These should be carried out after a period of withdrawal from drugs such as amphetamines and anticat-aplectic agents, which may affect the results. MSLTs are not suitable for children under the age of around 6 years. They show a short sleep latency with a mean of less than 5 min in 80 of narcoleptics. Sleep-onset REM sleep in two or more of the four or five MSLTs is present in over 75 of narcoleptics, but may also be seen in depression, REM sleep deprivation due to sleep restriction or fragmentation due, for instance, to obstructive sleep apnoeas, and in REM suppressant drug and alcohol withdrawal.

How common is genital herpes

Results of a recent, nationally representative study show that genital herpes infection is common in the United States. Nationwide, 45 million people ages 12 and older, or one out of five (21.9 ) of the total adolescent and adult population, is infected with HSV-2. HSV-2 infection is more common in women (approximately one out of four women) than in men (almost one out of five). This may be because male to female transmission is more efficient than female to male transmission. HSV-2 infection is also more common in blacks (45.9 ) than in whites (17.6 ). Race and ethnicity in the United States are risk markers that correlate with other more fundamental determinants of health such as poverty, access to quality health care, health-care seeking behavior, illicit drug use, and living in communities with high prevalence of

Tricuspid Valve Disease

Agustin Arbulu, a heart surgeon at Wayne State University in Detroit, has shown that when a tricuspid valve is severely damaged because of antibiotic-resistant infection and the infection is the result of illicit intravenous drug abuse, a good method of treatment is to remove the infected tricuspid valve and not replace it. This removes the source of the infection. If an artificial valve is put in, it too will likely become infected since the patient frequently resumes the illicit drug use.

Hiv Substance Abuse And The Impact On Infants

An assessment of HIV risk in mothers of 6750 children with perinatally acquired AIDS in the United States revealed 41 with history of injection drug use, 34 had had sexual contact with a partner with or at risk for HIV AIDS, 2 were recipients of contaminated blood or blood products, and in 13 no risk was specified (38). Not only are infants born to drug-dependent HIV-seropositive women at significant risk of becoming HIV-seropositive themselves, they are also at higher risk for a variety of other adverse outcomes (39). There is a rising incidence of mothers infected with HIV secondary to drug use. The association between cocaine use and high-risk sexual activity, including sex for drugs and multiple sexual partners, has led to a rising incidence of HIV infection in cocaine-using mothers. Sex with multiple partners increases the chances of reinfection with multiple HIV serotypes and greater virulence of infection. These features may be responsible for the higher rates of persistent...

Psychological Science

The history of psychological science from its beginnings in the laboratory of Wundt to the present day reveals a great broadening of its concern. Wundt's experimental procedures were generally limited to the question of identifying the elements of the structure of mind conceptualized as conscious experience. The behavioristic movement substituted a concern with the functioning of animal and human organisms interacting with an environmental context. Present-day cognitive psychology has returned to questions of mental activity, but with a different goal than that of Wundt. Along the way, psychology has adopted a number of methodologies and procedures that extended its scope, and it grew by encompassing a number of areas related to its main goal. Psychology adopted the analytic methodology of statistics and in many areas was able to harness mathematical models to augment its growing methodological armament. The methods and goals of psychological science were applied to a wide variety of...

Prevention Of Hiv Associated With Substance Abuse

Although newer combination therapies have the potential to lower the viral load, which may also reduce the likelihood of contagion, reducing risk behaviors remains the most important strategy for preventing the spread of HIV (162). Among drug abusers, behaviors associated with sharing injection equipment and high-risk sexual activities are fundamental in the transmission of HIV. Consequently, prevention efforts must target these behaviors. Despite initial skepticism about the likelihood of producing behavioral change in drug abusers, HIV-prevention efforts have been successful in this population. Because of stigmatization and the marginalized status of drug abusers, initial prevention efforts were directed at outreach and counseling about risk reduction. The results of NIDA's National AIDS Demonstration Research Projects provide compelling evidence that even relatively limited educational counseling about risk reduction can have beneficial effects. Many early attempts at risk...

General Treatment Issues

In recent years many important advances in treating HIV-seropositive patients have established the potential for both increased quality and duration of life with early presentation and management (10,12). The impact of these treatments on drug-dependent patients, however, has been far less than on other groups. HIV-infected active IDUs and those not in drug treatment are less likely to have sought out or be receiving treatment for their infection. Part of the problem is the lack of a consistent source of healthcare or health insurance (170,171). Even when free potent antiviral treatment was offered in a Vancouver study, only 17 of the eligible cohort received maximum treatment. Older male patients in drug treatment were most likely, and HIVseropositive females and IDUs least likely, to take advantage of potent HIV regimens (171). In the United States, IDUs experience greater morbidity and mortality than non-IDUs and male homosexuals when similar opportunities for potent HIV regimens...

Differential and usedependent block by local anaesthetics

Using local anaesthetics, the concept of differential nerve block was noted with sensitivity for block of nerve fibres increasing from sharp pain, cold, warmth and contact or touch, to finally motor fibres 5 . This was subjected to quantitative neurophysiological analysis by Gasser and Erlanger in 1929 when they reported on the differential susceptibility of compound action potentials in nerves to pressure and cocaine-containing solutions based on fibre size and conduction velocity, from Aa (fastest) to C-fibres (slowest) 7 . They suspected that diameter might be the main parameter accounting for differential nerve block, because they felt the process responsible for impulse propagation was essentially similar in all fibres. With cocaine they observed that small fibres (slowly conducting) tended to be blocked before large ones, but in all cases a varying proportion of large fibres were blocked well before the compound action potential for small fibres had disappeared. They concluded...

Fetal Alcohol Syndrome

Because addicts often abuse several drugs, it is important to consider that an irritable, tremulous, small baby may also result from use during pregnancy of crack cocaine or other agents. There are no laboratory tests of value to support or refute the diagnosis of fetal alcohol syndrome. Maternal education regarding the toxic effects of alcohol is of paramount importance in preventing the fetal alcohol syndrome. There is no safe minimum amount of alcohol consumption that can be guaranteed not to be toxic to a fetus, so mothers-to-be are urged to abstain entirely from alcohol throughout their pregnancy. There is no direct treatment for the effects of the fetal alcohol syndrome, although proper postnatal nutrition and care will help affected babies as they do unaffected ones. Approximately one in six babies born with this syndrome die. Of the remainder, about half suffer permanent physical or mental handicaps.

Human TCell Lymphotrophic Virus Type

The human T-cell lymphotrophic virus type 1 (HTLV-1) causes a rapidly progressive adult T-cell leukemia or lymphoma (ATLL), and a slowly progressive neuromyelopathy known as HTLV- 1-associated myelopathy-tropical spastic paraparesis (HAM-TSP). y , y The distribution of HTLV-1 infection is worldwide with major foci of endemic infection in southwestern Japan, the Caribbean, Central and South America, sub-Saharan Africa, the Middle East, and Melanesia. It is estimated that between 10 and 20 million people are infected with HTLV-1. In the United States and Europe, HTLV-1 is found primarily in intravenous drug abusers. y Transmission of HTLV-1 can occur from mother to child primarily by breast milk, between intravenous drug addicts through the sharing of contaminated needles and syringes, by sexual contact, and by the transfusion of contaminated blood products. Vertical transmission of HTLV-1 from mother to child has been reported to occur in 15 to 20 percent...

Emotionalpersonality Functions

Disease processes may present with a similar neurocognitive picture. Consideration of this issue is particularly important because HIV-infected individuals quite often present with histories that include other problems (e.g., alcohol drug abuse, depression and other psychiatric disorders, learning disabilities, head injury). In addition, concurrent CNS processes such as metabolic encephalopathy and OIs can also overlap with respect to cognitive deficits. Imaging studies may not show abnormalities in persons with HIV-associated minor cognitive and motor disorder, despite positive neuropsychological findings. In mild HIV dementia, neuroimaging suggests subcortical and cortical atrophy with MRI abnormalities seen in deep white matter. White matter abnormalities, which may represent disruptions of the blood-brain barrier, progress and are more diffuse with increasing severity of dementia. 10&1 There appears to be a positive relationship between MRI findings and neuropsychological...

Traumatic Brain Injury and Rehabilitation

Their head injury (40 had moderate to severe problems with substance abuse and 15 had mild to moderate substance abuse). The NHIF study also noted that the substance of choice was alcohol in over 95 of survey responses. In a review of alcohol and drug abuse studies in physically disabled patients in rehabilitation, alcohol-associated traumatic injuries made up 79 of one rehabilitation patient population (83). Regarding studies of drugs of abuse other than alcohol, differences in data collection and outcome and small numbers of patients limit the clinical conclusions that can be drawn (83,84).

Primary Intracerebral Hemorrhage

Hemorrhage in the basal ganglia, caudate nucleus, thalamus, pons, or cerebellum, angiography is usually not necessary. If the hemorrhage is in an atypical location or the patient is young and not hypertensive, angiography is indicated to exclude an AVM, aneurysm, vasculitis, or tumor. Patients who have ICH after cocaine use have a high likelihood of vascular malformations and aneurysms and need angiography.

Surgical Technique

Topical anesthesia with 4 cocaine is applied in cotton pledgets, followed by a 1 Xylocaine with epinephrine (1 100,000) transpalatal sphenopalatine block. Under direct fiberoptic endoscopic visualization of the nasal cavity and sinus ostia, further local anesthetic is injected as necessary. The guiding catheter is then inserted close to the sinus ostia (Fig. 25.2). Table 25.1 shows the angle and the guiding catheter usually required to enter each type of sinus. Sinus guide wires are then advanced through the catheters under fluoroscopic guidance, until their presence inside the sinus is confirmed.

Regulation of Food Intake and Energy Storage

Hypothalamus Food Intake Regulation

Neurons and Neurotransmitters in the Hypothalamus That Stimulate or Inhibit Feeding. There are two distinct types of neurons in the arcuate nuclei of the hypothalamus that are especially important as controllers of both appetite and energy expenditure (Figure 71-2) (1) proopiomelanocortin (POMC) neurons that produce a-melanocyte-stimulating hormone (a-MSH) together with cocaine- and amphetamine-related transcript (CART), and (2) neurons that produce the orexigenic substances neuropeptide Y (NPY) and agouti-related protein (AGRP). Activation of the POMC neurons decreases food intake and increases energy expenditure, whereas activation of the NPY-AGRP neurons increases food intake and reduces energy expenditure. Cocaine- and amphetamine-regulated transcript (CART) Peptide YY (PYY) Control of energy balance by two types of neurons of the arcuate nuclei (1) proopiomelanocortin (POMC) neurons that release a-melanocyte-stimulating hormone (a-MSH) and cocaine- and amphetamine-regulated...

Creation and Early History of NIMH

Over the years, scientific progress and opportunities, public health needs, and political directives have influenced NIMH's research priorities. In 1965, for example, President Johnson pledged to ensure the relevance of federally funded research to social ailments. NIMH responded by creating problem-focused centers to insure that basic and applied research, training, service demonstrations, and related activities would be devoted to critical targets. Centers were created to focus on Schizophrenia and suicide, but also on crime and delinquency, urban mental health, alcohol and drug abuse, minority group mental health, and, under congressional mandate, the prevention and control of rape. In 1970, award of the Nobel Prize to NIMH scientist Julius Axelrod for his studies of neurochemical processes in the brain signaled growing emphasis on research into basic biological and behavioral substrates of mental disorders. Still, the Institute's involvement in mental health services and its...

Opiate Treatment of Chronic Pain

In general, opiates are the most potent and rapid-acting medications for pain. Traditionally, opiate medications have been prescribed for acute trauma, postsurgical pain, and chronic pain associated with malignancy. Opiates may also be used in cases of nonmalignant chronic pain if other treatment options are not successful. Unlike alcohol, marijuana, cocaine, and other substances of abuse, opiates are generally obtained directly from physicians (although they can be purchased illegally on the street) and so manipulation of medical professionals often occurs. In many, if not most, cases the prescribing clinican never realizes that he or she has been used as a source of drugs for recreational purposes. Some patients sell their medications on the street to obtain the revenue needed to purchase other substances of abuse such as cocaine. In accordance with the philosophy first do no harm, most doctors are very cautious about prescribing opiates for nonterminal chronic pain conditions. On...

For Anthracycline Induced Cardiotoxicity

Longer follow-up has become important in screening, as both the prevalence and severity of cardiac abnormalities increase over time 48,59 . In a serial follow-up of 120 doxorubicin-treated patients, those with longer follow-ups were more likely to have reduced left ventricular wall thickness and secondary increased left ventricular afterload 48 . Asymptomatic cancer survivors are at increasing risk for cardiac dysfunction later in life. Patients may develop cardiomyopathy with CHF after years of latency 11, 35,36,42,48,60 . Although acute episodes can often be treated successfully, cardiac function generally shows a progressive decline even with long-term medication. Studies have shown that, six years after completion of therapy, 65 of childhood cancer survivors treated with anthracyclines have subclinical cardiac dysfunction that is often progressive 11,36, 48 . Heart failure frequently develops after an added stress on the heart, such as pregnancy, infection, an unsupervised...

Distribution and Physiological Function of the Serotonergic Neuron

In the CNS, serotonergic neurons are limited to a group of brain-stem reticular formation nuclei, the raphe nuclei. Dahlstrom and Fuxe (1964) originally described nine sero-tonergic cell groups, which they named B1 through B9. Most of these groups are associated with the raphe nuclei and the reticular region of the lower brain stem from which they project rostro-caudally, and thus to virtually all areas of the CNS receive serotonergic inputs. The serotonergic neurons in the midbrain and pontine dorsal and median raphe project to higher brain centers cerebral cortex, cerebellum, hippocampus, thalamus, hypothalamus, and basal ganglia. In contrast, serotonergic cell bodies in the ventral medulla, caudal pons, and pontomesencephalic reticular formation provide long descending projections to the spinal cord. The origins of the serotonergic projections to the dorsal horn are the neurons of the raphe magnus and adjacent reticular formation and are involved mainly in pain sensation. The...

Receptor Pharmacology

Additionally, the false substrates promote the heteroexchange of dopamine, causing reverse transport through the transporter. Therefore, drugs like amphetamine not only prevent the elimination of dopamine from the synaptic cleft but also induce release of cytosolic dopamine via reversal of the transporter. Cocaine and methylphenidate are prototypic drugs that bind to the transporter to prevent the reuptake of dopamine but are not themselves transported. Therefore, the increased release of dopamine by these latter drugs relies solely on the accumulation of dopamine released from synaptic vesicles and does not result from heteroexchange. Direct agonists bind to dopamine receptors and may or may not be selective for the D1 or D2 family of receptors. Given the heterogeneity of receptor localization (discussed previously), the development of highly selective compounds would seem to provide for relatively subtle manipulations of dopamine transmission. While...

Cardiomyopathy Congestive Heart Failure and Ventricular Arrhythmia

Their history and physical examination suggest 40 . Careful early invasive assessment of hemodynamics, followed by aggressive, tailored pharmacologic therapy and early heart transplantation, has been beneficial. However, before transplantation is considered, all reversible factors should be treated and the medical regimen should be optimized. Heart transplantation is an option for patients with end-stage cardiac failure, where the goal of transplantation is to improve functional capacity, quality of life and length of life. Rejection is no more likely in cancer survivors than in other transplant patients 138 . Cancer survivors require no significant modification of im-munosuppression, and their 2-year survival rate is similar to that of other recipients 138 . The absolute and relative contraindications to this approach include any major systemic condition with the potential to further deteriorate on immunosuppression,re-cently-treated cancer (not yet reaching 5-year, eventfree...

Central Nervous System Stimulants

CNS stimulants can be classified as Psychomotor stimulants compounds that display a stimulatory effect primarily on brain functions and which activate mental and physical activity of the organism. They are made up of methylxanthines (caffeine, theophylline, pentoxifyllin), amphetamines (dextroamphetamine, methamphetamine), and also methylphenidate and pemoline. Respiratory stimulants or analeptics compounds, which cause certain activations of mental and physical activity of the organism, and primarily excite the vasomotor and respiratory centers of the medulla (doxapram, almitrine).Drugs that suppress appetite or anorectics drugs that activate mental and physical activity of the organism, but primarily accentuate the excitatory center of satiation in the hypothalamus (phentermine, diethylpropion).In order to increase mental capability, nootropics drugs that increase the functional state of the brain are sometimes used, the effect of which is associated with blood flow and metabolism...

FAS Effects from Childhood to Adulthood

Children and adolescents with FAS FAE, even those without mental retardation, show behavioral deficits and excesses that present serious management challenges (e.g., Carmichael Olson & Burgess, 1997 Mattson & Riley, 1998). Common features include hyperactivity, inattention, impaired learning of verbal material, receptive and expressive language problems, difficulty conforming to social norms, and fine motor deficits. Temper tantrums in younger children and serious conduct disorders in older ones are a particular concern. Streissguth and Kanter (1997) described secondary characteristics that intervention might reduce and protective factors that reduce the those characteristics. The secondary factors are serious mental health problems disrupted school experience trouble with the law inpatient or prison confinement for mental health, substance abuse, or crime problems inappropriate sexual behavior and alcohol or drug problems. Protective factors are a stable and nurturant home,...

Addiction to Drugs Allostatic Regulation under Duress

There are several features of addiction that are relevant to allo-stasis. The first is the simple elevation in use of a number of neural systems during addiction, both in the appetitive and in the consummatory phases of the central motive state. The second is the dysregulation of the reward system associated with the chronic use of drugs (Koob and Le Moal, 2001). There are indications (for example, in animal models) that drug consumption can have long-term potentiation in specific neurons from cocaine ingestion (e.g., Ungless et al., 2001) and perhaps relapse from association of the drug with environmental events that are linked to this hyperexcitable state of the brain (Stanislav et al., 2001). The third link to allostasis is the long-term consequences of the drug abuse, and the vulnerability to allostatic overload. This chapter begins with a depiction of the central motive states (linking to chapters 2 and 3) of wanting drugs and some of the neural systems that underlie addictive...

Assessment Instruments For Substance Abuse Screening

Drug Abuse Screening Test (DAST) The AUQ consists of eight questions concerning the current desire to drink alcohol (3). Each question is scored on a six-point scale, from strongly disagree to strongly agree. The MAST is a more comprehensive self-administered questionnaire for diagnosing alcoholism (4,5). It consists of 25 simple yes or no questions. A score of 5-7 or more is indicative of alcoholism. The brief MAST, which consists of 10 questions and takes less time to use, is highly correlated with the complete 25-question MAST (6). The DAST is similar to the MAST, except that it is used to screen for drug abuse (4). It consists of 28 simple true or false questions. Internal reliability of the DAST has been reported to be about 0.92 or better (4). The AUDIT consists of 10 items associated with drinking behaviors, alcohol intake, and alcohol-related problems (7,8).

Definition and Clinical Descriptions

Impulsive behaviors including stealing, drug abuse, suicide attempts, self-mutilations, and mood lability are more prevalent in AN-BP than in AN-R. The AN-BP types also have a higher prevalence of premorbid obesity, familial obesity, and debilitating personality traits (Halmi, 1999).

Druginduced Disorders

Several conditions associated with drug abuse or dependence can present with psychotic symptoms such as hallucinations, delusions, and thought disorder. It is important that these conditions be diagnosed as substance-induced psychotic disorder and not as schizophrenia. In general, delirium is likely to be present along with psychosis in disorders associated with drug use. In contrast, disorientation is rare and symptoms do not fluctuate significantly over the course of the day in patients with schizophrenia. Also, auditory hallucinations are more common than visual hallucinations in schizophrenia the onset of the disturbance is also gradual and prolonged. Abuse of amphetamine and related compounds, as well as all forms of cocaine, are associated with hypervigilence and suspiciousness. This syndrome often progresses to a condition referred to as stimulant psychosis. Auditory visual or tactile hallucinations and frightening paranoid delusions are common in stimulant psychosis and...

Does Chronic Substance Abuse Cause Personality Disorders

There are several lines of evidence that suggest that the personality disturbance precedes the substance abuse. Examination of the individual characteristics that are considered risk factors for substance abuse may serve to illuminate the relationship between substance misuse and personality disorders. A growing body of evidence has identified impulsivity and conduct disturbance as risk factors for the development of a substance use disorder. For example, cross-sectional studies show that impulsive, antisocial, and aggressive traits, broadly termed behavioral disinhibition , distinguishes between children of alcoholics as compared with children of nonalcoholics (19). Moreover, prospective studies have demonstrated that higher levels of behavioral disinhibition are present among people who then go on to develop alcohol or drug problems (20-22). Behavioral disinhibition is a common feature of the Cluster B ASPDs and BPDs that co-occur frequently with substance use disorders. Such...

Demographic And Clinical Correlates Of Substance Abuse In Schizophrenia

Cocaine abusers, increased akathisia in alcoholics No difference increased in cocaine abusers (46). However, cocaine use was reported as a risk factor for acute dystonic reaction in the psychiatric population treated with neuroleptics (47). Rates of akathisia have been reported to be increased in alcohol abusers (16). Very few studies have examined the effects of substance abuse on cognitive function. Sevy et al. (48) reported more impairment in conceptual encoding and verbal memory but less impairment in attention in schizophrenic patients who were cocaine abusers compared to nonabusers. On the other hand, Nixon et al. (49) reported no difference in Trail-Making A and B and the Face-Recognition Test between alcohol-abusing and nonabusing schizophrenics. Similarly, Addington and Addington (50) have reported no difference in verbal ability, attention, executive functioning, and verbal and visual memory between abusers and nonabusers. Sandyk (45) reported less cognitive impairment as...

Therapeutic Interventions In The Prevention Of Vertical Hiv Transmission

The treatment guidelines for adults, adolescents, and pregnant HIV-infected women strongly recommend the use of ZDV as one of the NTRIs taken during pregnancy to achieve optimal chemoprophylaxis. Compliance with such recommendations has been reported by Minkoff et al. using data from the Women's Interagency HIV Study (64). On the contrary, other investigators have reported underuse of this regimen in clinical practice. Wiznia et al. observed that women who reported cocaine or intravenous drug use during pregnancy were more likely to refuse therapy, have inconsistent use of ZDV, or have missed the intrapartum component (65). A study performed using data from New Jersey Medicaid found that use of ZDV chemoprophylaxis was less likely in those with insufficient or no prenatal care. The authors also noted that inconsistent use was more frequent among women of African American descent (66). Wilson et al., reporting for the Perinatal Evaluation Project, observed that although ZDV was...

Indications in sleep disorders

Details of the choice of benzodiazepine are given in Chapter 7, but in general these drugs should be avoided wherever possible in the elderly. Short-acting drugs should be advised if the patient works with dangerous machinery, has to drive a motor vehicle or needs to be particularly alert at work. Benzodiazepines should be avoided wherever possible in children, in the presence of respiratory impairment, a predisposition to obstructive sleep apnoeas, or liver disease, or if there is a history of drug abuse.

The Primary VersusSecondary Distinction

In general, the presence of comorbid anxiety and substance use leads to worse clinical outcomes for dual diagnosis patients than for patients with single disorders (17). It is generally held that it is the overall degree of psychopathology rather than the specific diagnosis that foretells more unfavorable treatment and psychosocial outcomes for these patients (18,19). One major clinical outcome of concern that is more likely in patients with panic disorder and alcohol or drug abuse is suicide (20). The ECA data convincingly corroborated earlier evidence that suicide attempts are more common in subjects with panic disorder than in subjects with any other psychiatric diagnosis and no psychiatric diagnosis, with odds ratios of 2.62 and 12.18, respectively. This risk was even greater in panic patients who were comorbid for alcohol or drug abuse, with odds ratios of 3.28 and 4.03, respectively, compared to panic patients without the comorbidity.

Overview Of Substance Abuse And Psychiatricmedical Disorders

Data presented in this text (as well as anecdotal clinical experience) support the contention that the co-occurrence of substance abuse and other psychiatric problems extends beyond chance in many instances. Alcohol and illicit drugs have been shown in many studies to cause disturbances of mood, thought, and cognitive functions and affect interpersonal relationships. Thus, substance-related disorders can sometimes mimic other psychiatric illnesses. In addition, emotional and serious physical disabilities often appear to promote alcohol or illicit drug abuse dependence as a form of inappropriate self-medication. Alcohol use disorder and a drug use disorder OR 6-13 Bipolar disorder, type I, and alcohol use disorder OR 6 Bipolar disorder, type I, and a drug use disorder OR 11 Bipolar disorder, type I, and any substance use disorder OR 8 Bipolar disorder, type I, and an alcohol use disorder OR 6 Schizophrenia and an alcohol use disorder OR 4 Schizophrenia and a drug use disorder OR 6...

Ultrapositivistic Psychopharmacology Era 1970present

The class of drugs known as antipsychotics generally dampens DA activity. Since there are several different DA receptors, modern work has sought to more specifically target the D2 receptors, which are present in abnormally high quantities in the schizophrenic brain. Most antipsychotics are receptor blockers, which means that they prevent dopamine from having normal physiological interactions with its receptor. Other drugs that stimulate receptors are called agonists such drugs can promote schizophrenic symptoms. For instance, the indirect agonists such as cocaine and amphetamines can induce sufficiently strong paranoid symptoms that psychiatrists have difficulty distinguishing them from the real thing.

Evaluation Guidelines Table95

Testing with pilocarpine, cocaine, hydroxyamphetamine chest x-ray study Testing with pilocarpine, cocaine, hydroxyamphetamine chest x-ray study Testing with pilocarpine, cocaine, hydroxyamphetamine chest x-ray study Testing with pilocarpine, cocaine, hydroxyamphetamine chest x-ray study

Viral Causes of Liver Failure

Cocaine Hepatitis D virus (delta agent) is a defective virus that replicates only in the presence of HBsAg, which is used as the envelope protein. HDV infection is present in 30-70 of parenteral drug abusers and is found in less than 1 of homosexual men.23,46 HDV RNA is only detected in 10 of patients with fulminant hepatitis D.47 HDV usually follows a subfulminant course.4 HDV can occur either as a co-infection with HBV or as a superinfection in patients with chronic HBV.48 HDV co-infection in an HBV patient increases the risk of FHF, but decreases its associated mortality (52 vs. 73 ).49,50 Of those patients with fulminant HDV, co-infection occurs more often (53-77 ) than super-infection (23-47 ).50,51 FHF due to HDV super-infection has a higher mortality rate (72 vs. 52 ) and more often predisposes to chronic liver disease (54 vs. 31 ) than FHF due to HDV co-infection.49,52,53 At least one case of FHF due to co-infection has been reported in a patient with AIDS.54

Factors Mediating Substance Abuse In Schizophrenia

Behavioral sensitization, one of the theories to explain addictive behavior (60-64), is the process whereby intermittent stimulant exposure produces a time-dependent, enduring, and progressively greater behavioral response (6064). Sensitization is based on mesolimbic dopamine (DA) neurons, with cell bodies in the ventral tegmentum, mediating the positive reinforcing effects of drugs (61-64). Following stimulant exposure, animals sensitized to psychostimulants show enhanced DA turnover in terminal regions such as the nucleus accumbens and decreased DA activity in prefrontal cortex (60-64). However, decreased DA activity in prefrontal cortex has been observed with cocaine but not amphetamine (64). LeDuc and Mittleman (65) have reported that chronic treatment with haloperidol also produced enhanced sensitization of the psychomotor effects of cocaine in rodents. These authors (17) have suggested that neuroleptic treatment may be causally related to increased psychostimulant abuse in...

Problems with use

Develops maladaptive drug-seeking behaviour. This type of drug addiction is uncommon, but high dose benzodiazepines, especially temazepam, are taken for their euphoriant effect, with the risk of a fatal overdose. This type of physical 'dependency' is distinct from drug addiction in which the subject loses control over the use of the drug, has a compulsive need for it and

Presenting for Treatment

Tohen and colleagues (9) reported fairly low rates of lifetime SUD in first-episode manic patients. The authors reported that the lifetime prevalence of drug abuse or dependence in patients admitted for a first episode of mania was 17.1 (24 among women and 6 among men). In contrast, Keck et al. (10) reported much higher lifetime prevalence of SUD in their patients hospitalized for the first time for treatment of a manic or mixed episode. They reported a 38 prevalence of alcohol use disorders and a 32 prevalence of drug use disorder in their 34 first-episode manic patients. When these patients were compared with the 37 who had had multiple episodes of mania, no differences were found in the prevalence rate of SUDs. In another study (involving predominantly multiple-episode manic patients), Keck and colleagues (11) found that of the 106 bipolar disorder patients admitted for a manic or mixed episode who completed the 12-month follow-up, 55 (52 ) met...

Visual Hallucinations

Illicit drug use (cocaine, lysergic acid diethylamide LSD , marijuana), medications (digoxin, anticholinergics, and dopaminergics), and parasympatholytic eye drops (atropine) may also be responsible for visual hallucinations. A psychotic psychiatric disorder is suggested when complex visual hallucinations are accompanied by occasional auditory hallucinations. U Normal people may experience both formed and unformed visual images upon wakening (hypnopompic) or upon going to sleep (hypnagogic). A number of degenerative neurological diseases (Parkinson's disease, progressive supranuclear palsy), in the setting of medication use (levodopa, dopamine agonists, monoamine oxidase MAO inhibitors, and anticholinergics) can make visual hallucinations a common clinical disorder. Other disorders such as diffuse Lewy body disease may have visual hallucinations as a primary symptom as well.

Lifestyle Consequences

The emotional reactions that can occur in individuals with SCD are often complicated by inadequate recognition and treatment of pain by health care professionals. Many physicians and nurses have not had sufficient hands-on experience treating SCD pain, and thus they may be uncomfortable with aggressive medication management. Sometimes frequent hospitalization and emergency room visits are misinterpreted as drug-seeking behavior or faking pain. Although drug-related problems may occur in individuals with SCD, excessive concern over drug addiction by health care providers can lead to undermedication and inadequate pain management. Some individuals who have frequent frustrating encounters with inexperienced health care professionals become discouraged and alienated from the health care system.

Prevalence of SUD in Community Surveys

The Epidemiologic Catchment Area (ECA) study found that the lifetime prevalence of DSM-III drug dependence among respondents in the age range of 18 to 44 years was 5.1 (4). In the National Comorbidity Survey (NCS), of the respondents 15-54 years of age, 51.0 were reported to have used either illicit drugs or nonmedical prescription psychotropic drugs or inhalants at some time in their lives, and 15.4 had done so in the past 12 months (5). In the same survey, 7.5 (14.7 of lifetime users) had been dependent at some time in their lives and 1.8 had been dependent in the past 12 months (5).

Research Problems And Future Directions

Chronic pain is also difficult to study. It is as much a subjective feeling (which is difficult to accurately measure) as it is an objective physical phenomenon. Chronic pain is not a homogeneous disorder, but it has many sites, causes, levels of severity, prognoses, and other aspects. These multiple factors make these patients difficult to compare between groups and between studies. In addition, many studies provide data on chronic pain patients, but do not use appropriate controls and report important demographic information. Although much attention has been given to the relationship between chronic pain and opiate or alcohol abuse, much less is known about chronic pain and abuse of other substances such as marijuana and cocaine. One of the most important goals in this area is the development of more effective pain control medications that have little or no abuse dependence potential. Clearly the comorbidity of chronic pain and alcohol drug abuse represents a very difficult medical,...

Conclusions And Future Directions

Personality disorders and associated features in cocaine-dependent inpatients. Compr Psychiatry 35 335-340, 1994. 15. JP Barber, A Frank, RD Weiss, J Blaine. Prevalence and correlates of personality disorder diagnoses among cocaine dependent outpatients. J Personality Disord 10 297-311, 1996. 17. KM Carroll, SA Ball, BJ Rounsaville. A comparison of alternate systems for diagnosing antisocial personality disorder in cocaine abusers. J Nerv Mental Dis 181 436-443, 1993. 23. RD Weiss, SM Mirin, ML Griffin, JG Gunderson, C Hufford. Personality disorders in cocaine dependence. Compr Psychiatry 34 145-149, 1993. 45. DB Marlowe, KC Kirby, D Festinger, S Husband, JJ Platt. Impact of comorbid personality disorders and personality disorder symptoms on outcomes of behavioral treatment for cocaine dependence. J Nerv Mental Dis 185 483-490, 1997.

Treatment for Marijuana Abuse or Dependence

Treatment seeking for marijuana abuse is increasing. A more than two-fold increase was observed during the 1990s, such that the number of people seeking treatment for marijuana abuse now approximates the numbers seeking treatment for cocaine and heroin. Clinical trials evaluating treatments for marijuana dependence suggest that this disorder, like other substance dependence disorders, is responsive to intervention, yet the majority of patients have much difficulty achieving and maintaining abstinence. The types of treatment approaches with demonstrated efficacy for other substance dependence disorders (e.g., cognitive-behavioral, coping skills, contingency management, motivational enhancement) also appear effective with marijuana dependence. Interestingly, the response to treatment and relapse rates observed among marijuana-dependent outpatients also appear similar to those observed with other substances of abuse, suggesting that marijuana dependence is not easily treated.

Excessive daytime sleepiness in children

The causes of excessive daytime sleepiness in children (Table 6.4) include narcolepsy, restless legs syndrome, and periodic limb movements in sleep, cir-cadian rhythm disorders, sleep apnoeas, medical and psychiatric disorders, especially depression, drug abuse, the Kleine-Levin syndrome and sleep deprivation.

Why The Common Association Between Comorbid Substance Use Disorders And Bipolar Disorder

The hypothesis of self-medication and masking of affective symptoms has also received much attention as another plausible explanation for the high co-occurrence of SUD and bipolar disorder (24). It is common belief that the manic patients drink during their manic episodes to bring their symptoms under control (23,25,26) and use cocaine or other stimulants during their depressive episodes to bring their mood up. However, not all authors support the self-medication hypothesis. Mirin and colleagues (27) compiled data on 350 hospitalized, drug-dependent patients over a 10-year period. They found that both bipolar disorder and cyclothymia were significantly more frequent among stimulant abusers (17.5 ) than among opiate (5.4 ) or sedative-hypnotic (6.8 ) abusers, and concluded that cocaine abuse during mania was apparently an attempt to increase the high rather than improve the depression. In this hypothesis of self-medication or masking of symptoms, it has been suggested that substance...

Discriminative Touch Vibration and Conscious Sense of Joint Muscle Movement

Pacinian corpuscles (PC) are the mechanoreceptors responsible for the sensory transduction of vibratory sensation. These receptors are excited by very rapid changes in tissue distortion such as that produced by sinusoidal vibration. y When the skin is locally anesthetized by cocaine, there is a manyfold elevation in threshold for frequencies in the range of 5 to 40 Hz whereas that for higher frequencies is scarcely unchanged. This suggests that the perception of vibration depends on two separate primary afferents one innervating the skin and the other innervating the deep tissues. y Detection of vibration of the frequency range of 5 to 40 Hz probably depends more on RA transduction, whereas PC units account for detection at higher frequencies of vibration. y As stimulus intensity is increased, PC fibers may initially discharge irregularly or at some submultiple of the stimulus frequency. With slight increments, however, the point of phase locking between stimulus and firing of...

Drug Induced Hepatotoxicity

Patients with nonacetaminophen drug-induced FHF have a poorer prognosis.68 Severe liver failure has been reported in patients taking isoniazid.85 Increased risk of toxicity occurs in those who chronically ingest alcohol.86 Patients who ingest isoniazid with the enzyme inducer rifampin, have an increased risk of developing FHF. The interval between drug administration and onset of liver disease is shorter with rifampin.87,88 Psychotropic drugs such as the monoamine oxidase inhibitors and tricyclic antidepressants have been reported to cause FHF, particularly when used in conjunction with hepatic enzyme inducers.89,90 Nonsteroidal anti-inflammatory drugs (NSAIDs) can be hepatotoxic and several cases of FHF have been reported in patients using piroxicam, pirprofen, ibuprofen and indometha-cin.91-94 The mechanism of hepatocellular injury induced by these drugs is thought to be idiosyncratic rather than intrinsic toxicity.95 Halothane-induced FHF occurs within 2 weeks of general anesthesia...

Cognitive Impairments

Specialized approaches may be beneficial in improving compliance with complex medication schedules in patients with cognitive impairments. Information can be presented in simple language and repeated format, making use of written, verbal, and illustrated materials. One multimodal approach incorporating cognitive remediation strategies such as behavioral games, role playing, quizzes, memory books, large-format presentations, and frequent feedback has been found effective in reducing high-risk behavior in a small sample of opiate- and cocaine-dependent, HIV-seropositive patients (86).

Neurotransmitter Imaging of the Dopamine System

Dopamine Neuroreceptor Imaging in Substance Abuse. Apart from schizophrenia and receptor-occupancy-imaging studies with antipsychotic drugs, SPECT and PET have also provided valuable information in other psychiatric illnesses thought to reflect abnormalities in dopaminergic function. The dopaminergic system in the nucleus accumbens (ventral striatum) is thought to be centrally involved in the regulation of the endogenous reward system. Some of the behaviorally most reinforcing psychoac-tive drugs, such as cocaine and methamphetamine, cause an increase in dopaminergic transmission by blocking the dopamine transporters (DAT) necessary for reuptake of dopamine. A number of PET studies investigating the pharmacological properties of these drugs, and the relationships of these to the symptoms of drug abuse and dependence have been performed. Much of this research has been performed on cocaine as this substance blocks DAT, an effect that is responsible for both the elicitation of euphoria...

Additional Information

Narcotic (opioid) analgesics (morphine, meperidine) and phenobarbital cause a marked increase in biliary tract pressure. The increase of intraluminal common bile duct pressure by morphine (50-60 ) has been used to differentiate between acute and chronic cholecystitis. Morphine-augmented cholescintigraphy has been considered superior to conventional hepatobiliary scintigraphy in assessing cystic duct patency because diagnostic results are obtained faster. The increase in common bile duct pressure is sufficient to overcome the resistance to bile flow caused by a sludge-filled gallbladder, so that the radiotracer may penetrate the cystic duct into the gallbladder. A dose of 0.04 mg kg morphine sulfate diluted to 10 ml with saline is administered intravenously over 3 min, when the gallbladder has not been visualized within 60 min after the administration of the 99mTc-IDA complex. Serial images are then obtained at 5-min intervals for 30 min. In the case of persistent nonvisualization of...

Clinical Description and Course

Between 13 and 20 of patients are rapid cyclers (Cal-abrese, Fatemi, Kujawa, & Woyshville, 1996), who experience four or more episodes of depression, mania, hypomania, or mixed affective disorder in a single year these patients are disproportionately women. There are several known predictors of increased cycling of the disorder, including medication nonadherence, presence of psychosis, alcohol and drug abuse, sleep deprivation, and, in some patients, the use of antidepressant medications.

Directed Neurological Examination

The directed neurological examination should begin with a mental status evaluation, which includes a psychiatric assessment. This part of the examination actually begins during the history and may be expanded in a more formal fashion. The mental status examination should include assessments of level of alertness, orientation, and attention. Stupor may be organic in origin or psychiatric. Hypervigilant states may develop with delirium tremens as well as with drug overdoses, such as amphetamine, phencyclidine, and cocaine, or with paranoid states in general. A fluctuating level of consciousness is more likely to be associated with an organic cause, and the presence of stupor will interfere with the remaining aspects of the cognitive examination. Sudden alterations in behavior, especially behavior with automatisms, may also suggest a seizure disorder seizures of frontal lobe origin may be extremely bizarre, and sudden behavioral changes are often mistaken for psychogenic displays.

Table 3410 Startle Syndromes

Other cerebral (perinatal anoxia), diencephalic (stroke), and brain stem (inflammatory, hemorrhage) lesions have also been associated with hyperexplexia, but most reports lack the physiological investigations necessary to prove that the startle reflex was involved. Certain psychiatric diseases including post-traumatic stress disorder may be associated with evidence of hyperarousal and an exaggerated startle reflex. Others have observed increased startle reactions in catatonic schizophrenics, patients with GTS, and newborns following in utero exposure to cocaine. The majority of acquired cases of exaggerated startle, however, are idiopathic and have no identifiable cause. An additional differential diagnostic consideration in the presence of exaggerated startle is startle epilepsy. Characterized by epileptic seizures triggered by sudden unexpected stimuli preceded by a startle, this disorder has been described in patients with severe brain damage, most commonly perinatal anoxic...


Addiction is a term widely used to indicate any type of excessive repetitive involvement with an activity or substance, and it is applied as readily to exercise, reading, and television viewing as to alcohol, cocaine, or heroin use. Such broad use of the term detracts from its technical value, and in this entry the term will be used to refer only to substance use. When considering problematic patterns of use, two distinct patterns, abuse and dependence, are described (American Psychiatric Association, 1994). Substance Abuse refers to life problems from substance use use in situations in which it is physically dangerous, use interfering with occupational roles or with family and other social relationships, or use resulting in legal difficulties. In contrast, Substance Dependence is more syndromal. Physiological components of dependence may include tolerance the need for increasing amounts of the substance to attain the same behavioral and subjective effects or withdrawal, a physical...


Use of alcohol is common regular use or abuse of other drugs is less common (Grant & Dawson, 1999). At some time in their adult lives two thirds of Americans have been regular drinkers (consumed at least 12 drinks in a year). In contrast, just under 16 of Americans are regular drug users (illicit use of a drug at least 12 times in a year) at some point in their lives. The lifetime prevalence of Substance Abuse and Dependence varies by substance, with different prevalence rates for men and women. Alcohol Abuse or Dependence is most common, with a lifetime prevalence for men of 25.5 and for women of 11.4 . In contrast, 8.1 of men and 4.2 of women have had any form of drug abuse or dependence at some time in their lives. The most common drug of abuse or dependence is cannabis, followed by prescription drugs, cocaine, amphetamines, hallucinogens, opiates, and sedatives.


Community reinforcement combined with the use of vouchers (Higgins et al., 1994), and family therapy (Liddle & Dakof, 1995) are effective in treating drug dependence. Outcomes for those who complete long-term treatment in therapeutic communities are good, but dropout rates are high (Simpson & Curry, 1997). Treatments to facilitate involvement with self-help groups such as Alcoholics Anonymous or Narcotics Anonymous also are effective (Project MATCH Research Group, 1997), and continued active participation in self-help groups is correlated with better outcomes.


J., Bickel, W. K., Foerg, F. E., Donham, R., & Badger, G. J. (1994). Incentives improve outcome in outpatient behavioral treatment of cocaine dependence. Archives of General Psychiatry, 51, 568-576. Liddle, H., & Dakof, G. A. (1995). Family-based treatment for adolescent drug use State of the science Monograph . In E. Rahdert & D. Czechowicz (Eds.), Adolescent drug abuse Clinical assessment and therapeutic interventions (pp. 218-254). Rockville, MD National Institute on Drug Abuse Research. Simpson, D. D., & Curry, S. J. (Eds.). (1997). Drug abuse treatment outcome study Special issue . Psychology of Addictive Behaviors, 11(4), 211-337.


Because biomedical technologies to prevent transmission appear to be some years away, the principal public-health approaches to controlling the pandemic rest on education and behavior modification. Heightened awareness of the dangers of unprotected anal intercourse among gay men, for example, has led to a significant decline in new infections among this population. Nevertheless, as many public-health officials have noted, encouraging the modification of risk behaviors, especially those relating to sexuality and drug abuse, presents no simple task, even in the face of a dread disease. AIDS has clearly demonstrated the complex relationship of biological and behavioral forces in determining patterns of health and disease. Altering the course of the epidemic by human design has already proved to be no easy matter. The lifelong infectiousness of carriers the private, biopsychosocial nature of sexual behavior and drug abuse and the stigma already attached to those at greatest risk - all...

Opioid antagonists

These compounds are also antagonists in relation to agonist-antagonists. They antagonize the action of agonists, mixed agonists-antagonists, and they do not result in dependence or tolerance. They are used upon overdose of opioid analgesics or in the event of patient intolerance to them, and also in treating drug addiction.

Character Disorder

From this traditional definition, the concept of character disorders evolved to include four rather diverse patterns of abnormal behavior alcoholism, drug addiction, sexual deviancy, and psychopathy. Despite their diversity, several characteristics common to individuals so categorized were cited as justification for viewing them within a single conceptual framework. The behavior patterns typically constitute a violation of the codes and conventions of society. The problem behaviors most often result in immediate positive Alcoholism and drug abuse have traditionally been included under the heading of character disorders. Individuals with these symptoms generally show many dependency-autonomy conflicts and problems in the area of impulse control, conformity to social expectations, and personal value commitments that are common to a disorder of character. Similarly, sexual behaviors including exhibitionism, trans- In summary, character disorders, a slightly archaic term by standards of...

Clinical History

When interviewing a patient with complaints referable to the trigeminal system there are several key considerations to address. First is the nature of the patient's complaint (that is, pain, sensory changes, sensory loss, or motor difficulty) because the characteristic clinical features are critical components of an appropriate neurological diagnosis. For example, lancinating excruciating pain suggests trigeminal neuralgia and is distinguished from the more tolerable yet disturbing paresthesias of trigeminal sensory neuropathy. Determination of whether the symptoms are intermittent, paroxysmal, or chronic and the temporal profile of symptom development (i.e., whether symptoms began in an acute, subacute, or indolent fashion) also provides diagnostic clues. Thus, sudden complaints of sensory loss, paresthesias, or motor dysfunction in the face are consistent with vascular, traumatic, or demyelinating processes, whereas similar complaints developing over weeks more often reflect...

Mixed Mania

The majority of studies in bipolar disorder patients have reported higher rates of SUD in patients with mixed rather than classic episodes (12,33,35-38). Keller et al. (35) reported that bipolar patients with the mixed and rapid-cycling forms of the illness were more likely to abuse alcohol than patients with pure mania and pure depression. Sonne and colleagues (33) also found that bipolar disorder patients who abused substances were more likely to experience rapid cycling and to have dysphoric and irritable mood states than patients who did not abuse substances. Feinman and Dunner (32) noted that complicated and secondary, compared to primary, bipolar disorder patients had a greater percentage of rapid cycling. Primary bipolar disorder refers to patients with no past or present history of alcohol or substance abuse. Complicated bipolar refers to patients whose primary bipolar disorder was complicated by substance abuse that began after the onset of the bipolar disorder, and secondary...

Operative Technique

The procedure is performed with the patient under combined general and local anesthesia. Nasal vi-brissae are cut to get a better view of the nasal cavity when using the microscope. To minimize bleeding, topical decongestant is applied by packing the inferior and middle portions of the nasal meatus with gauze strips soaked in naphazoline hydrochloride and 2ml of 10 cocaine solution. Injection with

Human Immunoviruses

Direct effects of HIV on the brain and coinfection of the patient with other viruses such as cytomegalovirus may be etiological factors in cases of HIV infection and psychosis. In addition, drug abuse may be involved in the production of psychosis in HIV-positive patients. Sewell et al. (17) reported a higher prevalence of stimulant and sedative hypnotic abuse or dependence, greater global neuropsychological impairment, and a significantly higher mortality rate in patients with HIV-associated psychosis. Delusions with persecutory or grandiose

Dopamine Systems

One pathway central to reward is the dopaminergic mesocorticolimbic pathway. This originates from dopamine-containing cell bodies in the ventral tegmental area in the midbrain, passes through the medial forebrain bundle and projects to the nucleus accumbens, olfactory tubercle, frontal cortex and septal area.37 Many addictive drugs activate this system and it has been claimed that it constitutes the final common pathway for all drugs of abuse.38 Thus cocaine, amphetamine, opioids, nicotine, alcohol, cannabis and other drugs that are misused have all been shown to increase dopamine release in the nucleus accumbens.39-41 Natural rewarding behaviors, including sexual activity and food reinforcement, are probably also at least partially mediated by this system.42 Dopaminergic systems probably underlie the positive motivational or incentive aspects of reward and may form the basis of drug-seeking (approach) behavior.43

Opioid Systems

A second, interacting, reward system utilizing endogenous opioids (P-endorphin, enkephalins) appears to form the basis for consummatory rewards.37,43 Although opioids increase dopamine release in the nucleus accumbens, they also subserve reinforcement in animals by a non-dopaminergic mechanism. For example, lesions of the nucleus accumbens and dopamine receptor antagonists drastically reduce cocaine and amphetamine self-administration in animals but have much less effect on heroin self-administration. The opioid reward system involves not only the nucleus accumbens but also opioid systems in the periaqueductal grey, amygdala, locus coeruleus and elsewhere. It appears to be largely involved in the consummatory rewards of feeding, drinking, sexual and maternal behavior. Not only opioid narcotics but also alcohol44 and possibly benzodiazepines and cannabis have important actions on this system.

Substance Abuse

The dopamine projection from the midbrain to the nucleus accumbens is thought to be critical in the development of addiction to most drugs of abuse. Indeed, many drugs such as cocaine, amphetamine, ecstasy, and nicotine have been shown to directly activate dopamine neurons or release dopamine. Even drugs such as alcohol or heroin that do not directly bind to dopamine neurons are thought to produce addiction, at least in part, via indirect stimulation of meso-accumbens dopamine release. The release of dopamine by these drugs elevates dopamine substantially higher than the level that occurs following physiological response to a stress or a natural reward (mentioned earlier). Such aphys-iological elevations precipitate changes in gene expression in dopamine cells and elsewhere in limbic and motor circuits and ultimately mediate the behavioral changes associated with addiction. Given the apparent role of dopamine in addiction it would be predicted that dopamine antagonists might be useful...


Dopamine activity can be increased by four mechanisms (1) increased synthesis, (2) increased release, (3) prolongation of neurotransmitter activity, and (4) direct receptor stimulation. Synthesis of the neurotransmitter can be increased by giving dopa because it is the product beyond the rate-limiting enzyme and there is ordinarily an abundant amount of aromatic amino acid decarboxylase in the central nervous system. When dopa is combined with a peripherally active decarboxylase inhibitor, more dopa is delivered across the blood-brain barrier and can be used to synthesize central dopamine. Increased release can be effected by drugs such as cocaine, amphetamine, and methylphenidate, all forcing release of presynaptic catecholamines. The normal metabolism of dopamine involves reuptake of dopamine into the presynaptic cell, with subsequent metabolism by two enzymes, monoamine oxidase (MAO) and catechol O-methyltransferase (COMT). Prolongation of dopamine activity can be effected by...

Other Drugs of Abuse

SSRIs have also been shown in some animal and human studies to decrease consumption of other reinforcing drugs including cocaine, amphetamine and opiates. In rats, drugs which modify serotonergic function, including fluoxetine, reduced cocaine and amphetamine self-administration82,83 and zimelidine decreased morphine consumption in morphine-addicted animals.84 Antagonists of 5-HT3-receptors did not appear to have similar effects.85,86 Controlled trials in human drug-abusers are few. In open studies of fluoxetine in cocaine-abusing, heroin addicts entering methadone maintenance programs, cocaine intake and reported craving were reduced in patients taking fluoxetine for at least 1 week.54,87 The effects appeared to be slow in onset, the steepest decline in consumption occurring at 3 weeks, and to require high dosage of fluoxetine (45-120 mg daily) few subjects achieved total abstinence from cocaine. Some patients reported that fluoxetine decreased the quality of the cocaine 'high' and...

Abuse of SSRIs

Despite the moderate value of SSRIs in the treatment of drug addiction, there is increasing evidence that these drugs, like other antidepressants, may themselves be abused. In view of the two-edged, stimulant and suppressant, actions of 5-HT on reward systems, this observation is perhaps not as paradoxical as it may at first seem. Somewhat later Dorman et al96 reported misuse of dothiepin among intravenous drug abusers in Dublin 46 of 83 addicts at a methadone maintenance clinic admitting to misuse of dothiepin in the previous 6 months. Patients described obtaining euphoria and sedation with complex auditory and visual hallucinations which were regarded as pleasant. Dothiepin was taken orally in doses of 150-600 mg day. The abuse potential of MAOIs and TCAs may not be related to their effects on 5-HT since they also increase synaptic levels of noradrenaline and to some extent dopamine. They may thus have some actions in common with amphetamine which increases central dopaminergic,...

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