Mental and behavioral disorders due to the use of opiates

Epidemiology, etiology.

Opium – the basic substance contained in the juice of opium poppy (Papaver somniferum). About 20 alkaloids are obtained from opium, the most famous of which is morphine. It is possible to get t, n. semisynthetic alkaloids based on naturally found in opium (heroin, codeine, hydromorphine), as well as fully synthetic (meperidine, methadone, propoxyphene). The most widely used opiate is heroin, the main supplier of which to the world market are the regions of the Middle and Far East. It is mainly used among the urban population, more often by men than by women (3: 1), at the age of 18-25 years. More than 50% of them come from incomplete or divorced families in which parents often abused psychoactive drugs. About 90% of them have any mental disorder, most often – depression, then – alcoholism, various forms of psychopathy.

In the overwhelming number of cases, the identity of patients is characterized by self-doubt, low self-esteem, asocial inclinations, dominant dysphoric affect, low frustration tolerance. Morbidity is also determined by the subcultural influence of certain groups of the population and by facilitated access to drugs, as a result of which the incidence is higher among doctors than in the population.

Clinic. Parenteral administration of the drug causes analgesia, indifference to pain, drowsiness, misting of consciousness, a feeling of warmth, heaviness in the limbs and dry mouth. As a rule, there is euphoria (“onset”) that occurs shortly after intravenous administration and lasts 10–30 minutes, then sedation (“dragging”) dominates. The first dose may be accompanied by a dysphoric affect tinge, nausea and vomiting.

The analgesic effect reaches a maximum after 20 minutes after intravenous administration, approximately one hour after subcutaneous administration and lasts 4-6 hours, depending on the type of drug, dose and length of anesthesia. Hyperemia and itching of the skin of the face, especially the nose, may occur. There is a narrowing of the pupil, a spasm of smooth muscles (including the ureter and biliary tract), constipation. Idiosyncrasy to the drug occurs in the form of allergic reactions, anaphylactic shock, pulmonary edema.

Overdose is accompanied by slowing of breathing, bradycardia, a decrease in response to external stimuli, a decrease in temperature and blood pressure. Opioids suppress the function of the respiratory center in the brainstem (this effect is potentiated by phenothiazines and MAO inhibitors, and tolerance to it is not developed). Death in overdose is usually associated with respiratory arrest. The classic triad of opiate overdose: coma, “pin head” type pupils and respiratory depression. Conditionally lethal dose with initial tolerance – 60 mg of morphine; a gradual increase in tolerance makes it possible to receive several thousand mg.

The withdrawal syndrome (“breaking”) of morphine and heroin begins 6-8 hours after the last dose, with a background of at least 1-2 weeks of constant intoxication. The highest intensity of the syndrome is observed on days 2–3, decreasing over the next 7–10 days, although some manifestations (insomnia, bradycardia) may persist for up to several months. The more active the opiate is, the faster, shorter and more intense the withdrawal syndrome is. The clinical picture in mild cases is a lot like the state of the flu. In addition to the main symptoms (see below), dysphoria, hot flashes, weight loss, temperature dysregulation can occur. Death against the background of cancellation is rare, mainly due to concomitant pathology of cardiac activity.

The desire to resume taking opiates rarely accompanies withdrawal syndrome when prescribing them as analgesics, for example, during surgical intervention. Side effects of opiate abuse: endocarditis, septicemia, pulmonary embolism, infection with hepatitis viruses and HIV.

Diagnosis. To make a diagnosis of acute intoxication, in addition to manifestations common to F1x.0, the condition must meet the following criteria: 1) at least one of the following symptoms: a) apathy, sedation, b) psychomotor inhibition or disinhibition, c) decreased concentration and memory , restriction of higher mental functions, reduced mental productivity; 2) the presence of at least one of the following signs: a) drowsiness, b) blurred speech, c) constriction of the pupil (or expansion due to anoxia in severe overdose), d) impairment of consciousness (stupor, coma).

For the diagnosis of withdrawal syndrome, in addition to manifestations common to F1x.3, the condition should be characterized by at least three of the following symptoms: a) desire to resume taking the drug, b) a runny nose or sneezing, c) sweating, d) nausea, vomiting, g ) tachycardia or hypertension, e) psychomotor restlessness, g) headaches, h) insomnia, and) general malaise, weakness, j) transient visual, tactile or auditory hallucinations or illusions, l) a large convulsive fit.

Treatment. With an overdose, an opiate antagonist is injected (naloxone, nalorphine – 0.4 mg IV, again 4-5 times during the first 30-45 minutes). Owing to the short duration of the operation of nalok-son, the appearance of a pre-comatose state is possible in the first 4-5 hours, which requires careful monitoring of the condition.

When suppressing withdrawal, synthetic opiate methadone is used to replace heroin (20–80 mg orally). It should be canceled after the withdrawal of withdrawal syndrome, since it itself has a narcotic effect. To relieve methadone withdrawal (much weaker than with heroin), clonidine is used, 0.1-0.3 mg 3-4 times a day for the period of detoxification. The advantages of methadone are oral intake, the possibility of its legal production and productive activities during the reception; disadvantage – the preservation of drug addiction. Its use is particularly indicated in the treatment of female drug addicts in the state of pregnancy to prevent withdrawal syndrome in the newborn.

Similar to methadone opiate L-alpha-acetylmethadol provides for the suppression of withdrawal within 72-96 hours, making it possible for more rare reception. The use of opiate antagonists (naloxone, naltrexone) interrupts the euphoric effect of the drug, but by itself does not provide the patient with motivation to stop the abuse.

Due to the fact that pharmacological intervention does not provide a definitive solution to all psychosocial problems of the patient, the treatment complex should always include rehabilitation measures. For this purpose, individual and group psychotherapy, self-help groups (the program “Anonymous Addict”) are used,

Psychotherapy increases the overall effectiveness of treatment programs, especially if there is a concomitant psychiatric pathology. The optimal framework for rehabilitation is a therapeutic community that tears the patient out of their usual habitat, where most of the staff consists of former drug addicts who have the skills to carefully control the patient’s motivation to withdraw, without which patients are not allowed to be treated. Patients are in groups of the therapeutic community for 12–18 months until they can return to their place of residence. The goal is not only to achieve abstinence, but also the acquisition of useful social skills, the correction of antisocial attitudes. 90% of applicants leave therapy during the first year; for those remaining, a rather high effect is achieved.

Mental and behavioral disorders due to cannabinoids

Indian cannabis plant-based drugs (Cannabis sativa) have different narcotic activity depending on the content of the most psychoactive of 60 cannabioids delta-9-tetrahydrocannabiol (THC), the percentage of which determines the quality of the narcotic products circulating in the market.

Marijuana (“plan”, “weed”) is a diverse mix of leaves, seeds, stems, and hemp flower heads. According to the degree of activity, the narcotic products made from it are divided into 3 categories, denoted by Indian names. The least active bhang product is made from the heads of uncultivated plants. A greater amount of hemp resin is found in ganja, obtained from flowering heads and leaves of carefully selected cultivated plants. The most active is charas, which is the actual resin obtained from the tops of mature hemp; he is designated as hashish.

Cannabinoids can be consumed with food and drink, but are usually inhaled during smoking. Marijuana is called the gateway to the world of drugs. The first experiments with it in adolescents are often not accompanied by dangerous consequences characteristic of other psychoactive substances, which reduces the fear of transition to them. With relevant experience, the combined use of alcohol gives here a significant additive narcotic effect. Usage usually begins in high school. Risk factors are pedagogical neglect, contacts with asocial subcultures, depressive symptoms, low skills of problem-solving behavior.

Clinic. Intoxication develops immediately after smoking, reaches a maximum in 10-30 minutes. and lasts 2-4 hours, although psychomotor disorders may persist for several hours. The effect of oral administration lasts from 5 to 12 hours. Introspection, suggestibility, sensitivity to external stimuli, sharpness of apperception, intensity of perception of color, taste and music increase. There is a feeling of greater saturation of time with events, self-confidence, at the same time a feeling of relaxation and soaring, an increase in sexual urges. A smoker can often perceive himself as if from the outside, laughing at the symptoms he has. Perhaps the emergence of anxiety, aggressive impulses occur rarely. The ability to maintain contact with reality may allow an experienced smoker to hide the state of intoxication from others.

In high doses, marijuana, like hallucinogens, can cause disorders of the body pattern, perception of space and time. In addition to the main somatic symptoms (see below), dilated pupils and cough may be noted. With long-term intake of high doses, some signs of increased tolerance and mild withdrawal reactions (sleep disturbance, anxiety, irritability, vomiting, tremor, sweating, muscle pain) are detected, which, however, do not present major problems for experienced smokers.

Observations on chronic smokers of the Caribbean islands and eastern cultures (Jamaica, Egypt, India, Jamaica) allow us to distinguish as the main so-called. amotivational syndrome (passivity, reduction of impulses, purposeful activity and higher mental functions, apathy, weight gain, sloppiness). The significantly lower severity of the syndrome in North American smokers suggests its etiology, participation of socio-cultural and personal factors.

Oral administration can be a triggering factor for the appearance of delirium, transient delusional syndromes. Delayed episodes of intoxication that occur outside of smoking usually follow the preceding use of hallucinogens. Long-term use may be accompanied by obstruction of the pulmonary tract, emphysema, an increased risk of lung cancer. It also marks the so-called. amotivational syndrome characterized by passivity, lack of interests and motivations, “fallout” in the process of conversation, and difficulty concentrating. Sometimes this term is also used to refer to deficiency symptoms in schizophrenia.

The diagnosis of acute intoxication is made on the basis of the condition, in addition to the general for Flx.0, the following criteria: 1) the presence of at least one of the following symptoms: a) euphoria and disinhibition, b) anxiety, anxiety, c) suspicion or paranoid views, d) a sense of slowing down the course of time, e) a decrease in the focus of thinking, e) a decrease in concentration, g) a decrease in the speed of reactions, h) auditory, visual or tactile illusions, and) hallucinations with intact orientation, j) depersonalization or deres lizatsiya, l) reduced mental productivity; 2) the presence of at least one of the following symptoms: a) increased appetite, thirst, b) dry mouth, c) conjunctivitis symptoms, d) tachycardia.

Treatment. There is no specific therapy for the abuse of can-nabioids. When using the drug as a means of relieving anxiety, depression, attention should be paid to the accompanying mental pathology. The correction of social life, family relations is decisive. The abstinence control includes the periodic determination of the relevant metabolites in the urine.

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