Substance abuse alcohol abuse cannabis abuse opioid abuse sedatives and Hypnotics abuse volatile substance abuse seminar . Management clinical features epidemiology everything is described

1. SUBSTANCE ABUSE

2. Presented by :
Anisha Gogoi (36)
Muskan Sharma (37)
Tauhida Nasrin Choudhury (39)
Mrinmay Kalita (40)
Kangkan Kalita (41)
Prarthana Boruah (42)
Rakhi Kumari (43)
Rishal Singh (44)
Yogesh Prajapat (46)
Sohail Islam (47)
Sazzad Shahsil Shahnawaz (48)

3. CONTENTS :
1. Introduction and Classification
2. Epidemiology and Prevalence
3. Aetiology
4. Complications (physical, mental, social, legal, and occupational)
5. Alcohol
6. Cannabis
7. Opium and Opioids
8. Sedatives and Hypnotics
9. Volatile Inhalants
10.Management

4. INTRODUCTION
The World Health
Organization defines
‘substance abuse’ as
“the harmful or
hazardous use of
psychoactive
substances, including
alcohol and illicit
drugs”.

5. • Substance- refers to any drug,
medication or toxin that shares
the potential of abuse.
• Abuse- refers to maladaptive
pattern of substance use that
impairs health in a broad sense.
• Addiction- is a Physiological and
psychological dependence on
alcohol or other drugs of abuse
that affects the Central Nervous
System in such a way that
withdrawal symptoms are
experienced when the substance
is discontinued.

6. • Dependence- is defined as “a cluster of cognitive behavioral and
physiological symptoms that indicate a person has impaired control of
psychoactive substance use and continues use of substance despite
adverse consequences.
• Tolerance – is a state in which after repeated administration, a drug
produces a decreased effect or increasing doses are required to produce
the same effect.
• Substance withdrawal- is a group of signs and symptoms recurring when
a drug is reduced in amount or withdrawn, which last for a limited time.

7. CLASSIFICATION
• Ethanol
• Tobacco
• Sedatives and hypnotics
• Opiates and opioids
• Cocaine
• Cannabis
• Stimulants including Amphetamines and caffeine
• Hallucinogen-LSD
• Volatile substances- kerosene, petrol, whitener, gasoline etc
• Miscellaneous drugs and substances like Datura seeds, anabolic
steroids, cough syrup etc.

8. Common and major substances used in India
• Alcohol
• Tobacco
• Opioids
• Cannabis
• Tranquilizers
• Volatile solvents

9. EPIDEMIOLOGY AND CAUSES
OF SUBSTANCE ABUSE.

10. • The National Institute of Drug Abuse(NIDA), National Survey
of Drug Use and Health (NSDUH) conduct periodic surveys of
the use of illicit drugs in the United States.
• As of 2012,it is estimated that more than 22 million persons
older than the age of 12 years were classified as having a
substance-related disorder.
• The Ministry of Social Justice and Empowerment, Government
of India, has published a report titled, “” Magnitude of
Substance Use in India, 2019.”

11. • Alcohol is the most common
substance used followed by
cannabis and opioids.
• National Household Survey(2004)
reported:-
• Current drug use(past one month) –
• Alcohol-21%
• Cannabis-3%
• Opiates-0.7%
• Any illicit drug use-3. 6%
• Injection drug use(ever) -0. 1%

12. •The first nationwide
survey”Global Adult
Tobacco Survey”in
India(2009-2010) reported:-
•Current tobacco use in any
form among 34% adults.
•Among them 14% Tobacco
smoker and 25.9% use
smokeless tobacco.
•47.9% were Males and
20.3% were Females.

13. Gender and Age:-
• Primarily affects male
but females are also
vulnerable.
• Critical age of onset:-
15-24 years.
Socioeconomic and
Cultural Factors:-
• Religious and cultural
practices.
• Home-brewed alcohol
use-NE States.
• Opium in Rajasthan is
acceptable.

14. The Narcotic Drugs and
Psychotropic Substances Act, 1985
The Narcotic Drugs and Psychotropic Substances Act, 1985 prohibits a person from the
production/manufacturing/cultivation, possession, sale, purchasing, transport,
storage, and/or consumption of any narcotic drug or psychotropic substance.
• According to the Act, narcotic drugs include coca leaf, cannabis (hemp), opium, and
poppy straw; and psychotropic substances include any natural or synthetic material
or any salt or preparation protected by the Psychotropic Substances Convention of
1971.
• The penalties under this Act are severe considering the consequences of drug
abuse and its trafficking.
- The offences under the Act attract jail terms ranging from one year to 20 years a
fine depending on the crime.
- Under the Act, abetment, criminal conspiracy and even attempts to commit an
offence attract the same punishment as the offence itself.
- Preparation to commit an offence attracts half the penalty.
- Repeat offences attract one and a half times the penalty and in some cases, the
death penalty.
(cont.)

15. • The Narcotics Control Bureau was constituted in 1986 under the provisions of the
NDPS Act.
• Under the Act, property acquired by a person from drug-related offences, who has
been convicted under the Act can be seized, frozen and forfeited by the
government.
• All the offences under the NDPS Act are non-bailable.
• Also, no relief can be sought by the drug convicts by termination, remission, and
commutation of sentences passed.

16. AETIOLOGY:-
• It is a brain disease wherein
the voluntary drug using
behavior transforms into a
compulsive behaviour due to
change in the structure and
neurochemistry of the user.
• Drug availability, social
acceptability and peer
pressures may be the major
determinants of initial
experimentation with a drug.

17. A) Biological Factors:-
1.Genetics.
2.Neurobiology:-
• “Brain reward system”
• Craving is linked to the
concentration of Dopamine and
Endorphins in Nucleus
Accumbens and Hippocampus.
B) Psychological factors-
1.Concept of self-medication
2.Behavioural and conditioning
factors.
3.Personality- related

18. C) Environmental Factors:-
1.Social/Cultural/Legal Factors.
2.Drug related Factors.
• Substances which give more intense pleasure and act
quickly are likely to be used repeatedly.
• Drugs which give more distressing withdrawal symptoms
are more addictive.
• Using substance through inhalation and parenteral route
increases the addictive potential.
• Availability and social sanction of the particular drug.

19. COMPLICATIONS OF
SUBSTANCE(DRUG) ABUSE

20. • PHYSICAL COMPLICATIONS
• PSYCHOSOCIAL COMPLICATIONS
-FAMILIAL
-SOCIAL
-OCCUPATIONAL
-FINANCIAL
-LEGAL
• PSYCHOLOGICAL COMPLICATIONS

21. PHYSICAL COMPLICATIONS
• Overusing mood- or physiology-altering substances can
cause damage in a number of ways.
• Direct effects of substances: For example, snorting cocaine
through the nose can damage nasal cartilage, and taking
opiates can lead to opiate-induced constipation, a chronic
and potentially fatal form of constipation if a person does
not receive treatment.

22. • Injury: This can occur during the administration of a drug,
depending on the method. For example, injecting heroin with a
needle can lead to skin and muscle damage at the point of
injection.
• Injury can also occur while intoxicated. Often, drug use impairs
co-ordination and balance and can lead to falls and injuries

23. Cardiovascular health: Many substances lead to spikes in blood
pressure and heart rate, placing strain on the heart and blood vessels
and increasing the risk of stroke, heart attack, and death.
Respiratory Health: Many substances can cause COPD, Asthma, Lung
infections like pneumonia, Lung cancer and other form of cancer which
include cancer of larynx, trachea and pharynx.
Also includes Pulmonary edema, hemorrhages, pulmonary barotrauma.
Loss of hygiene and routine: Addiction can become an all-
encompassing feature in a person’s life, and reward systems in the brain
can rewire to prioritize the substance or behavior at the root of the
addiction over nutrition, resolving stressful situations, and hygiene.
Fetal damage: If a woman takes substances while pregnant, this can
lead to congenital anomalies or even death in the fetus.

24. Gastrointestinal health:
It includes oral ulcers, oropharyngeal malignancies,
esophagitis, acute gastritis, pancreatitis, fatty liver, cirrhosis,
etc.
Central nervous system:
It includes Amnesia, Hallucinations, Wernicke-korsakoff’s
syndrome, dementia, cerebellar degeneration, peripheral
neuropathy and myopathy.

25. PSYCHOSOCIAL COMPLICATIONS
• FAMILIAL COMPLICATIONS: Conflicts, inability to perform
responsibilities.
- Arguments and
fights with spouse.

26. • SOCIAL COMPLICATIONS:
- Social isolation, decrease social reputation.
• OCCUPATIONAL COMPLICATIONS:
- Absenteeism, loss of skill, loss of job.
• FINANCIAL COMPLICATIONS:
- Financial obligations not fulfilled
- Exhausting savings
- Selling properties.
• LEGAL COMPLICATIONS:
- Involvement in illegal activities to procure money for drug use (robbery,
assault,etc.)
- Breaking laws(drunken driving)
- Drug related crime(procuring and storing, selling illegal substances)
- Imprisonment

27. PSYCHOLOGICAL COMPLICATIONS
• Dependence/ Addiction
- Physical adaptations
- behavioural adaptations
• Substance induced Psychotic disorder
eg. Relapsing Schizophrenia by cannabis
• Sense of inferiority
• Poor impulse control
• Loneliness
• Desire to escape from reality
• Desire to experiment
• Anxiety
• Depression
• Panic attacks

28. ALCOHOL ABUSE
What is Alcohol Abuse?

29. ALCOHOL ABUSE
What is Alcohol Abuse?
Alcohol abuse is defined as repetitive
problems with alcohol in any one of four
life areas - social, interpersonal, legal, and
occupational - or repeated use in
hazardous situations such as driving
while intoxicated in an individual who
is not alcohol dependent.

30. ALCOHOLIC DRINK PREPARATIONS :

31. ALCOHOLISM
Alcoholism is a condition in an individual who consumes large amount of alcohol
over a long period of time.
It is characterized by-
● a pathological desire for alcohol intake.
● Black outs during intoxication.
● Withdrawal symptoms on ceasing alcohol intake.
Drinking becomes a problem when the consumption level is above 21units/week
for men and 14units/week for women.

32. TYPES OF ALCOHOLISM
According to Jellinek, there are 5 species of alcoholism/alcohol
dependence :
• Alpha - earliest stage, to relieve pain, can control drinking
• Beta - heavy drinkers, drink daily, physical symptoms, no addiction,
can quit, no withdrawal symptoms
• Gamma - loss of control in drinking, physical dependence, can quit,
withdrawal seen
• Delta - physical dependence, withdrawal seen, can’t quit
• Epsilion - final stage of drinking, continual and insanitable urge to
drink (craving), compulsive drinking

34. `

35. `

36. `

37. `

38. `
(cont.)

43. MEDICAL COMPLICATIONS OF ALCOHOLISM
● Neuropsychiatric- memory disturbances
(amnesia,blackouts), delusions,delirium
tremens,wernicke encephalopathy,korsakoff’s
psychosis,dementia, alcoholic hallucinosis.
● GIT- gastritis, periodic diarrhoea, oesophageal
cancer.
● Liver- fatty liver, hepatitis, cirrhosis.
● Pancreas- acute or chronic pancreatitis
● CVS- cardiomyopathy, dysrhythmia,
hypertension

44. COMPLICATIONS RELATED TO USE OF ALCOHOL
● Acute intoxication
● Tolerance
● Dependence syndrome
● Withdrawal syndrome

45. ACUTE INTOXICATION
Initially, alcohol produces excitement progessing to loss of restraint,
behavioural changes, garrulousness, slurred speech,ataxia, unsteady gait,
drowsiness, stupor and finally coma
TOLERANCE
With the repeated administration of larger doses of alcohol are required to
produce the same effect.
Cross tolerance: a person with the tolerance is likely to develop tolerance
towards second similar kind of drugs.

46. DEPENDENCE SYNDROME
According to ICD-11,this includes
● Strong internal drive to use alcohol.
● Impaired ability to control use, increasing priority given to use over other
activities.
● Persistence use despite harm or negative consequences.
● Physical symptoms of dependence

47. ● Tolerance to effect of alcohol.
● Withdrawal symptoms following cessation or reduction of alcohol use
● Use of alcohol or pharmacologically similar substances to prevent or
alleviate withdrawal symptoms
● Diagnosis may be made of alcohol use is continuous (daily or almost
daily) for atleast 1month.

48. WITHDRAWAL SYNDROME
Sudden cessation of alcohol intake in a chronic alcoholic can provoke a
withdrawal reaction which may manifest as-
● Common abstinence syndrome
● Alcoholic hallucinosis
● Seizures
● Alcoholic ketoacidosis
● Delirium tremens
● Wernicke korsakoff syndrome

49. COMMON ABSTINENCE SYNDROME
Onset- 6hrs to 8hrs after cessation of alcohol
ALCOHOLIC HALLUCINOSIS
Onset- 24hrs to 36hrs
SEIZURES
Onset- 7hrs to 48hrs
ALCOHOLIC KETOACIDOSIS
Onset- 24hrs to 72hrs

50. DELIRIUM TREMENS
Onset- 3 to 5 days
Features- dramatic onset of disordered mental activity characterized by-
● Clouding of consciousness
● Disorientation
● Loss of memory
● Vivid hallucinations
● Severe agitation
● Restlessness
● Intense fear
● Clover shaped ST changes in ECG

51. WERNICKE-KORSAKOFF SYNDROME
Wernicke’s encephalopathy
Triads of confusion,ataxia,opthalmoplagia
Drowsiness, disorientation, amnesia
Korsakoff psychosis
Impairment of memory and confabulation (falsification of memory)
Reversible only in 20% of cases.

52. DRUNKENNESS
Definition: It is a condition which results from excessive
intake of alcohol.
The person under its influence shows the following:
i. Loss of control over his mental faculties.
ii. Inability to perform the duties in which he is engaged.
iii. Dangerous to himself or to others.

53. MEDICO-LEGAL ASPECTS
• Sec. 85 IPC: Nothing is an offence which is done by a person who at the
time of doing it, by reason of intoxication, is incapable of knowing the
nature of the act, or what he is doing is either wrong or contrary to law;
provided that thing which intoxicated him was administered to him
without his knowledge or against his will
• Voluntary drunkenness is not an excuse for commission of crime
• Sec. 510 IPC: Misconduct by a drunken person in public is punishable
with imprisonment upto 24 h.

54. Driving under influence of alcohol
In India, according to Motor Vehicles
Act 1988, for the first offence,
punishment is imprisonment of 6
months and/or fine of Rs 2000. If a
second offence is committed within
3 years, the punishment is 2 years
and/or fine of Rs 3000. Under this
Act, there can be arrest without
warrant, a breath test and a
laboratory test can also be carried
out.

55. ASSESSMENT :
Reasons to assess patients :
• Screening
• Establish a diagnosis
• Planning effective treatment
• Referral
• Establish rapport
• Increase motivation
Setting :
• General Medical Hospital
• Community Clinic
• Psychiatric Hospital
• Prison
• NGO
• De-addiction Centre
• OPD Ward

59. ASSESSMENT (cont.) :
Detailed History
Physical Examination
Mental Status Examination
Laboratory Investigations -
• R/E blood
• LFT
• KFT
• Electrolytes
• ECG
• CT Scan Brain
• USG Abdomen

60. LABORATORY TESTS :
Identify acute and/or heavy drinking (> 5 drinks/day):
Blood Alcohol Levels (BAL)
 Gamma-glutamyl transferase
 Carbohydrate Deficient Transferrin
 Erythrocyte mean corpuscular volume
 CDT + GGTP best diagnostic combination

66. PSYCHOSOCIAL MANAGEMENT :
• Brief interventions-for primary settings
• F –feedback about adverse effects of alcohol
• R –personal Responsibility for changing behaviour
• A –Advice about reducing or abstaining
• M –Menu of options
• E –empathy
• S- self efficacy

67. STAGES OF CHANGE :
2.
CONTEMPLATION
3.
PREPARATION
4. ACTION
5.
MAINTENANCE
6. RELAPSE
1. PRE CONTEMPLATION
Prochaska & DiClemente, 1982;1986

68. Stage of Cycle What will help What you can do
Pre-contemplation Information about the client and the
problem
Help the client ventilate feelings about the
problem
Impact of the problem on the people
around
Avoid Confrontation
Educate about alcohol and drugs, focus on
rapport building
Encourage and appreciate any expression of the
desire to quite alcohol
Contemplation Assessment of the client’s feelings and
cognition about his drinking behavior
Facilitate the analysis of pros and cons
Help in realistic appraisal of the good and bad
things about doing drugs/alcohol
Preparation Choosing to give up drugs and committing to
specific goals
Reaffirm person’s ability to make change
Action Achieving the goals by taking concrete steps Help him lay a definite plan of action
Maintenance Continuing to take the steps and
strengthening commitment to give up
alcohol
Try to involve a significant other
MOTIVATION ENHANCEMENT THERAPY :

69. TREATMENT OF WITHDRAWAL SYMPTOMS :
BENZODIAZEPINES
The Drugs of Choice
Preferably Long Acting Benzodiazepines
There are three types of assisted withdrawal regimens –
• Fixed dose reduction
• Variable dose reduction
• front loading
CHOICE OF A BZD :
Long half-life (chlordiazepoxide, diazepam):  Seizures: ~ 58%
 Distress (“smoother
detox”)
Shorter half-life (lorazepam, oxazepam):  Over sedation
Safer in elderly / liver impairment

70. TREATMENT OF WITHDRAWAL SYMPTOMS (cont):

76. PHARMACOTHERAPY :
1. Disulfiram
2. Acamprosate
3. Naltrexone
4. Others
-SSRI
-Topiramate
-Ondansetron
-Baclofen

78. ANTI-CRAVING AGENTS :
ANTI-CRAVINGS
Most common
- Acamprosate
- Naltrexon
Others
- Ondansetron
- Topiramate
Recent
- BACLOFEN

79. ANTI-CRAVING MEDICINES
Medicine Mechanism Pharmacology Dose Side effects
Acamprosate Inhibits Glutamate
(NMDA) receptor
Good oral absorption
Food hampers absorption
Not metabolized
Excreted via kidney
6 tabs for body wt
>60 kg
4 tabs for <60 kg
Diarrhorea
Headache
Dizziness
Pruritus
Decreased libido
Confusion
Naltrexone Pure opioid antagonist
with highest affinity for
mu receptor
Better oral absorption 50 mg/day Nausea
Headache
Anxiety
Sedation
Topiramate Inhibits release of
dopamine in meso-
cortico-limbic pathway
Augments GABA function
Inhibits Glutaminergic
pathway
Inhibits carbonic
anhydrase enzyme
excreted via kidney 25 – 300 mg/day Weight loss
Parasthesia
Cognitive
impairment

80. CANNABIS

81. Cannabis
• Cannabis is the most widely use illegal drug in the world.
• It is produced from the plant- Cannabis sativa or Indian hemp
plant.
• Cannabinoids are the active chemical compounds in the
Cannabis.
• Among the Cannabinoids Tetrahydrocannabinol is the most
potent one.

82. Preparations of Cannabis
CANNABIS
PRODUCTS
ORIGIN ROUTE OF
CONSUMPTION
CONCENTRATION OF
TETRAHYDROCANNABINOL
(mg%)
Bhang Dried leaves of the
plant
Oral, smoking 1-3
Ganja Dried flowering top Smoking 6-20
Hasish Resinous extract of
the plant
Smoking 10-20
Hasish Oil Syrup extracted from
resin
Smoking 15-30

83. Ganja
Hashish oil
Hashish
Bhang

84. Method of use :

85. Effect of Cannabis
• Effect of Cannabis varies with blood
THC level.
• At low dose : Euphoria.
• Cannabis can impair
coordination.Dexterity and
Steadiness are both adversely
affected.
• With increase in dose – Perceptual
and sensory distortion may be
experienced.
• Some may experience Bad trip –
Restlessness,fear,panic .
• Higher dose may result in delirium,
psychosis and paranoid ideation
which may be self limited.

86. • Cannabis Intoxication – Cannabis intoxication commonly heightens users
sensitivities to external stimuli, reveals new details and subjectively slows
the appreciation of time.
• Cannabis withdrawal – Cessation of use in daily Cannabis users results in
withdrawal symptoms within 1 to 2weekof cessation.
Symptoms include – Irritability, Cannabis craving, nervousness, anxiety,
insomnia, decrease in appetite, restlessness, sweating, tremor.
• Amotivational syndrome- The amotivational syndrome has been associated
with long term heavy use and has been characterized by a person’s
unwillingness to persist in a task – be it at school, at work or in any setting
that requires prolonged attention.

87. TREATMENT
• Abstinence and support – Abstinence can be achieved
through direct intervention such as hospitalization or
through careful monitoring by the use of urine drug
screening ,which can Detect Cannabis upto 4 week.
• Support can be achieved through the use of individual,
family and group psychotherapist.

88. Opioids
Contents : Introduction
Neuropharmacology
Etiology
Diagnosis
Treatment and rehabilitation

89. Introduction
• Opioids have been used for analgesic and other medicinal purposes for
thousands for years, but they also have a long history of misuse for their
psychoactive effects.
• In developed countries, the opioid drug most frequently associated with
abuse and dependence is heroin.
• Over the last few decades there have been significant advances in
treatment and understanding of opioid dependence.
• Different opioid disorders include such common phenomenon as opioid
use disorder, opioid intoxication, opioid withdrawal , opioid induced sleep
disorder and sexual dysfunction.
• The association between the transfusion of HIV and i.v. opioid use is
now recognized as a leading national health concern

90. Neuropharmacology
• The primary effect of opioid drug are mediated via the opioid receptors
which include µ, κ, λ opioid receptor.
• µ opioid receptors are involved in regulation and mediation of analgesia,
respiratory depression, constipation and drug dependence. Κ opioid
receptor with analgesia , diuresis and sedation . And λ opioid receptor with
analgesia.
• The enkephalins , endorphins are endogenous opioids involved in neural
transmission and pain suppression.
• The endogenous opioids also have significant interactions with other
neuronal systems such as the dopaminergic and noradrenergic
neurotransmitter systems .

91. • The addictive rewarding properties of opioids are mediated through
activation of the ventral tegmental area dopaminergic neurons that project
to the cerebral cortex and the limbic system .
• Heroin , the most commonly abused opioid is more lipid soluble than
morphine which allow it to cross blood brain barrier faster and have a more
rapid and pleasurable onset than morphine.

92. TOLERANCE AND DEPENDENCE
• Tolerance to all actions of opioid drugs does not develop uniformly .
• Tolerance to some actions of opioids can be so high that a 100 fold
increase in dose is required to produce the original effect.
• Symptoms of opioid withdrawal do not appear unless a person has
been using opioids for a long time or when cessation is particularly
abrupt.
• The long term use of opioids results in changes in the number and
sensitivity of opioid receptors which mediate at least some of the
effects of tolerance and withdrawal.
• Short term use of opioids apparently decreases the activity of the
noradrenergic neurons in the locus coeruleus and long term use
activates a compensatory homeostatic mechanism within the neurons
and opioid withdrawal results in rebound hyperactivity.

93. ETIOLOGY
1. Psychosocial factors
2. Biological and Genetic factors
3. Psychodynamic theory

94. DIAGNOSIS
• Different opioid related disorders include opioid intoxication,
opioid induced psychotic disorder , mood disorder, sleep
disorder , sexual dysfunction and unspecified opioid related
disorder.

96. Clinical features and adverse effect
• Opioid can be taken orally, intranasally, intravenously,
subcutaneously. The associated symptom include :-
1. Filling of warmth
2. Heaviness of extremities
3. Dry mouth
4. Itchy face
5. Facial flushing
6. Physical effect such as respiratory depression, pupillary
constriction, constipation, smooth muscle contraction, changes
in the blood pressure, body temperature and heart rate.

97. 7. The most common and serious adverse effect associated with
opioid related disorder is the potential transmission of hepatitis
and HIV through the use of contaminated needles
8. Person can experience idiosyncratic reaction to opioid
resulting in anaphylactic shock , pulmonary edema and death if
they do not receive adequate treatment .

98. TREATMENT
• Overdose Treatment
I. The first task in overdose treatment is to ensure an
adequate airway. Tracheopharryngeal secretions
should be aspirated , an airway may be inserted and
patient should be ventilated mechanically.
II. Naloxone , a specific opioid antagonist is administered
intraveneously. Signs of improvement (increase
respiratory rate and pupillary dilation) should occur
promptly.
• Medically Supervised
withdrawal and detoxification
1. Opioid agents for treating opioid withdrawal include
methadone , levomethadyl , buprenorphine.

99. 2. Opioid antagonist such as naloxone block the effect of opioid .
Psychotherapy
Individual psychotherapy , behavioral therapy , cognitive
behavioral therapy , family therapy , support groups and social
skill training may all prove effective for specific patients.

100. SEDATIVE AND HYPNOTICS

101. SEDATIVES
• Definition:-
Sedative is a drug that reduces excitement and calms the
person.
It acts on the limbic system which regulates thought and
mental function.

102. HYPNOTICS
Hypnotics are the drugs that initiate sleep resembles to the
normal sleep.
Site of action is midbrain and ascending RAS (RETICULAR
ACTIVATING SYSTEM)

103. CLASSIFICATION:-
• Benzodiazepines:
Diazepam, lorazepam, clonazepam, clobazam, Chlordiazepam,
oxazepam, temazepam, midazolam, alprazolam, triazolam,
flurazepam, nitrazepam
• Barbiturates:-
Long acting : Phenobarbitone
Short acting: Pentobarbitone
Ultra short acting: Thiopentone, methohexitone
• Nonbenzodiazepine hypnotics:
Zolpidem, zopiclone, zaleplon
• Others: melatonin, ramelteon suvorexant

104. USES:-
• These drugs used in certain conditions like sleep disorders
such as lack of sleep ( insomnia).
• Sedatives and hypnotics are useful drugs in transient insomnia
(<3 days), short term insomnia (3 days to 3 weeks), long term
insomnia (> 3 weeks)
• Amphetamine, modafinil, amitriptyline are used in
hypersomnia ( narcolepsy)
• Tricyclic antidepressants are used in nocturnal enuresis.
• In addition to their psychiatric indications, these drugs are also
used as antiepileptics, muscle relaxants, anesthetics, and
anesthetic adjuvants

106. PATTERN OF ABUSE:-
• These drugs are often abused and in case of barbiturate type
drugs the desire to continue the drug is strong.
• There is cross tolerance between these drugs and alcohol.
• The withdrawal symptoms reach a maximum in 2 or 3 days and
subside slowly.
• Early signs are:- tremor, hyperreflexia, diaphoresis, irritability,
restlessness, anxiety, tinnitus etc.
• Late signs are:- profuse diaphoresis, marked disorientation,
persistent hallucination, extreme agitation , hypertension,
tremors, hyperthermia.

107. A) Oral use:
Sedatives and hypnotics can all be taken orally,
either occasionally to achieve a time-limited specific effect.
• The occasionally used pattern is observed in young person who
uses it for achieving specific effect; relaxation for an evening,
intensification of sexual activities, and a short lived period of mild
euphoria.
• Abusers of this type may have prescription from several
physicians And pattern of abuse is undetected Until obvious sign
of abuse is detected by family Or physician or co workers.

108. B) Intravenous use:-
• A severe form of abuse involves intravenous use.
• Abusers are young adult mainly.
• Intravenous barbiturates are used Associated with pleasant,
warm and drowsy feeling.
• Barbiturates are used more than opioid as it is less costly.
• Physical threat includes HIV, hepatitis B, cellulitis etc.

109. OVERDOSE:-
A) Benzodiazepine:-
• In contrast to the barbiturates
and barbiturate like substance
BZDs has large margin of safety
when taken overdose.
• The ratio of lethal dose to
effective dose is 200 to 1 or
higher.
• When grossly excessive amount
of more than 2g taken in suicide
attempts symptoms include only
drowsiness, lethargy, ataxia.
• Flumazenil can be used to
reverse the effects of BZD.

110. B) Barbiturates
• Barbiturates are lethal taken in
overdose because they induce
severe respiratory depression.
• In addition to intentional suicide
attempts, accidental or
unintentional overdose are seen.
• Barbiturates overdose is
characterized by coma, respiratory
arrest, cvs failure, death.
• Lethal dose to effective dose ratio
ranges between 3:1 and 30:1
• Dependant users take daily dose of
1.5 g short acting Barbiturates.

111. C) Barbiturate like substances:-
• The Barbiturate like substances vary in their lethality are
usually intermediate between the relative safety of BZD and
high lethality of Barbiturates.
• Overdose of methaqualone can result in restlessness,
muscle spasm, delirium, convulsions
• Combination of methaqualone with alcohol is very fatal.

112. Stimulants:-
Cocaine, amphetamine
Hallucinogens:-
LSD, Phencyclidine
Inhalants:-
Petroleum products glues, thinners, cleaners

113. VOLATILE SUBSTANCE ABUSE
• Volatile substance produces vapors that are inhaled for their
psychoactive effect.
• These agents are abused most frequently young adults and
teenagers.
• Often call it huffing, sniffing or tooting.
• Volatile substance are depressant which slow down the
activity of our brain.
• They can also be stimulant and causes hallucinations.

114. DIFFERENT VOLATILE SUBSTANCES
• Solvents
Used to keep product dissolved until they are ready for use.
Example- glues, dry cleaners, paint thinners, detergents,
perfumes , petrol etc.
• Gases, aerosol, propellants ( butane, propane)
Example- spray paint, hair spray, lighter
• Anesthetics
Example- ether, nitrous oxide, chloroform
• Nitrites
Example – isoamyl nitrite, isobutyl nitrite

115. REASON FOR VOLATILE SUBSTANCE ABUSE
• Low self esteem and poor self image and resulting self harm.
• Difficult family relationships.
• Lack of support through traumatic events and transitions .
• Peer influence.
• violence and other abuse.
• Opportunity and availability.

116. HOW VOLATILE SUBSTANCES ARE USED
• Glues tends to be sniffed from bags, including crisp bags.
• Liquids, including petrol, can be sniffed from a handkerchief
or a coat sleeve.
• Gaseous preparations such as butane can be sniffed from bags
or sprayed directly into the mouth
• Hands are often placed inside a large plastic bag to inhale the
fumes.
• Some people will inhale through both the nose and mouth to
enhance the effect.

118. HOW DO VOLATILE SUBSTANCE WORK
• Absorbed through the lungs into bloodstream.
• The chemical in solvents are fat soluble.
• Chemical pass rapidly to the brain through the NMDA/ GABA
receptor present in brain cell.
• Effects 20-30 second , last for the next 30- 40 minutes.
• Effect vary from person to person the ‘high’ usually last only a
few minutes.
• Duration of the experience depends on the product, glue has
a longer duration than butane.

119. CLINICAL EFFECT OF VOLATILE SUBSTANCE ABUSE
IMMEDIATE
• Feeling light headache and dizzy
• Agitations
• Aggressive behaviour
• Confusion and drowsiness
• Hallucinations
• Irritation to eyes, nose and throat
• Slurred speech
• Suffocation
• Sudden death syndrome
• Increase heart rate
• Nausea and vomiting
LONG TERM
• Dependence
• Brain damage
• Loss of hearing and vision
• Problems breathing
• Tremors
• Damage to the immune system,
bones, nerves, kidney, liver, heart
and lungs

120. MANAGEMENT :
SUBSTANCES MECHANISM OF ACTION/PURPOSE
Cross-tolerance Suppression of few
withdrawal
symptoms
(no cross-tolerance)
Symptomatic
treatment
For complicated
withdrawal
Alcohol - Oral long acting
benzodiazepine
s (diazepam)
- Lorazepam is
preferred for
patients with
alcoholic liver
disease
β-blocker _ Parenteral
benzodiazepines
Opiods Buprenorphine
(sublingual)
A-2 adrenergic
agonist (clonidine)
Antidiarrheals
, hypnotics
_
Benzodiazepines Oral long acting
benzodiazepines
_ _ _
Nicotine Nicotine gum,
lozenges and
transdermal patch
_ _ _

121. MANAGEMENT (cont):
Types of agents Types of
substances
Examples
Deterrents Alcohol Disulfiram
Anti-cravings Acamprosate, Fluoxetine,
and Naltrexone
Agonist Opioids Methandone,
Buprenorphine
Antagonist Naltrexone

122. CONCLUSION
- awareness about the challenges of drug abuse in
health and humanitarian crises
- create a society free of drug
- instilling a sense of responsibility among the
youth so that they don't fall prey to drugs.

123. REFERENCES (BIBLIOGRAPHY) :
1. Synopsis of Psychiatry by Kaplan & Sadock
2. The Essentials of Forensic Medicine & Toxicology by Dr. K. S. Narayan
Reddy
3. Harrison’s Principles of Internal Medicine by Anthony Fauci

124. EFFECTS OF DRUGS ON OUR
HEALTH

125. THANK YOU